PCL Mesh and Osteopore in Asian Rhinoplasty
Current Evidence Status
There are no established clinical practice guidelines specifically addressing the use of PCL mesh or Osteopore in Asian rhinoplasty. The available evidence consists entirely of retrospective case series examining outcomes with these materials, while traditional rhinoplasty guidelines emphasize autologous cartilage grafting as the standard approach 1.
Material Selection Framework
Primary Consideration: Autologous vs. Alloplastic
Autologous cartilage remains the gold standard for Asian rhinoplasty grafting procedures, particularly for tip work and structural support 1. The evolution of rhinoplasty has moved toward conservatism, rearrangement, and augmentation using autogenous cartilage grafts for repositioning, reinforcement, recontouring and reconstruction of virtually every component of the nasal skeleton 1.
When PCL Mesh May Be Considered
Based on available research evidence, PCL mesh appears most applicable in specific scenarios:
- Secondary rhinoplasty cases where septal cartilage has been previously harvested and insufficient autologous material remains 2, 3
- Septal extension grafts as batten grafts when composite grafting with remaining cartilage is possible 2
- Patients with very poorly developed nasal skeleton and thick skin where structural support requirements exceed available autologous options 4
Technical Application of PCL Mesh
Composite PCL Technique (Preferred Over Mesh-Only)
When using PCL mesh, composite grafting (PCL combined with autologous cartilage) demonstrates superior outcomes compared to mesh-only approaches 2. In a 774-patient series:
- 97.5% of composite PCL patients achieved satisfactory aesthetic outcomes versus 90.4% in mesh-only group 2
- 96.7% patient satisfaction in composite group versus 94.3% in mesh-only group 2
- Complication rate of 2.2% (17/774) in composite group versus minimal complications in mesh-only, though mesh-only had lower overall satisfaction 2
Specific Grafting Techniques
For Asian tip work, the following cartilage-based techniques should be prioritized:
- Shield grafting for tip projection and definition 4, 5
- Multilayer tip grafting for building up underdeveloped tips 4
- Modified vertical dome division for refinement 4, 5
- Septal extension grafts for projection and lengthening 5, 2
When PCL is incorporated, it functions as a batten graft supporting these cartilage constructs 2, 3.
Critical Complications and Limitations
PCL-Specific Risks
- Mesh infection (documented in case series) 2
- Mesh exposure/protrusion (2.33% incidence) 3
- Decreased tip projection over time due to biodegradation 2, 3
- Deviated nasal tip 2
Long-Term Degradation Concerns
PCL mesh undergoes biodegradation that affects nasal projection over time 3. In 56 patients followed beyond 24 months:
- Goode ratio (nasal projection measure) decreased by 5.00% from short-term to long-term follow-up 3
- Despite degradation, 96.4% of patients maintained satisfactory aesthetic outcomes 3
- Nasolabial and nasofrontal angles remained stable 3
Alloplastic Alternatives
Traditional Alloplastic Materials
For dorsal augmentation in Asian rhinoplasty, traditional alloplastic materials include:
- Silicone implants: Easy to use, reduce operative time, but carry risks of infection, deviation, extrusion, and delayed inflammation 5
- Gore-Tex: Similar advantages and risks to silicone 5
- Selection should consider: Surgeon experience, skin thickness, associated deformities, and aesthetic goals 4
Costal Cartilage Reserve
Costal cartilage should be reserved for difficult revision cases rather than primary rhinoplasty, except in patients with very poorly developed nasal skeleton and thick skin 4. This preserves the most robust autologous option for salvage situations.
Practical Algorithm
Decision Tree for Material Selection
Primary rhinoplasty with adequate septal cartilage: Use autologous cartilage grafts exclusively 1, 4, 5
Primary rhinoplasty with insufficient septal cartilage and thick skin: Consider alloplastic dorsal implant (silicone/Gore-Tex) with autologous cartilage tip work 4, 5
Secondary rhinoplasty with depleted cartilage reserves: Consider composite PCL mesh with remaining autologous cartilage for septal extension grafts 2
Difficult revisions or severe skeletal deficiency: Reserve costal cartilage harvest 4
Critical Pitfalls
- Avoid mesh-only PCL grafts when composite options are available, as outcomes are inferior 2
- Do not use PCL for dorsal augmentation - evidence supports its use only for structural tip support 2, 3
- Anticipate 5% loss of projection over 24+ months with PCL mesh due to biodegradation 3
- Maintain periosteal and mucosal attachments during any nasal framework manipulation to minimize destabilization 6
- Balance graft volume against potential for unesthetic nasal width and graft visibility 1