Facial Plastic Surgery in Asian Patients Treatment & Management

While there are no nonsurgical therapies for nasal augmentation, nonsurgical creation of a superior palpebral fold has been performed with the use of glues or tapes. Drawing a double-eyelid line also provides a temporary alternative; however, these procedures can be quite time consuming.

Many options are available for nonsurgical or noninvasive cosmetic treatments. Different types of lasers are available, varying according to their wavelength and pulse duration. Carbon dioxide and erbium: YAG lasers are the 2 most commonly used. The NLite (nonablative laser resurfacing), also known as photorejuvenation, uses light energy to stimulate new growth of collagen without removing skin tissue. Although it is less powerful at removing wrinkles than the other resurfacing methods, it may be used for delicate areas such as the eyes and neck, since it causes very little irritation. Myriad laser protocols are used today, which vary by type of laser, the amount of energy used, the pulse mode, and the number of passes made. The laser resurfacing and photorejuvenation procedures are office-based procedures that can be performed with local anesthesia with or without sedation.

Asian blepharoplasty

For the Asian patient seeking a more permanent solution to create a double eyelid, surgery is the only option. Although many methods have been described, creation of a firm adhesion between the mobile pretarsal tissue and the tarsus relies on creation of a firm fixation at the desired level and the removal of pretarsal tissue at a specific level.

Several techniques have been used to modify the epicanthal fold; the degree of effacement of the epicanthal fold depends on the placement of the medial aspect of the incision with regard to the epicanthal fold.

Asian rhinoplasty

Although reduction of a dorsal hump is occasionally requested, an overwhelming number of patients seek an augmentation of the nose. Augmentation of the nose has been performed using autologous grafts; however, most Asian rhinoplasty surgeons use alloplastic material such as silicone, Mersilene, polytetrafluoroethylene, and Medpor. The decreased incidence of infection and extrusion is attributed to the thicker skin and increased subcutaneous tissue.

Asian blepharoplasty

The patient's desires must be thoroughly understood prior to the surgery. The size of the supratarsal fold, the shape of the eyelids, and the status of the epicanthal folds should all be addressed in the preoperative assessment.

The most important aspect of any eyelid surgery is symmetry. Regardless of the method used, place emphasis on meticulous measurement of the inferior, medial, lateral, and superior limits of the incision. Address the need for alteration of the epicanthal fold. Failure to address this area in double-eyelid surgery can result in an aesthetically unpleasant result.

The patient should be sitting with eyes closed when marking the incisions. The inferior incision is usually made 6-10 mm from the ciliary margin while slight upward retraction of the mobile pretarsal skin is performed. An incision 6-7 mm from the ciliary margin is used for patients wishing for a smaller double eyelid, and patients who truly wish to have a westernized appearance need an incision 10 mm from the ciliary margin. The mark is extended both medially and laterally to the extent of the palpebral fissure, parallel to the tarsal margin. Placement of a curved paperclip along the proposed inferior incision can be used to retract the tissue and simulate the postoperative result.

The level of the superior incision is usually determined by the laxity of the eyelid skin. In younger patients, the skin does not need to be excised in every case. Pinching the skin with forceps provides an estimate of the maximum amount of tissue that can be removed. The amount of skin excised determines the eyelid size and, therefore, should be tailored to the type of eyelid desired. An elliptical area is then marked, which provides the margins for excision.

The pattern of the lateral incision dictates the shape of the eyelid. To create a more oval eyelid, a parallel incision is drawn so that the lateral limbus and the lateral canthus are in the same plane. To create a more round eyelid, the lateral incision is drawn so that the lateral canthus is approximately 2 mm below the lateral limbus.

The medial incision addresses the epicanthal fold. For patients who wish to preserve the epicanthal fold, the medial incision should be placed lateral to the epicanthal fold. For patients who wish to efface the epicanthal fold, the incision should be placed medial to the epicanthal fold. Some patients may desire an intermediate between the 2 folds in which the lateral aspect of the epicanthus is efface while the base of the fold is left intact; this can be addressed by placing the medial incision so that it terminates at or near the epicanthal root.

Those patients with prominent epicanthal folds who want more effacement of these folds may require a modified advancement flap. Several flaps have been described to modify the epicanthal fold.

Asian rhinoplasty

Discussing the specific desires of the patient is important in developing the perioperative plan. The characteristic anatomy of the nose usually requires an augmentation procedure as opposed to reduction rhinoplasty. The type of implant used for augmentation purposes, whether it is an alloplastic and/or autogenous graft, should be discussed in detail, taking into consideration the patient's anatomy and the patient and surgeon's preference.

Autogenous cartilage from the septum or ear cartilage is often inadequate to provide the dorsal augmentation needed in Asian rhinoplasty. Some potential graft sites to obtain adequate augmentation material include the rib, iliac crest, and calvaria. The autogenous material is more difficult to alter and does not always provide a smooth continuous contour.

