Reconstruction of the major saddle nose deformity using composite allo-implants

The major saddle nose deformity leaves a patient with an obvious aesthetic deficit as well as an equally disturbing functional handicap. Reconstructing the collapsed dorsum and tip and simultaneously restoring nasal function present a formidable challenge which has elicited a wide variety of solutions ranging from the use of a toothbrush handle to split calvarial grafting. As Murakami et al pointed out, the "variability exists to a large extent, because the saddle nose deformity is not a single entity but rather a spectrum of abnormalities." Attempts to categorize saddle nose deformities are useful; however, they often lack the simple impact and clarity of the pre-operative photograph. Moreover, the categorizations have not led to a uniform approach to this complicated problem. Nevertheless, Tardy's classification of minimal, moderate, and major saddle nose deformities provides a helpful framework for discussion of reconstructive options. Minimal deformities demonstrate a supratip depression of 1 to 2 mm and are easily corrected with cartilage or fascial overlays. Moderate saddle nose deformities are characterized by a significant loss of dorsal height as well as columellar retraction and broadening of the bony pyramid. A major deformity demonstrates "all of the stigmata of the moderately saddled nose, only to a more marked degree." In Tardy's opinion, an open approach may be warranted in these cases. We offer one solution to the major saddle nose deformity using a composite allo-implant of porous high-density polyethylene (PHDPE) (Medpor surgical implants, Porex Surgical, Inc., College Park, GA) and purified acellular human dermal graft (Alloderm, Life Cell Corp., TX.). While we readily admit that autogenous tissue is the preferred grafting material, we have encountered patients in whom this is not an option. Major saddle nose deformities typically require more augmentation than stacked septal or auricular cartilage can provide. Additionally, in patients seeking revision rhinoplasty, sufficient donor septal or auricular cartilage is often lacking. Resorption of irradiated cadaveric rib grafts has led us away from this material. Split calvarial bone grafts are our next recommendation for these patients; however, many patients refuse this option. In these patients we have turned to a composite allo-implant of PHDPE and acellular human dermal graft for reconstruction of the collapsed dorsum and tip.