Revision Rhinoplasty - Irregular Nose and Bloocell®️ Sheet-Type PCL Removal

Complicated 4th Fourth Revision Nose Job (PCL Implants Removal) in a Patient with Nasal Irregularities and Collapses

A patient who had previously undergone three rhinoplasty surgeries presented to our clinic with irregularities and depressions in different areas of the nasal bridge. The patient's last surgical report indicated that Bloocell®️poly-caprolactone (PCL) mesh had been used, and irregularities had appeared in the areas where this material was placed.

Warning: Some images published in this article are unsuitable for those under 18 and may be graphic or disturbing.

As seen in the image above, after the swelling on the patient's nose subsided, sharply defined protrusions and indentations appeared in different areas. The patient stated that these protrusions became more prominent, especially when smiling and upon waking, and that very noticeable asymmetrical areas were visible when the flash was on during photo shoots.

In the image above, the yellow arrows show the area with the sheet-type PCL scaffold mesh, which causes the left nasal bone wall to appear more prominent, while the green arrow shows the sunken and discolored area adjacent to this implant. There is a scarred area on the skin from a previous procedure, and a sunken area is visible between the implants placed in this region.

As seen in the image above, we found and removed numerous implant fragments on the bridge of the nose and in various other areas. In some areas, they were quite tightly adhered to the skin. The patient's skin was quite irregular after the implants were removed.

After the implants were removed, the nasal bridge, nasal bone, and supratip area were smoothed using a micromotor tungsten probe.

One of the two grafts prepared from temporal fascia taken from the left temple area was placed under the skin in the sunken area on the upper left side, where the purplish fixation suture is located, as shown in the image above.

The other of the two grafts prepared in the temporal fascia was placed under the skin along the midline in an elongated manner, as seen in the images above and below.

The image below shows the skin incision area for a temporal fascia graft taken from the left temple. A compression head bandage was applied for one day after the graft was harvested. The incision area was sutured with dissolvable sutures.

The sutured incision site after harvesting the left temporal fascia graft is shown above. The procedure is completed by applying a pressure dressing to the patient's head. This dressing is removed the next day, and the patient only needs to apply an antibiotic skin ointment to that area.

About Polycaprolactone (PCL) Implants

Recently, Polycaprolactone (PCL), which has also begun to be used in rhinoplasty operations, is a type of aliphatic polyester that is frequently used in biomedical applications. It is biodegradable, biocompatible, and slowly dissolves in a controlled manner. PCL, especially in mesh/scaffold form, allows the growth of bone, cartilage, and connective tissue. The information I want to convey to you from the source links is: "It is tolerated without creating a significant immune reaction in the body. It supports the easy attachment and proliferation of cells such as fibroblasts, chondrocytes, and osteoblasts on the surface. It is widely used in modern medicine and tissue engineering, especially in areas such as 3D printing, implants, tissue scaffolds, and controlled drug release. It is tolerated without creating a significant immune reaction in the body. It supports the easy attachment and proliferation of cells such as fibroblasts, chondrocytes, and osteoblasts on the surface. PCL is slowly broken down in the body by hydrolysis and enzymatic degradation. The complete dissolution time is generally between 2–4 years (depending on form, thickness, and crystallinity). Its degradation rate is relatively slow compared to many other biodegradable polymers. Sheet-Type PCL, which has a porous structure, has therefore begun to be used in rhinoplasty in areas such as septal support, tip projection, and dorsal augmentation. This structure can act as a scaffold during healing." 

Source links:

Clinical Application of Three-Dimensionally Printed Biomaterial Polycaprolactone (PCL) in Augmentation Rhinoplasty

Clinical Studies - BLOOCELL® | Bone & Cartilage Repair Matrix

According to the source links, PCL studies for tissue engineering indicate that complete degradation can take 3-4 years, and in some cases, especially when PCL is used in dense, non-porous, or thick forms, it can take up to 5 years. It had been a year and a half since our patient's last surgery, and during the operation, it was observed that the implant holes were covered with healing tissue and thin plates were used.

Problems Can Occur in Patients with Thin Nasal Skin!

As in the patient I'm sharing with you here, in patients with thin skin, even with a dissolvable material, a hard, plastic-like consistency can result in a protruding and irregular appearance under the skin. I generally prefer to use fascia grafts, which are used like the patient's own natural camouflage tissue. During the operation, it is not easy to remove these materials, which adhere tightly to the place where they are placed due to their porous structure, without damaging the skin.

The image above shows a collapse in the left nostril and nasal valve area prior to surgery. After placement of an alar batten graft and a marginal rim graft in that area, closely shaped nostrils are visible.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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