Aesthetic Plastic Surgery of the East Asian Face Hong Ryul Jin Thieme
(Trang không có chữ)
Thieme
(Trang không có chữ)
Aesthetic Plastic Surgery of the East Asian Face
Hong Ryul Jin, MD, PhD
Professor and Chair
Department of Otorhinolaryngology–Head and Neck Surgery
Boramae Medical Center
Seoul National University College of Medicine
Seoul, Republic of Korea
956 illustrations
Thiem e
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Library of Congress Cataloging-in-Publication Data
Names: Jin, Hong Ryul, editor.
Title: Aesthetic plastic surgery of the East Asian face / [edited by]
Hong Ryul Jin.
Description: New York : Thieme, [2016] | Includes bibliographical
references and index.
Identifiers: LCCN 2015048817| ISBN 9781626231436 (hardcover :
alk. paper) | ISBN 9781626231443 (eISBN)
Subjects: | MESH: Reconstructive Surgical Procedures | Cosmetic
Techniques | Surgery, Plastic--m ethods | Face--surgery | Asian
Continental Ancestry Group
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v
Dedicated to those physicians who believe that a philosophy is required to change even a small part of the face.
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vii
Contents
Foreword .................................................................................................................................................................................................ix
Dean M. Toriumi
Foreword .................................................................................................................................................................................................. x
Stephen S. Park
Preface .....................................................................................................................................................................................................xi
Acknowledgm ents ..............................................................................................................................................................................xii
Contributors ........................................................................................................................................................................................xiii
I Introduction
1. The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians ........................................................................... 3
Keng Lu Tan and Hong Ryul Jin
II Rhinoplasty
2. Augm entation Rhinoplasty Using Silicone Im plants .................................................................................................................13
In-Sang Kim
3. The Use of Costal Cartilage for Dorsal Augm entation and Tip Grafting ...............................................................................26
Victor Chung and Dean M. Torium i
4. Nasal Tip Modif cation in Asians: Augm entation and Rotation Control ..............................................................................47
Hong Ryul Jin and Jong Sook Yi
5. Hum p Resection ...................................................................................................................................................................................60
Tae-Bin Won and Hong Ryul Jin
6. Correction of the Deviated, Tw isted Nose .....................................................................................................................................72
Hun-Jong Dhong
7. Correction of the Saddle Nose .........................................................................................................................................................87
Keng Lu Tan and Chae-Seo Rhee
8. Alar Base Modif cation .......................................................................................................................................................................99
Ian Loh Chi Yuan and Hong Ryul Jin
9. Aesthetic Rhinoplasty for Southeast Asians...............................................................................................................................108
Eduardo C. Yap
10. Correction of the Short, Contracted Nose...................................................................................................................................122
Hong Ryul Jin
11. Managem ent of Alloplast-Related Com plications ....................................................................................................................135
Eunsang Dhong
III Blepharoplasty
12. Double-Eyelid Surgery: Nonincisional Suture Techniques ....................................................................................................151
Jin Joo Hong and Hae Won Yang
13. Double-Eyelid Surgery: Incisional Techniques ..........................................................................................................................162
Jae Woo Jang
14. Aging-Related Upper Blepharoplasty ...........................................................................................................................................173
Hokyung Choung and Namju Kim
15. Epicanthoplasty and Aesthetic Lateral Canthoplasty..............................................................................................................184
Yongho Shin
16. Lower Blepharoplasty ......................................................................................................................................................................196
Yoon-Duck Kim and Kyung In Woo
17. Correction of Ptosis ..........................................................................................................................................................................210
Woong Chul Choi and Juwan Park
18. Managem ent of Double-Eyelid Surgery Com plications ..........................................................................................................225
In-chang Cho and Aram Harijan
viii
Contents
IV Facial Bone Surgery
19. Zygom a Reduction ............................................................................................................................................................................243
