Asian Rhinoplasty Treatment & Management
- Author: Charles S Lee, MD, FACS; Chief Editor: Mark S Granick, MD, FACS more...
Obtain photographs for use in the operating room.
Determine the necessary thickness and configuration of the nasal implant. Place a straightedge ruler from the lash line to the supratip; the gap between this edge and the native dorsum determines the shape and thickness required of the implant.
Inspect the septum to verify its availability and prepare the patient for use of ear cartilage if necessary. Analyze the amount of columella shown on profile view. Ideally, 1 or 2 mm of the columella should be visible.
Lay the patient supine on the operating table and mark the cephalic edge of the implant pocket, which is the mid point between the medial canthus and base of the eyebrow. Outline the pocket where the toboggan graft will sit. The cephalic edge represents the point of maximal projection of the nose. Refer to the image below.
Harvesting the septal toboggan graft
See the list below:
Inject local anesthesia into the operative site, including the septal mucosa.
Harvest the septal graft through a hemitransfixion incision.
Incise along the caudal border of the septum, then use the Cottle elevator to elevate the mucoperichondrium from the cartilage along the dorsal border of the septum, proceeding posteriorly until reaching the perpendicular plate of the ethmoid. The mucosa along the caudal and dorsal borders adheres least to the cartilage, maximizing chances for a clean dissection.
Proceed with the dissection from a cephalad to caudad direction, reaching the maxillary crest. With a scalpel, sharply divide the decussation of the mucosa from the maxillary crest to elevate the periosteum.
Incise the septal cartilage, preserving 1.5 cm of septal cartilage along the caudal and dorsal border up to the nasal bones, at which point all the cartilage becomes available for harvest.
Elevate the mucosa of the opposite side. Using a swivel knife, harvest the septal cartilage. Preserve this future graft in moist gauze.
Close the incision with 5-0 chromic and obliterate the dead space of the donor site using a quilting suture of 4-0 chromic.
It is not necessary to pack the nose except with light gauze to collect oozing blood.
If ear graft is to be used, the author prefers a postauricular incision and harvesting of the entire conchal cavum cartilage. The donor site is closed with a compression dressing sutured over the dead space and is removed in 4-5 days. The ear graft is made into a shield shape, with a two-layered reinforcement at the base when necessary.
Dorsal implant augmentation
See the list below:
For open rhinoplasty, make an inverted V incision in the mid columella where the medial crura lie closest to the skin, buttressing the incision as it heals.
Incise along the caudal border of the medial crura, mesial crura, and marginal incision, and elevate the skin-soft tissue envelope, exposing the lower lateral cartilage and dorsum of the nose.
For endonasal rhinoplasty, a cartilage-splitting incision is made intranasally, and the cephalic rim of the lower lateral cartilage is excised. The dorsum of the nose is then approached from this incision. A separate marginal incision is later made to accommodate the toboggan-shield tip graft.
Elevate the soft tissue from the dorsum of the nose. Remaining in the supraperiosteal plane can limit bone resorption, which can occur under an implant.
Perform lateral osteotomies, if necessary, by in the standard manner, using a curved osteotome placed intranasally. Alternatively, a percutaneous approach may be used with the aid of a 2-mm osteotome as shown below. Next, insert the nasal implant into the dorsum and adjust as necessary.
Prior to final insertion, perforate the periphery of the Silastic implant using a 1.5-mm hole punch, allowing future ingrowth of soft tissue, which effectively immobilizes it.
After inserting the implant, irrigate with antibiotic solution.
Autogenous dorsal augmentation using diced cartilage with intact perichondrium or temporalis fascia
See the list below:
A posterior approach is used to harvest the concha cymba and concha cavum with the perichondrium intact on the posterior surface.
The donor site is closed with compression dressings to avoid hematoma formation.
The cartilage is diced into cubes smaller than 0.5 mm, with the perichondrium intact.
For dorsal augmentation greater than 2.5 mm, the material may be wrapped in temporalis fascia. Typically, the fascia measures 20 mm wide by 45 mm long.
Lower lateral cartilage
A cephalic trim of the lower lateral cartilage is performed conservatively, preserving 6 mm of cartilage. In patients with a short nose, the scroll area is disarticulated without excision in order to minimize any additional shortening.
Lateral crural mattress sutures, dome-defining sutures, and interdomal sutures (5-0 PDS, dyed, P3 needle) are placed as necessary to obtain the appropriate lateral crural shape. Each step is taken with special attention to potential cephalic tip over-rotation.
If possible, the preferable technique is to not divide the domes outright. This preference is because of the possibility of graft complications requiring its removal, resulting in possible nasal tip collapse and its disastrous consequences.
