Aesth Plast Surg
https://doi.org/10.1007/s00266-020-01648-8
ORIGINAL ARTICLE
Late-Onset Inflammation in Asian Rhinoplasty Using Alloplastic
Implants
Kyung-Chul Moon1 • Kyu-Il Lee1 • Jong-Seok Lee1 • Ae-Ree Kim2
Eun-Sang Dhong1 • Deok-Woo Kim3 • Seung-Kyu Han1
Received: 15 December 2019 / Accepted: 12 February 2020
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Abstract
Background Late-onset inflammation is a rare complica-
tion that may occur several months to years after under-
going an uneventful rhinoplasty using alloplastic implants
and an uneventful postoperative course. Studies to deter-
mine the pathophysiological mechanisms of late-onset
inflammation related to implants used in rhinoplasty are
limited. The purpose of the study was to analyze differ-
ences between non-healthy capsules (NHC) with late-onset
inflammation and healthy capsules (HC) without inflam-
mation as controls to determine the possible cause of the
inflammation.
Methods Between April 2009 and May 2018, 39 patients
who underwent rhinoplasty with alloplastic implants
underwent histological studies. Twenty-one patients in the
NHC group showed late-onset inflammation, while 18
patients in the HC group did not display late-onset
inflammation. Capsules around the alloplastic implants
were harvested, and histological studies using hematoxylin
and eosin, Masson’s trichrome, colloidal iron, and CD31
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00266-020-01648-8) contains sup-
plementary material, which is available to authorized users.
& Eun-Sang Dhong
prsdhong@kumc.or.kr
1
Department of Plastic Surgery, Korea University Guro
Hospital, 148 Gurodong-Gil, Guro-Ku, Seoul 08308, South
Korea
2 of the most important aspects of Asian rhinoplasty [2]. As
Department of Pathology, Korea University Guro Hospital,
148 Gurodong-Gil, Guro-Ku, Seoul 08308, South Korea
3 through minimally invasive procedures, the demand for
Department of Plastic Surgery, Korea University Ansan
Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si,
Gyeonggi-do 15355, South Korea
RHINOPLASTY
•
staining were performed and compared between the NHC
and HC groups.
Results In hematoxylin and eosin and Masson’s trichrome
staining, edematous granulation tissues, inflammatory cel-
lular contents, and a disorganized collagen layer were
increased in the NHC group compared to the HC group.
The colloidal iron staining revealed mucin deposition in the
NHC group. CD31-positive cells were observed lining the
capsule in both groups; however, the lining cells were
damaged in the NHC group.
Conclusion Granulation tissues, inflammatory reaction,
collagen degeneration, mucin deposition, and endothelial
lining cell damage were greater in the NHC group com-
pared to the HC group. Damaged capsules may play a
crucial role in late-onset inflammation.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Complication
Histology
Implant

Inflammation
Rhinoplasty
Introduction
Asian noses are generally described as having a low nasal
dorsum, thick skin, and a poorly developed cartilaginous
framework [1]. Therefore, nasal dorsal augmentation is one
increasing numbers of patients seek esthetic improvement
effective and durable alloplastic materials for nasal dorsal
augmentation has grown dramatically. In particular,
123

