Asian rhinoplasty is one of the most common surgical procedures performed by surgeons dealing with the Asian face. However, there is little conformity in surgical approaches and a wide variety of techniques exists. This is confusing for the novice surgeon who does not yet have the benefit of many years of practice and who in choosing a particular technique may encounter numerous unpleasant problems years after the initial surgery and not know how to deal with them. This chapter is a description of the author’s personal technique based on over 20 years of experience in Asian rhinoplasty.
There is a wide variation in the different types of Asian noses. Some are thin-skinned with visible lower lateral cartilages and tip definition like a Caucasian nose, others are thick-skinned, ill-defined, bulging noses with bulbous tips and overhanging alar lobules. Still, others may have a dorsal hump with a hooked appearance whilst others may have wide splayed nostrils and lack of columella support giving an amorphic look.
Despite these variations most Asians seeking rhinoplasty in Singapore or in other Asian countries want similar outcomes for their noses which include the following:
- Higher dorsal bridge
- Increased length of nose
- Slimmer nose
- Well projected tip
- Refined, sharp tip
- Well proportioned alar lobules
- Narrower nostril base
- A visible columella
- A smooth orbital-nasal line
The overwhelming request of most patients is to raise the height of the nasal dorsum followed by achieving a sharp, well-projected tip. As a result, most Asian rhinoplasties are augmentation rhinoplasties in which some form of implant is added as opposed to Caucasian rhinoplasties which are mostly reduction or straightening rhinoplasties in which tissue is removed.
Most Caucasian surgeons mistakenly believe that the typical Asian patient requesting a rhinoplasty wants a nose that looks like that of a Caucasian. This is furthest from the truth. Asian patients only want high slim noses which are aesthetically pleasing and appropriate to their ethnic origin. They want their noses to be at the upper end of the aesthetic scale for their ethnicity ie. to be a ‘beautiful Asian. They do not want to be ‘westernised’.
The use of silicone implants
For many decades, surgeons have relied heavily on the use of silicone implants. These come in a wide variety of sizes, lengths and shapes and can be carved from a silicone block or pre-moulded. They have been used successfully by generations of surgeons and are easy to obtain and insert. In its simplest form and in the appropriate patient, under local anesthetic, an incision can be made along the rim of one nostril or in the upper buccal sulcus, a pocket is created over the dorsum of the nose and the implant is inserted.
If approached from a nostril incision, a pocket can be created downwards into the columella and the L-strut of the implant is then abutted against the anterior nasal spine. This creates a tenting effect on the tip and dorsum and the nose is miraculously transformed in a matter of 30 minutes.
Patients are highly appreciative of their immediate transformation, the lack of swelling and rapid recovery. They are happy and the surgeon is commended.
Problems with Silicone implants
Problems can arise weeks to years later and the nose can become distorted and deformed as a result. Infection, inaccurate placement and undue pressure of the implant against the skin of the tip of the nose are the usual culprits. Patients should always be warned of the potential complications from silicone implant surgery which include:
- Infection
- Extrusion
- Crookedness
- Warping
Tackling Infection
Being a foreign body, the implant must be inserted under surgical sterility and antibiotic coverage provided. The access incision should be well sutured to prevent contamination. Even so, the risk of infection remains high. Infection can occur early within a week or two after surgery or it can occur many months to years later. It usually shows up with a swelling, redness and tenderness at the tip. Very rarely, the episode of infection can be overcome by a course of heavy antibiotics.
More often than not, there may be an accompanying foul-smelling pussy discharge from an opening within the nostrils. At this point, the implant has to be completely removed, the pocket cleansed and then allowed to heal for several months before contemplating re-implantation. The biggest mistake for a novice surgeon to attempt is to wash the implant and pocket and then re-implant it immediately. This invariably dooms the nose to reinfection with devastating consequences to the cosmetic result.
If the infection is detected early, an excellent aesthetic outcome can be achieved as no tissue necrosis is encountered. Once the infection settles and the scars soften, nasal augmentation can be attempted again successfully, preferably with the composite rhinoplasty technique to be described shortly. But once the infection is left to fester for too long, there is significant tissue necrosis and loss of volume. The resultant nose after implant removal can look scarred, puckered and collapsed. Such scars have to be managed by a series of subcisions and even surgical excision before implantation at a later date.
