Asian Rhinoplasty

Yong Ju Jang

INTRODUCTION

Augmentation rhinoplasty is the most commonly performed rhinoplasty in Asian countries. In addition to augmentation rhinoplasty, corrective rhinoplasty for nasal deviation and saddle, hump, and short nose deformities are also frequently conducted. In the field of Asian rhinoplasty, the main esthetic goal is to increase the size and definition of the nose. However, the unique anatomical features of the Asian nose should be seriously considered in the context of Asian rhinoplasty. Compared to a typical Caucasian nose, the typical East Asian nose tends to have thicker skin and more abundant subcutaneous soft tissue. The tip of the Asian nose is usually lower, and the lower lateral cartilages are small and weak. The nasal bones are poorly developed and thick and manifest as a low dorsum and radix. The septal cartilage is also thin and small. Therefore, the size and quantity of harvestable septal cartilage may not be adequate for complete rhinoplasty, increasing the need for harvesting grafts from other sites. The shape of the nasal tip is usually altered by tip grafting using autologous cartilage. Augmentation or camouflage of the nasal dorsum is performed using various alloplastic or biologic implant materials. Reinforcement of the septal cartilage framework is another important concept in Asian rhinoplasty used to achieve good long-term surgical outcomes.

HISTORY

When evaluating nasal obstruction, diagnostic methods such as a thorough medical history in terms of nose-related illnesses, endoscopic examination of the nasal cavity, objective airway testing, and radiologic imaging are indispensable tools for making comprehensive judgments about the cause of the ailment. For successful rhinoplasty, in addition to the above, it is critically important to also thoroughly examine the patient’s personality traits. It is also extremely important to recognize in advance those patients who are more likely to experience postoperative dissatisfaction. During the preoperative consultation, the surgeon must determine whether the patient has a rational and acceptable motivation to undergo the surgery. In addition, by paying attention to minute details, the surgeon must determine whether the patient is overly anxious. It is also important to obtain information about the preexisting medical illness and history of smoking, drug abuse, or whether they are taking anticoagulants or herbal products.

PHYSICAL EXAMINATION

During the initial consultation, the shape and function of the patient’s nose should be carefully examined. The overall shape of the nose, height of the nasal tip and dorsum, and thickness of the skin-soft tissue envelope should be carefully examined. Both inspection and palpation play important roles in assessing the anatomical characteristics of the nose. The nasal function and shape are closely related; therefore, a proper evaluation of nasal breathing is also important.

INDICATIONS

There are no absolute indications for cosmetic rhinoplasty. Any patient with a desire to change the shape of his/her nose can undergo rhinoplasty. However, individuals with an underprojected nasal bridge are more prone to seek rhinoplasty compared to those with a well-developed nose. A patient with a poorly defined and projected nasal tip, a consequence of underdeveloped alar cartilage combined with thick skin, is also more likely to seek rhinoplasty. Individuals with conditions such as a convex nasal dorsum, a deviated nose, a traumatic deformity, and saddle and short noses are also good candidates for rhinoplasty. However, one prerequisite for surgery is that the patient’s cosmetic problem should be recognizable to others and surgically correctable.

The following are also important factors when considering rhinoplasty:

The patient’s cosmetic issue must be within the scope of the surgeon’s technical skill set.
Consensus regarding the anticipated results must be reached between the patient and the surgeon.
The patient must be physically and psychologically fit to undergo the surgery.
The accompanying risks of surgery must be acceptable to both the patient and the surgeon.

CONTRAINDICATIONS

Patients who are suffering from serious medical illnesses should not undergo rhinoplasty surgery. The patient’s psychological fitness is a very important factor in the decision against rhinoplasty. Individuals with the following characteristics are not satisfactory candidates to undergo rhinoplasty:

Unrealistic expectations of the surgery
Lack of a clear understanding of the cosmetic problem
A vague motivation for undergoing the surgery
Displays of unreliable and exaggerated attitudes
Communication difficulties
Body dysmorphic disorder
Major psychosis, such as manic-depressive illness or schizophrenia
Excessive dissatisfaction with a prior rhinoplasty result

PREOPERATIVE PLANNING

Photo documentation of the patient’s face is a critical and necessary process. During preoperative planning, the surgeon and patient should discuss the desired shape of the nose and the preferred implant or graft material. Through computer simulations, the preferred shape of the patient’s external nose can be accurately determined prior to rhinoplasty; notably, this type of patient participation during the planning stage of rhinoplasty may enhance communication between the patient and the surgeon. Computer simulations also help patients who are considering rhinoplasty to gain a more realistic expectation of the surgery and to relieve anxiety. Regarding dorsal augmentation, it is important to know what type of implant or material the patient prefers. The surgeon should explain the merits and demerits of all available dorsal implantation materials and allow the patient to express his/her preference. When the surgeon anticipates the need for ear or rib cartilage harvesting, the additional morbidity and complications associated with cartilage harvesting should be explained to the patient.