silicone implants are the most commonly used alloplastic
implants in Asian rhinoplasty. The availability of ready-
made products makes implantation convenient and the
relative hardness of silicone makes it suitable for fashion-
ing the nasal shapes desired for Asians with thick skins [3].
Despite the renowned safety of the implants, late-onset
inflammation is a rare complication, which may occur
several months to years after undergoing an uneventful
rhinoplasty using alloplastic implants and an uneventful
postoperative course. The complication is characterized by
intermittent nasal dorsal tenderness, swelling, and some-
times granuloma-like skin lesions. In severe cases, punc-
ture with fluid drainage on the external or intranasal area
may be present. Late-onset inflammation may result in
significant esthetic and functional complications.
Several hypotheses can be proposed to explain the
pathophysiology of late-onset inflammation. One potential
avenue of causality relates to subclinical infection and peri-
implant biofilm development. Delayed hypersensitivity
reactions may lead to late-onset inflammation. Mechanical
dynamics and late seroma may also contribute as etiologic
factors. However, published descriptions of late-onset
inflammation after the use of alloplastic implants for
rhinoplasty are mainly individual or small case reports,
generally followed by speculation of the etiology. There-
fore, studies to determine the pathophysiological mecha-
nisms of late-onset inflammation related to implants used
in rhinoplasty are limited. A histological study demon-
strating late-onset inflammation associated with alloplastic
implants in rhinoplasty may help elucidate the possible
pathophysiological mechanisms of the inflammation.
The purpose of the study was to analyze the clinical and
histological differences between non-healthy capsules
(NHC) with late-onset inflammation around alloplastic
implants used in rhinoplasty and healthy capsules (HC)
without inflammation as controls to determine the possible
pathophysiological mechanisms of the inflammation.
Patients and Methods
This retrospective study protocol was approved by the
Institutional Review Board and performed in full accor-
dance with the principles of the Declaration of Helsinki.
Between April 2009 and May 2018, a total of 409
patients visited our center for rhinoplasty due to esthetic
dissatisfaction. Among the 409 patients, those who met the
following inclusion criteria were included in this study:
patients from other clinics who received alloplastic
implants for nasal dorsal augmentation, patients with his-
tological results of the capsules around the alloplastic
implants, and patients without missing data.
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Aesth Plast Surg
A total of 39 patients (aged 19–55 years, 28 females and
11 males) were included in this study. Twenty-one patients
in the NHC group showed late-onset inflammation. Eigh-
teen patients in the HC group did not show late-onset
inflammation, but they wanted revisional rhinoplasties due
to esthetic dissatisfaction. Late-onset inflammation was
defined as clinically symptomatic inflammation that
developed at least 6 months after the most recent rhino-
plasty using alloplastic implants. Patients with late-onset
inflammation included those with pain or redness on the
nose; patients with waxing and waning episodes of nasal
swelling; patients with fluctuation on the nasal dorsum or
septal area; patients with granuloma-like skin lesions on
the nose; or patients with punctures and fluid drainage.
The demographics of the patients in the two groups are
shown in Table 1. Patient photographs and histological
results were also recorded. A single surgeon performed all
surgeries. The mean follow-up duration after treatment was
14.8 ± 9.2 months.
Management of Late-Onset Inflammation
Patients with late-onset inflammation were empirically
administered antibiotics, and percutaneous drainage was
initiated. When late-onset inflammation did not recur fol-
lowing such drainage, no further surgical intervention was
performed. When late-onset inflammation recurred despite
drainage, the patient was taken to the operating room for
implant removal, capsulectomy, and histological study of
the capsules. All alloplastic implants were removed, and
the capsules around the implants were inspected. Total
capsulectomies were performed. When granuloma-like
skin lesions were present, curettage of the tissues was also
performed. The space where the implant resided was irri-
gated copiously with betadine solution, followed by
antibiotic-containing saline; then, a secondary septorhino-
plasty was performed in the same setting. Implants were
not used in the secondary septorhinoplasties. All capsules
were sent for histological examinations.
Histological Evaluation
For histological evaluation, three 1-cm2 capsule samples
were collected from the center of the capsules in the NHC
and HC groups. Therefore, 63 and 54 samples in the NHC
and HC groups, respectively, were evaluated histologically.
The samples were fixed in 4% formaldehyde, dehy-
drated, embedded in paraffin, cut into 4-lm-thick sections,
and processed for histological analysis. We used hema-
toxylin and eosin, Masson’s trichrome histochemical, col-
loidal iron histochemical, and CD31 immunohistochemical
stains to evaluate the differences in the collagen production
and arrangement, inflammatory reactions, granulation
Aesth Plast Surg

Table 1 Patient demographics

Characteristics Healthy capsule (N = 18) Non-healthy capsule (N = 21) P value

Age 34.5 ± 10.9 29.9 ± 9.5 0.088 

Sex (male:female) 4:14 7:14 0.442§
Implant type
Silicone 15 17 0.847§
Ò
Gore-Tex 3 4 0.520à
Years after implant insertion 8.1 ± 5.3 6.6 ± 7.2 0.494 
Symptoms
Tenderness 0 10 \ 0.001à
Swelling 0 9 \ 0.001à
Implant deviation 14 11 0.099§
Implant extrusion 0 2 0.179à
Granuloma-like skin lesion 0 6 0.021à
Puncture with fluid drainage 0 5 0.027à
Nasal trauma including nasal bone fracture 0 8 \ 0.001à
Diabetes mellitus 3 0 0.052à
Smoking 2 5 0.303à
Nasal obstruction (NOSE score [ 10) 8 9 0.921§
Follow-up, month 15.4 ± 9.7 14.3 ± 11.9 0.728 
NOSE nasal obstruction symptom evaluation
 