Of the alloplastic materials available, silicone is the most widely used in Asia. Alloplastic materials provide enough substance to achieve the augmentation needed when performing rhinoplasty on Asian individuals. To avoid some of the complications associated with silicone implants, some surgeons have combined the use of silicone and cartilage implants. Preoperative discussion with the patient should also include the wishes of the patient regarding correction of any alar flaring, keeping in mind that direct alar wedge resection results in an externally visible residual scar.

If an alloplastic material is used for augmentation of the nose, initiating cephalosporin 1 day prior to surgery is suggested.

Asian blepharoplasty (incision technique)

Once the incision lines are marked and the patient is prepped and draped, the skin is infiltrated with local anesthetic. An incision is made through the skin and subcutaneous tissue down to the orbicularis oculi muscle. Some surgeons excise a small 2- to 3-mm strip of orbicularis muscle from beneath the skin of the inferior incision. This maneuver provides a wider base for adhesion formation of the palpebral fold.

The orbital septum is excised, exposing the periorbital fat. The amount of periorbital fat removed depends on the depth of the sulcus desired. Conservative removal of the medial fat is urged to prevent the occurrence of a deep hollowness and hypertrophic scarring due to the increased tension placed on the skin with excessive removal.

Retract the remaining fatty tissue to adequately expose the levator aponeurosis, which appears as a white glistening membrane. To provide fixation, nylon sutures (6-0 or 7-0) are placed in the midpupillary, lateral canthal, and medial canthal areas from the levator aponeurosis and/or the tarsus to the dermis. Removal of soft tissue over the levator aponeurosis is important to allow a firm adhesion to form between the skin and the tarsus, effectively converting the mobile pretarsal portion of the lid to a rigid segment. The skin can be closed in a subcuticular fashion with either an absorbable or a nonabsorbable suture once hemostasis with electrocautery is achieved.

Asian blepharoplasty (nonincision technique)

The desired incision line is marked as previously described. The 2 points of entry of the suture are marked next. These points are determined by making the desired fold in the incision line using a fine forceps. Local anesthesia is then infiltrated into the skin and conjunctiva.

Each arm of a double-armed 6-0 Prolene suture is inserted into the marked skin points through the conjunctiva. Each end is then passed back through the full thickness of the lid, entering through the same needle hole on the conjunctival side and exiting through the marked skin site. With both arms now on the skin side, one needle is passed subcutaneously to exit out of the other marked site. The suture is then tied.

Asian rhinoplasty

The rhinoplasty procedure can be performed under local anesthesia using lidocaine with epinephrine. Sodium bicarbonate can be added to the mixture to decrease the amount of burning felt on infiltration of the nose.

Because of the attenuated lower lateral cartilages in Asian patients, techniques of tip rhinoplasty usually performed on whites have disappointing results. The cartilages are usually not strong enough to provide tip projection and support, and thick lobular skin and subcutaneous tissue obscure the results. The most popular alloplastic implant used in the Asian patient is the L-shaped silicone implant. The long arm provides augmentation to the nasal dorsum, and the short arm of the implant serves as a columellar strut. A unilateral marginal incision creates the pocket for the implant. A marginal incision in the other nostril can be made if difficulty is encountered in creating the pocket.

With a blunt-tip scissors, dissection is performed between subcutaneous tissues above and the alar and lateral cartilages below. Do not dissect between the medial crura because the columellar portion of the implant will lie over the crura and create a new projected tip. The superior extent of the dissection is midway between the intercanthal and interbrow lines.

Once symmetry of the subcutaneous pocket is ensured, some surgeons shred the periosteum to allow for regrowth around the implant and to provide stabilization; however, stabilization of the implant can also be achieved through a subperiosteal dissection over the nasal bones that results in a pocket for the cranial portion of the implant. If a dorsal hump is present, use a rasp to shave it down.

Although some surgeons make a preoperative nasal cast and use it as a guide in fashioning the implant prior to surgery, the prefabricated silicon implant is usually tailored at the time of surgery. The cranial portion of the implant is carved to blend with the nasion and preserve the nasofrontal angle. The lateral walls of the implant are beveled to ensure that the implant cannot be readily palpated through the skin. The short arm of the implant should not be used to thrust the tip forward. Pressure necrosis will most likely ensue and result in extrusion of the implant and perforation of the lobular skin, which is a dreaded complication. A conservative length of the columellar strut is chosen. The function of the strut is to stabilize the implant between the medial crura, help position the new nasal tip, and provide bulk to the existing columella (so it becomes more visible).

Once the implant is contoured successfully, it is placed into the previously created pocket. At this point, alar trimming and/or lateral osteotomies can be performed, if necessary. Application of tape and a nasal splint is performed to stabilize the implant as the nose heals.

