Male Rhinoplasty Patient #20
Friday, March 9, 2012
Nose Job New York - Male Rhinoplasty Photos
Thursday, March 8, 2012
Rhinoplasty Patient A Frontal View
27 year old woman who injured her nose in the past. She had a twisted nose and was unhappy with the size and droopiness of the nasal tip. She also desired a slightnly narrower nasal bridge.
Wednesday, March 7, 2012
Changing the Nostril Shape
The nasal base and nostril shape are important characteristics to consider during the planning and execution of aesthetic and reconstructive rhinoplasties. The first descriptions of nasal base reductions to alter the nostril shape were described more than a century ago by Weir. Modifications of this technique were reported by Joseph." In 1943, Aufricht, using the methods of Weir and Joseph, described a modified technique in alar reduction that remains popular today.' The authors present a discussion on anatomic aspects of the nasal base, strategies to analyze the nasal tip and nostril shape from the base view, and variations in nostril shape. Finally, a systematic approach of surgical techniques to alter the nostril shape is provided.
ANATOMY
In evaluating the nostril shape from the base view it becomes apparent that contributions from the lower lateral cartilages, the anterior nasal spine, the caudal septum, the maxilla, the upper lip, and the skin and soft tissue envelope of the nose all contribute to the overall appearance. Variations or changes in any of these structural components or their relation-ships to one another may alter the appearance and attractiveness of the nostril shape, and ultimately, affect nasal function.
The lower lateral cartilages (LLCs) are critical in defining the nasal tip and nostril shape. Each LLC is composed of three crura: the medial, middle, and lateral (Fig. 1). Each of these portions is composed of two segments. The medial crus is divided into the footplate and columellar segments. Angulation of the foot-plate segment occurs in a medial to lateral and anterior to posterior direction. The columellar segment is ideally oriented vertically and is primarily responsible for nostril length and nasal tip projection.
The middle crus begins at the columellar and lobular juncture and ends at the lateral crus.'" Its two components are the lobule and domal segments. The lobular segments can be extremely varied, and this corresponds to much of the extensive variation and diversity in tip shape. One of the hallmark features of the domal segment that affect appearance of the nasal tip and nostril shape is notching of the cartilage at its caudal aspect. This notching corresponds to the soft tissue triangle of the lobule. The lateral crus is the primary component of the nasal ala. It begins at the nasal domal junction and courses laterally and cephalad. The lateral crus terminates in a chain of accessory cartilages.
EVALUATION
With this in mind, it is important to recognize that significant individual and racial and ethnic variations within the structural components of the nasal tip exist. These anatomic variants correspond to dramatic differences in nasal tip size, shape, and nostril configuration. In general, the nose can be described as being platyrrhine (African), mesorrhine (Asian), or leptorrhine (Caucasian) (Fig. 2).10 The African and Asian nose, to varying degrees, share many common features and can be described as less projected and having a shorter columella, increased nasal flare, increased interalar width, and more horizontally oriented nostrils when compared with the leptorrhine nose. A poorly defined anterior nasal spine, decreased vertical projection of the columellar segment, thinner and less rigid lower lateral cartilages, and thicker skin with increased subcutaneous
fat are some of the structural differences that account for the variance.
The axis of the ala is critical for surgical planning. Sheen16 defined three varying alar axis: divergent, straight, and convergent (Fig. 3). Alar base reduction should be discouraged in patients with a convergent axis.' When evaluating the nasal tip from the base view, it can be divided into seven subunits (Fig. 4). The various subunits correspond to the segments of the lower lateral cartilages discussed previously. In addition, nasal width, tip projection, nostril shape, and symmetry are evaluated best from the base view.
When deciding on which base reduction techniques will produce the desired outcome, the rhinoplastic surgeon must distinguish between alar flare and alar base width.' Alar flare is the maximum degree of convex bowing of the alar base above the alar crease. On the other hand, interalar width or alar base width is the distance from one alar crease to the other (Fig. 5A). Alar flare and increased alar width can be responsible for increased nasal width. Specific strategies to address these abnormalities are discussed in the section on operative techniques. When evaluating the nasal tip from the frontal view, the width of the nose should not extend past the imaginary line that extends inferiorly from the medial canthus (Fig. 5B).
Tip projection as seen from the base view can be analyzed best by using ratios and proportions. In general, the nostril width, from alar crease to alar crease, should be equal to the nostril height measured from the subnasale to the nasal tip defining point. The nostril to infralobule ratio should be approximately 2: 1. Farkas et al described seven standard nostril types varying from vertical to horizontal in orientation (Fig. 6). Round and horizontal nostrils are often associated with poor projection. The ideal nostril shape is elliptical, with its axis at a 45° angle measured from the lateral border.'
When deciding the appropriate surgical procedure to use for tip refinement and nostril shape augmentation, the structures that are responsible for creating a misshapen nasal tip and nostril must be considered. A systematic approach to the various subunits is described. For illustration purposes, the procedures are described as isolated or individual techniques. Multiple procedures, however, may need to be performed simultaneously to obtain the de-sired appearance and achieve a satisfactory aesthetic and functional outcome. In the rhinoplasty operation, aesthetics and function set the objective and anatomy determines the operative technique.'
Nasal Base
Changes to the nasal base require addressing the alar base and nostril sill. The most dramatic deformity of this area is the cleft lip nose. The severity of the nasal deformity is proportional to the severity of the cleft lip deformity. The anatomic characteristics of the unilateral cleft lip-nasal deformity have been well described. Multiple procedures using closed and open rhinoplasty techniques are described throughout the literature. By closing the cleft lip deformity with the Millard technique, satisfactory correction of the lip and nasal deformity is sometimes possible primarily (Fig. 7). A common finding with the bilateral cleft lip nose is underprojection and a short columella. Using a V-Y advancement technique incision allows the surgeon to ex-pose and augment the nasal tip structures while lengthening the columella'' (Fig. 8). Discrepancies of the alar base or the nostril sill correspond to asymmetric nostril shape. In addition, alar flare and increased interalar width lend themselves nicely to alar base reduction techniques. There are multiple variations of alar base excisions that are, in some form, a modification of the techniques initially de-scribed by Weir, Joseph, or Aufricht (Figs. 9A and C). If the problem is isolated to increased alar width, direct excisions of the nasal sill should be performed (Fig. 9B).
Figure 7. A, Unilateral incomplete cleft lip deformity with concomitant nasal deformity. B, Postoperative cleft lip re-pair using Millard technique. Note improvement in nasal deformity.
If a large amount of tissue excision is required for adequate reduction of interalar width, an alternative to direct nasal sill excisions is the alar cinch' (Fig. 10). This technique requires releasing and repositioning of the ala at its base. It becomes apparent that narrowing the alar width results in modest increases in tip projection and reorientation of the nostril to a more vertical configuration. An additional technique that can be used for addressing nostril asymmetry, alar flare, and increased interalar width, is the alar base stitch. This procedure can be performed as a unilateral or bilateral procedure with corresponding effects to projection and nostril orientation (Fig. 11).
Reconstruction of the nasal tip often re-quires the transfer of tissue from local and regional sites. The differences in skin thickness brought in to reconstruct the defect may result in excess tissue bulk and narrowing of the nostril. Inferior based transposition flaps work well to correct this type of deformity of the nasal base (Fig. 12).3 On occasion, discrepancies of alar flare can also occur with nasal reconstruction or in the unilateral cleft lip patient. In the case of nostril narrowing, a transposition flap using cheek tissue to widen the nasal sill is an excellent reconstructive option (Fig. 13). In cases in which there is stenosis of the nasal base secondary to trauma, excision of malignancies or iatrogenic injury, a composite graft works well. Combining auricular cartilage and skin, shaped in a triangle, can be placed in the floor of the nose to repair this deformity (Fig. 14)."
Figure 8. A, Planning of the V-Y advancement incision. B, The nasal tip has been augmented with a columellar strut and a shield graft, and the columella has been lengthened with the use of a V-Y advancement technique. (By permission of Mayo Foundation.)
Figure 9. Techniques for reducing the alar base and nasal sill. A, Excision of alar base for reduction of nasal flare. B, Direct excision of nostril floor to reduce the nasal sill. C, Combined reduction of alar base and nasal floor to reduce alar flare and nostril size. Note the more vertical orientation of the nostril. (By permission of Mayo Foundation.)
