the nose is a central structure of the face , so attempts to reconstruct ideal form and esthetics can be complicated .
the majority of patients with cleft lip nose deformity require augmentation rhinoplasty for a more balanced nasal dorsum .
traditionally , autogenous cartilages from various sites are used to correct cleft lip nose deformity . however , sometimes results of corrective rhinoplasty using auricular or septal cartilages are unsatisfactory due to the weakness of the graft material . in that case
, rib cartilage could be a good material of choice for corrective rhinoplasty for cleft lip nasal deformity .
however , the harvesting procedure leaves a cutaneous scar that is unacceptable , especially for a young female patient .
so we need to find alternative surgical options to replace the autogenous rib cartilage . in 1998 ,
a new biomaterial called permacol ( tissue science laboratories plc , aldershot , uk ) was licensed in europe for permanent implantation in human body .
permacol consists of acellular , cross - linked porcine dermal collagen that is resistant to degradation by collagenase .
it had been widely used in general and gynecological surgery in the treatment of hernia   and otolaryngology surgery such as surgical closure of nasal septal perforation .
recently it was described in facial contour augmentation surgery including esthetic augmentation rhinoplasty   and reconstruction of a post - traumatic nasal deformity .
the author augmented nasal dorsum after reconstruction of the lower third of the nose during corrective rhinoplasty in patients with cleft lip nasal deformity . in this report
we describe three cases of rhinoplasty procedures using autogenous auricular cartilage and synthetic porcine dermal collagen with highlights of how to use it .
a 17-year - old female patient with secondary deformity due to unilateral incomplete cleft lip and palate was referred to the department of oral and maxillofacial surgery , gangneung - wonju national university dental hospital .
five years ago , she underwent autogenous bone graft on her cleft alveolus . during this time , her chief complaint was the deformed nose , so we decided upon corrective rhinoplasty and minor revision surgery on her upper vermilion . after taking standard rhinoplasty photograms , formal consent for the use of xenograft material was obtained .
the operation was performed under general anesthesia with additional anesthetics consisting of 2% lidocaine and 1:100,000 epinephrine in the planned dissection area . via an open rhinoplasty approach with intercartilaginous and stair - shaped transcolumellar incision ( fig .
1a ) , the lower lateral cartilage was dissected from surrounding soft tissues and prepared a subperiosteal pocket for the xenograft on nasal bone ( fig .
the permacol sheet comes ready to use and can be cut to the desired size easily .
we inserted two layers ( 3 mm ) of permacol under the dorsal skin of the nose , and fixed it to the underlying cartilages with 4 - 0 polydioxanone ( fig .
after closing the surgical wounds , we applied external nasal stent and tape for two weeks , as well as a nasal conformer for six months at night postoperatively .
esthetic results in visits at one month , six months , and one year were satisfactory for patients and surgeon ( fig .
2 ) . the dorsal implant was intact and did not show any resorption or displacement . a 17-year - old male patient with secondary deformity due to unilateral
he had undergone several surgeries including distraction osteogenesis for collapsed maxilla , secondary alveolar bone grafting for cleft alveolus , and pharyngoplasty by the author . on this occasion ( january 25 , 2009 ) , corrective rhinoplasty was performed . under general anesthesia , open rhinoplasty was performed via an intercartilagenous incision , continuous with the transcolumellar incision on the line of previous scar ( fig .
3c ) , we applied it as a columellar strut and gull - wing type graft ( fig .
4 ) . a 14-year - old male patient with secondary deformity due to bilateral cleft of primary palate presented to the department .
his mother s chief complaint was the visible scar on upper vermilion and the compressed nose , so we decided to perform a cheilorhinoplasty . under general anesthesia ,
open rhinoplasty was done via an intercartilagenous incision inside both nostrils and the incision for scar revision ( fig .
, we applied it as a columellar strut and gull - wing type graft for prominent nasal dome ( fig .
we then implanted two layers of permacol in the form of an onlay graft , and fixed it to the grafted auricular cartilages with monocryl sutures ( fig .
a 17-year - old female patient with secondary deformity due to unilateral incomplete cleft lip and palate was referred to the department of oral and maxillofacial surgery , gangneung - wonju national university dental hospital .
five years ago , she underwent autogenous bone graft on her cleft alveolus . during this time , her chief complaint was the deformed nose , so we decided upon corrective rhinoplasty and minor revision surgery on her upper vermilion . after taking standard rhinoplasty photograms , formal consent for the use of xenograft material was obtained .
the operation was performed under general anesthesia with additional anesthetics consisting of 2% lidocaine and 1:100,000 epinephrine in the planned dissection area . via an open rhinoplasty approach with intercartilaginous and stair - shaped transcolumellar incision ( fig .
1a ) , the lower lateral cartilage was dissected from surrounding soft tissues and prepared a subperiosteal pocket for the xenograft on nasal bone ( fig .
the permacol sheet comes ready to use and can be cut to the desired size easily .
we inserted two layers ( 3 mm ) of permacol under the dorsal skin of the nose , and fixed it to the underlying cartilages with 4 - 0 polydioxanone ( fig .
after closing the surgical wounds , we applied external nasal stent and tape for two weeks , as well as a nasal conformer for six months at night postoperatively .
esthetic results in visits at one month , six months , and one year were satisfactory for patients and surgeon ( fig .
