3. 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
4. With Asian Rhinoplasty Augmentation is a large part of this type of rhinoplasty
Asian 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 projection
Dorsal projection
Tip refinement
Because 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 nose
Be aware that structural components of the Asian nose can be totally different from the caucasian nose
I have seen a lot of variants including:
Extremely weak lower lateral cartilages: buckled cartilages, very thin connective segments
Disconnection 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 discovery
I therefore always consent for ear cartilage grafts
Even 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 graft
15 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 Medpor
But 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 inside
Smaller dorsal needs: cartilage with fascia on top?
6. Again computer imaging is going to direct what I will need to do
It helps me decide for example if the tip graft will give more projection or do more shaping at the
columellar lobule junction
Or 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 did
So 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
7. 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
8. 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 area
I have never had an extrusion
I 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 grafts
Medpor 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 enough
I 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 delight
The medpor is covered completely by cartilage by native cartilage and on top of that tip grafts
I start all tip shaping with the usual medial, transdomal and interdomal sutures
I test the position of the caudal extension with preliminary closure and assessment
I 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!!
10. Here I have the dorsal graft in place
Right now it is not in the right position and I need to move it superiorly
I test it usually on the surface to see where it is going to augment
I don’t want it higher than the top of the iris or crease
Most people believe that in asians it should be below what is normal for caucasians
This is done first
I 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 before
During 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 look
Very importantly I fix the dorsal graft in place with permanent sutures in at least 3 different
places: keystone, upper laterals and near anterior septal angle
Also 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
12. Here is a picture of another silicone implant in position
I just did this 2 weeks ago
The 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 visually
The lateral crural battens are in place fixated again with 4-0 nylon and 4-0 fast gut
Some 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?
14. Tip Shaping
After 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 deformity
Here you see the tip graft with inferior horizontal cuts for shaping the columella lobule
angle
You can also see the lateral batten grafts
I 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
16. Here is another tip graft in an Asian patient
Showing 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 help
Orienting the lateral crural will help
Lateral crural overlays can help with straightening the tip
Reorienting the sutures at the tip can help
But nothing is better than straightening the septum
18. Here is another vantage point of the total tip graft and lateral crural batten onlay graft
note 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
19. Surgical Steps:
-Prior to more
tip graft and tip
suturing the tip
cartilages
-Consider skin
thinning -
SMAS
20. Prior to more tip graft and tip suturing the tip cartilages
I Consider thinning the skin and specifically and very importantly the SMAS
This is a very meticulous dissection and maneuver
I grab the smas with brown adsons and dissect it out with an iris scissors
You 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 tech
Brown adsons for smas exposure and elevation
Blunt dissection mostly
Coincidentally what you are seeing is some radiesse in the supratip area
22. I would now like to concentrate on certain topics
Here is a picture of a silicone implant extruding through the tip in a patient that received
this surgery from Korea
This is a direct consequence of having the silicone extend to the tip
Also I believe another big reason is the superficial dissection that people take to place
them as well
When it is within the skin the nose and skin fight this positioning
It is much better to be next to bone and cartilage
This is still done commonly in Asia and America
Sometimes it works but many times it doesn’t
It is easier to do this than going through all the steps that I do to augment the asian nose
So what do you do now?