As is the case with the nasal base, nasal re-construction with the use of flaps may result in thickness of the anterior ala. A superior based alar margin transposition flap results in an increase in nostril size, thinning of the alar skin, and a more vertically oriented, triangular shaped nostril (Fig. 18).3
Medial Wall
Altering the structure of the medial wall primarily involves augmenting or manipulating the caudal end of the septum, medial crural feet, or the anterior nasal spine. Caudal end septal deformities can present themselves as major asymmetries in the nostril shape with associated nasal airway obstruction. Mild deformities of the caudal septum can be corrected easily by a septoplasty, whereas more severe caudal end deformities may require a closed.
Lateral Wall
Abnormalities of the lateral wall are related primarily to structural anomalies and deficiencies of the lateral crus or excess tissue of the ala. Unlike deformities of the nasal base, which are more often aesthetic, lateral wall abnormalities can result in significant functional deficits. In the case of alar collapse, the nostrils are vertically oriented and narrow. On inspiration, partial or complete obstruction of the external nasal valve may occur. Alar batten grafting using lower lateral replacement, augmentation, or transposition techniques allows for correction (Fig. 15). Bulky skin and large nostrils should be addressed by alar rim excision (Fig. 16). Careful attention to the location of the incision is critical to make certain that the closure will be placed as internally as possible. This will ensure that the scar is camouflaged within the shadows of the nose. The rim incision can be combined with alar base reduction excisions (Fig. 17). This is an excellent option when dealing with the ethnic nose that may have thick alar skin and alar flare.
As described earlier, the footplate segment of the medial crura is angled in two dimensions. Excessive lateral angulation of one or both of the medial feet can result in unsightly contouring of the columellar base (Figs. 20A-C). This type of contour deformity can be corrected as an office procedure or in conjunction with other rhinoplasty techniques by suture fixating the medial crural feet to one another, with or without subcutaneous fat excision (Fig. 20D). In addition, removal of excess anterior nasal spine bone or subcutaneous fat contributes to a smooth transition into the lobule.
There are many techniques that can be used to improve tip definition, change the tip projection, or narrow the nose. Dome division is an incisional technique initially described by Goldman.' The focus is on the domal segment of the middle crura and requires complete vertical division of the LLC. This maneuver results in increased tip definition and refinement. Because of the potential long-term problems with bossae formation, however, the authors recommend reconstituting the tip following dome division and trimming of excess LLC. The use of a columellar strut and tip graft are important tools in the armamentarium of the rhinoplastic surgeon. The primary goal is to provide adequate tip support, enhance tip refinement, and blend the tip into the contour of the nasal dorsum. An alternative to increase projection and enhance refinement is nasal tip.
Against this background, changes to the columellar are performed in an attempt to in-crease or decrease nasal tip projection. The columella can be viewed as the center pole of a tent. Addition or subtraction to the height of the center pole results in an increase or de-crease in projection. Changes in projection transmit changes to the nostril shape and orientation and create the illusion of changes in alar base width (Figs. 21 and 22).
SUMMARY
The nasal tip and resultant nostril shape have complex anatomical structure consisting of a cartilaginous framework and skin and soft tissue envelope. When preparing to perform rhinoplasty operations, it is important to consider ethnic and individual variations in the nasal tip, the nostril shape, and internal structure. By dividing the nasal tip into its respective subunits, the rhinoplastic surgeon can then formulate a systematic and pragmatic approach to the nasal base, lateral wall, and columella. Altering or augmenting one or all of these areas results in changes to the nasal tip and to the shape and orientation of the nostril.
REFERENCES
ANATOMY
In evaluating the nostril shape from the base view it becomes apparent that contributions from the lower lateral cartilages, the anterior nasal spine, the caudal septum, the maxilla, the upper lip, and the skin and soft tissue envelope of the nose all contribute to the overall appearance. Variations or changes in any of these structural components or their relation-ships to one another may alter the appearance and attractiveness of the nostril shape, and ultimately, affect nasal function.
The lower lateral cartilages (LLCs) are critical in defining the nasal tip and nostril shape. Each LLC is composed of three crura: the medial, middle, and lateral (Fig. 1). Each of these portions is composed of two segments. The medial crus is divided into the footplate and columellar segments. Angulation of the foot-plate segment occurs in a medial to lateral and anterior to posterior direction. The columellar segment is ideally oriented vertically and is primarily responsible for nostril length and nasal tip projection.
The middle crus begins at the columellar and lobular juncture and ends at the lateral crus.'" Its two components are the lobule and domal segments. The lobular segments can be extremely varied, and this corresponds to much of the extensive variation and diversity in tip shape. One of the hallmark features of the domal segment that affect appearance of the nasal tip and nostril shape is notching of the cartilage at its caudal aspect. This notching corresponds to the soft tissue triangle of the lobule. The lateral crus is the primary component of the nasal ala. It begins at the nasal domal junction and courses laterally and cephalad. The lateral crus terminates in a chain of accessory cartilages.
EVALUATION
 Figure 1. The anatomy of the lower lateral cartilage can be viewed as having three components. (1) medial crus (footplate and columellar segment); (2) middle crus (lobule and domal segments); and (3) lateral crus (body and accessory chain). (By permission of Mayo Foundation.) and ideas primarily reflect a white population.10 |
With this in mind, it is important to recognize that significant individual and racial and ethnic variations within the structural components of the nasal tip exist. These anatomic variants correspond to dramatic differences in nasal tip size, shape, and nostril configuration. In general, the nose can be described as being platyrrhine (African), mesorrhine (Asian), or leptorrhine (Caucasian) (Fig. 2).10 The African and Asian nose, to varying degrees, share many common features and can be described as less projected and having a shorter columella, increased nasal flare, increased interalar width, and more horizontally oriented nostrils when compared with the leptorrhine nose. A poorly defined anterior nasal spine, decreased vertical projection of the columellar segment, thinner and less rigid lower lateral cartilages, and thicker skin with increased subcutaneous
fat are some of the structural differences that account for the variance.
The axis of the ala is critical for surgical planning. Sheen16 defined three varying alar axis: divergent, straight, and convergent (Fig. 3). Alar base reduction should be discouraged in patients with a convergent axis.' When evaluating the nasal tip from the base view, it can be divided into seven subunits (Fig. 4). The various subunits correspond to the segments of the lower lateral cartilages discussed previously. In addition, nasal width, tip projection, nostril shape, and symmetry are evaluated best from the base view.
When deciding on which base reduction techniques will produce the desired outcome, the rhinoplastic surgeon must distinguish between alar flare and alar base width.' Alar flare is the maximum degree of convex bowing of the alar base above the alar crease. On the other hand, interalar width or alar base width is the distance from one alar crease to the other (Fig. 5A). Alar flare and increased alar width can be responsible for increased nasal width. Specific strategies to address these abnormalities are discussed in the section on operative techniques. When evaluating the nasal tip from the frontal view, the width of the nose should not extend past the imaginary line that extends inferiorly from the medial canthus (Fig. 5B).
Tip projection as seen from the base view can be analyzed best by using ratios and proportions. In general, the nostril width, from alar crease to alar crease, should be equal to the nostril height measured from the subnasale to the nasal tip defining point. The nostril to infralobule ratio should be approximately 2: 1. Farkas et al described seven standard nostril types varying from vertical to horizontal in orientation (Fig. 6). Round and horizontal nostrils are often associated with poor projection. The ideal nostril shape is elliptical, with its axis at a 45° angle measured from the lateral border.'
Figure 2. Variations in nasal shape based on race. The leptorrhine nose (A, Caucasian), when compared with the platyrrhine nose (C, African), has increased tip projection and more vertically oriented nostrils. The mesorrhine nose (B, Asian) has intermediate features. Nostril to infralobule ratios decrease when progressing from leptorrhine to platyrrhine. (By permission of Mayo Foundation.)
Figure 3. The alar axis as described by Sheen. A, Divergent. B, Straight. C, Convergent. (From Sheen JH: Adjunctive techniques. In Sheen JH, Sheen AP (eds): Aesthetic Rhinoplasty. St. Louis . Mosby, 1987; with permission.) (By permission of Mayo Foundation.)
Figure 4. Seven subunits of the nasal base. (1) Columella base, (2) central columella, (3) infralobular triangle, (4) soft tissue triangle, (5) lateral wall, (6) ala, and (7) nostril sill. (By permission of Mayo Foundation.)
Figure 5. A, Alar flare, described as the maximum degree of convex bowing above the alar crease. Alar base width, the distance from one alar crease to the other. B, Optimal nasal tip width from frontal view is equal to intercanthal distance. (By permission of Mayo Foundation.)