Late infection and or extrusion
The biggest culprits are tension and pressure which conspire to spoil an initially good result.
In performing an augmentation the skin is invariably stretched and expanded by the implant. The implant not only presses down on its bony cartilaginous base, but it also pushes upwards on the dorsal skin and forwards on the tip skin. The L-strut will be pushed down to the anterior nasal spine. These pressure points are unavoidable and it is therefore not possible to insert an implant under ‘no tension’. However, the overlying skin and soft tissue can usually accommodate to these stretching forces and achieve a ‘no tension’ state after a few days.
It is when the implant is too large that problems arise. In a mistaken attempt to create better tip projection and definition, implants that are too sharp or long for that nose are inserted. The pressure on the tip skin can be considerable and this leads firstly to pressure ischaemia and a reactive thinning of the overlying tip skin. Once this happens the implant must be removed to safeguard the integrity of the overlying skin. Either that or the implant must be reduced in size and a cartilage graft sutured onto the tip of the implant to act as an autologous interposition graft between the implant and the tip skin.
The first warning sign is that the tip skin becomes red and inflamed and the patient may complain of slight pain at the tip. At a later stage. If these signs are ignored, this can be followed by tissue necrosis and infection or the tip skin becomes thinner until the implant eventually extrudes. At this late stage, removing the implant will result in a deformity of the tip often with a dent or a puckered scar. This becomes difficult to reconstruct.
Other problems which can arise are intrinsic to the silicone material itself. Its presence in the body provokes a capsule formation around it. Over time this capsule can contract and warp the implant, making the nose appear crooked. Or more commonly it will contract towards the direction of the access incision and pull the implant off the midline. The enveloping capsule also accentuates the outline of the implant, especially on either side of the dorsum where a faint shadow or groove betrays its presence.
The silicone implant at the tip may also displace the lower lateral cartilages laterally so that the tip becomes tri-lobed and wider in appearance. This can be a source of unhappiness for the implant patient as contrary to achieving a slimmer nasal tip they end up with a wider, more bulbous and odd-looking tip.
Over time the nasal skin over a nasal implant can become stretched, shiny and thin with the development of telengiectasia. Under certain lighting (usually backlighting) the nasal implant can glow with a strange, reddish translucence. To avoid this phenomenon, silicone implant manufacturers started making flesh-coloured or beige implants with some success.
A common unwanted complication over time is the migration of the implant towards the glabellar/forehead region creating an unpleasant and exaggerated prominence there. At the same time, the tip can become upturned and shortened with undesirable nostril show. This again is undoubtedly due to excess tension at the tip
Achieving better techniques for Asian Rhinoplasty
Augmentation rhinoplasty in the Asian nose using a silicone implant is usually performed under local anesthesia as has been discussed above. This is fast, convenient and economic for the patient who can thus avoid additional general anesthetic and recovery room charges. Ideally, the augmentation rhinoplasty should be achieved with autologous materials only and still preferably performed under local anesthesia.
However, this is difficult to achieve as a large amount of cartilage might be required which would necessitate cartilage graft harvest from either the ribs or the septum of the nose. Both of these procedures are uncomfortable and unpleasant for the patient if not performed under general anesthesia. Furthermore, costochondral grafts over the dorsum of the nose have a tendency to warp or develop surface irregularities with time.
This problem of having insufficient autologous material and being performed under local anesthesia can be addressed by composite rhinoplasty.
The Composite Rhinoplasty
This is an open rhinoplasty technique where there is an amalgamation of gortex (which is used to create the dorsum of the nose) with autologous ear cartilage (which is used for tip stability and projection). In this way, more tension at the tip can be achieved than if a Silastic implant had been used. The gortex is snugly into a subperiosteal pocket over the dorsum of the nose and is lightly sutured to the cartilage grafts of the tip which are firmly secured between the medial crura and over the domes of the resident nasal cartilage.
More than sufficient cartilage can be harvested from a single ear without appreciably altering its shape. This can be performed easily under local anesthesia with very little pain in addition to the injections around the nose. The procedure can be performed in under two hours and patients can be discharged that same day after a short rest in the recovery room.
