In 2018, the global minimally invasive surgery market was worth $36.5 billion. According to a report by Research and Markets, global demand for minimally invasive surgery is expected to expand over the next few years—by 2024, the market will likely be worth $58.2 billion.
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June 2020The trend toward minimally invasive surgery, of course, extends across all healthcare disciplines and is driven by the desire to provide convenient, high-quality, cost-effective care. Why pay for a lengthy hospital stay if the same outcome can be achieved via outpatient surgery or an in-office procedure? The risk of blood loss and infection can also be decreased by choosing a minimally invasive option, and patients can typically resume their usual activities sooner after minimally invasive surgery than traditional open surgery.
Patients and physicians have two choices for minimally invasive rhinoplasty: injectable dermal fillers, which can be used to reshape the nose (sometimes called “liquid rhinoplasty”; see “Liquid Rhinoplasty: How to Make Patients Aware of the Risks” in the April 2020 issue of ENTtoday), and Latera, a dissolvable nasal implant that can be used to support the upper and lower lateral nasal cartilages to prevent and treat nasal valve constriction or collapse.
“Latera and liquid rhinoplasty are comparable in the sense that they can both be done in a less invasive way than traditional rhinoplasty, potentially under local rather than general anesthesia,” said Iyad Saidi, MD, PhD, inventor of Latera and an otolaryngologist in private practice in Franconia, Va. (Dr. Saidi is the co-founder of Spirox, the company that developed Latera, and retains an interest in sales of the device.)
However, Latera and liquid rhinoplasty treat completely different issues: Latera is intended to correct a structural, functional issue; liquid rhinoplasty addresses cosmetic concerns. Yet, these two minimally invasive options have one more similarity: Both are probably best for only a small subset of patients who need or desire rhinoplasty.
“My belief is that Latera has a small but legitimate place in functional rhinoplasty and, quite frankly, the same with filler rhinoplasty,” said Stephen S. Park, MD, chair of the department of otolaryngology–head & neck surgery, and director of the division of facial plastic and reconstructive surgery at the University of Virginia School of Medicine in Charlottesville. “For a very small subset of patients, filler rhinoplasty may be a good option, particularly when performed by surgeons who understand the vascular anatomy of the nose. Similarly, for Latera, there are some very specific patients for whom it makes sense; it can be a reasonable option when inserted by surgeons who understand the pathophysiology of nasal obstruction, the precise anatomic etiology, and where to place the device.”
My belief is that Latera has a small but legitimate place in functional rhinoplasty and, quite frankly, the same with filler rhinoplasty. —Stephen S. Park, MD
Latera: A Tool for Functional Rhinoplasty
“Performing rhinoplasties, I quickly learned that it’s a technically difficult procedure that usually requires quite a bit of tissue dissection. I started wondering about how to improve the structure of the nose with less disruption of the nasal tissue,” Dr. Saidi said, explaining the genesis of Latera, which was approved by the FDA in 2016.
While most functional rhinoplasties involve the use of cartilage or polymer grafts to reshape the interior structure of the nose, Latera is a tiny absorbable PLLA polymer implant that has a ball tip on one end and a forked tip on the other. The implant can be placed inside the lateral wall of the nose to support the upper and lower lateral cartilage. The implant gradually dissolves and is absorbed by the body over approximately 24 months. During that time, fibrous scar tissue forms in the area.
“It’s conjectured that the scar tissue may provide longer-lasting structural support after the Latera material has dissolved,” Dr. Saidi said. “We’ve followed patients up to three years after insertion, and most people continue to report benefits even past the point where we’d expect that actual implant to have dissolved.”
LATERA vs. Liquid Rhinoplasty
| LATERA | Liquid Rhinoplasty | |
|---|---|---|
| Description | Dissolvable nasal implant designed to treat nasal valve collapse | The injection of dermal fillers to reshape the nose |
| Availability | Released & received FDA clearance in 2016 | Available for >15 years |
| Use | For functional rhinoplasty | For cosmetic rhinoplasty |
| Results | Implant dissolves in about 24 months; effect lasts for years | Results last for about a year; procedure can be repeated |
| Risks | Risks include mild bruising, inflammation, and pain | Risks include blindness, skin necrosis, and infection |
A two-year follow-up study published in Facial Plastic Surgery reported the outcomes of 30 patients who underwent Latera implantation—14 in an operating room under general anesthesia and 16 under local anesthesia in a clinic setting. A total of 56 implants were placed across the 30 patients. Patients noted significant quality-of-life improvement, including reduced nasal congestion, less trouble breathing through the nose, and less difficulty sleeping, as measured by the Nasal Obstruction Symptom Evaluation (NOSE) survey. A 57.7% reduction in nasal obstruction symptoms was noted two years post-procedure (Facial Plast Surg. 2017;32:233-240).