OPERATIVE TECHNIQUESWhen deciding the appropriate surgical procedure to use for tip refinement and nostril shape augmentation, the structures that are responsible for creating a misshapen nasal tip and nostril must be considered. A systematic approach to the various subunits is described. For illustration purposes, the procedures are described as isolated or individual techniques. Multiple procedures, however, may need to be performed simultaneously to obtain the de-sired appearance and achieve a satisfactory aesthetic and functional outcome. In the rhinoplasty operation, aesthetics and function set the objective and anatomy determines the operative technique.'
Nasal Base
Changes to the nasal base require addressing the alar base and nostril sill. The most dramatic deformity of this area is the cleft lip nose. The severity of the nasal deformity is proportional to the severity of the cleft lip deformity. The anatomic characteristics of the unilateral cleft lip-nasal deformity have been well described. Multiple procedures using closed and open rhinoplasty techniques are described throughout the literature. By closing the cleft lip deformity with the Millard technique, satisfactory correction of the lip and nasal deformity is sometimes possible primarily (Fig. 7). A common finding with the bilateral cleft lip nose is underprojection and a short columella. Using a V-Y advancement technique incision allows the surgeon to ex-pose and augment the nasal tip structures while lengthening the columella'' (Fig. 8). Discrepancies of the alar base or the nostril sill correspond to asymmetric nostril shape. In addition, alar flare and increased interalar width lend themselves nicely to alar base reduction techniques. There are multiple variations of alar base excisions that are, in some form, a modification of the techniques initially de-scribed by Weir, Joseph, or Aufricht (Figs. 9A and C). If the problem is isolated to increased alar width, direct excisions of the nasal sill should be performed (Fig. 9B).
Figure 6. Nostril types as described by Farkas et al. (From LG, Hreczko TA, Deutsch CK: Objective assessment of standard nostril types: A morphometric study. Ann Plast Surg 11:381-389, 1983; with permission.)
Figure 7. A, Unilateral incomplete cleft lip deformity with concomitant nasal deformity. B, Postoperative cleft lip re-pair using Millard technique. Note improvement in nasal deformity.
Reconstruction of the nasal tip often re-quires the transfer of tissue from local and regional sites. The differences in skin thickness brought in to reconstruct the defect may result in excess tissue bulk and narrowing of the nostril. Inferior based transposition flaps work well to correct this type of deformity of the nasal base (Fig. 12).3 On occasion, discrepancies of alar flare can also occur with nasal reconstruction or in the unilateral cleft lip patient. In the case of nostril narrowing, a transposition flap using cheek tissue to widen the nasal sill is an excellent reconstructive option (Fig. 13). In cases in which there is stenosis of the nasal base secondary to trauma, excision of malignancies or iatrogenic injury, a composite graft works well. Combining auricular cartilage and skin, shaped in a triangle, can be placed in the floor of the nose to repair this deformity (Fig. 14)."
Figure 9. Techniques for reducing the alar base and nasal sill. A, Excision of alar base for reduction of nasal flare. B, Direct excision of nostril floor to reduce the nasal sill. C, Combined reduction of alar base and nasal floor to reduce alar flare and nostril size. Note the more vertical orientation of the nostril. (By permission of Mayo Foundation.)
Figure 10. Alar cinch technique. A, Vertically oriented incisions completed within the nasal sill and horizontally oriented backcuts correspond with the amount of narrowing desired. B, Tissue to be cinched is de-epithelialized, and tissue overlying the anterior nasal spine is undermined. C and D, De-epithelialized tissue is cinched at the midline with a straight Keith needle. E, Vertically oriented nasal sill incision is closed. (By permission of Mayo Foundation.)
Figure 11. Alar base stitch. A, Excision of alar crease and nasal sill. B, Suture fixation with the use of a nasal base stitch. C, After, note that the nostrils are more vertically oriented and the alar base width is decreased. (By permission of Mayo Foundation.)
Figure 12. Correction of nostril asymmetry with the use of an inferiorly based transposition flap. A, Inferiorly pedicled tissue to be excised from lateral nasal wall. B, Tissue from nasal floor and vestibule is split. C, Pedicled flap is inset. (By permission of Mayo Foundation.)
Figure 13. Widening of the alar base and nasal vestibule with the use of cheek transposition flap. A, Excision of cheek tissue pedicled inferiorly. B, Medial rotation of cheek tissue into nasal vestibule and lateral advancement of ala. C, Inset of pedicled flap and recreation of alar crease. (By permission of Mayo Foundation.)
Medial Wall
Altering the structure of the medial wall primarily involves augmenting or manipulating the caudal end of the septum, medial crural feet, or the anterior nasal spine. Caudal end septal deformities can present themselves as major asymmetries in the nostril shape with associated nasal airway obstruction. Mild deformities of the caudal septum can be corrected easily by a septoplasty, whereas more severe caudal end deformities may require a closed.
Figure 14. A, Stenosis of the nasal base with partial obstruction at the nasal vestibule secondary to a phenol burn injury. B, Stenosis and obstruction are corrected with the use of a composite skin and cartilage auricular graft.
Abnormalities of the lateral wall are related primarily to structural anomalies and deficiencies of the lateral crus or excess tissue of the ala. Unlike deformities of the nasal base, which are more often aesthetic, lateral wall abnormalities can result in significant functional deficits. In the case of alar collapse, the nostrils are vertically oriented and narrow. On inspiration, partial or complete obstruction of the external nasal valve may occur. Alar batten grafting using lower lateral replacement, augmentation, or transposition techniques allows for correction (Fig. 15). Bulky skin and large nostrils should be addressed by alar rim excision (Fig. 16). Careful attention to the location of the incision is critical to make certain that the closure will be placed as internally as possible. This will ensure that the scar is camouflaged within the shadows of the nose. The rim incision can be combined with alar base reduction excisions (Fig. 17). This is an excellent option when dealing with the ethnic nose that may have thick alar skin and alar flare.
Figure 15. A, Note the alar collapse with partial obstruction of external nasal valve. B, The alar collapse was corrected with batten grafts, resulting in improved nostril width and correction of nasal obstruction.
Figure 16. Alar rim excision. A, An ellipse of tissue is excised from the alar rim. B, Primary closure results in reduced alar flare and a more vertically oriented nostril. (By permission of Mayo Foundation.)
Figure 17. Alar base reduction in conjunction with lateral wall (rim) excision. A, An ellipse of tissue is removed from the alar rim in combination with an ellipse from the alar base. B. Primary closure results in a decrease in alar flare and alar base width. Works well with thick skinned individuals with increased nostril width. (By permission of Mayo Foundation.)
Figure 18. Correction of nostril asymmetry with the use of a superiorly based rotation flap. A, Superior pedicled tissue to be excised from lateral nasal wall. B, Tissue from nasal vestibule and apex is split. C, Pedicled flap is inset and rim is closed. (By permission of Mayo Foundation.)
or open septorhinoplasty with transplantation of the caudal end and suture fixation of the septum to the medial crural feet and the prespinous fascia (Fig. 19).As described earlier, the footplate segment of the medial crura is angled in two dimensions. Excessive lateral angulation of one or both of the medial feet can result in unsightly contouring of the columellar base (Figs. 20A-C). This type of contour deformity can be corrected as an office procedure or in conjunction with other rhinoplasty techniques by suture fixating the medial crural feet to one another, with or without subcutaneous fat excision (Fig. 20D). In addition, removal of excess anterior nasal spine bone or subcutaneous fat contributes to a smooth transition into the lobule.
There are many techniques that can be used to improve tip definition, change the tip projection, or narrow the nose. Dome division is an incisional technique initially described by Goldman.' The focus is on the domal segment of the middle crura and requires complete vertical division of the LLC. This maneuver results in increased tip definition and refinement. Because of the potential long-term problems with bossae formation, however, the authors recommend reconstituting the tip following dome division and trimming of excess LLC. The use of a columellar strut and tip graft are important tools in the armamentarium of the rhinoplastic surgeon. The primary goal is to provide adequate tip support, enhance tip refinement, and blend the tip into the contour of the nasal dorsum. An alternative to increase projection and enhance refinement is nasal tip.
Figure 19. A, Caudal end deformity of nasal septum with partial airway obstruction. B, Resolution of nostril asymmetry and nasal obstruction following open technique septorhinoplasty with a caudal end septal transplant.
Figure 20. A, Foot segment of medial crura with variations in angles. B, High angulation contributes to a more horizontal nostril orientation. C, Straight configuration allows for a more vertical orientation of the nostril. D, Suture fixation of the medial crural feet, changing high angulation to straight. (By permission of Mayo Foundation.)
Against this background, changes to the columellar are performed in an attempt to in-crease or decrease nasal tip projection. The columella can be viewed as the center pole of a tent. Addition or subtraction to the height of the center pole results in an increase or de-crease in projection. Changes in projection transmit changes to the nostril shape and orientation and create the illusion of changes in alar base width (Figs. 21 and 22).