Sanghoon Park and Jihyuck Lee
20. Mandible Reduction .........................................................................................................................................................................254
Sanghoon Park and Seungil Chung
21. Aesthetic Orthognathic Surgery ....................................................................................................................................................268
Seong Yik Han and Kar Su Tan
22. Genioplasty .........................................................................................................................................................................................286
Seong Yik Han and Kar Su Tan
V Facial Skin and Hair Rejuvenation
23. Managem ent Strategies for the Aging Asian Face: Philosophy and Evolution .................................................................303
Samuel M. Lam
24. Facial Fat Grafting ..............................................................................................................................................................................311
Kyoung-Jin (Saf ) Kang
25. Endoscopic Forehead and Brow Lift .............................................................................................................................................324
Tee Sin Lee and Stephen S. Park
26. Facial Rejuvenation Using Energy Devices .................................................................................................................................339
Un-Cheol Yeo
27. Hair Transplantation in East Asians .............................................................................................................................................349
Sungjoo (Tommy) Hwang
28. Aesthetic Laser Hair Rem oval for the Asian Face ......................................................................................................................364
Wooseok Koh
VI Minimally Invasive Facial Plastic Surgery
29. Aesthetic Facial Use of Botulinum Toxin in East Asians..........................................................................................................377
Kyle Seo
30. Facial Contouring Using Fillers ......................................................................................................................................................392
Jongseo Kim
31. Managem ent of Facial Filler Injection Com plications .............................................................................................................405
Hyoung Jin Moon and Jong Sook Yi
Index .....................................................................................................................................................................................................415
ix
Foreword
There is no population in the world that has a higher
grow th of interest in aesthetic surgery than the East Asian
population. It is reported that one in five women in the
Republic of Korea have undergone aesthetic facial surgery.
This dram atic increase is m ultifactorial and is in part
driven by local popular culture and media. This trend has
been notable over recent years, with the advent of Korean
popular culture and the associated desire to look like the
famed K-pop stars. The look is quite characteristic of Korean
aesthetics, with many patients showing their surgeon
photos of the same Asian media personalities. This trend
has become so fashionable that it is no longer a stigma to
undergo cosmetic surgery in the Republic of Korea and
China. In fact, it m ight now be considered a status symbol
and reflect upward mobility in the eyes of many. This age
of the “selfie” and Facebook has made “looking good” even
more important to this growing population. These social
changes have dram atically increased the dem and for Asian
cosmetic surgery, stimulating a significant increase in the
number of surgeons performing the surgery.
The aesthetics of the Asian face are constantly changing,
and surgical techniques must change to accommodate
such changes. Today, there is often the desire for a rounder
forehead, higher nasal dorsum, narrower nasal tip, and a
less round, more angular mandible and chin. Many of these
characteristics m ay indicate a desire for a more “Western”
look. However, there are different degrees of change and this
must be recognized by the surgeon. Hong Ryul Jin understands
the importance of this variance from patient to patient. This
requires the surgeon perform ing enough surgeries to have
acquired a number of techniques in their armamentarium.
In this book, Dr. Jin has compiled an outstanding collection
of chapters written by an expert group of surgeons. The
book covers the most updated techniques on contouring the
Asian face covering rhinoplasty, Asian eyelid surgery, facial
contouring, and aging-face surgery. The book also covers
the rapidly changing field of nonsurgical treatm ents, such
as botulinum toxin, fillers, and lasers.
In the section on rhinoplasty, the authors discuss
the use of implants and autologous materials for Asian
augmentation rhinoplasty. The difference in these techniques
is very significant and is reflected in these writings. Use of
implants continues to be the most commonly used method
to augment the nose. Nuances in the techniques are discussed
in great detail and are covered by several authors. Combined
techniques using alloplastic materials for dorsal augmentation
and ear cartilage for the nasal tip have become popular
to avoid some of the potential complications of extending
alloplastic implants into the nasal tip. The use of costal
cartilage for augmentation is discussed in detail, describing
techniques used to stabilize the nasal tip and augment the
nasal dorsum. Also covered are the nuances of performing
dorsal augmentation with costal cartilage and how to
minimize the likelihood of warping. Popular techniques, such
as diced cartilage for dorsal augmentation and tip grafting,
are covered as well.