SURGICAL TECHNIQUE

Nasal Tip Surgery

In my experience, the tip suture technique is not particularly useful in Asian patients, particularly those with thick nasal skin and weak alar cartilages. Instead, the tip grafting technique results in better refinement and projection in Asian patients. Septal cartilage is the preferred graft material; however, if this is insufficient, conchal or costal cartilage may also be used. In patients with extremely thick skin, costal cartilage is a useful tip grafting material.

Shield Graft

The shield graft is one of the most commonly used maneuvers for enhancing tip projection and definition in Asian patients. While carving the graft, beveling of the periphery of the graft should be performed using a knife, or the cartilage should be crushed so that the graft margin does not become visible through the skin. This procedure is particularly necessary among those with thin skin. The graft must be shaped like a shield or a ginkgo leaf, and the top part must be broad so that both ends of the top side can indicate tip-defining points. However, performing this technique may make the columellar-lobular angle blunt and infratip lobule unnaturally long, and increase the risk of excessive rotation of the tip. The leading edge of this shield graft must be slightly higher
than the height of the existing dome of the tip. Usually, this technique effectively lengthens the infratip lobular segment and thereby enhances tip projection. Sometimes, the shield graft can be easily bent cephalically after skin closure, resulting in an undesired esthetic effect. To solve this problem and maintain an appropriate projection, a buttress graft should be placed immediately behind the shield graft.

Multilayer Cartilaginous Tip Grafting

Because of the diverse anatomical features of alar cartilage contours, the placement of a single shield graft is often insufficient and does not result in the desired projection and definition. To overcome the limitations of conventional tip grafting, I use multilayer tip grafting in patients with thick skin, a bulbous tip, and an underprojected shape of the tip (Fig. 25.1). Septal, conchal, tragal, and/or costal cartilage is harvested
depending on the amount of cartilage required and the quality and amount of nasal septal cartilage available in the patient. Where necessary, caudal extension of the septum, columellar strut placement, dome suturing, and/or trimming of skin-soft tissue envelope is performed prior to the multilayer tip grafting. Following these procedures, the first cartilaginous shield graft layer is placed on the dome and secured with 5-0 PDS suture. Additional shield graft layers are then placed on top of the first layer. The more caudal layer is placed so that its leading (superior) edge is always higher than the height of the existing dome and the layer(s) beneath it. The numbers of graft layers applied depends on how much projection is required and is determined intraoperatively. The horizontal width of the shield graft is adjusted according to the thickness of the tip. For thin skin, the horizontal width should be wider to provide better tip definition. For thick skin, a narrower width provided better results. Meticulous smoothing of graft margins with gentle carving is important to provide a smooth tip. Similar to shield grafts, a buttress graft is required in many cases. This technique is fairly versatile and can easily adjust the tip projection vector, which is particularly useful for nasal lengthening. Complications associated with this technique include transient tip erythema, infection, visible graft contours with delayed-onset skin erythema, nostril deformity, and overprojection.

FIGURE 25.1 A: Intraoperative photo of multilayer tip grafting using septal cartilage. B: Pre- and postoperative photos of a representative case involving multilayer tip grafting.

FIGURE 25.1 (Continued) C: Illustration of surgical procedures.

Onlay Tip Grafting

Onlay tip grafting is a procedure during which one or several graft layers are horizontally placed on the dome of the tip (Fig. 25.2). When performing rhinoplasty on Asian patients, stacked onlay graft placement on the domal portion of the tip is frequently combined with dorsal augmentation using an alloplastic implant material. Graft visibility is a common complication. To prevent graft visibility, the width of the graft should be almost equal to that of the domal portion of the tip and the graft margin should be properly smoothed.

Septal Extension Graft

This procedure can have various effects, including tip support reinforcement, tip projection and rotation adjustment, dorsal length extension, columellar advancement, and nasolabial angle improvement. Because this invisible graft is located within both alar cartilages, the risks of tip graft visibility or dermal thinning, which are common complications of other tip grafting techniques, are avoided. For successful septal extension grafting, the septal cartilage must be thick and strong; if the cartilage is weak, both the cartilage harvested for grafting and the supporting L-strut will also be weak, leading to gradual deformation of the septal extension graft and supporting L-strut and deprojection or deformation of the tip. 5-0 nylon or 5-0 PDS is used to fix the septal extension graft to the septal cartilage. Three to four sutures are usually enough, but a locking suture is occasionally required at the transitional area of dorsal septum and caudal septum in order to prevent rotation of the graft in an anterocaudal direction.