SUMMARY
The nasal tip and resultant nostril shape have complex anatomical structure consisting of a cartilaginous framework and skin and soft tissue envelope. When preparing to perform rhinoplasty operations, it is important to consider ethnic and individual variations in the nasal tip, the nostril shape, and internal structure. By dividing the nasal tip into its respective subunits, the rhinoplastic surgeon can then formulate a systematic and pragmatic approach to the nasal base, lateral wall, and columella. Altering or augmenting one or all of these areas results in changes to the nasal tip and to the shape and orientation of the nostril.
Figure 21. A, Note the vertically oriented nostrils with an overprojected and wide amphorus nasal tip. B, After open septorhinoplasty with columellar strut, dome division, and a shield graft. Note, the decrease in nasal tip projection orients the nostrils more horizontally and creates the appearance of an increased alar base width.
Figure 22. A, Note the horizontally oriented nostrils, under-projected nasal tip, and wide alar base width. 8, After open septorhinoplasty with a cantilevered dorsal rib bone and cartilage graft and a columellar strut. The increase in nasal tip projection orients the nostrils more vertically and creates the appearance of a decreased alar base width.
- Aufricht G: A few hints and surgical details in rhinoplasty. Laryngoscope 53:317-320, 1943
- Bardach J: Correction of nasal deformity associated with bilateral cleft lip. In Bardach J, Slayer KE (eds): Surgical Techniques in Cleft Lip and Palate. St. Louis , Mosby Year Book, 1991
- Burget GC, Menick J: Aesthetic reconstruction of the nose. St. Louis , Mosby Year Book, 1994
- Daniel RK: The nasal tip: Anatomy and aesthetics. Plast Reconstr Surg 89:216-224, 1992
- Daniel RK: The nasal base. In Regnault P (ed): Rhinoplasty: Aesthetic Plastic Surgery. Boston , Little, Brown, 1993
- Farkas LG, Hreczko TA, Deutsch CK: Objective assessment of standard nostril types: A morphometric study. Ann Plast Surg 11:381-389, 1983
- Goldman IB: The importance of the medial crura in nasal tip reconstruction. Arch Otolaryngol Head Neck Surg 65:143-147, 1957
- Huffman WC, Lierle DM: Studies on the pathologic anatomy of the unilateral hare-lip nose. Plast Reconstr Surg 4:225-234, 1949
- Joseph J: Nasenplastik and Sonstige Gesichtplastiken: Ein Atlas and Lehrbuch. Leipzig , Germany , Curt Kabitzsch, 1932
- Larrabee WF Jr, Makielski KH: Surgical anatomy of the face. New York , Raven Press, 1993
- Larrabee WF, Sherris DA: Principles of facial reconstruction. New York , Raven Press, 1995
- Gaylon McCollough E: General concepts. In Gaylon McCollough E (ed): Nasal Plastic Surgery. Philadelphia , WB Saunders, 1994
- Natvig P, Sether LA, Gingrass RP, et al: Anatomical details of the osseous-cartilaginous framework of the nose. Plast Reconstr Surg 48:528-532, 1971
- Nolst Trenite' GJ: Rhinoplasty: A practical guide to functional and aesthetic surgery of the nose. Nether-lands, Kugler Publications, 1993 and 1998
- Planas J, Planas J: Nostril and alar reshaping. Aesthet Plast Surg 17:139-150, 1993
- Sheen JH: Adjunctive techniques. In Sheen JH, Sheen AP (eds): Aesthetic Rhinoplasty. St. Louis , Mosby, 1987
- Sherris DA: Caudal and dorsal septal reconstruction: An algorithm for graft choices. Am J Rhinol 11:457-466, 1997
- Simons LR: Vertical dome division in rhinoplasty. Otolaryngol Clin North Am 20:785-796, 1987
- Sykes JM, Senders C: Surgery of the cleft lip nasal deformity: Operative Techniques of Otolaryngology. Otolaryngol Head Neck Surg 1:219-224, 1990
- Sykes JM, Senders CW, Wang TD, et al: Use of the open approach for repair of secondary cleft lip-nasal deformity. Facial Plastic Surgery Clinics of North America 1:111-126, 1993
- Weir A: On restoring a sunken nose without scarring the face. NY Med J 56:449-454, 1892
Tuesday, March 6, 2012
Asian Rhinoplasty
Asian rhinoplasty is one of the most challenging ethnic rhinoplasties that plastic surgeons face primarily secondary to the lack of nasal dorsum and weak cartilaginous framework in combination with thick skin and soft-tissue envelope. Three goals that should be achieved are as follows:
1. Pleasing the patient
2. Achieving an aesthetically pleasing and functional result
3. Maintaining a natural look.
Of these goals, pleasing the patient can prove to be the most difficult to achieve, because many patients possess unrealistic expectations and a desire to achieve an aquiline Caucasian nose. The patients may envision noses similar to those of models or celebrities, even though it may not be suitable for their faces, because of their lack of awareness of the underlying nasal structures. The surgeon’s most important task is to attempt to convince the patient that this result is unrealistic, nonfunctional, aesthetically unpleasing, and difficult to achieve with his or her thick skin. Only when this task is accomplished, with good communication and understanding of realistic outcomes between the surgeon and patient, may the surgery proceed with caution.
One of the most common problems in Asian rhinoplasty is the desire to achieve a less bulbous, Westernized nasal tip. To attain a defined nasal tip, aggressive over-resection of lower lateral cartilages is usually performed. When aggressive lower lateral cartilage reduction occurs, this usually causes the following problems: loss of projection, counterrotation (ptosis), loss of support, nasal obstruction, more bulbous nasal tip, and possible long-term nasal tip contour irregularities.
Modern rhinoplasty practices suggest that less is more and that aggressive cartilage removal is antiquated. Less cartilage removal, additional nasal support through structural grafting, and tipsuturing techniques are being advocated at national and international facial plastic meetings, suggesting that these techniques may lead to decreased revision rhinoplasties.
This article describes the Asian nasal anatomy, rhinoplasty goals, preoperative nasal evaluation and surgical planning, surgical sequence and techniques, postoperative care, risks and complications, and pearls.
Fig. 1. (A) Frontal, oblique, lateral, and basal views of an Asian woman preoperatively and 7 months postoperatively.
(B) Frontal, oblique, lateral, and basal views of an Asian man preoperatively and 6 months
postoperatively.
ANATOMY
A brief description of the Asian nose is discussed and the descriptions described are present in most, but not all, typical Asian noses (Fig. 1A, B). These include the following:
The primary goals in Asian rhinoplasty are as follows:
Excellent physician-patient communication is critical. During the consultation process, it is paramount to concentrate carefully on the patient’s desires and goals. It is important to assess whether or not the patient has realistic expectations and to determine the cause of the patient’s unhappiness with his or her nose. During this process, the plastic surgeon needs to assess whether the patient is a good candidate for ethnic surgery. Can your conservative rhinoplasty achieve the patient’s goals and make them satisfied with the overall result? Poor patient selection can lead to an unhappy patient and a significant amount of stress to the surgeon regardless of how successful the surgery is.
Furthermore, during the history and physical examination, special attention must be directed to determine if there is a component of nasal airway obstruction. If so, is the nasal airway obstruction static or dynamic and what are its characteristics? What factors alleviate or worsen this? For the physical examination, the authors use a nasal analysis worksheet (Fig. 2) while performing a detailed visual and tactile evaluation of the nose.
During the physical examination, it is important to look, listen, and feel. First, the bilateral paramedian vertical light reflexes along the dorsum should be carefully inspected visually for symmetry.
Next, it is important to listen and observe the patient during normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable, such as supra-alar, alar, or rim collapse (slitlike nostrils) during static or dynamic states. External valve collapse (lower lateral cartilage pathology) can be ascertained using a cottontipped applicator, while manually obstructing the contralateral nostril, to elevate the area of nasal obstruction, such as the alar rim, midalar cartilage, or supra-alar region. Often, nasal obstruction in the supra-alar region may identify an extremely narrow pyriform aperture secondary to low lateral osteotomies. By elevating the ptotic nasal tip, one can easily identify improvement of nasal airway obstruction.
As the internal valve is the narrowest region of airflow, the Cottle maneuver can easily detect internal valve collapse. External visualization of the medial crura feet in the basal view can also reveal any contribution to nasal airway obstruction. The nose should be palpated while examining the bony and cartilaginous skeleton, the tip, and skin and soft-tissue envelope to assess for any underlying asymmetries or lack of structure.