The many techniques available for managing the Asian
eyelid are covered, including incisional and nonincisional
suture techniques, as well as conventional incisional
techniques. Precision measurement and marking, anesthetic
injections, incision placement, management of the fixation
method, postoperative care, and managing complications
are all discussed. Also covered is the management of the
epicanthal fold.
In the section on facial contouring, the chapters cover
management of the Asian malar region, mandible, perialar
augmentation,
chin
augmentation,
masseter
muscle
contouring, forehead contouring, and complications. Also
covered are the nuances of facial contouring that provide the
surgeon with many options for creating a more aesthetically
pleasing Asian face.
The section on nonsurgical management covers the
use of botulinum toxin for facial muscle contouring, brow
contouring, and rhytid m anagem ent. This section also
covers fat injections and contouring using autologous fat.
Laser resurfacing is discussed as well.
Dr. Jin has been a strong academic figure in Korea for
many years and has become well known around the world.
He has frequently lectured in the United States and all
over Asia. He is now considered an international expert
on Asian rhinoplasty and Asian facial cosmetic surgery.
His international influence is reflected in the diversity
of the authors contributing to his book, and he has done
a masterful job editing this work. Readers will find this
book comprehensive in its content and detail of surgical
descriptions and use of quality operative photography and
illustrations. This book is an essential reference for the
surgeon interested in providing the best outcomes in Asian
aesthetic facial surgery.
Dean M. Torium i, MD
Professor
Division of Facial Plastic and Reconstructive Surgery
Departm ent of Otolaryngology–Head and Neck Surgery
University of Illinois
Chicago, Illinois
x
Foreword
Hong Ryul Jin has led the way in creating a unique book on
aesthetic facial surgery for the East Asian patient. There
are m any unique variances w ith patients from this region
of the world, and they have put together a collection of
chapters that cover all aspects of facial aesthetic surgery
as it pertains to the Asian face. The book highlights the
m any nuances in facial aesthetic surgery in this group,
and any surgeon w ho has the occasional Asian patient
w ill be well served to have this edition in his or her
reference library.
A solid portion of this book is dedicated to the
techniques of Asian rhinoplasty. It is not limited to strictly
alloplastic dorsal implants, but covers many subtleties that
are often required with Asian patients. The third section
is dedicated to the periorbital rejuvenation of the Asian
patient, including ptosis and the double eyelid procedure.
There are intricacies to this procedure that distinguish
a good from a great result, and this book captures them
well. The remaining sections touch on other procedures
performed in facial aesthetic surgery, including facial
bone contouring, minimally invasive and office based
procedures, and hair rejuvenation.
Herein is a collection of many authors with vast
experience in facial aesthetic surgery in the Asian
population. It is comprehensive, eloquently written, and
will serve as an invaluable resource for years to come. Dr.
Jin is to be congratulated for a terrific book.
Stephen S. Park, MD
Professor and Vice-Chairm an
Departm ent of Otolaryngology
Director, Division of Facial Plastic Surgery
University of Virginia
Charlottesville, Virginia
xi
Preface
Aesthetic facial plastic surgery has come under the spotlight
in East Asian countries in the past two decades. Korea came
under the spotlight in this field recently and intrigued m any
from all corners of the world to com e, learn, and update
their techniques. It is my hope that this knowledge can be
shared far and wide w ith the English speaking crowd, who
has been finding it difficult to access information that has
been passed on in various Asian languages.
The chapters in this book describe most of what you
need to know about aesthetic plastic surgery on the face.
The chapters were written by my renowned colleagues in
their respective specialties, detailing special techniques and
potential pitfalls. These details do not come from overnight
enlightenm ent, but rather reflect experience and learning
accumulated over decades of surgeries. The content in this
book is highly scientific and evidence based, which means
it has proven to be safe and efficient. This book not only
focuses on introducing techniques that are new, but teaches
the basic concepts of how-to-do-it in a structured m anner
to ensure that readers are able to clearly conceptualize the
techniques and theories behind every maneuver.
I sincerely hope and expect that this book will guide the
new surgeons venturing into aesthetic plastic surgery of the
Asian face, as well as provide valuable information to the others.
