Disclosure 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. 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performed (especially by nonphysicians or those with limited training), injection of paraffin or liquid silicone has been replaced by alloplastic augmentation, most commonly silastic.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. The popularity of open rhinoplasty in the United States has led to an increased interest in applying this method to Asian rhinoplasty. 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. 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 in the rare patient who has sufficiently strong cartilage (about 10% of patients). Currently, the author prefers creating an anterior strut graft with ear cartilage when using the open rhinoplasty approach. In the author's experience, even two layers of cartilage appear inadequate to maintain the projection beyond two years. While septal cartilage appears adequate for tip projection in closed rhinoplasty, the compromise of circulation at the tip when using the open rhinoplasty approach may contribute to long-term weakness, absorption of the septal cartilage, or both. Conchal cartilage grafts placed as a strut appear to have a more durable outcome. 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.
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. One way to offset this involves suturing the lower lateral cartilages to each other to prevent rotation; bolster this effect with ear cartilage two layers thick, or use a modification of Robert Flowers' toboggan-graft technique (a modified Millard anterior nasal strut). Secure a septal cartilage graft, two layers thick, to the base of the columella, with a buttress behind the graft at the tip if necessary to further offset the tip rotation. As mentioned above, the author currently prefers conchal cartilage, made two layers thick, to serve as an anterior strut graft when using the open approach. Perhaps owing to circulatory disruption, septal cartilage appears to weaken or resorb over time, resulting in the loss of tip projection. 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. 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. |
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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. Harvesting the toboggan graft
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. Dorsal implant augmentation
Lower lateral cartilage Suture the medial crura to each other to preserve their relationship, cinching the knot up to the point just prior to cartilage distortion. Trim the cephalic edge of the lower lateral cartilage if excessive and score the domes. Suture the cut edges together to create the desired angulation. 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. 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. 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. Alar resection
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 care: Provide close follow-up care to look for any persistent supratip swelling, which should be treated by placing Kenalog-10, 0.2 mL into deep subcutaneous tissue and repeating once or twice at 2-week intervals. The patient should apply intermittent finger pressure at home. 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 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.
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 if any surgeons who perform large numbers of Asian rhinoplasties use autogenous tissue as a primary source of augmentation. Medicolegally, do not extrapolate the standards that apply for Caucasian rhinoplasty with regard to dorsal augmentation to Asian rhinoplasty. Alloplastic tissue augmentation is well within the standard of care in Asian rhinoplasty. 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.
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. In the future, open rhinoplasty will have an expanded scope in Asian rhinoplasty.
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