24. Here is an intraoperative view
There was obviously a lot of scarring
First think was to find the remnant cartilage that is remaining and remove the silicone
implant
Most of the time when just the implant is placed the plane is not necessarily along dorsal
cartilage and bone but within the SMAS or above
A lot of damage can be done in this case as it was for this lady
Keep your finger on the nasal skin
I have gotten through the nasal skin once
After we took the implant out we created a turkish delight with temporalis fascia and
cartilage minced up into 1mm cubes
28. This is the incision you can use to harvest the Deep Temporalis Facia Graft
A large piece is needed
Sutured around the 1cc syringe
Top of the syringe cut off
Catilage minced to 0.5mm squares injected into fascia
Closure with 4-0 fast gut
Placement and assessment
Removal of grafts to fit
Remember the fascia is absorbed mostly and you need to know that the cartilage creates
the dorsum
Most people say you don’t lose much but I have experienced that the fascia goes away
30. Here is a picture of the deep temporalis fascia and superficial temporalis fascia
This 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
32. Here are the results of that procedure
I 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 more
Probably traumatized from the original surgery
34. Here is a side view
I think she has excellent results but maybe not perfect
But the enemy of a good sometimes great result as they say is perfect or striving and
pushing towards perfect and making things worse
You could have gotten some more augmentation at the lobule area
36. 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
significantly
The tip looks projected in a better position as well
The tip is also transitioning well into the dorsum
42. Here is a post op about a week after dorsal reduction and tip refinement
Here is another example that asian rhinoplasty is not always augmentation rhinoplasty in
nature
44. Here is the 1month view showing tip rotation refinemtent
She has some swelling in the lateral part of her nasal dorsal sidewalls
Maybe a little inverted V deformity
46. The dorsal prominence is reduced
I think she is a little overly rotated but I think this is going to come down nicely over time
She could use more of a supratip break but she didn’t want a scooped out look in her
words nor a ski jump
She wanted to maintain some ethnicity in her nose but didn’t like her bridge
So we didn’t create a very large supratip break
I think I could have reduce the bridge more and also lengthened the nose more
It might drop more
48. This another asian client gorgeous girl
We did a tip graft and as well as nostril sill reduction and alar weir excisions
I personally like to wait on weir excisions although in this case things worked out fine
I think with an open approach, extensive undermining, septal exposure things can get
devasculized and disaster can happen
So I like to stage the weir excision
She 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
52. Here is another before and after
I actually widened her bridge by doing medial osteotomies on the right side with a
spreader graft to hold the position
This 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
grafts
She 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 hair
For her I think her rhinoplasty transformed her look
Which leads me to my next talk on Asian Rhinoplasty
With Asian Rhinoplasty Augmentation is a large part of this type of rhinoplasty
Asian 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 projection
Dorsal projection
Tip refinement
Because 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 nose
Be aware that structural components of the Asian nose can be totally different from the caucasian nose
I have seen a lot of variants including:
Extremely weak lower lateral cartilages: buckled cartilages, very thin connective segments
Disconnection 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 discovery
I therefore always consent for ear cartilage grafts
Even 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 graft
15 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
Medpor
But 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 inside
Smaller dorsal needs: cartilage with fascia on top?
Again computer imaging is going to direct what I will need to do
It helps me decide for example if the tip graft will give more projection or do more shaping at the columellar lobule junction
Or 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 did
So 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
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 area
I have never had an extrusion
I 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 grafts
Medpor 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 enough
I 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 delight
The medpor is covered completely by cartilage by native cartilage and on top of that tip grafts
I start all tip shaping with the usual medial, transdomal and interdomal sutures
I test the position of the caudal extension with preliminary closure and assessment
I 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!!
Here I have the dorsal graft in place
Right now it is not in the right position and I need to move it superiorly
I test it usually on the surface to see where it is going to augment
I don’t want it higher than the top of the iris or crease
Most people believe that in asians it should be below what is normal for caucasians
This is done first
I 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 before
During 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 look
Very importantly I fix the dorsal graft in place with permanent sutures in at least 3 different places: keystone, upper laterals and near anterior septal angle
Also 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
Here is a picture of another silicone implant in position
I just did this 2 weeks ago
The 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 visually
The lateral crural battens are in place fixated again with 4-0 nylon and 4-0 fast gut
Some 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?
