Asian Rhinoplasty

Philip A Young, MDAesthetic Facial Plastic Surgery, PLLC

Face to FaceHo Chi Minh City, Vietnam

2014

Which leads me to my next talk on Asian Rhinoplasty

Asian Rhinoplasty:-Most of the time Augmentation-Thicker Skin-Reduction of the Skin-Structural Components: Weaker, Deformed, Abnormal-Septal Sources Suspect-Ear Cartilage always discussed-Dorsal Options

With Asian Rhinoplasty Augmentation is a large part of this type of rhinoplastyAsian noses often, and I use often because there have been many times where I have carried out a reductive

rhinoplasty for this group of people, fit this type of general approach of:Tip projectionDorsal projectionTip refinementBecause of their thicker skin, one consideration is thinning the skin or more specifically thinning the SMAS!More specifically you are thinning the muscular layer of the noseBe aware that structural components of the Asian nose can be totally different from the caucasian noseI have seen a lot of variants including: Extremely weak lower lateral cartilages: buckled cartilages, very thin connective segmentsDisconnection between the medial and intermediate crura, Disconnection between the intermediate to lateral crura

If you think that you are going to get all of your necessary cartilage grafts from the septum I would rethink this, the septum cartilage harvest can be minimal

Sometimes you can identify it during surgery most of the time it is an intraoperative discoveryI therefore always consent for ear cartilage graftsEven when I have a decent amount of septal cartilage like 15 x 15mm I often find I still need more because I need a

strong caudal dorsal septal extension graft, tip graft, lateral crural batten grafts, columellar | lobular graft15 x 15 just isnt enough. Maybe the other side if you are going to create a dorsum with deep temporalis fascia. And if

this is the plane harvest some septal bone while doing the septoplasty

Dorsal options are abound and I consider MedporBut I like silicone better Cartilage grafts shaped from ear, rib?Turkish delight options: temporalis fascia, alloderm, glue (baker),Larger dorsal needs: complete cigar type of turkish delight 1 cc syringe special syringe with green tip insideSmaller dorsal needs: cartilage with fascia on top?

Computer Imaging:

Again computer imaging is going to direct what I will need to doIt helps me decide for example if the tip graft will give more projection or do more shaping at the

columellar lobule junctionOr we will need more caudal extension, whether we need to graft the glabellar area and take less

dorsum etc. etc.As I said some asian noses need a reduction rhinoplasty as this lady didSo instead of sparing some of the basics of the rhinoplasty approach I will get right into it

Also computer imaging is good for understanding the patient desires but always tell them this helps us and really no one in the world can get you a perfect result

At least I preface the result and computer imaging

Surgical Steps:-Silicone Dorsum-Extension to the supratip area only-Caudal extension graft: ear, medpor-Coverage of medpor with native cartilage-Usual Sutures-Cartilage grafts for support

Again, I think it is best to convey my thoughts by going through the surgery and maybe you can understand my thoughts

For the dorsum I like to use silicone if they don’t have an objection, you can consider more extravagant options if this doesn’t work for them rib, cadaver rib, turkish delight,

I keep the dorsal graft away from the tip and the dorsal graft extends only to the supratip areaI have never had an extrusionI elevate to the bony pyriform to allow me room to fix the silicone in place at the keystone area, mid

vault, and anterior septal angle.Instead of wrapping the graft I enter the graft with 4-0 nylon at exact locations on each side, figure of

eight helps to fix it midline,Check Midline!!!Also need room inferiorly at the anterior septal angle for the extension graft.The turksh delight is fixed at the glabella with 4-0 fast gut over bolster and anterior septal angle just

like my silicone graftsMedpor implants can be fixed with a k wire in the midline. This is challenging in my opinion.

Tip projection can be done as for a caucasian if there cartilages are strong, not the case most of the time

And in most cases I have to project the tip with caudal extension grafts, columellar grafts or medpor.To me columellar strut grafts are not useful and strong enoughI consider medpor when the septum is very weak and if I have a paucity of cartilage from the ear and

septum and when I need it for the dorsum for a turkish delightThe medpor is covered completely by cartilage by native cartilage and on top of that tip graftsI start all tip shaping with the usual medial, transdomal and interdomal suturesI test the position of the caudal extension with preliminary closure and assessmentI know that I can always add more to move more caudally or for projection but I have to reduce it

more later and reverse a lot of things I have already done earlier If I place it to caudally.

Releasing the medial crura skin is important for later closure!!