Asian blepharoplasty

The amount of postoperative edema and resultant blepharoptosis is dependent largely on the amount of skin and fat excised and the level of fixation of pretarsal skin. Inform the patient that the swelling could last up to 6 months following surgery. Postoperative antibiotics are used at the discretion of the surgeon. Ice to the area may decrease the edema.

Asian rhinoplasty

The patient is recommended to refrain from any vigorous activity that may cause bleeding or disrupt the placement of the nasal implant. Postoperative antibiotics are administered to prevent infection.

Asian blepharoplasty

If a nonabsorbable suture is used to close the skin, the suture can be removed as early as postoperative day 4.

Asian rhinoplasty

The nasal splint may be left in place 5-7 days. Document postoperative results with photographs taken at varying times. If asymmetry is noticed and is not attributed to postoperative edema, the patient can be instructed to carefully manipulate the implant to the desired position.

Laser resurfacing/photorejuvenation

Postprocedural erythema and edema can be severe in the first 10 days after laser-based or light-based therapy. Redness, itching, and sensitivity may last up to 4 months. Patients must be advised to avoid sunlight during healing and, beyond recovery, to avoid excess sun exposure. Oral antibiotics are routinely prescribed and in severe cases, oral anti-inflammatory medications may be used. Dressings are used to keep the skin moist during the first 2 weeks after the procedure. After the dressings are removed, patients must be instructed to apply moisturizers for another 2-3 weeks.

Asian blepharoplasty

• Asymmetry can result from differences in marking the skin incisions, differences in skin tension on supratarsal fixation, and differing skin excision widths. Asymmetry can be avoided by taking extra care in marking out lines of incision.
• Blepharoptosis usually results from a high supratarsal incision with a high supratarsal fixation. Levator function can be hindered with scarring that can occur at the level of fixation, resulting in ptosis.
• Supratarsal depression can result from overzealous orbital fat removal. This complication appears more pronounced in patients with thin lid skin and deep-set eyes.
• Retraction: Ectropion or lid margin eversion can occur if fixation of the orbicularis muscle and dermis are higher than normal skin tension.
• Failure to maintain lid fold: The importance of anchoring the dermis and orbicularis muscle to the levator aponeurosis or tarsal plate cannot be overemphasized. Otherwise, the lid fold may fade or disappear completely. Absorbable sutures may increase the risk of failure once they have been absorbed, allowing the distraction forces of the orbicularis muscle and dermis to continue.
• Hemorrhage can be a devastating complication if blindness occurs. Meticulous hemostasis with electrocautery can easily avoid this problem.

Nasal augmentation

• Infection risk is one of the leading reasons some surgeons do not advocate the use of alloplastic material. Infection may be due to a break in sterile technique or in processing of the implant. An implant that is too large may compromise the circulation on the surrounding tissues, decreasing the availability of inflammatory cells and antibiotics to the area. Improper antibiotic coverage and rough handling of tissue are also implicated in infection. If removal of the nasal implant is necessary, the underlying cartilage often is frail and difficult to manage.
• Perforation/extrusion of the nasal implant can occur; however, it is less commonly observed in Asian patients because of increased skin thickness. Proper contouring of the implant and proper creation of the pocket is essential to prevent any skin tension from occurring, which can make the implant more likely to perforate the skin. When using the L-shaped implant, the short arm component should not be used primarily to thrust the tip forward because this can increase the rate of extrusion of the implant.
• Implant malposition, displacement, and unnatural appearance are caused by technical error because of improper implant size, contouring, and/or pocket preparation. Having the patient carefully manipulate the implant into the desired position can treat early asymmetry. Otherwise, the implant may have to be removed and replaced.

Laser-based and light-based therapies

• Prolonged erythema can occur.
• Postinflammatory hyperpigmentation can occur.
• Scarring can occur.
• Patients with herpes simplex may experience acute exacerbations.
• As these are relatively new procedures, the long-term effects on skin are still not yet known.

Although autogenous grafting has been described and used for augmentation purposes in Asian rhinoplasty, many surgeons favor the use of alloplastic material because of its ease in contouring, wide availability, and decreased infection and extrusion rate. Decreased infection and extrusion rate are attributed to the increased thickness of Asian skin.

The future of facial plastic surgery performed on Asian patients largely depends on the types and variety of alloplastic material available on the market. Newer material, such as polytetrafluoroethylene and Medpor, may supplant the use of silicone as the implant of choice in augmenting and contouring the Asian nose.

Iin addition to surgical interventions, a growing trend toward noninvasive therapies such as laser resurfacing and photorejuvenation can be seen, as they afford the patient less down time, more convenience, and a more youthful appearance as a result. These are therapies that can be given alone or as a complement to the more invasive surgical procedures.