Post-Traumatic Nasal Pyramid Reconstruction with a Custom-Made Titanium Implant: First Case Report with Ultrastructural Evaluation

1. Introduction

1.1. Nasal Fracture Reconstruction

Nasal bone fractures are the most common facial skeletal injury, accounting for a significant proportion of trauma-related presentations and affecting both functional and aesthetic outcomes [1,2,3]. Epidemiological data indicate a bimodal age distribution, with the highest incidence predominantly in adolescents and young adults [3,4]. The clinical spectrum of nasal fractures is broad, encompassing simple non-displaced fractures to complex comminuted injuries with septal involvement, each presenting unique diagnostic and therapeutic challenges [2,5,6,7]. Traditional management has centered on closed reduction within two weeks of injury occurrence, which is cost-effective and generally yields satisfactory early results for simple fractures [1,5,6,8]. However, this technique is linked with a substantial rate of secondary deformity, particularly in cases with significant disruption or unfavorable fracture patterns, often necessitating subsequent open interventions [7,8,9]. Open reduction and structural reconstruction are preferred in delayed presentations or when rigid fixation and precise anatomical restoration are required, especially for severe bony deviations, L-strut deformities, and nasal valve compromise [5,8,9,12]. Contemporary systematic reviews and practice management guidelines have sought to standardize the acute and delayed management of these injuries and to reduce the incidence of residual deformity [10].

1.2. Personalized Medicine and Advances in the Current Era

Recent advances in personalized medicine and surgical technology have driven the development of custom-made titanium-based implants for structural craniofacial and nasal reconstruction [13,14,15]. Customized titanium-based implants provide the potential for enhanced stability, biocompatibility, and tailored anatomical corrections in complex or revision cases where conventional methods are not suitable [13,16]. The integration of imaging modalities, computer-assisted design, and additive manufacturing enables precise customization that addresses both functional and cosmetic deficits while minimizing the risk of recurrent deformity and airway obstruction [14,15]. Titanium is one of the most extensively studied biomaterials, with a long record of osseointegration and favorable soft-tissue response across dental, orthopedic, and craniofacial applications [17,18]. As the literature increasingly emphasizes individualized, technology-assisted approaches, custom titanium implants represent a promising frontier in the management of challenging nasal bone fractures and post-traumatic nasal pyramid defects.

2. Case Presentation

2.1. Patient Description

A 50-year-old male patient, military personnel with a history of comminuted nasal bone fractures at an early age, was referred to our clinic at the 424 General Military Hospital, Thessaloniki, Greece, due to nasal obstruction and significant post-traumatic nasal deformity. The patient had undergone prior failed nasal reconstructions in other institutions, utilizing autologous cartilage and bone graft techniques, which unfortunately led to melting and collapse of the nasal bridge, cartilaginous septum, and lateral cartilages.

A detailed clinical and three-dimensional (3D) CT evaluation was performed to assess breathing ability and residual nasal anatomy. Nasal obstruction was mainly due to internal nasal valve collapse [12]. Under-reduction of the nasal dorsal hump had led to significant saddle-nose deformity and nasal tip ptosis due to inadequate structural support [11]. The bony nasal septum and piriform apertures were intact. Furthermore, with the patient declining any further bone and cartilage harvests, reconstructive alternatives were very limited.

We proposed to the patient an innovative solution integrating computer-aided design and a three-dimensional custom-made titanium nasal prosthesis to reconstruct the nasal shape for functional and cosmetic purposes. A reliable reconstruction with a satisfying result was obtained, and the patient resumed his professional activities. No additional surgical procedures were required 24 months post-operatively.

2.2. Surgical Planning

Taking into consideration the patient’s surgical history, nasal reconstruction with an IPS (Individual Patient Solutions) titanium-based implant was proposed. Advantages, disadvantages, and possible complications were carefully explained. The patient underwent cone-beam computed tomography (CT) and plain radiographs so that the amount of available bone and cartilage and the appropriate location for the implant could be evaluated. All digital data were transferred to a DICOM (Digital Imaging and Communications in Medicine) file, which was then imported into the IPS Case Designer software (KLS Martin Manufacturing LLC, Florida, USA). With the help of 3D virtual surgical planning [14,15], a functionalized patient-specific implant was designed, meeting hard- and soft-tissue anatomical requirements. The material of choice for the implant was titanium, a highly biocompatible material [17,18] that had not previously been reported for use in nasal pyramid reconstruction. Titanium screw measurements were 1.2 mm in diameter and 7 mm in length.

2.3. Operative Setting

The procedure was performed at the 424 General Military Hospital of Thessaloniki, Greece. Following induction of general anesthesia and endotracheal intubation, an open rhinoplasty was carried out.

