Your Questions

Q: Dr. Eppley, I am interested in a revision rhinoplasty. Do yout have experience in removing medpor L shaped implants? This nose has become tight and hard.

A: Revision rhinoplasty often involves removal of synthetic implanted materials. I have removed more than my fair share of Medpor implants all over the face. I am assuming when you say an L-shaped Medpor implant you are referring to its use in the nose for dorso-columellar augmentation. Contrary to common perception, medpor implants can be removed without undue difficult even though they get fibrous tissue ingrowth into them and can be quite adherent. Their removal from the nose is the ‘trickiest’ area to do it because of the naturally thinner tissues of the overlying skin. The tissues may be very carefully lifted off of the implant so as not to damage the blood supply to the overlying skin. I have  removed such nasal implants numerous times over the years but the key questions is…what do you want to do to replace it? Depending upon its size, the tissues can contract and become distorted after its removal. In other words, your nasal skin and its shape is not going to return to what it was before the initial implant surgery. This is the more important concept to consider in your revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a revision rhinoplasty about ten years ago. I had a Medpor nasal shell put in. It was a thicker shell which augmented my nose too much in width, but I’ve always liked the right side and the profile is good. However, the left side is too bulbous and makes my nose look too big. I have talked to two rhinoplasty surgeons who have given different opinions although both are very confident about working with Medpor. One suggests removing the shell and replacing it with a smaller implant or a rib graft. The other said to leave the implant in and just carve into it on the left side and make it smaller. What’s your opinion? What do you think will yield the best results, but also be the safest in preventing infection and is less intrusive?

A: The concept of narrowing your existing implant rather than replacing it with a new implant or a rib graft is a sound one to me. If you like most of what you have in place and just need a little tweaking of it, then you should just modify the existing implant. Doing so also has the advantage that it is really what I call an ‘autoimplant’ at this point. It is part implant and part autogenous since you have tissue ingrowth into it. I would also contend that using the existing implant has less of an infection risk than placing a new one, since the ability to get it inoculated with bacteria into its porous structure is less due to the existing tissue ingrowth.

Whether you carve it in place or take it out to reshape the existing implant is matter of nuances. Either way you have to do a complete dissection over the top and both sides of the implant. Even for in situ carving, you need the space to work. The only difference is that in removal you have to release it underneath from the  cartilage-bony framework. Based on my experience, I could not tell you until I was in there which way I would do it. If I had good access with it in place, I would carve it down without removing it. If I could not get a space to work and was concerned about the overlying skin, then I would remove it, carve it down and re-insert. I don’t think any surgeon can tell you which exact method is best until they are in there. What matters is which way will give the best rhinoplasty revision result and not injure the overlying skin cover.

I have never found Medpor implants hard to remove. Surgeons say it is hard because they have never done it or are comparing it to silicone implants which slide out quite easily. Medpor implants require more care and finesse in their removal to not injure surrounding tissues but they can be removed even though they are more adherent to the tissues.

Dr. Barry Eppley

Indianapolis, Indiana