Lengthening of the Asian Nose.

The Asian nose has its unique morphology and forms a significant proportion of noses treated by the rhinoplasty surgeon not only in Asia but also in other countries where the Asian diaspora resides. The anatomical features and dimensions of the Asian nose differ from noses of persons of African, Caucasian, Indian, and Middle Eastern origins, poses its own challenges, and warrants a unique set of techniques for its aesthetic improvement. In this article, we present an overview of the approach to the lengthening of the Asian nose, drawing from our own experience with managing the Asian nose and referencing the published literature on the subject.

Correction of Short Nose.

To correct an Asian short nose with low dorsum, short columella, and poorly defined nose tip, augmentation rhinoplasty has been popularized. A simple augmentation no longer is considered an efficient rhinoplasty approach for Asians aesthetically; most surgeons simultaneously perform nasal elongation and augmentation during rhinoplasty. To extend the nose length successfully, important factors are cartilages, mucosal and skin conditions, and presence and degree of fibrotic changes. In addition, surgeons should consider preoperatively how much should be extended from an aesthetics perspective. This article introduces the current practice of surgical correction of the short nose in Asians.

Surgical Techniques for the Correction of Postrhinoplasty Depressed Scars on the Nasal Tip.

IMPORTANCE: Augmentation rhinoplasty is common in the Asian population and the lack of suitable autologous material for augmentation has led to the use of alloplastic materials. Many of these patients develop complications, including a depressed dimple-like scar of the nasal tip. Causes of such dimpling include the use of large implants, infection, extrusion, and surgeon incompetence. OBJECTIVE: To describe the various techniques that can be used to correct dimpling of the nasal tip. DESIGN, SETTING, AND PARTICIPANTS: Data were retrospectively reviewed from 28 patients who had undergone surgical procedures from January 1, 2013, through July 31, 2014, in a rhinoplasty clinic in Seoul, Korea, for the correction of a contracted nose with nasal scars secondary to previous rhinoplasties. Data analysis was conducted from August 1, 2014, through February 16, 2015. INTERVENTIONS: Before surgery, a complete rhinological examination was conducted, digital photographs were taken, and an assessment was made regarding the severity of the dimpling, the condition of the nasal skin, and the underlying supporting structures. Based on these factors, the appropriate type of procedure was planned. MAIN OUTCOMES AND MEASURES: Patient satisfaction with change after surgery was assessed using a 3-point Likert scale (3 indicates satisfied; 2, fairly satisfied; and 1, dissatisfied). Outcomes were also reviewed by 2 surgeon-peers who gave an outcome score ranging from 1 to 10 (1 indicates a poor cosmetic outcome; 10, the best possible outcome). RESULTS: The nasal contour and tip symmetry were restored to aesthetic standards with these relatively simple techniques. Eleven patients (39.2%) were treated with unilobed flap, 4 (14.2%) with a bilobed flap, 3 (10.7%) with Z-plasty, 9 (32.1%) with soft-tissue interposition, and 1 (3.5%) with a transposition flap. Twenty-four of the 28 patients (85.7%) were satisfied with their outcomes and 4 (14.3%) patients were dissatisfied and were given a revision procedure, following which they were satisfied with their outcomes. The follow-up period ranged between 6 to 32 months (mean, 12.3 months). The mean surgeon-reviewed outcome score for soft-tissue interposition procedure was 8.0 of 10; for the unilobed flap, 8.0 of 10; for the bilobed flap, 7.5 of 10; for the transposition flap, 8.0 of 10; and for Z-plasty, 7.8 of 10. CONCLUSIONS AND RELEVANCE: These techniques are reproducible and the choice of the technique depends on the shape, size, and location of the scar; skin condition; patient expectations; and the surgeon's experience and comfort level with the procedure. LEVEL OF EVIDENCE: 4.

The Seesaw Technique for Correction of Vertical Alar Discrepancy.

Alar vertical discrepancy including alar base has been viewed as one of the most challenging reconstructive problems in rhinoplasty. The authors have created a simple technique that consistently gives aesthetically acceptable results. The authors have designed the seesaw technique to correct alar discrepancy (type 1 to 3). Type 1 has been used in 14 patients, type 2 has been used in three patients, and type 3 has been used in seven patients. Alar discrepancy was corrected satisfactorily in all cases, with good cosmetic outcome. One case required scar revision and another case required revision for overcorrection; satisfactory results were ultimately achieved in both cases. This new technique is quite easy to design and is effective in the correction of alar discrepancy. It yields good postoperative results along with satisfactory aesthetic outcomes.

Pressure necrosis of septal cartilage associated with bilateral extended spreader grafts in rhinoplasty.

