Asian Rhinoplasty 

Updated: Oct 14, 2016
Author: Charles S Lee, MD, FACS; Chief Editor: Mark S Granick, MD, FACS 

Overview

Background

The same goal exists for rhinoplasty performed on Asians as for rhinoplasty performed on Caucasians, which is to build a natural-appearing structure that blends harmoniously with the face. As a group, Asians require augmentation of the nose to achieve this result, in contrast to Caucasians who usually require reduction. As with other types of surgery performed on Asians, successful surgery results in a feature consistent with the patient's ethnic identity. Thus, the goal of surgery should be an attractive Asian nose, not the creation of an attractive Caucasian nose on an Asian face.[1, 2] For more information on aesthetic medicine, including news and CME activities, visit Medscape’s Aesthetic Medicine Resource Center.

See the image below depicting completion of rhinoplasty procedure.

After completion of procedure. After completion of procedure.

History of the Procedure

Previously, surgery has focused primarily on dorsal augmentation. Although still performed (especially by nonphysicians or those with limited training), injection of paraffin or liquid silicone has been replaced by alloplastic augmentation, most commonly silastic. Historically, the surgeon addressed the tip by augmenting it together with the dorsum in a one-piece, L-shaped implant with the bend of the L forming the new tip. Because extrusion at the tip remains an ongoing concern with implants of this type, the surgeon frequently protects the tip with cartilage from the ear, septum, or lower lateral cartilage.

The nasal tip and especially nasal tip lengthening vis-à-vis facial thirds remains the primary challenge of Asian rhinoplasty (see the image below).

Lengthening procedure (different patient) for the Lengthening procedure (different patient) for the short nose. A graft placed behind the toboggan graft holds it out to extension.

The popularity of open rhinoplasty in the United States has led to an increased interest in applying this method to Asian rhinoplasty.

Nevertheless, due to the poorer healing characteristics of Asian skin, some practitioners prefer the endonasal approach to Asian rhinoplasty.

For nasal dorsal augment, a recent surge of interest in autogenous reconstruction using autogenous cartilage has been observed. Costal cartilage is increasingly used in the United States. Recent attention has been drawn to diced conchal cartilage wrapped in Surgicel[3] or temporalis fascia.[4] The diced cartilage obviates the problems associated with warping, which can occur with rib. As much as 4 mm or more of dorsal augmentation can be achieved using conchal cartilage.

Problem

Address the problem as isolated to the dorsum, tip, alar base, vertical dimension, or all of the above. The Asian nose shares similar ideal dimensions with the Caucasian nose but with emphasis on subtleness: the dorsum requires less height, the tip less definition, the alar base less narrowness. As in Caucasians, ideally the radix begins at or slightly below the lash line. The length, measured from the idealized radix to the base of the columella (subnasale), occupies the central third of the face. The tilt of the columella measures 90-115° from the vertical plane, with higher angulation preferred for smaller women.

Southeast Asians (Malay, Filipino, southern Chinese) typically require the most dorsal augmentation (4 mm or more), while northeast Asians (Korean, Japanese, northern Chinese) require less (1.5-2.5 mm) or none. It may be necessary to better define the tip and increase its projection. A deficient premaxilla may need augmentation, as evidenced by a retracted columella with deficient columellar show from lateral view. The nose may require lengthening as measured from the radix to the tip or from the radix to the base of the columella.

The need for alar reduction is frequent in southeast Asians but much less so in northeast Asians. In most cases, both the flare and width need to be corrected; this necessitates an incision into the alar groove.

Pathophysiology

Skin

Nasal skin's thickness better conceals the anatomic detail of the underlying nasal skeleton. This allows better blending of alloplastic or autogenous augmentation with native tissues. Nevertheless, do not use this as an opportunity for sloppiness in surgical technique, because in this patient population, expectations are exceedingly high.

Cartilage

The more delicate cartilaginous tissues of the lower lateral cartilage generally require reinforcement with autogenous cartilage from the ear or septum to obtain a desired result. Affecting a result with pure cartilage reshaping techniques is difficult and usually inadequate. Septal cartilage frequently requires two-layered reinforcement because of its thinness. When harvesting septal cartilage, preserve 1.5 cm of caudal and dorsal septum to prevent nasal dorsal collapse. In about 20% of cases, the septal cartilage is inadequate and additional cartilage from the ear is necessary.

Generally, the lower lateral cartilage is too soft and pliable to adequately support the tip. Such softness precludes the successful use of onlay grafts to the tip, except for the rare patient who has sufficiently strong cartilage (about 10% of patients). Currently, when the author performs an open rhinoplasty, preference is given to creating a columellar strut combined with a shield graft when the septal cartilage is sufficiently strong.

