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Alloplastic rhinoplasty posed a risk of infection even with the use of porous high-density polyethylene (pHDPE) materials, investigators found.

Postoperative infection occurred in about 3% of more than 600 rhinoplasty procedures, and every infection involved a patient who received alloplastic materials. Infections happened in one in five rhinoplasty procedures in which pHDPE implants were used, as reported online in Archives of Facial Plastic Surgery.

The incidence of postoperative infection was 5.3% among patients who underwent procedures involving expanded polytetrafluoroethylene (ePTFE).

"The use of pHDPE and ePTFE implants in rhinoplasty is associated with an increased risk of postoperative infection," wrote Andrew Winkler, MD, of the University of Colorado in Aurora, and colleagues. "This risk remains significant after demographic factors, medical comorbidities, and revisional surgical status are controlled for."

Their findings are in contrast to those of previously published studies regarding the use of pHDPE in the nose but parallel those regarding the use of ePTFE, they said. "Caution is recommended when using pHDPE in rhinoplasty, especially as a columellar strut, although there may be situations in which the increased risk is acceptable," they added.

Despite the desirability of autologous-tissue implants for rhinoplasty, materials for reconstruction are not always readily available. Implants made of ePTFE have been used more often, because of concerns about infection and extrusion with pHDPE. However, recent studies have indicated a greater risk of foreign-body reactions with ePTFE than previously realized, the authors noted.

To meet a need for more information about complication risks with synthetic materials, Winkler and colleagues retrospectively reviewed medical records of patients who underwent rhinoplasty or septorhinoplasty at Oregon Health and Science University in Portland during August 1999 to March 2008.

The search of records identified 662 procedures involving 659 patients, all performed by the same three faculty surgeons.

The procedures involved alloplastic materials in 151 (22.8%) cases: ePTFE in 99 cases and pHDPE in 76 cases, including 24 cases wherein both materials were used. In about 85% of cases, alloplastic materials were used in functional applications.

Use of ePTFE alone was limited to augmentation of the nasal dorsum. Surgeons employed pHDPE for several applications, including use as a columellar strut in 40 (6%) cases (6%), an alar batten implant in 14 (2.1%) cases, and both applications in two (0.3% cases).

Factors associated with an increased likelihood of alloplastic materials use were a history of cocaine use (RR 3.23), prior rhinoplasty or septoplasty (RR 3.23 and RR 2.72, respectively), an open surgical approach (RR 2.15), and septal perforation (RR 2.02).

During a mean follow-up of 12.1 months, 19 (2.8%) patients developed postoperative infections, all of which occurred after use of alloplastic materials. No infections occurred in patients who did not receive implants made of ePTFE or pHDPE.

Postoperative infection occurred in 10 of 52 rhinoplasties involving pHDPE implants. The infection rate increased to 21.8% in patients who received pHDPE as a columellar strut.

Of the 75 patients who received ePTFE implants, four (5.3%) developed a postoperative infection, including two patients who received both ePTFE and pHDPE.

Infection occurred in five of 24 cases (20.8%) involving simultaneous use of pHDPE and ePTFE.

Additionally, 18 of 151 (11.9%) patients developed implant exposure, which usually was associated with infection. Patients who received pHDPE columellar struts had the highest exposure rate (23.4%).

Bivariate analysis showed that factors significantly associated with an increased risk of postoperative infection were:

• Alloplast of any type: RR 29.09 (95% CI 6.80 to 124.50)
• Implantation of a pHDPE columellar strut: RR 21.24 (95% CI 8.37 to 53.88 )
• Prior septoplasty: RR 6.91 (95% CI 2.77 to 17.21)
• Diabetes: RR 6.34 (95% CI 1.65 to 24.45)
• Prior rhinoplasty: RR 5.01 (95% CI 2.05 to 12.21)
• Use of an ePTFE dorsal onlay: RR 4.11 (95% CI 1.70 to 9.97)

Factors not associated with infection included patient sex, surgeon, functional versus cosmetic procedure, current tobacco use, and history of cocaine use (P>0.05 for all).

This retrospective study had limitations including data that was based on available medical records. Also, the infection rate may have been underestimated because some patients who developed infections may have gone elsewhere for care. Finally, the data set did not include information on the timing of the infection so the authors did not know if the risk of infection diminished over time.

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