2 ) . the dorsal implant was intact and did not show any resorption or displacement .
a 17-year - old male patient with secondary deformity due to unilateral complete cleft lip and palate was referred to our department .
he had undergone several surgeries including distraction osteogenesis for collapsed maxilla , secondary alveolar bone grafting for cleft alveolus , and pharyngoplasty by the author . on this occasion ( january 25 , 2009 ) , corrective rhinoplasty was performed . under general anesthesia , open rhinoplasty was performed via an intercartilagenous incision , continuous with the transcolumellar incision on the line of previous scar ( fig .
3c ) , we applied it as a columellar strut and gull - wing type graft ( fig .
a 14-year - old male patient with secondary deformity due to bilateral cleft of primary palate presented to the department .
his mother s chief complaint was the visible scar on upper vermilion and the compressed nose , so we decided to perform a cheilorhinoplasty . under general anesthesia ,
open rhinoplasty was done via an intercartilagenous incision inside both nostrils and the incision for scar revision ( fig .
, we applied it as a columellar strut and gull - wing type graft for prominent nasal dome ( fig .
we then implanted two layers of permacol in the form of an onlay graft , and fixed it to the grafted auricular cartilages with monocryl sutures ( fig .
there is a vast number of surgical techniques and grafting materials for cleft lip nose deformity reconstruction . in general ,
autogenous tissues remain the gold standard for reconstructive surgery of cleft lip nose deformity . especially for augmentation of the nasal dorsum
however , autogenous grafting procedures require additional surgery and donor site morbidity , and sometimes graft material is limited .
thus maxillofacial plastic and reconstructive surgeons always need to prepare allogeneic or alloplastic materials as an alternative .
silicone , high - density porous polyethylene , expanded polytetrafluoroethylene , and human dermal collagen   are used as alloplastic materials for augmentation rhinoplasty , and have both advantages and disadvantages .
permacol can be a useful material for augmentation rhinoplasty because it is readily available in the required volume , it is easy to shape , and it seems to maintain the structural integrity of the nose . in this study ,
three patients underwent corrective rhinoplasty via external approach using autogenous auricular cartilage and permacol composite grafting .
the original dimension of the permacol sheet used was 60301.5 mm , and two layers of permacol were inserted into the nasal dome with customized size for each patient .
if layering is required , the material can be cut into separate sheets , creating edges rather than folding or rolling , probably due to possible colonization of microorganisms .
, the auricular cartilage was covered with a double layer of permacol to form the ideal nasal contour .
afterwards , the author felt two layers of permacol was aesthetically sufficient for the patient with thin nasal skin ( case 1 , 3 ) , but deficient for the patient with thick facial soft tissues ( case 2 ) .
previous studies demonstrate that permacol , when implanted in human body , is readily surrounded by host tissues such as fibroblasts and vascular endothelial cells .
hunter et al .   observed a permacol explant 15 months post implantation , originally inserted for augmentation rhinoplasty .
macroscopically , permacol was covered with a clear layer of fibrous tissue , characterized histologically by the irregular arrangement of collagen as well as the presence of some cells and elastin fibers .
suggested that permacol acted as a matrix into which autogenous tissue could grow . from those studies and our own limited experiences with three patients ,
inserted fourty - five permacol implants for augmentation rhinoplasty over a 4-year period , with only one case of postoperative implant removal .
they concluded that permacol seemed to be a biocompatible alternative to conventional grafting materials , with minimal morbidity .
compared to the removal rate of silicone   and the infection rate of gore - tex , pitkin s clinical results are encouraging .
moreover , permacol can be safely used in a contaminated field . in our study , immediately after the operation , no patients complained of any foreign body sensations or discomfort at usual daily activities .
.   recommended long - term follow - up for the use of permacol because some graft absorption was noted in their patient , who had undergone nasal profile augmentation .
the author followed three patients for more than five years , but there was no sign of graft absorption .
hopkins et al .   also report successful long - term use of permacol in rhinoplasty . in conclusion
, we obtained pleasing results in reconstruction of cleft lip nose deformity with simple and safe surgical procedures . in our limited experience with three patients
, the author concludes that the permacol can be a reliable surgical option for patients with cleft lip nose deformity .
 esthetic reconstruction of cleft lip nose deformity is a challenging task in surgical management of patients with orofacial cleft . 
 the author reconstructed cleft lip nose deformity effectively using autogenous auricular cartilage and a relatively new graft material of porcine dermal collagen , permacol. after correction of the deformed lower third of the nose with patient s auricular cartilage , we applied permacol to augment the entire nasal dorsum . 
 three patients were treated and followed for up to five years . 
 all patients improved in nose aesthetics without any inflammatory or immunogenic reaction . 
 the author suggests that the use of permacol for nasal profile augmentation in the treatment of cleft lip nose deformity is an alternative surgical strategy with minimal surgical invasiveness . the author report long - term experience with combined use of auricular cartilage and permacol in nasal reconstruction for cleft lip nose deformity . 
Introduction
Case Report
Case 1
Case 2
Case 3
Discussion