Tip Shaping
After 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 deformity
Here you see the tip graft with inferior horizontal cuts for shaping the columella lobule angle
You can also see the lateral batten grafts
I 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
Here is another tip graft in an Asian patient
Showing 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 help
Orienting the lateral crural will help
Lateral crural overlays can help with straightening the tip
Reorienting the sutures at the tip can help
But nothing is better than straightening the septum
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
Prior to more tip graft and tip suturing the tip cartilages
I Consider thinning the skin and specifically and very importantly the SMAS
This is a very meticulous dissection and maneuver
I grab the smas with brown adsons and dissect it out with an iris scissors
You 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 tech
Brown adsons for smas exposure and elevation
Blunt dissection mostly
Coincidentally what you are seeing is some radiesse in the supratip area
I would now like to concentrate on certain topics
Here is a picture of a silicone implant extruding through the tip in a patient that received this surgery from Korea
This is a direct consequence of having the silicone extend to the tip
Also I believe another big reason is the superficial dissection that people take to place them as well
When it is within the skin the nose and skin fight this positioning
It is much better to be next to bone and cartilage
This is still done commonly in Asia and America
Sometimes it works but many times it doesn’t
It is easier to do this than going through all the steps that I do to augment the asian nose
So what do you do now?
Here is an intraoperative view
There was obviously a lot of scarring
First think was to find the remnant cartilage that is remaining and remove the silicone implant
Most of the time when just the implant is placed the plane is not necessarily along dorsal cartilage and bone but within the SMAS or above
A lot of damage can be done in this case as it was for this lady
Keep your finger on the nasal skin
I have gotten through the nasal skin once
After we took the implant out we created a turkish delight with temporalis fascia and cartilage minced up into 1mm cubes
In this case we added tip grafts and lateral crural onlay batten grafts
We eventually trimmed those long suture tails
This is the incision you can use to harvest the Deep Temporalis Facia Graft
A large piece is needed
Sutured around the 1cc syringe
Top of the syringe cut off
Catilage minced to 0.5mm squares injected into fascia
Closure with 4-0 fast gut
Placement and assessment
Removal of grafts to fit
Remember the fascia is absorbed mostly and you need to know that the cartilage creates the dorsum
Most people say you don’t lose much but I have experienced that the fascia goes away
Here is a picture of the deep temporalis fascia and superficial temporalis fascia
This 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
Here are the results of that procedure
I 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 more
Probably traumatized from the original surgery
Here is a side view
I think she has excellent results but maybe not perfect
But the enemy of a good sometimes great result as they say is perfect or striving and pushing towards perfect and making things worse
You could have gotten some more augmentation at the lobule area
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 significantly
The tip looks projected in a better position as well
The tip is also transitioning well into the dorsum
Here is an example of a reductive rhinoplasty done on a male patient
Here is the frontal view with the tip refined as well
The patient was very happy with his results
Here is a post op about a week after dorsal reduction and tip refinement
Here is another example that asian rhinoplasty is not always augmentation rhinoplasty in nature
Here is the 1month view showing tip rotation refinemtent
She has some swelling in the lateral part of her nasal dorsal sidewalls
Maybe a little inverted V deformity
The dorsal prominence is reduced
I think she is a little overly rotated but I think this is going to come down nicely over time
She could use more of a supratip break but she didn’t want a scooped out look in her words nor a ski jump
She wanted to maintain some ethnicity in her nose but didn’t like her bridge
So we didn’t create a very large supratip break
I think I could have reduce the bridge more and also lengthened the nose more
It might drop more
This another asian client gorgeous girl
We did a tip graft and as well as nostril sill reduction and alar weir excisions
I personally like to wait on weir excisions although in this case things worked out fine
I think with an open approach, extensive undermining, septal exposure things can get devasculized and disaster can happen
So I like to stage the weir excision
She 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
This is her tip graft and lateral onlay grafts
This is a different vantage of what we did with her tip
Here is another before and after
I actually widened her bridge by doing medial osteotomies on the right side with a spreader graft to hold the position
This 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 grafts
She 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 hair
For her I think her rhinoplasty transformed her look
This person had just dorsal augmentation with 4.5 mm dorsal nasal graft
That’s all he wanted
This person had an augmentation rhinoplasty and he actually wanted the more supratip fullness which I carefully constructed with a supra tip graft
Here is a side view showing the ethnicity maintained
Here is just a basically a reconstruction
Caudal extension
Tip grafts
Nostril sill excisions