Mann–Whitney U test
à
Fisher’s exact test
§
Pearson’s Chi-square test

tissue, synovial metaplasia, mucin deposition, and
endothelium between the two groups. Four sections from
each sample were processed for staining, one for each of
the four staining methods used.
Hematoxylin and eosin staining was performed to
determine general microanatomical characteristics,
including the collagen layers, inflammatory reactions,
granulation tissues, and synovial metaplasia. Synovial
metaplasia was assigned when epithelial cells lining the
capsular tissue were arranged in a palisading manner,
overlying a fibrous capsule, with basally located nuclei and
cytoplasmic processes directed toward the surface.
Masson’s trichrome was performed to determine colla-
gen production. For Masson’s trichrome staining, the sec-
tions were incubated in warmed Bouin’s fluid (ScyTek
Laboratories, Logan, UT) at 60 °C for an hour. The sec-
tions were washed and immersed in Weigert iron hema-
toxylin (Sigma-Aldrich, Darmstadt, Germany) to
differentiate the nuclei. To stain the cytoplasm, the samples
were immersed in acid fuchsin solution (Sigma-Aldrich)
for 10 min. Then, the samples were treated with phos-
phomolybdic–phosphotungstric acid solution (Sigma-
Aldrich) for another 10 min as a mordant. Aniline blue
(Sigma-Aldrich) was used to stain the collagen. The
collagen was stained bright blue, and cytoplasm, muscle,
and erythrocytes were stained red by Masson’s trichrome
staining.
Colloidal iron histochemical staining was performed to
determine mucin deposition. For colloidal iron staining, the
sections were rehydrated via a graded ethanol series and
treatment with 12% acetic acid solution for a minute. The
sections were then covered with colloidal iron working
solution for an hour. Acidic mucins were stained blue, and
hyaluronic acid and proteoglycans were stained bright blue
by colloidal iron staining.
Endothelial cell dispersion in the vascularized areas in
the capsule was assessed by CD31 staining. A standard
streptavidin–biotin–peroxidase complex method was used.
The sections were rehydrated via a graded alcohol series
and treated with 3% hydrogen peroxide for 20 min to block
endogenous peroxidase. Antigen retrieval was then per-
formed for 20 min using 10 mM citrate buffer (pH 6). The
sections were incubated with a CD31 antibody (1:200,
clone JC70A, Dako, CA) in the Bond-III autostainer (Leica
Microsystems, Wetzlar, Germany). Endothelium was
defined as the simple squamous epithelium lining the
vessels and lymphatics.

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 Aesth Plast Surg

The staining intensities were recorded as follows: 0,

negative or minimal focal staining; ?, mild staining; ??,
moderate staining; and ???, marked staining. Positive
and negative controls were performed for each stain. His-
tological analyses were performed by two histologists
under a light microscope at 409, 1009, and 2009
magnifications.

Statistical Analyses

The data are presented as mean ± standard deviation.

Mann–Whitney U-tests were used to compare quantitative
variables between the two groups. Chi-square or Fisher’s
exact tests were used for categorical variables. P val-
ues \ 0.05 were considered statistically significant. All
statistical analyses were performed using SPSS for Win-
dows, version 12.0 (SPSS, Inc, Chicago, IL).

