Dorsal Nasal Augmentation essentially calls for a sculptures streak. The Plastic Surgeon should practice shaping the material in a lab and only when fully conversant and confidant then only apply his skill in the Operating Room.
A couple of important points to consider whilst doing an Alloplastic Implant Surgery, moreover so in the case of low threshold recipient site like nasal dorsum are:
Maintain a “Super Sterile technique” that includes
- Implant is maintained in original sterile packing until subcutaneous recipient packet is created. Vide infra.
- A change of gloves of the surgical team and the use of a fresh Operation trolley. A vigorous washing off of all of the powder
- Use of virgin blades
- Vacuum impregnation of antibiotic and maintenance of sculptured implant in antibiotic solution until placement.
- Insertion of implant with no touch technique
- Keep handling of the implant to a minimum.
A thorough step-by-step appraisal of the procedure will now be discussed.
- Pre-op consultation and documentation done.
- External marking of the implant pocket is done.
- Subcutaneous pocket dissected out through an inter-cartilaginous incision.
- Sub-periosteal pocket dissected out with a periosteal dissector
- Attention shifted to sculpturing of implant once homeostasis achieved and maintained.
- The graft sculptures using 11 no and 15 no virgin blades and maintaining the aforementioned super sterile technique.
- Vacuum impregnation of implant with antibiotic.
- Gentamycin 2 cc diluted in 30 ml of saline is taken in a 10 ml syringe
- The implant is loaded into the syringe from behind.
- The syringe is held upright and the plunger is pulled back, blocking the bevel with a gloved finger.
- Small air bubbles will be seen emerging from the implant
- The implant will sink down once it is fully impregnated
- The implant introduced into the sub periosteal pocket and the external pressure maintained to co apt it to the bone surface. Incision closed and splinting of the implant done
Advice on Implant Sculpturing
- A rough model made by crude strokes with 11 and 15 number virgin blades.
- This is then feathered so that there are no rough edges.
- The implant is shaped as per Mc Carthy’s description like the prow of a boat, beveling out gradually.
- The undersurface of the implant is excavated to leave a depression that will help the implant to sit on the rhinion and not slide off on to either side.
- To facilitate better tissue adherence vertical and horizontal hatching of the dorsal surface of the implant is done. This helps in preventing migration of the implant.
Using a self illuminated dorsal nasal retractor the cavity is cleaned of all tissue debris, bone fragments, fat fragments and hematomas.