Asian Rhinoplasty

While Asian rhinoplasty is considered among the most demanding and difficult surgeries to perform, Dr. Nassif and the other surgeons at Spalding Drive Plastic Surgery possess the skill and aesthetic vision to achieve wonderfully natural, stunning results. Dr. Nassif will work to minimize flaws while preserving nasal functioning and structural integrity. His technique when delivering his Los Angeles Asian Rhinoplasty is highly conservative, preserving adequate cartilage and thus preventing the need for revision surgeries.

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. Our Los Angeles 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

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. Hydrodissection aids in dissecting SMAS/mucoperichondrium en bloc 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 may be placed.

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). This technique will release any constraints from the cartilage and may increase the natural projection and allow a lateral crural steal. 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. 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. 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, shield tip graft, bruised onlay dome or infratip lobular grafts, or a combination of any of these grafts. Dr. Nassif 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.

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. To augment the nasolabial or subnasal regions, plumping grafts or a posterior septal extension graft may be considered. Our surgeon also uses diced cartilage injected through a 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. 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 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, rib perichondrium, or deep temporalis fascia is placed over the tip complex to prevent long-term visibility of the grafts through the skin.

If additional cartilage is needed, autologous cartilage is preferred. Auricular cartilage harvesting from the concha cavum and cymba may be approached from the anterior or posterior surface. Costal cartilage, 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.

Our surgeons prefer low to low osteotomies followed by fading medial osteotomies or infracturing.