Results

Clinical Findings

In the NHC group, the average time from the patient’s last
implant insertion to late-onset inflammation was 6.6 years.
All patients in the NHC group were successfully treated
with implant removal, capsulectomy, and septorhinoplasty
using autogenous cartilage grafts. The capsules around the
implants were thick and strongly adhered to the sur-
rounding soft tissues of the nasal skin and cartilages. The
intercapsular spaces were glistening, and drainage showed
the presence of purulent or serous fluid (Figs. 1 and 2,
Video 1).
In the HC group, the average time from the patient’s last
implant insertion to late-onset inflammation was 8.1 years.
These patients did not show fluid-filled capsules around the
implants. Their capsules were mature and thin, without
evidence of inflammation. Capsular contracture around the
capsule was minimal, and excision of the capsules was
easier than in the NHC group (Table 2).
Histological Findings
The histological findings in the NHC and HC groups are
summarized in Table 3.
Hematoxylin and Eosin Staining
In the NHC group, all 63 samples from the 21 patients were
organized in three layers. The innermost layer, the contact
surface with the implant, was lined by a single row of cells.
Beyond this layer, in the intermediate layer, synovial
metaplasia was found. The outer layer was a loosely
Fig. 1 A patient with late-onset inflammation. A 28-year-old female
patient with a granuloma-like skin lesion on the left nasal sidewall
was referred from another clinic. She underwent augmentation
rhinoplasty using a silicone implant 8 years ago. During secondary
septorhinoplasty, a silicone implant was found and removed. The
lower lateral cartilages were mostly destroyed. The intercapsular
space was filled with purulent fluids, and the capsule was totally
excised. In the histological study, colloidal iron staining was
markedly positive and Masson’s trichrome staining showed collagen
degeneration. The CD31-staining cells comprising the innermost
layer were damaged. A microbiological study of the fluid was
negative, and the patient was successfully managed with fluid
drainage, silicone implant removal, capsulectomy, secondary sep-
torhinoplasty using autogenous cartilage grafts, and intravenous
antibiotics. a, b Preoperative views. c Intraoperative views. d, e Six
months after revisional septorhinoplasty
organized collagen layer with edematous granulation tis-
sues. Inflammatory cellular contents, evidenced by the
presence of macrophages and neutrophils, were also
increased. However, no evidence of anaplastic large cell

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Aesth Plast Surg
Fig. 2 A patient with late-onset inflammation. A 22-year-old female
patient was referred for intermittent swelling and a granuloma-like
lesion on her right nasal mucosa that began 2 months ago. The patient
underwent rhinoplasty using a silicone implant 2 years ago at another
clinic. During secondary rhinoplasty, the silicone implant was found
and removed. The capsule was filled with purulent fluid, and the
capsule was totally excised. For correction of the destroyed right
lower lateral cartilage and nasal tip, an alar batten graft and shield
graft using concha cartilage were performed. A dermo-fat graft from
the gluteal area was additionally performed for nasal dorsal
Table 2 Intraoperative findings
Characteristics
Intercapsular space
Serous fluid
Purulent fluid
Positive microorganisms in fluid culture
Staphylococcus aureus
Streptococcus epidermidis
Enterococcus aerogenes
lymphoma or T cell hyperplasia was observed in any
samples.
In the HC group, all 54 samples from the 18 patients
were organized in three layers. The innermost layer adja-
cent to an implant was lined by a single row of cells.
Beyond this layer, synovial metaplasia was found. The
outermost layer was a dense regular collagen layer without
any signs of foreign body reaction or inflammatory cell
augmentation. Histological studies were strongly positive for col-
loidal iron staining and Masson’s trichrome staining showed collagen
degeneration. In the innermost layer of the capsule, which was the
surface in contact with the implant, a damaged single stratified lining
of CD31-staining cells was observed. Microbiological culture of the
purulent fluid was identified as Staphylococcus aureus. She was
successfully managed with purulent fluid drainage, silicone implant
removal, capsulectomy, secondary septorhinoplasty using autogenous
cartilage grafts, and intravenous antibiotics. a Preoperative views. b,
c Intraoperative views. d Six months after revisional septorhinoplasty
Healthy capsule (N = 18) Non-healthy capsule (N = 21)
0 15
0 6
0 8
0 4
0 3
0 1
recruitment. All collagen layers were aligned relatively
parallel to the implant, compared to the NHC group.
Masson’s Trichrome Staining
In the NHC group, marked staining of organized collagen
was not present. However, marked staining of organized
collagen was present in most samples of the HC group.
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 Aesth Plast Surg