In many cases, septal cartilage as an anterior strut graft appears adequate for tip projection in closed rhinoplasty, if a minimum of 22 mm of cartilage can be obtained to act as both a strut and a shield graft. When an endonasal approach is used, a 1-layered graft appears adequate to maintain durable tip projection.

When tip grafting, defatting should be limited in order to decrease the likelihood of graft visibility. This is particularly true in the open approach, as the 2-layered graft combined with a columella incision can lead to compromised circulation at the tip area and more significant scarring.

More recently, Erol has reported on aggressive tip defatting when performed with closed rhinoplasty and a higher dose of triamcinolone (Kenalog 10/1 mL).[5]

Nasal bones

The shorter and more delicate nasal bones place the patient at higher risk for internal valve collapse; consider spreader grafts in the rare patient requiring isolated dorsal reduction. Fortunately, alloplastic dorsal augmentation functions as a spreader graft, precluding the need for this as a separate maneuver in many cases.

Because of the shorter height of the nasal bones, the author finds that a curved osteotome provides a more consistent result than the percutaneous approach.

Indications

The indication for Asian augmentation nasal surgery is a patient with realistic expectations and mental stability. Asian male rhinoplasty patients appear to have a higher rate of dissatisfaction from nasal surgery. Careful screening is recommended, especially with regard to outcome and the likely shortfalls of the operation.

Relevant Anatomy

First analyze the nasal dorsum, which begins at or slightly below the eyelash line. A straight line drawn from this point to the supratip area determines the appropriate dimensions of the nasal implant. Because of the high visibility of implants ending in the mid dorsum, it may be necessary to lower the height of the dorsum to accommodate a longer implant, even if the dorsal deficiency appears isolated to the radix.

Next, assess the nasal tip for three characteristics: the need for increased projection, tip definition, and/or length from radix to tip. Because of their interrelationship, the need for improvement in any one of these aspects impacts the other two.

The resilience of the lower lateral cartilage determines the approach used to correct the deficiency. According to Millard-Sheen, a well-developed firm nasal tip may require nothing more than a suture-reshaping technique or a graft isolated to the nasal tip identical to a Caucasian rhinoplasty. More typically, a tip grafting technique is required. As the tip becomes increasingly delicate, construct increasingly substantial tip cartilage.

As the nasal tip projection is increased with a graft, the nose rotates cephalically, shortening the radix-tip length. Several techniques can be used to offset the cephalic rotation. These include the extended septal strut with the a wider dorsal edge; a septal extension graft; and the backstopped shield graft or reversed shield graft (convex surface placed caudally).[6]

Septal cartilage graft secured to the columella. Septal cartilage graft secured to the columella.

As mentioned above, when using an open approach, the author prefers conchal cartilage, made 2 layers thick, to serve as an anterior strut graft. Perhaps owing to circulatory disruption, septal cartilage appears to weaken or resorb over time, resulting in the loss of tip projection. The endonasal approach preserves better circulation to the tip area, and this may explain the better survivability of cartilage tip grafts.

Next, look for maxillary spine deficiency, as evidenced by a retracted columellar base and an acute nasolabial angle. The degree of deficiency may require a plumping graft of cartilaginous tissue. Finally, determine whether the alar base requires correction of width or flare. Increasing the projection of the nasal tip usually obviates the need for this in the northeast Asian population (Koreans, Japanese). More frequently, this procedure is performed on Southeast Asians such as Filipinos and Malay. When correcting the flare, the surgeon should avoid a pasted-on appearance of the nostril at all costs. This is done by preserving a slight curvature to the nostril when making the lateral incision.

Contraindications

Prior injections of liquid silicone or paraffin to the nasal dorsum predispose patients to infections when the nose is augmented with alloplastic material. The patient should accept the risk of infection rates, which border on 40% or more.

 

Treatment

Preoperative Details

Photographs

Obtain photographs for use in the operating room.

Nasal implant

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.

Intraoperative Details

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.

Lengthening procedure (different patient) for the Lengthening procedure (different patient) for the short nose. A graft placed behind the toboggan graft holds it out to extension.

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.

    A 2-mm osteotome placed percutaneously. Perform th A 2-mm osteotome placed percutaneously. Perform this step prior to tip work.
  • 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.

Placing an intercrural 6-0 Prolene taper needle su Placing an intercrural 6-0 Prolene taper needle suture to stabilize the framework.

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.

Alar resection

See the list below:

  • Resect the alar base depending on the need for correction of alar flaring or alar base narrowing.[7] 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.[8]

    Marking for alar base resection. Marking for alar base resection.
  • 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.

Postoperative Details

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.

Follow-up

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.

Complications

Infection

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.

Implant extrusion

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.[4] 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.[4]