Hong Ryul Jin
xii
Acknowledgments
It was not an easy journey for the publication of this book,
and I would like to express my most heartfelt gratitude to
all my colleagues who have contributed to it.
I thank Thieme Publishers and its people for allowing me to
publish this. Due to their great work, this book changed from
an ugly duckling into a swan. Doctors who contributed their
valuable expertise to this book need special acknowledgment
for their patience in allowing and enduring my continuous
requests. I also wish to thank my fellows, Woo-Seong Na, Hahn
Jin Jung, and Somasundran Mutusamy, for helping me to edit
the manuscript. Our excellent illustrator, Mrs. Hyun-Hang Lee,
who devoted her time and talents to this book, did a wonderful
job in expressing the details in every drawing per the requests
of each contributor. I give my sincere thanks to her.
xiii
In-chang Cho, MD
Bio Plastic Surgery Clinic
Seoul, Republic of Korea
Woong Chul Choi, MD
Director of Myoung Oculoplastic Surgery
Clinical Attending Professor
Department of Ophthalmology
St. Maryʼs Hospital
Catholic University of Korea
Seoul, Republic of Korea
Hokyung Choung, MD, PhD
Assistant Professor
Department of Ophthalmology
Boramae Medical Center
Seoul National University College of Medicine
Seoul, Republic of Korea
Seungil Chung, MD, PhD
Division of Facial Bone Surgery
Department of Plastic Surgery
ID Hospital
Seoul, Republic of Korea
Victor Chung, MD
Director
La Jolla Facial Plastic Surgery
San Diego, California
Eunsang Dhong, MD, PhD
Professor
Department of Plastic and Reconstructive Surgery
Guro Hospital, Korea University Medical Center
Seoul, Republic of Korea
Hun-Jong Dhong, MD, PhD
Professor
Department of Otorhinolaryngology–Head and
Neck Surgery
Samsung Medical Center
Seoul, Republic of Korea
Seong Yik Han, MD, DDS, PhD
Director
Facial Plastic Surgery
Simmian Maxillofacial Plastic Surgery Unit
Seoul, Republic of Korea
Aram Harijan, MD
Academic Consultant
Well Plastic Surgery Clinic
Seoul, Republic of Korea
Jin Joo Hong, MD, PhD
Head
JJ Medical Group
Seoul, Republic of Korea
Sungjoo (Tommy) Hwang, MD, PhD
Director
Dr. Hwangʼs Hair Transplantation Clinic
Seoul, Republic of Korea
Jae Woo Jang, MD, PhD
Vice President
Ophthalmic, Plastic, and Reconstructive Surgery
Kim’s Eye Hospital
Konyang University
Seoul, Republic of Korea
Hong Ryul Jin, MD, PhD
Professor and Chair
Department of Otorhinolaryngology–Head and
Neck Surgery
Boramae Medical Center
Seoul National University College of Medicine
Seoul, Republic of Korea
Kyoung-Jin (Safi) Kang, MD, PhD
Director
Educational Center of KCCS
Seoul Cosmetic Surgery Clinic
Busan, Republic of Korea
In-Sang Kim, MD
Chief Executive
Department of Facial Plastic Surgery
Doctor Be Aesthetic Clinic
Seoul, Republic of Korea
Jongseo Kim , MS
Director
Department of Plastic Surgery
Kim-Jongseo Plastic Surgery Clinic
Seoul, Republic of Korea
Contributors
xiv
Contributors
Namju Kim, MD, PhD
Associate Professor
Department of Ophthalmology
Seoul National University Bundang Hospital
Seongnam-Si, Kyeonggi-Do, Republic of Korea
Yoon-Duck Kim, MD, PhD
Director
Oculoplastic and Orbital Surgery Division
Professor
Department of Ophthalmology
Samsung Medical Center
Sung Kyun Kwan University School of Medicine
Seoul, Republic of Korea
Wooseok Koh, MD
Director
Department of Dermatology
JMO Hair Removal Dermatology Clinic
Seoul, Republic of Korea
Samuel M. Lam, MD, FACS
Director
Willow Bend Wellness Center
Plano, Texas
Jihyuck Lee, MD
Chief
Division of Facial Bone Surgery