Table 3 Histological findings

Characteristics Healthy capsule (N = 54) Non-healthy capsule (N = 63) P value

H&E staining
Inflammatory reaction
??? 0 48 \ 0.001§
?? 6 12 0.236§
? 15 3 0.001§
0 33 0 \ 0.001§
Synovial metaplasia
??? 39 45 0.777§
?? 15 18 0.924§
? 0 0 –
0 0 0 –
Masson’s trichrome staining
Collagen production
??? 48 0 \ 0.001§
?? 6 0 0.007à
? 0 48 \ 0.001§
0 0 15 \ 0.001§
Colloidal iron staining
Mucin deposition
??? 0 51 \ 0.001§
?? 0 12 \ 0.001§
? 9 0 0.001à
0 45 0 \ 0.001§
CD31 Staining
Endothelial lining cell damage
??? 0 48 \ 0.001§
?? 0 15 \ 0.001§
? 12 0 \ 0.001§
0 42 0 \ 0.001§
H&E hematoxylin and eosin
à
Fisher’s exact test
§
Pearson’s Chi-square test

Histochemical Colloidal Iron Staining Discussion

Positive colloidal iron staining was identified in all samples
of the NHC group. In the HC group, marked colloidal iron
staining was not present.
Immunohistochemical CD31 Staining
In the NHC group, the innermost layer, which was the
surface in contact with the implant, consisted of a single
stratified lining of CD31-staining cells dispersed through-
out the capsule. However, the lining cells comprising the
layer were damaged. In the HC group, a single stratified
lining of CD31-staining cells was also found in the inner-
most layer of the capsules; however, these lining cells were
not damaged (Figs. 3 and 4).
Late-onset inflammation is a rare complication, but the
inflammation has not been observed in patients who
undergo rhinoplasty without alloplastic implants. Late-on-
set inflammation surrounding alloplastic implants in
rhinoplasty, an unpredictable complication, has attracted
increased interest. The rate of complications after aug-
mentation rhinoplasty with silicone implants has been
reported to vary greatly from 4 to 24% [4]. However, the
rate of late-onset inflammation after the use of silicone
implants in rhinoplasty has not been reported yet. The rate
in primary surgery that resulted in late-onset inflammation
after the use of Gore-TexÒ was 1.3%, whereas it ranged
from 4.3 to 5.4% following secondary surgery [5].

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Aesth Plast Surg

Fig. 3 Histology of a healthy

capsule. a Hematoxylin and
eosin staining, b Masson’s
trichrome staining, c colloidal
iron histochemical staining,
d CD31 immunohistochemical
staining of a healthy capsule at
200X magnification

Fig. 4 Histology of a non-

healthy capsule. a Hematoxylin
and eosin staining, b Masson’s
trichrome staining, c colloidal
iron histochemical staining,
d CD31 immunohistochemical
staining of a non-healthy
capsule at 200X magnification

In this study, histological findings in the NHC group
showed more inflammatory cells, granulation tissues, dis-
organized collagen, damaged endothelial lining cells, and
mucin deposition compared to the HC group.
Specifically, this study demonstrated that an innermost
layer consisting of endothelial lining cells was present in
both the NHC and HC groups. However, the lining cells
were damaged in the NHC group and intact in the HC
group. Damaged endothelial lining cells may play a major
role in late-onset inflammation. Ingrowth of synovium-like
mucosa or de novo proliferation of granulation tissues and
inflammatory cells was found in the outer layer of the
capsules. Inflammatory cells may secrete many angiogenic
factors, possibly increasing the angiogenic and neovascular
response, resulting in microvessel formation. In severe
inflammation, a dense and thick connective tissue layer
may form around the capsule by the aggregation of
monocytes and fibroblasts. Macrophages may also play a
key role to stimulate fibroblasts in the formation of gran-
ulation tissue and fibrosis, resulting in nasal foreshortening
[6].
The synovium may secrete a thin film of fluid between
the opposing surfaces that provides lubrication and serves
as a vehicle for the transport of oxygen, glucose, and other