Following a thorough external nasal evaluation, the endonasal examination ensues with anterior rhinoscopy. The nasal septum is inspected for perforations, septal deviation, and for quantity of septal cartilage, because Asians often have short septums with insufficient cartilage. Other important causes of nasal obstruction are hypertrophic turbinates, obstructive synechiae between the lateral nasal wall and septum, nasal masses or polyps, and congenital abnormalities (concha bullosa).
During the physical examination, a problem list with solutions should be clearly documented on the nasal analysis sheet. For example, common problems include:
In addition to standardized rhinoplasty preoperative photographs, computer imaging is useful to improve communication between surgeon and patient and visually solidify the end result. This strategy is useful only if patients are notified that the final image is not a guarantee of results. However, despite proper notification and consent, there have been reports of lawsuits filed by patients for results that are inconsistent with what was generated during the consultation.
Computer imaging can help identify the patient’s expectations and unrealistic expectations can be identified through these images. Therefore, computer imaging is a powerful tool that further enhances patient evaluation for surgery. There have been numerous instances when computer morphing has identified patients with unrealistic expectations. Furthermore, the computer image can be used as a guide during surgery.
Often in Asian rhinoplasty, the patient has microgenia, and a chin implant would benefit the overall a esthetic appearance. Computer imaging will help the patient make a decision to undergo a chin implant.
SURGICAL SEQUENCE AND TECHNIQUES
Initially, attention is directed toward septoplasty and septal cartilage harvesting, with possible inferior turbinate reduction. This stage is followed by external rhinoplasty incisions and skeletonization for the external approach, or an endonasal approach if minimal tip work is to be performed, then nasal tip surgery with harvest/placement of autologous grafts, osteotomies if indicated, and next dorsal augmentation with autologous or alloplastic grafts, and lastly alar base reduction.
SEPTOPLASTY AND INFERIOR TURBINATE REDUCTION
Asian noses rarely exhibit a deviated septum. If a deviated septum is identified, a standard septoplasty is performed. If the septum is not deviated, septal cartilage is harvested, leaving approximately 10 mm for the caudal and dorsal strut. Often, only a small amount of cartilage is harvested, which is insufficient for grafting, and auricular cartilage or costal cartilage for structural and dorsal grafting is often necessary. The patients are always informed preoperatively that this is a possibility. The literature notes multiple techniques and approaches to correct a deviated septum, so this is not discussed in detail here. If indicated, conservative turbinate reduction by your method of choice can be performed.
OPEN RHINOPLASTY
Injection
Most Asian rhinoplasties require an external approach to maximize exposure to the underlying framework and access to the nasal tip. After infiltrating the nose with ample lidocaine with epinephrine to help hydrodissect the skin from the skin and soft-tissue envelope and for control of hemostasis, a subdermal dissection over the nasal tip is performed, leaving the superficial muscular aponeurotic system (SMAS) dorsal to the cartilage mucoperichondrium. Once the nose has been opened, additional local anesthetic is injected to hydrodissect the mucoperichondrium from the lower lateral cartilages (Fig. 3). Hydrodissection aids in dissecting SMAS/mucoperichondrium en bloc (Fig. 4A–E) from the nasal tip to use as an onlay or camouflage a tip graft. A subperiosteal dissection over the nasal dorsum is performed if dorsal augmentation is required or if a bony hump is present.
NASAL TIP SURGERY
Tip surgery is the most difficult part of rhinoplasty, especially because the goals are improved definition, narrowed tip, increased projection, and rotation. If adequate projection is present with an over-rotated infratip lobule, a bruised cartilage infratip lobule graft Fig. 5 may be placed. Fig. 6 are often employed in most Asian rhinoplasty because poor tip projection is often identified.
A conservative cephalic trim is performed leaving approximately 6 to 7 mm as the caudal remnant (Fig. 7). Next, the vestibular tissue is undermined from the posterior surface of the alar cartilage (lateral and medial crura) (Fig. 8). This technique will release any constraints from the cartilage and may increase the natural projection and allow a lateral crural steal.1,2 This technique increases nasal tip projection and tip rotation. The lateral crura are advanced onto the medial crura to project the nasal tip and to rotate the tip. The lateral crura are advanced adjacent to the dome medially (Fig. 9). A bilateral interdomal suture and a transdomal suture are placed using 5-0 polydioxanone suture.
The tongue-in-groove technique may also be used to elevate a hanging columella and to increase tip projection and rotation as desired (Fig. 10A–F). In this technique, the medial crura are advanced on the anterior caudal septum using 5-0 polydioxanone suture. Releasing the lower and medial lateral cartilages from the adherent vestibular tissue with placement of an extended or basic columellar strut may be all that is required instead of structural grafting to increase tip projection. Numerous grafts may modify tip projection such as a basic columellar strut (Fig. 11A,B), shield tip graft (Fig. 6), bruised onlay dome or infratip lobular grafts (Fig. 5), or a combination of any of these grafts. The authors place a columellar strut in nearly 100% of ethnic rhinoplasties to provide the foundation for projection as the nasal tip is reconstructed. Columellar struts may be carved from septal cartilage (authors preference), auricular cartilage (least preferred), or rib cartilage Fig. 12. In many instances, cartilage is present along the dorsal septum for revision rhinoplasty. In addition to the endonasal septoplasty approach, the dorsal septal cartilage may be obtained via open approach by elevating the middle vault mucoperichondrium from the septum, after release of the caudal end of the upper lateral cartilage. Dorsal septum may be harvested without lack of dorsal support provided that at least a 1 cm dorsal caudal septal strut of cartilage is protected. If the harvested septal cartilage is short 2 segments can be sutured to one another (Fig. 12). To augment the nasolabial or subnasal regions, plumping grafts or a posterior septal extension graft may be considered. The authors also use diced cartilage injected through a tuberculin syringe for plumping grafts (Fig. 13).
In addition to using septal cartilage, a columellar strut may be created from auricular cartilage by suturing a double-layered segment with the concave sides facing each another (Fig. 14). A shield graft or infratip lobular graft can extend the infratip lobule and create proper domal highlights. Shield grafts made from auricular cartilage are usually less rigid than septal grafts but either is sufficient. If the graft extends a moderate amount above the native tip, a buttress graft (Fig. 15A, B) is placed posterior to the shield graft to prevent
warping of the graft. In addition, lateral alar contour grafts can be placed to camouflage the lateral edges of the shield graft. With shrink wrappage, you can see the contour of an unsightly graft; these grafts give a smooth transition to create a balanced alar-dome contour. With placement of a shield graft, the infratip lobule is usually over-rotated. One or 2 infratip lobule grafts with bruised cartilage can be placed to correct this over-rotation. Once all grafts are sutured into place, nasal SMAS/mucoperichondrium (Fig. 16), rib perichondrium, see Fig. 17 or deep temporalis fascia (Fig. 18) is placed over the tip complex (Fig. 19) to prevent long-term visibility of the grafts through the skin.
If additional cartilage is needed, autologous cartilage is preferred. Auricular cartilage (Fig. 20) harvesting from the concha cavum and cymba may be approached from the anterior (Fig. 21A–C) or posterior (Fig. 22) surface. Costal cartilage (Fig. 23), which has been well described in the literature, is the preferred autologous cartilage for Asian rhinoplasty. If using costal cartilage, the perichondrium from the rib is used.
OSTEOTOMIES
Conservative management of the nasal bones is essential, because many Asian patients have low nasal bones, and because of the high risk of asymmetric nasal fractures. If osteotomies are indicated, the nasal mucosa inside the lateral nasal wall is infiltrated with local anesthetic to help achieve vasoconstriction and hemostasis.
The author prefers low to low osteotomies followed by fading medial osteotomies or infracturing.
