We read with interest the article by Richardson et al. on morcellized porous polyethylene dorsal grafts for rhinoplasty. The technique does appear to be very innovative. We recognize that there are several forms of alloplastic implants that can be used as improvizational material. However, we do have a few concerns regarding the particulate polyethylene graft used by the authors.

The pore size in porous polyethylene (ppe) ranges between 100 and 250 μm in diameter, with half the pores being larger than 150 μm in diameter. These pores are engineered to possess tunnel like-interconnecting networks which allows for excellent soft tissue in growth and coverage. The rapidity of vascularized tissue in growth that pervades through ppe has been relied upon to make this material more resistant to infection than other implants.

Though the authors report favourable results, we have some questions. With respect to the properties of ppe mentioned above, we are concerned about how particulate ppe would influence and benefit fibrous tissue ingrowth. This is because we feel cutting the ppe graft into morsels would obliterate the pores.

We would also like to know if the authors had any event of an adverse host vs foreign body response. If such an event does occur, we expect a secondarily infected particulate ppe implant to manifest with multiple foci of infection? In such a patient, removal or revisional rhinoplasty would become increasingly difficult.

The authors, in their article also state that minor modifications in the shape of the implant can be made up to three weeks post operatively, thus, in so many ways predictably enhancing the soft tissue drape. But, as advantageous as particulate ppe may seem, over the course of 3 weeks, there exist hazards of migration and haematoma/seroma accumulation between the particulate matter, the host bed and the skin.

It is our opinion that a second stage review by the authors to evaluate contours, the long term soft tissue drape and the risk of extruded, resorbed or migrated implants would be more appropriate.