Rhinoplasty of the Asian nose requires almost completely different techniques than that of the Caucasian nose. In the Caucasian nose it is usually about reduction and rearrangement of structures, while in the Asian nose it is about augmentation and extension of structures. The anatomy of the Asian nose is characterized by a weak and underdeveloped bone and cartilage support structure with usually a thicker overlying soft tissue layer. This creates an aesthetically short nose with poor tip projection and wider flared nostrils.
While augmentation of the bridge of the Asian nose is often done by a silicone or PTFE-coated silicone implant, the management of the tip is a different matter. Attempting to extend the silicone implant in an L-shaped to increase nasal tip projection and a downward tip rotation is fraught with long-term problems due to the pressure of the implant on the overlying tip skin. As a result, nasal tip management should be done by using the patient’s own cartilage. However, donor cartilage from the septum in Asians is usually in short supply for the amount needed to extend and support the nasal tip.
The best method to control tip projection and rotation is through the use of septal extension and tip onlay grafts. But the paucity of septal cartilage requires an additional donor source for both types of grafts and this is the ear. The septum is the donor site for the septal extension graft(s) and the ear is the donor site for the cap or infralobular tip grafts. These two types of grafts combined with defatting of the underside of the dome skin and dome suture plication complete the nasal tip reshaping.
Septal extension grafts in the Asian nose can usually extend up to 6mms or more after the lower alar cartilages and its attached soft tissues are released and stretched. The key maneuver is in how to fix the extension grafts onto the caudal end of the septum. A single graft can be overlapped onto the septum and brought forward. But the most stable method is to create a V-shaped graft construct. One extension graft is applied at the top of the causal septum in a horizontal direction and secured on one side of the septum. The other graft is applied between the tip of the initial extension down at 45 degrees and fixed to a lower position on the septum on its opposite side. A recent study has shown/suggested that this septal extension construct is biomechanically more stable to resist the pullback of the stretched overlying tissues.
Once the nasal tip has been grafted and stabilized, the dorsal augmentation is then done. If the patient is not amenable to a rib graft for bridge augmentation, a silicone implant must be used. The thickness and length of the implant is determined by taking a ruler and placing it between the midpoint of the glabella and resting it on the nasal tip. The underlying space between the ruler and the nasal skin determines the graft shape and length. This is ideally measured and carved as the first part of the rhinoplasty procedure and is done before the nose is even opened. This allows for an accurate graft sizing since the tissues are not distorted.
My preferred technique in Asian rhinoplasty tip management is a dual cartilage graft approach with septal extension and onlay tip augmentation. Dorsal augmentation can be managed by a rib graft implant, which is the patient’s choice.
Dr. Barry Eppley
Indianapolis, Indiana