“Latera is a nice procedure for a directed problem, meaning nasal valve collapse,” said Krista Olson, MD, associate professor of otolaryngology and director of the Baylor Facial Plastic and Reconstructive Surgery Center in Houston. “It won’t do anything for a septal deviation or turbinate hypertrophy, but as an isolated procedure, I do consider it a useful tool in my armamentarium.”
Some physicians use Latera alongside other procedures. “When used in combination with septoplasty and turbinate work, Latera can stabilize the lateral wall,” said Dean M. Toriumi, MD, an otolaryngologist in private practice in Chicago.
However, because multiple factors can contribute to nasal obstruction, surgical rhinoplasty may still be the best option for many patients, including those who have experienced nasal trauma or previously undergone septoplasty or rhinoplasty. Even patients who have nasal valve collapse may not be ideal candidates for treatment with Latera.
“It really depends on what area of the nasal valve is affected,” Dr. Olson said. “If I need to address upper lateral cartilage collapse, my preference is to do that with cartilage grafts.”
On the flip side, Latera can be a good option for appropriately selected patients who would prefer to avoid surgery. “If a patient is particularly elderly, or unsafe to go to the operating room, an office-based procedure such as this may be a viable option,” Dr. Park said.
Side effects of Latera appear to be minimal. Dr. Olson said that some patients report being able to feel the implant through the skin; some complain that it makes wearing glasses uncomfortable. “Usually, that’s a short-lived phenomenon,” she said, “but I’ve had to remove a few of them, usually from older patients with thin skin.”
Can Latera Improve Appearance?
Physicians have been using injectable dermal fillers to tweak the shape of the nose for more than 15 years. However, practicing physicians have noticed an uptick in demand, which they attribute to social media posts that suggest fillers as an easy, low-cost way to improve appearance.
Latera is a nice procedure for a directed problem, meaning nasal valve collapse. It won’t do anything for a septal deviation or turbinate hypertrophy, but as an isolated procedure, I do consider it a useful tool in my armamentarium. —Krista Olson, MD
The reality, of course, is that injecting fillers into the nose is a relatively high-risk procedure, as side effects can include blindness and skin necrosis. “What we call ‘filler rhinoplasty’ or ‘non-invasive rhinoplasty’ may have a little role within the world of rhinoplasty, but it has a huge, potentially catastrophic downside,” Dr. Park said. Additionally, fillers dissolve in about a year, so any cosmetic improvement is limited.
For most patients who desire a new-and-improved nose, surgical rhinoplasty remains the best option. But can Latera also improve appearance?
As part of the two-year follow-up study of Latera insertions, independent physicians reviewed before and after photos of patients to assess for cosmetic changes. Initially, no negative cosmetic changes were noted by either the physician reviewers or patients. At 18 months post-procedure, independent physician reviewers noted “significant cosmetic improvement” in five subjects. At 24 months, one subject had experienced noticeable adverse cosmetic changes and one subject had significant cosmetic improvement (Facial Plast Surg. 2017;32:233-240).
Some, including Latera inventor Dr. Saidi, think the device may be a useful tool to enhance appearance. “We know that cosmetic changes of the noses can be best achieved by appropriately building and correcting the structural elements of the nose,” he said. “If a house has a leaning porch, breaking down one side just so it’s symmetric is not as good as fixing the side that’s weak.”
Other physicians are skeptical of Latera’s utility for cosmetic change. “I would not expect that it would have a significant impact on the appearance of the nose,” Dr. Olson said. “Certainly, it isn’t going to replicate the changes we see with cartilage grafting.”
Dr. Toriumi agreed, noting the fact that, overall, Latera typically doesn’t impact a patient’s appearance either positively or negatively. “For significant, long-lasting cosmetic change, a surgical rhinoplasty is still the best option,” Dr. Toriumi said.
Appropriate selection of patients and expert delivery and positioning of Latera or dermal fillers are key to the successful use of these products for minimally invasive rhinoplasty.
Jennifer Fink is a freelance medical writer based in Wisconsin.