2.4. Surgical Approach

A mid-columellar inverted-V incision was made, which was then transitioned to marginal incisions with the help of skin hooks and sharp dissection (Figure 1). The full-thickness mucocutaneous flap was reflected superiorly to expose the bony and cartilaginous remains. The dome and dorsal part of the lower lateral cartilages, the dorsal part of the septal cartilage, and the upper lateral and sesamoid cartilages were missing.

2.5. Implant Placement

A periosteal elevator was used to dissect the periosteum over the nasal bones up to the nasofrontal angle. After preparation of the implant hole, the implant was placed in the midline, over the nasal bones, covering the distance between the nasion and the tip, forming an artificial nasal dorsum. Small incisions were made at the level of the inner canthus of the eyes bilaterally to ensure correct implant placement. Cortical screws of 1.5 mm × 5 mm were used to stabilize the implant on the frontal and residual nasal bones (Figure 2). To achieve adequate support of the tip, a thin titanium plate was used, anchored between the caudal free edge of the implant and the anterior caudal surface of the vomer bone (Figure 3). A symmetrical small wedge-shaped part of the lower lateral crura was excised bilaterally to create the desired nostril size and base width. Stabilization sutures were placed between the lower lateral cartilages to bring them together and contour the nasal tip. At the end, the mucocutaneous flap was repositioned, and the trans columellar and marginal incisions were closed with interrupted permanent (5-0 nylon) sutures. Adhesive steri-strips were applied horizontally from the nasofrontal angle to the supratip and a larger strip around the infratip lobule, to avoid postoperative edema and support the tip, respectively. A custom-made nasal splint was applied for postoperative stabilization. Finally, sterile petrolatum gauzes were packed in the nasal cavity. A CT scan was obtained postoperatively to ensure the proper position of the nasal implant (Figure 4 and Figure 5).

2.6. Postoperative Recovery

Total hospitalization lasted seven days. Gauzes were removed after five days, while the splint and skin sutures were removed after ten days. As soon as the nasal packing was removed, the patient reported recession of upper airway breathing difficulties and return of normal nasal breathing. Regarding the postoperative cosmetic outcome, the nasal structure was restored without post-traumatic signs, which provided appropriate rehabilitation to improve the patient’s quality of life. At the 6-month follow-up evaluation, during which the patient exhibited no complaints, he was satisfied with the final result.

2.7. Tissue Sampling for Ultrastructural Analysis

Biopsy specimens were collected from the nasal mucosa and connective tissue adjacent to the implant site two years (24 months) after placement of the titanium implant. The tissue sample preparation is further explained in section 3.1.

3. Materials and Methods

3.1. Tissue Sample Collection and Preparation for Transmission Electron Microscopy (TEM)

For the tissue sampling the following procedure was performed:

• The samples were immediately immersed in 2.5% glutaraldehyde in 0.1 M phosphate buffer (pH 7.4) at 4 °C for primary fixation.
• Following rinsing in phosphate buffer, tissues were post-fixed in 1% osmium tetroxide for 1 h to preserve membrane integrity and enhance contrast.
• The specimens were then dehydrated via a graded ethanol series (30%, 50%, 70%, 90%, and 100%) and cleared in propylene oxide.
• For embedding, the samples were infiltrated and embedded in epoxy resin (Epon/Araldite mixture), which was polymerized at 60 °C for 48 h.
• Ultrathin sections (70–90 nm) were cut using an ultramicrotome equipped with a diamond knife and mounted on copper grids. Sections were stained with uranyl acetate and lead citrate to enhance visualization of subcellular structures.
• The prepared grids were examined by TEM operating at 80 to 120 kV.
• Images were captured digitally at varying magnifications to evaluate cellular and subcellular morphology, including nuclei, mitochondria, microvilli, vacuoles, and connective tissue organization.
• Scale bars were included in all micrographs to provide dimensional references.

4. Results

4.1. Ultrastructural Findings

Transmission electron microscopy of the nasal mucosa and underlying connective tissue adjacent to the IPS custom-made titanium implant demonstrated predominantly preserved tissue architecture with focal adaptive and stress-related changes across all examined fields (Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11). In high-magnification views, the lamina propria and intercellular substance appeared thickened, yet the respiratory epithelium maintained an orderly stratification with intact basal and ciliated cells, indicating structural integrity despite local remodeling. Epithelial cells contained numerous secondary lysosomes and phagosomes, reflecting active intracellular processing of extracellular material and suggesting ongoing metabolic adaptation at the peri-implant interface rather than overt cytotoxic damage (Figure 6 and Figure 9).