OBJECTIVE: To investigate septal cartilage compressive changes as a result of bilateral extended spreader grafts (ESGs), which are commonly used in rhinoplasty. The buckling, rupturing, or necrosis of the recipient site leads to nasal tip structural deformity. These pathologic changes associated with bilateral ESGs warrant the clinician's attention and in-depth basic and clinical research. METHODS: The basic experimental study involves New Zealand rabbits, randomly assigned to groups A, B, C, and D, with group A as a reference. The right auricular cartilage was harvested and transplanted into a corresponding anatomic location of the left ear. The compressive effect was studied by gross observation and microscopic examination with hematoxylin-eosin staining after 3 months. In a clinical experiment, revision rhinoplasty surgical procedures were performed in 10 human patients 6 months to 1 year after placement of bilateral ESGs. The compressive changes of septal cartilages between the ESGs were observed intraoperatively. RESULTS: In group A of the rabbits, no pathologic change was noted, but 2 cases of attenuation were observed in group B (33.3%), 6 cases of central fracture (100%) with 1 case of perforation (16.7%) in group C, and 6 cases of different degrees of defects in group D (100%). Clinical intraoperative observations revealed 1 case of defects and necrosis (10%), 4 cases of attenuations and cracks (40%), and 5 cases of attenuations (50%). CONCLUSIONS: Septal cartilage compressive necrosis leading to structural damage by bilateral septal ESGs is a clinically significant complication of rhinoplasty. Owing to its affect on the viability of the original septal cartilages, we believe the unilateral ESG with columellar strut is preferred, especially in Asian patients.

Surgical anatomy of cartilaginous structures of the Asian nose: clinical implications in rhinoplasty.

OBJECTIVES/HYPOTHESIS: The morphologic features of upper and lower lateral cartilage and septal cartilage of the cadaveric nose were analyzed to provide practical anatomical knowledge for Asian rhinoplasty. STUDY DESIGN: Cadaveric dissection. METHODS: A total of 21 Korean adult cadavers were dissected. External nasal morphology was observed, measured, photographed, and analyzed. Histologic features were observed with a light microscope in coronally-transected specimens stained with hematoxylin and eosin. RESULTS: The lengths of the upper and lower lateral cartilage of Korean cadaveric noses were similar to those of white noses. The widths of the upper and lower lateral cartilage were substantially smaller in Korean cadaveric noses than in those of whites. Upper lateral cartilage include substantial transverse portions near the keystone area that should be preserved in component reduction rhinoplasty. The relationships between the upper lateral cartilage and the lower lateral cartilage were divided into four types. Type I, in which the upper lateral cartilage and lower lateral cartilage are interlocked to form a Z-shape, is the most common. The posterior portion of the septal cartilage, which is connected to the perpendicular plate of the ethmoid and vomer, is thickest. CONCLUSIONS: Cartilaginous structures of Asian noses were substantially different from those of whites in terms of their shape, size, thickness, and relationship with other structures. The data from surgical anatomical observations of the cartilaginous framework of Korean cadaveric noses provided in this report will provide valuable information for performing rhinoplasty on Asian patients.

Subnasale flap for correction of columella base deviation in secondary unilateral cleft lip nasal deformity.

OBJECTIVE: To present the effects of subnasale (SN) flap on the correction of deviated columella base in patients with secondary unilateral cleft lip nasal (UCLN) deformity. PATIENTS AND METHODS: The patients were 6 adult Koreans with cleft cases (mean age, 29.1 y; range, 20-43 y; 1 man and 5 women; secondary UCLN deformity with columella base deviation). After the open rhinoplasty with the Padovan incision had been completed for correction of the secondary UCLN deformity, the SN flap was used for correction of the deviated columella base. The design of the SN flap started from the central portion of the SN region that will be the reconstructed columella and extended to the nasal floor in the larger nostril site. Then, the SN flap was transposed into the smaller nostril site. The columella skin was also elevated and placed into the larger nostril site with the distal end inserting into the donor site. The patients' follow-up period was 16 to 40 months. RESULTS: The SN flap after the open rhinoplasty with the Padovan incision resulted in minimal scarring on the donor and recipient sites. The deviated columella base was straightened in all cases. During the surgical follow-up period, there was no recurrence of the columella base deviation in any patient and no other noteworthy complications were found. CONCLUSIONS: For correction of the columella base deviation in patients with secondary UCLN deformity, the SN flap can be a viable treatment option.

Correction of pollybeak and dimpling deformities of the nasal tip in the contracted, short nose by the use of a supratip transposition flap.