Surgical Steps:-Dorsal augmentation first-Then Tip beginning with Caudal Extension-Then Tip Grafts for Refinement-Lastly Alar base Work

Here I have the dorsal graft in placeRight now it is not in the right position and I need to move it superiorlyI test it usually on the surface to see where it is going to augmentI don’t want it higher than the top of the iris or creaseMost people believe that in asians it should be below what is normal for caucasiansThis is done firstI mark the superior point and then I use a 4-0 fast gut to pull the silicone implant through.Then I move on to the tip with caudal extension as I mentioned beforeDuring the time I’m replacing the skin covering and assessing the appearance, again I

like to place a stitch at the transcolumellar incision to really see how it will lookVery importantly I fix the dorsal graft in place with permanent sutures in at least 3

different places: keystone, upper laterals and near anterior septal angleAlso to insure it being centered I will mark the midline at the radix and pull it through with

4-0 fast gut and tie it over with a bolster

Surgical Steps:-Lateral Crural Batten Grafts in place-4-0 nylon-4-0 fast gut to fix it inferiorly and make sure it isn’t cephalically placed

Here is a picture of another silicone implant in positionI just did this 2 weeks agoThe bolster is up in the top of the picture with the midline marking showing where is

center and I measure it from medial canthus and visuallyThe lateral crural battens are in place fixated again with 4-0 nylon and 4-0 fast gutSome think 4-0 biosyn is better than nylon some times you can get suture reactions with

the permanent nylon

I like to irrigate with bacitracin or triple antibiotics bacitracin, gentamycin and keflex | clindamycin?

Surgical Steps:

Tip ShapingAfter the caudal extension graft has added some tip projection I reassess the need for

grafts. When a lot of tip projection is needed I may need to add lateral crural batten grafts to

smooth the transition from the tip graft and avoid the pinched tip deformityHere you see the tip graft with inferior horizontal cuts for shaping the columella lobule

angleYou can also see the lateral batten graftsI mentioned this in the earlier talk

Also during this time I not only set the skin in place to see the results I actually do a test suture each time at the columellar incision for a more accurate look at what I’m gettting

Sometimes a columellar graft will rotate the tip no the tip graft?Sometimes a cap graft will get you the rotation not adding to the shield graft

Surgical Steps:

Here is another tip graft in an Asian patientShowing the total tip graft in place with the lateral batten graft

Make sure the septum is straight otherwise you’ll be working too hard later to get it straight

Orienting the tip graft will helpOrienting the lateral crural will helpLateral crural overlays can help with straightening the tipReorienting the sutures at the tip can helpBut nothing is better than straightening the septum

Surgical Steps:

Here is another vantage point of the total tip graft and lateral crural batten onlay graftnote the batten graft extends more laterally than it is shown

Many times you will need to dissect as if you are doing a lateral crural repositioning with lateral crural strut grafts for cephalically placed lateral crura

Surgical Steps:-Prior to more tip graft and tip suturing the tip cartilages-Consider skin thinning - SMAS

Prior to more tip graft and tip suturing the tip cartilagesI Consider thinning the skin and specifically and very importantly the SMASThis is a very meticulous dissection and maneuverI grab the smas with brown adsons and dissect it out with an iris scissorsYou have to be careful and willing to accept the consequence of tip skin loss if not done

well or done to aggressively!!

2 pronged skin hook and presentation by the techBrown adsons for smas exposure and elevationBlunt dissection mostly

Coincidentally what you are seeing is some radiesse in the supratip area

Silicone Extrusion in the tip:-Direct consequence of having silicone in contact with tip skin

I would now like to concentrate on certain topicsHere is a picture of a silicone implant extruding through the tip in a patient that received

this surgery from KoreaThis is a direct consequence of having the silicone extend to the tipAlso I believe another big reason is the superficial dissection that people take to place

them as wellWhen it is within the skin the nose and skin fight this positioningIt is much better to be next to bone and cartilageThis is still done commonly in Asia and AmericaSometimes it works but many times it doesn’tIt is easier to do this than going through all the steps that I do to augment the asian noseSo what do you do now?