Technique
The author currently uses gortex from the XXXXX company. This comes in the form of several layers of gortex sheets laminated together to form blocks of AxBxC mm. The patient is marked and measured preoperatively and the gortex block is then custom carved with an #11 blade to create a tapered linear “I” implant that stretches from the desired point in the glabella to the supratip area. The gortex implant does not extend into the tip subunit. The gortex is placed over the dorsum to simulate the desired result and adjustments are made to the shape until it is appropriate. The surface of the implant is smoothened out with sandpaper and the gortex is then sterilised and autoclaved.
The patient is prepared for nose surgery in the usual fashion and local anesthetic (2% Lidocaine with 1;200,000 noradrenaline) is delivered as infraorbital nerve blocks as well as infiltration of the entire nasal area. The anterior and posterior surfaces of the selected ear are also similarly anesthetised. The patient is then cleaned and draped after which nasal packs soaked in Cocaine 5% are inserted into both nostrils.
An anterior incision is made anteriorly along the antihelix of the anesthetised ear and the skin and perichondrium is dissected off the conchal fossa. Two curved grafts are taken from the double concavity of the fossa leaving the intervening convex bridge untouched. The skin is re-approximated with a 6.0 Nylon running suture and a tie-over bolster dressing is applied to the anterior aspect of the concha. The longest of the grafts is bivalved along its longest axis, then folded on itself and sutured together with a running mattrass suture of 5.0 Maxon/PDS. This creates a perfectly straight and rigid columellar strut graft that is sutured between the medial crura of the lower lateral cartilages.
An Open Rhinoplasty using a stairstep or inverted-V columalla incision is commenced. The skin envelope is elevated over the tip and soft tissue lobules by entering into the plane of the superficial areolar layer. This reveals the fibromuscular layer that clads the underlying cartilages and once this is lifted off at the plane of the deep areolar layer, a subperiosteal pocket over the dorsum of the nose is easily created. No debulking of soft tissue is needed as this will diminish vascularity and lymphatic drainage of the tip and supratip areas leading to prolonged swelling.
Once the domes of the lower lateral cartilages have been exposed, if desired they can be reduced by performing a cephalad resection. Any grafts harvested from this manouver are ideal for placing later as veneer grafts over the tip of the nose as they are very soft and malleable. Should additional cartilage be required, this can be harvested from the septum which should by this time be profoundly anesthetised by the cocaine packs.
A pocket between the medial crura of the lower lateral cartilages is extended down to the anterior nasal spine. The previously prepared conchal graft is sutured between the medial crura and then inter and intradomal sutures are applied to the tip to create the desired shape. Additional grafts from the remaining piece of conchal cartilage or from the lower lateral resection are layered on as veneer grafts over the tip sutured firmly to the columella strut graft. A tacking dissolvable suture is used to unite the tip of the “I” implant to the tip grafts. In this way, a composite “L” implant has been created.
The fibrofat flap and skin envelope are then sutured back into place as accurately as possible. The cocaine packs are replaced with Tulle Gras nasal packs and a thin plaster of paris is applied to the external surface of the nose. These are removed on the 4th and 7th days respectively.
Postoperative Instructions
The patients are warned beforehand of all possible complications that can arise from surgery. They are mentally prepared that the nose will be hugely swollen for up to two weeks following which it will start to subside and be more presentable but the residual swelling will not fully resolve till 9-12 months later, sometimes longer. Patients are seen at two to three-month intervals.
Benefits of the Composite Rhinoplasty
Gortex appears to be a more biocompatible material than silastic. It is easy to carve and shape and merges seamlessly with the overlying soft tissue. Over time, there is no appreciable capsule formation with visible outline of the implant or a shiny appearance of the overlying skin. The incidence of infection and deviation of the implant is much lower than silicone and if it does deviate postoperatively it can be easily bent back into shape as it is malleable.
With a gortex implant over the dorsum of the nose, the patient can be assured of a smooth natural contour for many years. There is no resorption or build-up of external calcifications. The tip is made entirely of autologous cartilage and can be projected to the desired degree with no worry of excessive tension or pressure problems of the overlying skin.