OBJECTIVE: To discuss our experiences with the use of a supratip transposition flap to simultaneously correct pollybeak deformity and nasal tip dimpling. DESIGN: From April 1, 2007, through August 31, 2008, 10 Asian women with a contracted, short nose that exhibited nasal tip dimpling were retrospectively included in this study. By use of an open approach, the osteocartilaginous framework was elongated first. If the pollybeak and dimpling deformities of the nasal tip were found after the closure of the transcolumellar incision, a supratip transposition flap was designed to correct the combined deformities over the supratip and nasal tip areas. Finally, bilateral marginal incisions were closed. RESULTS: The follow-up period ranged from 2 to 16 months, with an average of 5 months. No immediate complications were noted in this small series. Four of 10 patients required minor flap revisions, with satisfactory results attained thereafter. All patients were satisfied with the aesthetic result after scar maturation. CONCLUSIONS: The use of the supratip transposition flap not only corrects pollybeak deformity but also resolves dimpled nasal tip depression. The techniques presented herein add to the armamentarium of revision rhinoplasty surgeons, especially those dedicated to the treatment of the Asian patient who undergoes rhinoplasty.

Correction of severe alar retraction with use of a cutaneous alar rotation flap.

BACKGROUND: Severe alar retraction is one of the most challenging problems to correct in nasal surgery. Management for severe alar retraction traditionally requires multiple stages and uses several surgical techniques. This article introduces a single-stage technique to correct severe alar retraction deformities using a cutaneous alar rotation flap in conjunction with alar batten grafts. METHODS: Patients with severely retracted alae underwent ala reconstruction using a cutaneous alar rotation flap and autogenous cartilage batten grafts. RESULTS: Thirteen patients with severe alar retraction underwent alar reconstruction using cutaneous alar rotation flap and alar batten grafts. The alar retraction was corrected in all cases, achieving improvements functionally and aesthetically. No recurrence of alar retraction was noted. The incision sites for the patients healed with acceptable cosmetic results, with only one patient requiring scar revision. CONCLUSIONS: The cutaneous alar rotation flap is an effective and reliable surgical option to correct severe alar retraction. Advantages of this technique include a single-stage approach, ease of design, tissue match, and rich blood supply. Scar from the flap design can be kept inconspicuous by precise placement of the incision within the junction of the ala and the nasal dorsum, following principles of the aesthetic nasal subunits.

Histologic study of Gore-Tex removed after rhinoplasty.

OBJECTIVES/HYPOTHESIS: Gore-Tex is known to be a relatively safe material. However, it leads to complications. Although widely used, the reasons complications occur are poorly understood. Thus, this study attempted to investigate histological changes between the Gore-Tex, removed within a certain period of time after rhinoplasty, and its neighboring tissues. METHODS: This study involved 122 Gore-Tex samples obtained at the time of reoperation in patients who had undergone augmentation rhinoplasty. The subject group included 31 men and 91 women. The mean patient age was 30.2 years, and the mean Gore-Tex implantation period was 23.2 months (range, 1 week-13 years). We noted the shapes of the Gore-Tex samples, their relationships and extent of adhesion with neighboring tissues, and the changes of thickness. We also observed tissue ingrowth, calcification, inflammation, foreign body reaction, and structural changes using light microscopy and electron microscopy. RESULTS: After the Gore-Tex samples had been in place for an extended period of time, the neighboring tissues grew into the central portions of the samples, which enhanced adhesion between the samples and the tissues. In addition, Gore-Tex samples that had been implanted for longer periods of time were associated with decreased thickness and calcification, foreign body reactions, and increased structural changes. CONCLUSIONS: In contrast to previous studies, our study showed that Gore-Tex samples implanted in human bodies for extended periods of time prompted ingrowth of neighboring tissues, calcified tissue degeneration, and inflammation. Foreign body reactions were found in a large number of samples. The Gore-Tex structures were destroyed and transformed. As a result, it is important to follow the stability of Gore-Tex material on a long-term basis.

Gross and pathologic analysis of long-term silicone implants inserted into the human body for augmentation rhinoplasty: 221 revision cases.