RADIX AND DORSAL AUGMENTATION
For radix and dorsal augmentation, the surgeon needs to create an adequately sized pocket for the grafts, while ensuring that the pockets are just barely larger than the graft. Anything larger will encourage graft displacement with unpleasing results. Autologous grafts (septal, conchal, or costal cartilage) are preferred to alloplastic grafts such as layered 1- to 2-mm polytetrafluoroethylene sheeting (Fig. 24). Because of the high risk of infection and subsequent extrusion, silicone implants (Fig. 25) are not used. For minimal radix or dorsal augmentation, nasal SMAS/mucoperichondrium, rib perichondrium, or deep temporalis fascia (see Fig. 16) is preferred. For moderate radix or dorsal augmentation, bruised cartilage (septal, conchal, or costal) is placed posterior to the harvested nasal scar tissue/mucoperichondrium, rib perichondrium, or wrapped in temporalis fascia (Fig. 26A–D). Diced cartilage wrapped in fascia (DCF) (Fig. 27), popularized by Calvert 3 and Daniel, has become the authors’ preference for considerable dorsal augmentation. The diced cartilage is placed in a 1-mL tuberculin syringe with the distal end removed, which allows the diced cartilage to easily pass through the syringe into the temporal fascia (Fig. 27). The temporalis fascia is wrapped around the syringe and secured with a running 5-0 chromic suture. An alternative method is to place the perichondrium posterior to the nasal soft-tissue/skin envelope in the region of augmentation and to inject the diced cartilage along the dorsum posterior to the perichondrium. The perichondrium may also be placed via percutaneous sutures posterior to the nasal soft-tissue/skin envelope. To create a smooth dorsal augmentation, the DCF graft should extend to the cephalad supratip region. En bloc cartilage grafts placed over the dorsum may warp and look unnatural; therefore, the authors do not favor them.
ALAR BASE REDUCTION Alar base reduction can be simply divided into narrowing the ala with or without the vestibular component, nasal sill/floor, or a combination of both. Nasal sill excision alone is rarely used in the authors’ practice for Asian rhinoplasty, because this narrows the nostril and nasal floor with subsequent narrowing of the airway without reducing the alar lobule (Fig. 28A, B). With this technique, the only way to achieve alar reduction is to create a standard sill incision at the junction of the ala and nostril as shown in Fig. 29. If the Asian patient refuses this, this technique may be used with limited results. In most patients, the alar lobule needs to be reduced to achieve harmony and balance with the Asian rhinoplasty.
Sheen and Sheen4 have described numerous ways to reduce the alar lobule and nostril, which if performed properly, will create an aesthetically pleasing result with a minimally visible scar (Fig. 32A–D). To simplify this, vestibular reduction decreases nostril size, and cutaneous reduction of the alar lobule modifies the size and contour of the alar lobule. Two types of alar bases (Fig. 30A, B) are described:
Type I excises the alar lobule (cutaneous) only without any vestibular skin. This process entails an external alar excision along the entire border of the alar lobule. Photos of a patient with type I weir with a nasal sill component are shown. (Fig. 31A–D). In general, a 3- to 4-mm reduction will lead to a significant reduction. However, in certain patients, the authors have removed as much as 5 to 6 mm of alar lobule, which is not common practice. Additionally, patients with I type I alae with nasal sill components can also undergo excision of the alar lobule extending into the nasal sill to reduce the alar base (Fig. 33A–C). Type II primarily excises the alar lobule (cutaneous) with some vestibular tissue (less than cutaneous).
The same type of incision and resection are performed as in type I. The exception is that the incision enters the internal vestibular lining of the nose with an excision of a small to moderate amount of vestibular tissue. The techniques described do not include routine nostril sill/floor excisions that may be incorporated into either of the described alar base reduction techniques. To obtain the most aesthetically pleasing scar, the following pearls should be heeded. Traditional teaching instructs the incision to be approximately 1 mm on the nasal side of the alar-facial junction. After noticing a few visible scars at the cephalad alar lobule due to the placement of the incision despite meticulous closure techniques, the authors now make the incision in the alar-facial junction, which is less noticeable postoperatively. The incision is beveled and a medial flap technique is used when vestibular tissue is resected. The medial flap technique (Fig. 34A–D) involves making the alar-facial incision initially while extending medially along the alar base and stopping short of the last 2 to 3 mm. A back cut that preserves a small triangular (medial) flap is made before the superior cut. The wedge of tissue is excised and the natural continuity of the lateral nasal sill is preserved. Gentle bipolar cautery is used for hemostasis followed by subcutaneous closure with 5-0 Vicryl and a running 6-0 Prolene for the skin closure. If vestibular resection is performed, 5-0 chromic is used in a running or interrupted pattern, with suture removal in 7 days.
POSTOPERATIVE NASAL CARE
REFERENCES
1. Kridel RWH, Konior RJ, Shumrick KA, et al. Advances in nasal tip surgery: the lateral crural steal. Arch Otolaryngol Head Neck Surg 989;117:1206–12.
2. Kridel RWH, Scott BA, Foda HMT. The tongue-ingroove technique in septorhinoplasty. Arch Facial Plast Surg 1989;1:246–56.
3. Calvert JW, Brenner K, DaCosta-Iyer M, et al. Histological analysis of human diced cartilage grafts. Plast Reconstr Surg 2006;118(1):230–6.
4. Sheen JH, Sheen AP. Aesthetic rhinoplasty. St Louis (MO): The Mosby Company; 1987.
1. Pleasing the patient
2. Achieving an aesthetically pleasing and functional result
3. Maintaining a natural look.
Of these goals, pleasing the patient can prove to be the most difficult to achieve, because many patients possess unrealistic expectations and a desire to achieve an aquiline Caucasian nose. The patients may envision noses similar to those of models or celebrities, even though it may not be suitable for their faces, because of their lack of awareness of the underlying nasal structures. The surgeon’s most important task is to attempt to convince the patient that this result is unrealistic, nonfunctional, aesthetically unpleasing, and difficult to achieve with his or her thick skin. Only when this task is accomplished, with good communication and understanding of realistic outcomes between the surgeon and patient, may the surgery proceed with caution.
One of the most common problems in Asian rhinoplasty is the desire to achieve a less bulbous, Westernized nasal tip. To attain a defined nasal tip, aggressive over-resection of lower lateral cartilages is usually performed. When aggressive lower lateral cartilage reduction occurs, this usually causes the following problems: loss of projection, counterrotation (ptosis), loss of support, nasal obstruction, more bulbous nasal tip, and possible long-term nasal tip contour irregularities.
Modern rhinoplasty practices suggest that less is more and that aggressive cartilage removal is antiquated. Less cartilage removal, additional nasal support through structural grafting, and tipsuturing techniques are being advocated at national and international facial plastic meetings, suggesting that these techniques may lead to decreased revision rhinoplasties.
This article describes the Asian nasal anatomy, rhinoplasty goals, preoperative nasal evaluation and surgical planning, surgical sequence and techniques, postoperative care, risks and complications, and pearls.
A
B
Fig. 1. (A) Frontal, oblique, lateral, and basal views of an Asian woman preoperatively and 7 months postoperatively.
(B) Frontal, oblique, lateral, and basal views of an Asian man preoperatively and 6 months
postoperatively.
ANATOMY
A brief description of the Asian nose is discussed and the descriptions described are present in most, but not all, typical Asian noses (Fig. 1A, B). These include the following:
- Thick skin with abundant fibrofatty tissue
- Deep, low, and inferiorly set radix
- Short, broad, and flat nasal bones with low nasal bridge and dorsum
- Wide, bulbous, thick-skinned, deficient, ptotic, nasal tip with abundant, fibrous, nasal superficial muscular aponeurotic system (SMAS), broad domes, minimal tip definition, flimsy and weak lower lateral cartilages
- Short and retracted columella
- Wide, thick, horizontal ala with flaring nostrils
- Retracted, acute nasolabial angle (less than 90 degrees) nasolabial junction with underdeveloped nasal spine.
The primary goals in Asian rhinoplasty are as follows:
- Thinner nasal bridge
- Augmented dorsum
- Refined tip with increased projection and rotation
- Vertically oblique nostrils and triangular nasal base
- Increased columellar length
- Obtuse nasolabial angle (greater than 90 degrees)
- Moderate skin and soft-tissue envelope thickness for aesthetically pleasing tip definition.
Excellent physician-patient communication is critical. During the consultation process, it is paramount to concentrate carefully on the patient’s desires and goals. It is important to assess whether or not the patient has realistic expectations and to determine the cause of the patient’s unhappiness with his or her nose. During this process, the plastic surgeon needs to assess whether the patient is a good candidate for ethnic surgery. Can your conservative rhinoplasty achieve the patient’s goals and make them satisfied with the overall result? Poor patient selection can lead to an unhappy patient and a significant amount of stress to the surgeon regardless of how successful the surgery is.
Furthermore, during the history and physical examination, special attention must be directed to determine if there is a component of nasal airway obstruction. If so, is the nasal airway obstruction static or dynamic and what are its characteristics? What factors alleviate or worsen this? For the physical examination, the authors use a nasal analysis worksheet (Fig. 2) while performing a detailed visual and tactile evaluation of the nose.
During the physical examination, it is important to look, listen, and feel. First, the bilateral paramedian vertical light reflexes along the dorsum should be carefully inspected visually for symmetry.
