Reconstruction of nasal defects has a long history dating back almost 2000 years to the days of Sushruta, the famous Indian surgeon, and the pharaohs. Partial thickness defects can be managed very satisfactorily by surgery. Full thickness defects can be reconstructed by surgery or a prosthesis. Reconstruction of large, full thickness defects of the nose following ablative oncological surgery remains a challenge, despite recent advances in surgical reconstruction techniques. The necessity to restore the complex three-dimensional shape of the nose, with a satisfactory cover, lining and appropriate support often requires staged procedures and the availability of healthy local tissue. Even with the use of free tissue transfer, the final aesthetic outcome leaves much to be desired, especially when adjacent tissue has also been lost. The risk of recurrence and the use of radiotherapy often add further challenges to the reconstruction.

When the decision has been made to undertake a prosthetic reconstruction, the prosthesis can be retained by an implant or other methods. The use of tissue adhesives to retain an implant can be associated with contact dermatitis and allergic reactions, loss of adhesion and dislodgement, and unsightly bulky prosthetic edges . Attaching the prosthesis to spectacles overcomes these shortcomings, but means the glasses cannot be removed independently of the prosthesis.

An implant-retained prosthesis overcomes these limitations and gives the patient the security of a stable prosthesis . Increasing experience with implant-retained craniofacial prostheses has allowed satisfactory reconstruction of isolated auricular, orbital and nasal defects in addition to complex defects involving multiple craniofacial structures . This experience has been largely limited to specialized centres in Canada, Sweden and the USA and the available literature is often in the form of multi-institutional studies evaluating implant-retained prostheses used to reconstruct multiple sites .

Experience of reconstructing large, full thickness nasal defects with implant-retained prosthesis is limited and has mainly referred to the overall success or failure rates of these implants . A literature review documented 128 implants placed in the nasal skeleton to retain nasal prostheses of which 23 were placed within a field of radiotherapy. The success rates were 60–100% in patients who had not received radiotherapy and 50–100% in patients who had received radiotherapy . Little information is available on the technical aspects of the procedure or the factors influencing the success of these implants and the retained prosthesis. The authors present their experience with 34 patients, who received 111 implants to reconstruct large, full thickness rhinectomy defects and they evaluate the multiple factors that could influence the success of these implants and the retained prosthesis.

Defect modification

Following excision of the tumour with adequate margins ( Figs 1 and 2 ), the residual defect is modified to help retain the prosthesis. The prominent bony lip of the piriform aperture is trimmed and the anterior part of the nasal septum and the inferior turbinates is removed ( Fig. 3 ). This provides a flat base for the prosthesis and allows access for instrumentation and maintenance of hygiene. Implants of sufficient length to obtain bi-cortical purchase are placed in the nasal floor, taking care to avoid the tooth roots. A split skin graft, shaped like an elephant ( Fig. 4 ) is then laid on the nasal floor, piriform rims and around the implants, taking care not to distort the upper lip and cheeks ( Fig. 5 ). This provides an immobile base for the prosthesis, which is free of secretions. This is followed by construction and delivery of the prosthesis ( Fig. 6 ).

Clinical picture of nasal tumour.

Unmodified post-rhinectomy defect.

Areas of defect modification.

‘ Elephant’ shaped skin graft.

Postoperative appearance of the implants in situ .

Nasal prosthesis in situ .