BACKGROUND: In augmentation rhinoplasty, delayed morphologic changes are often observed with silicone implants, despite them being known as a safe implant material. The purpose of this study was to identify the cause and time course of delayed shape changes of silicone implants, through the long-term evaluation of inserted implants and their surrounding nasal soft tissues after their removal at revision rhinoplasty operations. METHODS: Two hundred twenty-one silicone implants removed during revision rhinoplasty were studied. The period of insertion ranged from 1 month to 25 years, with an average of 6 years 7 months. Calcification within the silicone implants and, when available, the capsular soft-tissue attachments were examined with the naked eye and light microscopy. RESULTS: Calcification was first observed grossly with the naked eye after 5 years 8 months of insertion. With light microscopy, calcification debris could be seen after 4 years. After implant insertion for more than 9 years, focal calcification could be seen in 50 percent of implants. When implants had been inserted for more than 15 years, a denatured type of large calcification was clearly observed. Plasma cell, macrophage, and neutrophil proliferation was noted in the soft-tissue capsule surrounding the superficial calcifications in those individuals with an early inflammatory response, and lymphocyte proliferation was noted in those with a late inflammatory response. CONCLUSIONS: Silicone implants were noted to induce calcification when inserted for a long time, causing long-term morphologic changes. This should be taken into consideration when choosing silicone implants for augmentation rhinoplasty.

Subnasale flap for correction of columellar deformity.

BACKGROUND: Columellar defects or deformities are challenging problems to correct. Many different techniques have been described, yet none are ideal, especially for the purpose of aesthetic improvement. METHODS: Local flaps are designed from the subnasale region extending into the nasal floor. It is a one-stage procedure that transfers well-matched skin to the columella. Flaps are rotated medially to improve various types of columellar deformities. The flap was used in 20 cases for defective, narrow, and deviated columella. RESULTS: Results in all of the cases were satisfactory, with minimal complications. CONCLUSIONS: The procedure is relatively simple, and primary closure of the donor site is possible without causing external deformity. The subnasale flap can be fashioned without a visible donor-site scar. It is indicated for partial to total reconstruction of columellar defects, aesthetic improvement of narrow columella, and correction of deviated columella.

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

Augmentation rhinoplasty of the Asian nose may be effectively accomplished with alloplastic materials. However, certain circumstances mandate the use of autologous grafts (e.g., dorsal augmentation that exceeds 8 mm and patient intolerance of alloplastic implants). Septal and auricular cartilages are inadequate for dorsal augmentation of the Asian nose. The use of costal cartilage for autologous augmentation in select Asian patients has proven to be a reliable method in more than 500 operative cases during a 10-year period. This study was designed to evaluate the ideal costal cartilage graft for augmentation rhinoplasty. Forty-two preserved cadavers were studied for the relationship of the individual rib cartilages to the surrounding tissue and for the length and caliber of each costal cartilage. The seventh rib was found to be the ideal rib graft by virtue of its safe location and overall size for grafting. The seventh rib is situated over the abdominal cavity, so the risk of pneumothorax is insignificant. The internal thoracic artery and vein descend in close apposition behind the first to sixth ribs but begin a course medial to the ribs inferior to this point, and therefore vascular injury during seventh-rib harvesting is unknown. The seventh rib also provides the greatest overall available length (90.7 mm, right; 89.6 mm, left) and thickness (17.6 mm, right; 17.5 mm, left). Despite the more conspicuous location of the incision required to harvest the seventh rib, the limited 3-cm incision that is used has healed favorably in almost all cases. The other major drawback for seventh-rib harvesting is the dissection required through the overlying rectus abdominis muscle, but little technical difficulty or postoperative morbidity is added with muscle dissection. The seventh rib is advocated as the ideal choice for augmentation rhinoplasty and potentially other recipient sites.

Secondary rhinoplasty of the Asian nose: correction of the contracted nose.

The contracted nose is a unique entity that follows primary rhinoplasty in the Asian patient. The proposed reasons for this complication are capsular contraction from a silicone nasal implant, pressure necrosis of the lower lateral cartilage resulting from the nasal implant, and infection after alloplastic implantation. The two principal anatomic constituents that must be addressed at the time of secondary rhinoplasty are the lower lateral cartilages and the skin envelope. The lower lateral cartilages should be derotated, projected, and transfixed with an extended spreader graft. Additional onlay grafting may be required to provide greater nasal tip derotation and projection. A transcolumellar incision situated at the columellar-labial angle permits undermining of the upper lip skin to release tension on the incision. If the nasal tip retraction is severe, then the skin envelope may be insufficient to provide coverage to the new cartilaginous framework. In this case, a paramedian forehead flap is recommended to provide adequate tissue coverage. Correction of alar-columellar disparity should be undertaken with composite grafting only after 6 months have transpired to gauge the ultimate relation between the alae and columella. Infection that arises after correction of the contracted nose can be devastating. It should be treated aggressively, but tailored to the severity of the infection. Wound tension along the columella may predispose to skin necrosis and consequent cartilage exposure, which should be managed in turn with prostaglandin emollients to accelerate wound healing and to prevent infection.