123

micronutrients from the bloodstream to tissues [7].
Although the function of synovial metaplasia at the lining
the peri-implant area is unknown, maintenance of a syn-
ovial sheath for gliding and lubrication between tissues and
the implant interface with the capsules may be related to
synovial metaplasia. In addition, synovial metaplasia may
play a protective role in alloplastic implants. However,
when the endothelial lining cells are damaged by any
cause, continuous contact with the implant, combined with
synovial metaplasia, may activate a secondary pathway
leading to late-onset inflammation. The clinical relevance
of this dynamic relationship resides in the increased risk of
late-onset inflammation [8].
Histochemical staining for colloidal iron is expressed in
mucin and sulfated mucopolysaccharides [9]. In this study,
mucin deposition was found to be increased after colloidal
iron staining in the NHC group. Viscous or serous fluids
filling the intercapsular spaces might consist of
mucopolysaccharides.
Recently, histological studies have demonstrated that
silicone implants were associated with synovial meta-
plasia following breast implant surgery, possibly due to a
connection between textured silicone implants and
anaplastic large cell lymphoma, as these tumors often
present as late-onset inflammation with seromas [10–12].
Therefore, we hypothesized that capsular histology of
nose implants may have similar histology as breast
implants, particularly silicone implants. However,
anaplastic large cell lymphoma was not found in any
specimen in either group in this study.
The mechanisms leading to late-onset inflammation are
still unclear, and the cause seems to be largely multifac-
torial. Macro- and/or micromovements of the implant and
shear stress between the capsule and the implant may
create separation with subsequent new capsular formation
around the alloplastic implant and fluid accumulation
[8, 13]. Capsular fracture and the new capsular formation
into the fracture may cause late-onset inflammation. Eight
out of 21 patients in the NHC group experienced nasal
trauma in this study. Although it is difficult to determine
the cause of the inflammation, the late-onset inflammation
response itself may contribute to the development of tissue
destruction through the continuous recruitment of proin-
flammatory cells such as macrophages and lymphocytes,
and release of inflammatory mediators, and proteases [14].
Fluid composed of mucopolysaccharides could potentiate
late-onset inflammation.
Late-onset inflammation and delayed infection should
be distinguished. Clinical manifestations in the NHC group
were different from surgical site infections. Cellulitis and/
or pus drainage is often seen in patients with surgical site
infections. However, most patients in the NHC group did
not show cellulitis in this study. Furthermore, serous and
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Aesth Plast Surg
purulent fluids in the intercapsular space of the NHCs were
found in 15 (71%) and six (29%) of 21 patients, respec-
tively. Microorganisms were not isolated from 13 of 21
patients (62%) in the NHC group. Among eight patients
who showed positive culture results, six patients showed
granuloma-like skin lesions on the nose and these
microorganisms might infiltrate the skin lesions.
Based on the results of the study, we suggest that the
removal of alloplastic implants, including NHCs, may help
resolve late-onset inflammation. In particular, alloplastic
implants in patients with granuloma-like skin lesions
should be removed immediately to reduce infection. In
contrast, in the HC group, mature and thin capsules can be
used in revisional rhinoplasties.
Some limitations of our study need to be addressed.
Ideally, the entire capsule should be visualized histologi-
cally to determine if delamination and capsular fractures
occurred during the surgery. Further studies with additional
biomarkers and larger groups of patients may reveal more
information about the histology of capsules around nasal
alloplastic implants. However, due to the relatively low
prevalence of late-onset inflammation and ethical consid-
erations, a methodological design investigating capsular
histological study in long-term definitive implants cannot
be performed. Although our results are not comprehensive
enough to identify the exact pathophysiological mecha-
nisms of late-onset inflammation, we believe that differ-
ences in the histological findings between the NHC and the
HC groups may support the hypothesis that capsular frac-
ture following mechanical dynamics may be associated
with late-onset inflammation. Despite these aforemen-
tioned limitations, this study might be the first to analyze
the NHCs and HCs around alloplastic implants in rhino-
plasty histologically, which provided valuable knowledge
for further research in this domain.
Conclusion
The NHC group with late-onset inflammation after the use
of alloplastic implants in rhinoplasty showed more
inflammatory cells, granulation tissues, disorganized col-
lagen, damaged endothelial lining cells, and mucin depo-
sition than the HC group. Therefore, we conclude that
damaged capsules and ingrowth of synovium-like mucosa
or de novo proliferation of granulation tissues and
inflammatory cells may play a crucial role in late-onset
inflammation related to alloplastic implants. Despite late
presentation, over years after the rhinoplasty, patients
should be informed of late-onset inflammation before
rhinoplasty using alloplastic implants. Furthermore, when
late-onset inflammation occurs, patient explanations can be
based on this study.
Aesth Plast Surg
Compliance with Ethical Standards
Conflict of interest None of the authors have any conflict of interest
to disclose.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all indi-
vidual participants included in this study.
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