Septal toboggan graft
At most, the graft measures 22 mm long and 10 mm wide at the dome end and 4 mm, the width of the columella, at the narrow end. A 22-mm graft increases tip projection without cephalic rotation. Decreasing the length of the graft, necessitating placement of the graft higher along the medial crura, increases the amount of cephalic rotation. Make a two-layer graft under two circumstances: for very thin cartilage, which requires reinforcement for strength, and when unable to obtain an adequately long graft, resulting in undesirable overrotation of the tip. A reinforced, two-tiered graft affords rigidity to prevent rotation. A buttress behind the toboggan graft at the dome serves the same purpose. Usually, preserve the domal subcutaneous fat; this affords skin protection against the underlying graft. Close columella skin with 6-0 nylon and intranasal tissue with 5-0 chromic. See the image below.
Ear graft from the concha cavum can be harvested from a posterior approach and carved in the same manner as the septum. This technique almost always requires reinforcement at the base of the graft when an open approach is used.
For endonasal rhinoplasty, the toboggan graft, whether septal or conchal, is generally 1 layer thick. An outline of the graft is drawn on the skin overlying the columellar-tip area, and a pocket is created through a marginal incision in accordance to the skin markings. The graft is slipped into position and the access incision closed with 5-0 chromic suture.
See the list below:
Resect the alar base depending on the need for correction of alar flaring or alar base narrowing. Most surgeons easily grasp the concept of a wide alar base. Alar flare can imagined as an exaggerated result of an underprojecting nasal tip. This is easily visualized by depressing the nasal tip and observing the resulting changes to the ala.
To correct the alar base, mark the join of the ala to the face as depicted below. Resecting the tissue lateral to the join reduces the flare; resecting the tissue medial to the join narrows it. As recommended by Sheen, the incision hides better if made just above the facial-alar groove. 
When the alar base is addressed, generally both flare and width need correction. The resection averages 4-5 mm in Southeast Asians.
After excision, close the deep layer with 4-0 Vicryl and the skin with 6-0 nylon.
Place a Thermoplastic splint and a light mustache dressing.
Place a light petroleum jelly gauze intranasally.
Plumping grafts to columella
If necessary, place small pieces of cartilage into the base of the columella through the columellar incision to improve columella show.
Place the patient on antibiotics for 7 days. Remove the petroleum jelly gauze on the first postoperative day and the skin sutures on the fourth day, and remove the external splint on the seventh day.
Provide close follow-up care to look for implant displacement or malposition, as well as infection or hematoma. Kenalog is generally avoided in the area of any alloplastic implantation because of the risk of infection. Wait 9 months to a year from initial surgery before performing a second surgery because of significant changes that can occur during that interval.
Infection can present many months after surgery. When early infection is identified, begin a course of wide-spectrum antibiotics until culture results return. Depending on the severity and time of onset, consider antimicrobial irrigation on a daily basis with the implant in situ. However, most often, the prosthesis will need removal. After 6-9 months, consider placement of another implant or use of autogenous tissue augmentation.
Implants usually extrude intranasally near the membranous septum or through the skin at the dome. If the implant has not violated the skin or mucosal lining, the nose can be corrected without removal of the implant. A protective layer of auricular or septal cartilage can be placed between the implant and skin. If the implant has exposed itself, sterility has been breached; remove the implant and wait 6-9 months before reinserting another alloplastic implant. Because patients do not tolerate tip deformity to the same degree as they would a dorsal deformity, and because permanent contracture can occur at the nasal tip, consider performing a tip-plasty simultaneous to silastic removal or repositioning.
Open rhinoplasty scar
The poorer scarring characteristics of Asian skin require meticulous incising and closing of the columella. When the operation is performed properly, the scar remains minimally visible.
For more information, see Medscape article Complications of Rhinoplasty.
Outcome and Prognosis
The widespread use of alloplastic implants for dorsal augmentation is a characteristic feature of Asian rhinoplasty. Because of the relative scarcity of autogenous tissue compared to the amount of augmentation required, few surgeons who perform large numbers of Asian rhinoplasties use autogenous tissue as a primary source of augmentation.
Rib grafts and, more recently, diced cartilage grafts have been advocated for use in dorsal augmentation. Their use is not yet widespread.
The Asian nose, perhaps because of thicker skin quality, tolerates silastic augmentation to the dorsum remarkably well. Nevertheless, problems such as skin thinning and extrusion do occur, especially when the alloplastic implant is placed toward the mobile tip. Limiting alloplastic augmentation to the dorsum and using autogenous tissue tip-plasty can maximize the probability of a favorable outcome.
Future and Controversies
Surgeons only recently have applied open rhinoplasty techniques to the Asian nose. The importance of using autogenous tissue for tip-plasty combined with the difficulty of tip-plasty in Asian noses make the merits of open rhinoplasty obvious. Nevertheless, the midcolumellar scar of open rhinoplasty is more noticeable in Asians than in Caucasians, and the author currently prefers an endonasal approach.
The use of autogenous tissue such as rib cartilage compared to a simpler alloplastic augmentation of the dorsum remains a controversial issue. The donor site morbidity of rib grafting frequently meets with patient resistance. Less morbid alternatives, such as diced cartilage wrapped in temporalis fascia, are currently being explored.
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