Department of Plastic Surgery
ID Hospital
Seoul, Republic of Korea
Tee Sin Lee, MBBS (S’pore), MRCS (Edin), MMed (ORL),
FAMS (ORL)
Deputy Director and Consultant
Facial Plastic and Reconstructive Surgery Service
Department of Otorhinolaryngology–Head and
Neck Surgery
Changi General Hospital
Clinical Lecturer
Yong Loo Lin School of Medicine
National University of Singapore
Singapore
Hyoung Jin Moon, MD
President
Dr. Moon Aesthetic Surgery Clinic
Seoul, Republic of Korea
Juwan Park, MD, PhD
Associate Professor
Department of Ophthalmology
Yeouido St. Mary’s Hospital
The Catholic University of Korea
Seoul, Republic of Korea
Sanghoon Park, MD
Chairman
Department of Plastic Surgery
ID Hospital
Seoul, Republic of Korea
Stephen S. Park, MD
Professor and Vice-Chair
Department of Otolaryngology
University of Virginia
Charlottesville, Virginia
Chae-Seo Rhee, MD, PhD
Professor
Department of Otorhinolaryngology–Head and
Neck Surgery
Seoul National University College of Medicine
Seoul National University Bundang Hospital
Seongnam-Si, Kyeonggi-Do, Republic of Korea
Kyle Seo, MD, PhD
Clinical Associate Professor
Department of Dermatology
Seoul National University College of Medicine
Seoul, Republic of Korea
Yongho Shin, MD, PhD
Director of Bio Plastic Surgery Clinic
Clinical Attending Professor
Department of Plastic Surgery
Korea University
Seoul, Republic of Korea
Kar Su Tan, MBBS (S’pore), MRCS (Edin), MMed (ORL),
FAMS (ORL)
Medical Director
The Rhinoplasty Clinic ENT Facial Plastics
Singapore
Keng Lu Tan, MD, MRCS, MS (ORLHNS)
Ear, Nose, and Throat, Head and Neck Surgeon
Facial Plastic and Reconstructive Surgeon
Department of Otorhinolaryngology
University of Malaya
Kuala Lumpur, Malaysia
xv
Contributors
Dean M. Toriumi, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
University of Illinois at Chicago
Chicago, Illinois
Tae-Bin Won, MD, PhD
Associate Professor
Department of Otorhinolaryngology—Head and
Neck Surgery
Seoul National University Hospital
Seoul, Republic of Korea
Kyung In Woo, MD, PhD
Professor
Department of Ophthalmology
Sungkyunkwan University School of Medicine
Samsung Medical Center
Seoul, Republic of Korea
Hae Won Yang, MD
Chief
Division of Plastic and Reconstructive Surgery
JJ Medical Group
Seoul, Republic of Korea
Eduardo C. Yap, MD
Facial Plastic Surgeon
Belo Medical Group
Manila, Philippines
Un-Cheol Yeo, MD, PhD
Chairman
S and U Dermatologic Clinic
Clinical Professor
Department of Dermatology
Samsung Medical Center
Sungkyunkwan University
Seoul, Republic of Korea
Jong Sook Yi, MD
Assistant Professor
Department of Otorhinolarynology–Head and
Neck Surgery
Bundang CHA Medical Center
Seongnam-si, Republic of Korea
Ian Loh Chi Yuan, MBBS, MRCS, MMED, FAMS
Director
Facial Plastic and Reconstructive Service
Department of Otorhinolaryngology–Head and
Neck Surgery
Changi General Hospital
Singapore
(Trang không có chữ)
I
Introduction
(Trang không có chữ)
3
1 The Changing Face of Aesthetic Facial Plastic Surgery
among East Asians
Keng Lu Tan and Hong Ryul Jin
■Introduction
The recent surge in the number of people seeking aesthetic
facial surgery is a testament to the emphasis placed on one’s
looks as a way to gain considerable leverage in society. The
new movement also involves the concept of eternal youth-
fulness; being young is considered attractive, and looking
younger can improve the competitiveness of a worker.1,2
This trend, which started in Western countries around the
end of the twentieth century, is fast becoming worldwide.