Vascular structures in the vicinity of the implant showed ultrastructural features compatible with remodeling. Sections of small vessels exhibited pronounced thickening of the internal and external elastic laminae, together with expansion of intercellular spaces within the vessel wall, implying altered mechanical load and increased permeability during the healing phase (Figure 7). These changes were not accompanied by endothelial necrosis or fibrinoid degeneration, supporting a controlled adaptive response rather than vasculitic damage. At the implant–tissue interface, discrete titanium particles were observed embedded within an organized extracellular matrix, with collagen fibers and ground substance closely opposed to the implant surface [19,20]. Notably, there was no evidence of granulomatous foreign-body reaction, dense inflammatory infiltrate, or fibrotic encapsulation, pointing to a stable and biocompatible contact zone (Figure 8).

Several fields demonstrated completely preserved lamina propria without pathological lesions, and epithelial cells showed normal nuclei, mitochondria, and cell membranes, consistent with sustained cellular viability. In contrast, localized areas displayed features compatible with transient stress: apical ciliary damage or loss in ciliated columnar cells, cytoplasmic vacuolization, and intercellular oedema, most pronounced at the level of the basal lamina (Figure 9 and Figure 10). These alterations were focal, did not extend throughout the mucosa, and were not associated with widespread apoptosis or necrosis, suggesting reversible injury related to surgical manipulation or early mechanical loading rather than chronic implant toxicity. Overall, the ultrastructural profile across all images supports a predominantly non-inflammatory, well-tolerated interface between the custom titanium implant and adjacent nasal tissues (Figure 10 and Figure 11).

5. Discussion

Post-traumatic nasal reconstruction presents unique challenges, especially in cases with prior failed grafts and compromised soft-tissue integrity [9,11]. In this first reported case of nasal pyramid reconstruction using a custom-made titanium implant, we observed not only favorable clinical outcomes but also compelling ultrastructural evidence of implant biocompatibility and tissue adaptation.

The expanded ultrastructural assessment of the nasal mucosa and peri-implant connective tissue reinforces the clinical impression that the IPS custom-made titanium implant achieves a stable and biocompatible integration in the nasal pyramid. The coexistence of preserved epithelial and stromal architecture, normal organellar morphology, and organized extracellular matrix deposition around titanium particles is in line with the expected behavior of titanium in craniofacial and nasal applications, where it is known to support long-term tissue compatibility without provoking chronic inflammation [13,17,18,21]. The predominance of secondary lysosomes, scattered vacuoles, and limited connective tissue distortion is more suggestive of physiological turnover and adaptive remodeling than of destructive degeneration, particularly in a setting of complex post-traumatic reconstruction and prior failed grafts.

The vascular changes observed-elastic lamina thickening and increased intercellular spacing-can be interpreted as manifestations of vascular remodeling in response to modified mechanical and hemodynamic conditions created by the implant and reconstructed nasal framework. Importantly, these alterations occurred without ultrastructural hallmarks of vasculitis or thrombosis, which supports their adaptive rather than pathological nature. Similarly, focal ciliary damage, microvilli attenuation, and intercellular edema at the epithelial–stromal interface likely reflect transient insult due to surgical elevation of mucosal flaps, periosteal dissection, and early implant loading—phenomena also described in other titanium implant settings where long-term mucosal and osseous integrity is ultimately preserved [18,19].

The absence of necrosis, extensive apoptosis, granulomatous foreign-body reaction, or dense lymphohistiocytic infiltrates across all examined images is particularly reassuring, as these findings would typically be expected in cases of titanium intolerance, surface contamination, or implant-related infection [20]. Coupled with the patient’s complete functional recovery, lack of infectious or inflammatory complications, and stability of the reconstruction at 24-month follow-up, the ultrastructural data strongly support the concept of a harmonious tissue–implant interface in this novel indication. From a reconstructive standpoint, this case suggests that custom-made titanium implants can provide durable structural support and mucosal compatibility in patients with severe post-traumatic deformity, limited autologous graft reserves, or multiple prior failures [13,16,21]. Future investigations with larger series and integration of ultrastructural analysis, immunohistochemistry, and molecular markers of inflammation and remodeling will be essential to define long-term safety, optimize implant design, and refine patient selection criteria for personalized nasal pyramid reconstruction using titanium implants.

This case not only expands the reconstructive options for patients with limited autologous graft availability but also sets a precedent for integrating advanced imaging modalities into postoperative evaluation. Subsequent research could be enhanced by connecting ultrastructural observations with molecular indicators of tissue integration and stress response, thereby further refining the criteria for implant selection and design.

6. Conclusions

In conclusion, the findings of this report indicate that a custom-made titanium implant provides a successful nasal pyramid reconstruction in a patient with severe post-traumatic deformity and failed prior grafts. Clinical outcomes and ultrastructural evaluation confirmed biocompatibility, stability, and long-term safety. Titanium implants may represent a novel solution for challenging nasal reconstructions, expanding the reconstructive armamentarium.