Next, it is important to listen and observe the patient during normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable, such as supra-alar, alar, or rim collapse (slitlike nostrils) during static or dynamic states. External valve collapse (lower lateral cartilage pathology) can be ascertained using a cottontipped applicator, while manually obstructing the contralateral nostril, to elevate the area of nasal obstruction, such as the alar rim, midalar cartilage, or supra-alar region. Often, nasal obstruction in the supra-alar region may identify an extremely narrow pyriform aperture secondary to low lateral osteotomies. By elevating the ptotic nasal tip, one can easily identify improvement of nasal airway obstruction.
As the internal valve is the narrowest region of airflow, the Cottle maneuver can easily detect internal valve collapse. External visualization of the medial crura feet in the basal view can also reveal any contribution to nasal airway obstruction. The nose should be palpated while examining the bony and cartilaginous skeleton, the tip, and skin and soft-tissue envelope to assess for any underlying asymmetries or lack of structure.
Following a thorough external nasal evaluation, the endonasal examination ensues with anterior rhinoscopy. The nasal septum is inspected for perforations, septal deviation, and for quantity of septal cartilage, because Asians often have short septums with insufficient cartilage. Other important causes of nasal obstruction are hypertrophic turbinates, obstructive synechiae between the lateral nasal wall and septum, nasal masses or polyps, and congenital abnormalities (concha bullosa).
During the physical examination, a problem list with solutions should be clearly documented on the nasal analysis sheet. For example, common problems include:
- Bulbous, poorly projected tip with a plan of open rhinoplasty with structural grafting
- Low dorsum with a plan of augmentation with diced costal plan of augmentation with diced costal cartilage wrapped in costal perichondrium.
- Wide ala with a plan of bilateral alar base reduction.
In addition to standardized rhinoplasty preoperative photographs, computer imaging is useful to improve communication between surgeon and patient and visually solidify the end result. This strategy is useful only if patients are notified that the final image is not a guarantee of results. However, despite proper notification and consent, there have been reports of lawsuits filed by patients for results that are inconsistent with what was generated during the consultation.
Computer imaging can help identify the patient’s expectations and unrealistic expectations can be identified through these images. Therefore, computer imaging is a powerful tool that further enhances patient evaluation for surgery. There have been numerous instances when computer morphing has identified patients with unrealistic expectations. Furthermore, the computer image can be used as a guide during surgery.
Often in Asian rhinoplasty, the patient has microgenia, and a chin implant would benefit the overall a esthetic appearance. Computer imaging will help the patient make a decision to undergo a chin implant.
SURGICAL SEQUENCE AND TECHNIQUES
Initially, attention is directed toward septoplasty and septal cartilage harvesting, with possible inferior turbinate reduction. This stage is followed by external rhinoplasty incisions and skeletonization for the external approach, or an endonasal approach if minimal tip work is to be performed, then nasal tip surgery with harvest/placement of autologous grafts, osteotomies if indicated, and next dorsal augmentation with autologous or alloplastic grafts, and lastly alar base reduction.
SEPTOPLASTY AND INFERIOR TURBINATE REDUCTION
Asian noses rarely exhibit a deviated septum. If a deviated septum is identified, a standard septoplasty is performed. If the septum is not deviated, septal cartilage is harvested, leaving approximately 10 mm for the caudal and dorsal strut. Often, only a small amount of cartilage is harvested, which is insufficient for grafting, and auricular cartilage or costal cartilage for structural and dorsal grafting is often necessary. The patients are always informed preoperatively that this is a possibility. The literature notes multiple techniques and approaches to correct a deviated septum, so this is not discussed in detail here. If indicated, conservative turbinate reduction by your method of choice can be performed.
 |
Injection
Most Asian rhinoplasties require an external approach to maximize exposure to the underlying framework and access to the nasal tip. After infiltrating the nose with ample lidocaine with epinephrine to help hydrodissect the skin from the skin and soft-tissue envelope and for control of hemostasis, a subdermal dissection over the nasal tip is performed, leaving the superficial muscular aponeurotic system (SMAS) dorsal to the cartilage mucoperichondrium. Once the nose has been opened, additional local anesthetic is injected to hydrodissect the mucoperichondrium from the lower lateral cartilages (Fig. 3). Hydrodissection aids in dissecting SMAS/mucoperichondrium en bloc (Fig. 4A–E) from the nasal tip to use as an onlay or camouflage a tip graft. A subperiosteal dissection over the nasal dorsum is performed if dorsal augmentation is required or if a bony hump is present.
NASAL TIP SURGERY
 |
| Fig. 4. Nasal SMAS/mucoperichondrium excised from the nasal tip. |
 |
| Fig. 5. (A) Lateral and (B) frontal view of a bruised infratip lobular graft. |
A conservative cephalic trim is performed leaving approximately 6 to 7 mm as the caudal remnant (Fig. 7). Next, the vestibular tissue is undermined from the posterior surface of the alar cartilage (lateral and medial crura) (Fig. 8). This technique will release any constraints from the cartilage and may increase the natural projection and allow a lateral crural steal.1,2 This technique increases nasal tip projection and tip rotation. The lateral crura are advanced onto the medial crura to project the nasal tip and to rotate the tip. The lateral crura are advanced adjacent to the dome medially (Fig. 9). A bilateral interdomal suture and a transdomal suture are placed using 5-0 polydioxanone suture.
The tongue-in-groove technique may also be used to elevate a hanging columella and to increase tip projection and rotation as desired (Fig. 10A–F). In this technique, the medial crura are advanced on the anterior caudal septum using 5-0 polydioxanone suture. Releasing the lower and medial lateral cartilages from the adherent vestibular tissue with placement of an extended or basic columellar strut may be all that is required instead of structural grafting to increase tip projection. Numerous grafts may modify tip projection such as a basic columellar strut (Fig. 11A,B), shield tip graft (Fig. 6), bruised onlay dome or infratip lobular grafts (Fig. 5), or a combination of any of these grafts. The authors place a columellar strut in nearly 100% of ethnic rhinoplasties to provide the foundation for projection as the nasal tip is reconstructed. Columellar struts may be carved from septal cartilage (authors preference), auricular cartilage (least preferred), or rib cartilage Fig. 12. In many instances, cartilage is present along the dorsal septum for revision rhinoplasty. In addition to the endonasal septoplasty approach, the dorsal septal cartilage may be obtained via open approach by elevating the middle vault mucoperichondrium from the septum, after release of the caudal end of the upper lateral cartilage. Dorsal septum may be harvested without lack of dorsal support provided that at least a 1 cm dorsal caudal septal strut of cartilage is protected. If the harvested septal cartilage is short 2 segments can be sutured to one another (Fig. 12). To augment the nasolabial or subnasal regions, plumping grafts or a posterior septal extension graft may be considered. The authors also use diced cartilage injected through a tuberculin syringe for plumping grafts (Fig. 13).
 |  |  | ||
| Fig. 6. Shield graft carved from septal cartilage. | Fig. 7. Cephalic trim marked leaving a 7 mm caudal remnant of left lower lateral cartilage (arrow). | Fig. 8. Released lower and medial lateral cartilages (arrows) from the adherent vestibular tissue to aid in increasing tip projection. | ||
 |
Fig. 9. (A–D) Lateral crural steal aids in increased nasal tip projection and rotation. The lateral crura are advanced onto the medial crura to project the nasal tip and to rotate the tip. The lateral crura are advanced adjacent to the dome medially. A bilateral interdomal and a transdomal suture are placed with a 5-0 suture of your choice (Courtesy of Russell W.H. Kridel, MD, Houston, TX). |
| Fig. 10. (A) Tongue-in-groove technique (From Kridel RW, Scott BA, Foda HM, et al. The tongue-in-Groove technique in septorhinoplasty: Arch Facial Plast Surg 1989;1:246–56). (B) A 5-0 polydioxanone suture is passed through the posterior caudal medial crural ligament (arrow) from the outside to the inside (toward the septum). The suture can also be passed through the posterior medial crural cartilage (arrow). (C) The suture is passed through the anterior septal angle (arrow). (D) The suture is finally passed in the opposite direction exiting the medial crural ligament or the medial crural cartilage. (E) Overhead and (F) frontal view of the tip with increased tip projection. |
 |
| Fig. 11. Columellar strut (large arrow) carved from septal cartilage placed in a pocket between the medial crura (small arrows). |
 |
| Fig. 12. Two short segments of septal cartilage sutured to one another toward their distal ends creating a longer columellar strut. |
 |
| Fig. 13. Diced cartilage placed into tuberculin syringe for plumping grafts. |
 |
| Fig. 14. An auricular cartilage columellar strut created by suturing a double-layered segment with the concave sides facing one another. |
If additional cartilage is needed, autologous cartilage is preferred. Auricular cartilage (Fig. 20) harvesting from the concha cavum and cymba may be approached from the anterior (Fig. 21A–C) or posterior (Fig. 22) surface. Costal cartilage (Fig. 23), which has been well described in the literature, is the preferred autologous cartilage for Asian rhinoplasty. If using costal cartilage, the perichondrium from the rib is used.
 |
| Fig. 15. (A) Lateral and (B) front view of a buttress graft preventing bending of a shield graft. |
OSTEOTOMIES
 |
| Fig. 16. Mucoperichondrium placed over a shield graft to prevent visibility of the graft through the skin. |
 |
| Fig. 17. Coastal cartilage is shown below rib perichondrium (white arrow). |
The author prefers low to low osteotomies followed by fading medial osteotomies or infracturing.