Silicone Extrusion in the tip:-Exposure -Knowledge of the anatomy-Find the right plane-Don’t follow surgically created planes

Here is an intraoperative viewThere was obviously a lot of scarringFirst think was to find the remnant cartilage that is remaining and remove the silicone

implantMost of the time when just the implant is placed the plane is not necessarily along dorsal

cartilage and bone but within the SMAS or aboveA lot of damage can be done in this case as it was for this ladyKeep your finger on the nasal skinI have gotten through the nasal skin onceAfter we took the implant out we created a turkish delight with temporalis fascia and

cartilage minced up into 1mm cubes

Silicone Extrusion in the tip:-Tip Reconstruction-Cap graft-Total tip graft-Lateral Crural Battens

In this case we added tip grafts and lateral crural onlay batten graftsWe eventually trimmed those long suture tails

Deep Temporalis Fascia Graft-Minced Cartilage-Small 1cc syringe

This is the incision you can use to harvest the Deep Temporalis Facia GraftA large piece is neededSutured around the 1cc syringeTop of the syringe cut offCatilage minced to 0.5mm squares injected into fasciaClosure with 4-0 fast gutPlacement and assessmentRemoval of grafts to fitRemember the fascia is absorbed mostly and you need to know that the cartilage creates

the dorsumMost people say you don’t lose much but I have experienced that the fascia goes away

Deep Temporalis Fascia

Here is a picture of the deep temporalis fascia and superficial temporalis fasciaThis is not the exposure that you will get but it is to show you the appearance of the deep

temporalis fascia which you already know likely

Before: After:

Here are the results of that procedureI wanted to treat the skin and do some scar revisions for her nose but she was already so

happy that she didn’t want to do any moreProbably traumatized from the original surgery

Before: After:

Here is a side viewI think she has excellent results but maybe not perfectBut the enemy of a good sometimes great result as they say is perfect or striving and

pushing towards perfect and making things worseYou could have gotten some more augmentation at the lobule area

Before: After:

Here is a before and after of a patient that we augmented the dorsum with silicone 4mm With the lashes as the reference you can see we increased the height of the dorsum

significantlyThe tip looks projected in a better position as well The tip is also transitioning well into the dorsum

Before: After:

Here is an example of a reductive rhinoplasty done on a male patient

Before: After:

Here is the frontal view with the tip refined as wellThe patient was very happy with his results

Before: After:

Here is a post op about a week after dorsal reduction and tip refinementHere is another example that asian rhinoplasty is not always augmentation rhinoplasty in

nature

Before: After:

Here is the 1month view showing tip rotation refinemtentShe has some swelling in the lateral part of her nasal dorsal sidewallsMaybe a little inverted V deformity

Before: After:

The dorsal prominence is reducedI think she is a little overly rotated but I think this is going to come down nicely over timeShe could use more of a supratip break but she didn’t want a scooped out look in her

words nor a ski jumpShe wanted to maintain some ethnicity in her nose but didn’t like her bridgeSo we didn’t create a very large supratip break

I think I could have reduce the bridge more and also lengthened the nose moreIt might drop more

Before: After:

This another asian client gorgeous girlWe did a tip graft and as well as nostril sill reduction and alar weir excisionsI personally like to wait on weir excisions although in this case things worked out fineI think with an open approach, extensive undermining, septal exposure things can get

devasculized and disaster can happenSo I like to stage the weir excisionShe was very happy with her results and is just such a gorgeous girl!

One more note I find that if you push the cartilage projection too much with your septal extension graft or medport implant you can disaster

Something not noted in the literature which I think can happen is the slow demise of your results.

In this case it is not the skin that is the problem but your cartilage grafts. I think the demise is about a week later than skin demise

Something to think about

In Situ:

This is her tip graft and lateral onlay graftsThis is a different vantage of what we did with her tip

Before: After:

Here is another before and afterI actually widened her bridge by doing medial osteotomies on the right side with a

spreader graft to hold the positionThis is an important, sometimes making the nose wider gets better results!She also had her SMAS thinned, alar Weir’s, and tip refinement with tip suturing and

graftsShe was also extremely happy. I could tell how happy she was when she came in with

short hair. Girls need a lot of confidence to wear short hairFor her I think her rhinoplasty transformed her look

Before: After:

This person had just dorsal augmentation with 4.5 mm dorsal nasal graftThat’s all he wanted

Before: After:

This person had an augmentation rhinoplasty and he actually wanted the more supratip fullness which I carefully constructed with a supra tip graft

Before: After:

Here is a side view showing the ethnicity maintained

Before: After:

Here is just a basically a reconstructionCaudal extensionTip graftsNostril sill excisions

Before: After:

Medpor dorsal augmentationMedpor caudal extension graftTip graftsWier excisionNasal lengthening

Before: After:

Oblique views

Before: After:

Here is a ethnic crooked nose deformity shown

Before: After:

Dorsal hump reduction mild tip shaping