Case Report 3

(Nasal Reconstruction)





The Tycho Brahe Implant


On New Years' Eve in 1566, the Danish Astronomer, Tycho Brahe, fought a duel with his nephew. Tycho lost his nose following a blow from a sabre in this family dispute. He had a prosthetic nasal implant made from silver and gold and wore this for some 36 years until his death. In 1901 his remains were exhumed in Prague, but no trace was ever found of the nose. The method and design of the nasal implant below is a tribute to Tycho's perseverance, ingenuity and contribution to reconstructive surgery as we approach the 21st century.

Hereditary Haemorrhagic Telangiectasia This patient suffers from an inherited bleeding condition, which in this case (rarely) presented as very severe life threatening nose bleeds (epistaxis) which did not respond to radical surgery. Over a 10 year period she underwent hundreds of operations to stop the recurrent nose bleeds, which resulted in total collapse of the nose, and had little effect on the recurrent bleeding problem. Bleeding was so severe that she required an i.v. placed in the right atrium of the heart (Hickman Line) for emergency blood transfusions. She was naturally most reluctant to undergo life saving total nasal amputation, the treatment of choice, for the severity of this condition.




 





Total Collapse of Nose

The contour of the prosthesis was designed using a combination of digital photographic manipulation techniques developed by the surgeon and biomodel pre-surgical planning, as a 2-stage procedure.







Customised Titanium Implant 3 years Photomorphanlysis

The clinical outcome at 51 months is remarkable with good nasal bridge and tip profile. It is to be noted that this case was planned as a two stage procedure.


Case Summary

1.Implant stable @ 67 months (May 2002)
2.Atraumatic Surgical Technique - increased margins of safety.
3.No second donor surgical site required to effect primary reconstruction.
4.Surgery time - 8 hours in the operating theatre.
5.Intensive care - 21 hours (related to medical history rather than to surgery).
6.Enhanced rehabilitation.
7.Reduction in morbidity - simple salvage the implant is illustrated in this case
8.Implant aesthetics - excellent.
9.Normal speech and swallowing.
10.Restoration of sense of smell
11.Significant Cost Savings for Purchasers of Health Care.
12.Reduction in severity of bleeding - only minor intermittent epistaxis (nose bleeds) following implant insertion. Hickman line removed.





Complications

  • Revision of columella reconstruction was required with a small local flap.
  • Stenosis of the left nostril was treated with a stent.
  • Minor exposure of implant at 34 and 46 months closed with local flap.
  • Episodes of minor soft tissue infection (see below).
  • Partial facial palsy (right side) related to revision flap surgery.
  • Further revision surgery required for recurrent perforation in May 2002.





Comment



1. Implant stable @ 67 months (May 2002)

This implant system has demonstrated stability over a 67 month period. Implant exposure/perforation was related to pressure from the nasal bridge of the patient's spectacles. This was associated with episodes of minor soft tissue infection, treated with antibiotics.

2. Skin Perforation

Skin perforation occurred as a result of pressure related to the nasal bridge of the patient's spectacles on a donor site of tissue (nasolabial flap) harvested to reconstruct the columella (strut of tissue between the nostrils). This could have been prevented by using a different flap technique.

Salvage of the implant was possible with local surgery, as a result of the inert nature of the titanium, and its lack of porosity, which prevents the colonisation of bacteria within its substance.

Salvage of an conventional osseous/cartilaginous reconstruction, in the presence of skin perforation, would have been difficult if not impossible; such a complication would have resulted in secondary infection, and the partial, or total loss, of the tissue used in the reconstruction.

Recurrent perforation is still a problem at 67 months in a small area in the region of the tip of the right sided nasolabial flap and will require further soft tissue surgery.

3. Bleeding

Major uncontrollable bleeding has ceased following insertion of the implant, which acts like a pressure pack. Occasional admission to hospital has been necessary for transfusion related to less acute bleeding episodes.






Restitution of Dignity, Self Esteem and Quality of Life




Outcome 51 Months




3 months following Closure of Perforation


Note that there has been successful closure of the perforation on the lateral side of the nose on the patient's right side.

This perforation would have been prevented if a nasolabial flap had not been raised to reconstruct the columella
and we believe that this method of columella reconstruction should be avoided if possible when used in conjunction with the Tycho Brahe Nasal Implant System.






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Patient Comment @ 51 months

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This case was jointly managed with:
Mr. Paul Chui FRCS 1949-2003

Consultant ENT Surgeon, Doncaster Royal Infirmary, England.