RADIX AND DORSAL AUGMENTATION
For radix and dorsal augmentation, the surgeon needs to create an adequately sized pocket for the grafts, while ensuring that the pockets are just barely larger than the graft. Anything larger will encourage graft displacement with unpleasing results. Autologous grafts (septal, conchal, or costal cartilage) are preferred to alloplastic grafts such as layered 1- to 2-mm polytetrafluoroethylene sheeting (Fig. 24). Because of the high risk of infection and subsequent extrusion, silicone implants (Fig. 25) are not used. For minimal radix or dorsal augmentation, nasal SMAS/mucoperichondrium, rib perichondrium, or deep temporalis fascia (see Fig. 16) is preferred. For moderate radix or dorsal augmentation, bruised cartilage (septal, conchal, or costal) is placed posterior to the harvested nasal scar tissue/mucoperichondrium, rib perichondrium, or wrapped in temporalis fascia (Fig. 26A–D). Diced cartilage wrapped in fascia (DCF) (Fig. 27), popularized by Calvert 3 and Daniel, has become the authors’ preference for considerable dorsal augmentation. The diced cartilage is placed in a 1-mL tuberculin syringe with the distal end removed, which allows the diced cartilage to easily pass through the syringe into the temporal fascia (Fig. 27). The temporalis fascia is wrapped around the syringe and secured with a running 5-0 chromic suture. An alternative method is to place the perichondrium posterior to the nasal soft-tissue/skin envelope in the region of augmentation and to inject the diced cartilage along the dorsum posterior to the perichondrium. The perichondrium may also be placed via percutaneous sutures posterior to the nasal soft-tissue/skin envelope. To create a smooth dorsal augmentation, the DCF graft should extend to the cephalad supratip region. En bloc cartilage grafts placed over the dorsum may warp and look unnatural; therefore, the authors do not favor them.
 |
| Fig. 18. Deep temporalis fascia used for augmentation or to cover cartilage grafts. |
 |
| Fig. 19. Deep temporalis fascia draped over the nasal tip and grafts. |
Sheen and Sheen4 have described numerous ways to reduce the alar lobule and nostril, which if performed properly, will create an aesthetically pleasing result with a minimally visible scar (Fig. 32A–D). To simplify this, vestibular reduction decreases nostril size, and cutaneous reduction of the alar lobule modifies the size and contour of the alar lobule. Two types of alar bases (Fig. 30A, B) are described:
- Type I: excessive alar lobule with normalsized nostrils
- Type II: large nostrils and excessive alar lobules.
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| Fig. 21. (A) Auricular cartilage harvested from the anterior approach. (B) Anterior surface of the ear following incision closure and coapting sutures placed through the concha cavum and cymba (arrow). (C) Healing anterior auricular incision. | |||
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| Fig. 26. (A) Crushed cartilage placed in temporalis fascia. (B) Crushed cartilage wrapped in temporalis fascia. (C) Before: crushed cartilage wrapped in deep temporalis fascia used as a radix/cephalad dorsal graft (arrow) and fascia placed over the dome (arrowhead). (D) After. |
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| Fig. 27. Diced cartilage is placed in a 1-mL tuberculin syringe with the distal end of the syringe removed. Enlarging the distal end of the syringe will allow the diced cartilage to flow easily through the syringe. Deep temporalis fascia is wrapped around the syringe and secured with a running 5-0 chromic suture. |
The same type of incision and resection are performed as in type I. The exception is that the incision enters the internal vestibular lining of the nose with an excision of a small to moderate amount of vestibular tissue. The techniques described do not include routine nostril sill/floor excisions that may be incorporated into either of the described alar base reduction techniques. To obtain the most aesthetically pleasing scar, the following pearls should be heeded. Traditional teaching instructs the incision to be approximately 1 mm on the nasal side of the alar-facial junction. After noticing a few visible scars at the cephalad alar lobule due to the placement of the incision despite meticulous closure techniques, the authors now make the incision in the alar-facial junction, which is less noticeable postoperatively. The incision is beveled and a medial flap technique is used when vestibular tissue is resected. The medial flap technique (Fig. 34A–D) involves making the alar-facial incision initially while extending medially along the alar base and stopping short of the last 2 to 3 mm. A back cut that preserves a small triangular (medial) flap is made before the superior cut. The wedge of tissue is excised and the natural continuity of the lateral nasal sill is preserved. Gentle bipolar cautery is used for hemostasis followed by subcutaneous closure with 5-0 Vicryl and a running 6-0 Prolene for the skin closure. If vestibular resection is performed, 5-0 chromic is used in a running or interrupted pattern, with suture removal in 7 days.
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| Fig. 28. (A) Preoperative base view of the standard nasal sill incision. (B) Postoperative view of the nasal sill procedure revealing a narrowed nostril and nasal floor with subsequent narrowing of the airway without reducing the alar lobule. |
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| Fig. 29. (A) Preoperative base view of the lateral nasal sill/alar incision. (B) Postoperative view of the lateral nasal sill/alar incision with a mild to moderate amount of alar lobule reduction. The nostril is also narrowed with subsequent narrowing of the airway. |
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| Fig. 30. (A) Base view of type I: excessive alar lobule with normal-sized nostrils. (B) Base view of type II: large nostrils and excessive alar lobules. |
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| Fig. 31. (A) Base view of type I: excessive alar lobule with normal-sized nostrils. (B) Lateral view of surgical markings showing the alar lobule (cutaneous) excision without vestibular skin. It involves an external alar excision along the entire border of the alar lobule. (C–D) Base view of the surgical markings. |
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| Fig. 32. (A–D) Postoperative photos of alar base reduction scar. |
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| Fig. 33. (A) Preoperative front, (B) base, and (C) lateral views of type I with surgical marking showing the alar lobule excision including extension into the nasal sill. |
POSTOPERATIVE NASAL CARE
- Meticulous cleansing of incisions
- Basic saline nasal sprays
- Suction bulb to suction nose pro re nata (PRN)
- Head elevation
- Ice compresses
- Postoperative nighttime taping for 6 to 10 weeks
- Kenalog 10 mg/mL after 4 weeks PRN
- Over-aggressive cartilage removal; causing loss of tip projection and tip ptosis
- Prolonged bruising or hyperpigmentation
- Infection
- Prominent alar scarring
- Excessive alar reduction
- Abnormal-appearing ala - Flat ala with loss of natural base curves
- Nasal asymmetry, graft irregularity, displacement and extrusion
- Graft absorption
- Prolonged swelling.
- Carefully evaluate the nasal anatomy and physiology and patient’s mental state
- Establish realistic aesthetic and functional goals for the patient and for yourself
- Prepare a detailed preoperative evaluation and surgical plan
- Maintain nasal airway function
- Perform revision procedures only when truly warranted.
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| Fig. 34. (A, B) The medial flap technique involves making the alar-facial incision initially while extending medially along the alar base and stopping short of the last 2 to 3 mm. (C). A back cut that preserves a small triangular (medial) flap is made before the superior cut. (D) The wedge of tissue is excised and the natural continuity of the lateral nasal sill is preserved. |
1. Kridel RWH, Konior RJ, Shumrick KA, et al. Advances in nasal tip surgery: the lateral crural steal. Arch Otolaryngol Head Neck Surg 989;117:1206–12.
2. Kridel RWH, Scott BA, Foda HMT. The tongue-ingroove technique in septorhinoplasty. Arch Facial Plast Surg 1989;1:246–56.
3. Calvert JW, Brenner K, DaCosta-Iyer M, et al. Histological analysis of human diced cartilage grafts. Plast Reconstr Surg 2006;118(1):230–6.
4. Sheen JH, Sheen AP. Aesthetic rhinoplasty. St Louis (MO): The Mosby Company; 1987.
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