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.

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.

GOALS

The primary goals in Asian rhinoplasty are as follows:

1. Thinner nasal bridge
   
2. Augmented dorsum
3. Refined tip with increased projection and rotation
4. Vertically oblique nostrils and triangular nasal base
5. Increased columellar length
6. Obtuse nasolabial angle (greater than 90 degrees)
7. Moderate skin and soft-tissue envelope thickness for aesthetically pleasing tip definition.

PREOPERATIVE NASAL EVALUATION AND SURGICAL PLANNING

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:

1. Bulbous, poorly projected tip with a plan of open rhinoplasty with structural grafting
2. Low dorsum with a plan of augmentation with diced costal plan of augmentation with diced costal cartilage wrapped in costal perichondrium.
3. Wide ala with a plan of bilateral alar base reduction.

If structural grafting is indicated, plan for the constituent material. A thorough knowledge of the types of autologous (septal, conchal, costal cartilage, and deep temporalis fascia) or alloplastic grafting and of harvesting techniques is needed.

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.

Fig. 3. Local injection used to hydrodissect the mucoperichondrium from the right lower lateral cartilage

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

Fig. 4. Nasal SMAS/mucoperichondrium excised from the nasal tip.

Fig. 5. (A) Lateral and (B) frontal view of a bruised infratip lobular graft.

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).

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.

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

Fig. 14. An auricular cartilage columellar strut created by suturing a double-layered segment with the concave sides facing one another.

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.

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).

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.

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.

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: excessive alar lobule with normalsized nostrils
• Type II: large nostrils and excessive alar lobules.

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.

Fig. 22. Postauricular closure following conchal cartilage harvesting. Fig. 23. Costal (rib) cartilage carved into a columellar strut (left), rim grafts (middle) and alar batten grafts (right).

Fig. 24. Layered 1- to 2-mm polytetrafluoroethylene sheeting. Fig. 25. Typical silicone L-strut used for dorsal augmentation.

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.

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.

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.

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.

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.

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.

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.

Fig. 32. (A–D) Postoperative photos of alar base reduction scar.

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

RISKS AND COMPLICATIONS

• 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.

PEARLS

• 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.

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.

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.