As of this writing Asia is the most actively growing
economy in the world. With more than half of the world’s
population residing on this continent, the impact of any
movement in Asia will be in uential.3 With the population
getting more a uent and with the increasing a ordability
of a higher standard of living, the past 10 years have seen
many Asians seeking aesthetic procedures to enhance their
facial features or to attenuate the aging process. Although
the broad term Asians is generally used to denote people
who originate from Asia, in truth various ethnicities and
races with di erent facial morphologies reside in Asia.
West and South Asia stretches to Turkey and India, where
Caucasoid people (i.e., Turks and Indians) are found. In
Pearls
• Asians, particularly those in East Asia, have seen
rapid development in the eld of aesthetic facial
plastic surgery, especially in the re nement of
Asian-speci c techniques, over the past two decades.
• The typical Asian belief in not altering the physical
appearance of one’s face, attributed to respect for
the elderly and one’s ancestors, has evolved with
globalization, resulting in a more neutralized Asian
culture, which is a cross between East and West.
More Asians realize that to be at the leading edge of
society, an attractive appearance plays an important
role in determining success. There has been a shift
in social acceptance of aesthetic surgery, and we see
more demand for it than ever before.
• East Asian features of the face are discussed in detail
in the following chapters, with particular attention
to single-eyelid, small palpebral aperture, at nasal
bridge and tip, malar prominence, broad mandible,
retruded premaxilla, and many other Asian-speci c
aesthetic surgeries.
• Common aesthetic surgeries of East Asians also
include double-eyelid surgery, epicanthoplasty,
rhinoplasty, facial bone contouring surgery, fat
injection, and many other techniques discussed in
this book.
• Newer techniques, including the combination
of nonsurgical techniques in facial rejuvenation
such as llers and botulinum toxin, and laser hair
removal and hair transplantation speci c to East
Asian characteristics, are discussed in detail. The
pros and cons of nonsurgical techniques such as
laser and ultrasound for facial rejuvenation are also
thoroughly described to keep readers updated with
the latest technologies and the options available to
achieve desired outcomes.
• Most important, this book not only contains surgical
techniques and pearls from surgeons who are
experts in their respective elds of aesthetic facial
plastic surgery, but also incorporates comments on
pitfalls and complications, and how to overcome
them, in detail.
East Asia, where China, Korea, and Japan are located, peo-
ple possess East Asian features. Although East Asians are
grouped in the Mongoloid strain along with the Southeast
Asians (Indonesians, Thai, Polynesians, etc.), the facial fea-
tures among the Mongoloids are still quite distinct from
each other.3 Fig. 1.1 depicts the average of di erent beauti-
ful Asian faces as described by Rhee.4 Indians, Chinese, and
Japanese are all considered Asians; however, their facial
features can be quite di erent.
Due to Asia’s long-standing trade routes connecting
East and West, modern Asian cities are often comprised
of multiple ethnic groups, re ecting the modern trends of
interracial marriages and globalization. There is a rapidly
transforming e ect of globalization on facial features as
well, although at this time we still see rather characteristic
Oriental features among East Asians.
Aesthetic facial surgery in East Asia has expanded and
developed at an exponential rate in the past two decades.
Such rapid progress has enabled us to develop surgical
techniques suitable for Asians and to accumulate a con-
siderable amount of experience (Fig. 1.2). The new skill
sets and experience have been translated into technical
advancement and better surgical outcomes. Those experi-
ences and advances in aesthetic facial surgery more suited
I Introduction
4
Fig. 1.1 Attractive composite faces of di erent races. Attractive famous female entertainers’ faces were morphed by sequentially mixing
photographs at the mean values to generate the composite faces. (Used with permission from Rhee et al. Attractive composite faces of
di erent races. Aesthetic Plast Surg 2010;34:800–801.)
Hair removal or
transplantation
Fat injection
Blepharoplasty
Rhinoplasty
Botox and fillers
Facial bone
contouring
Fig. 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians. These various techniques will
be addressed throughout this textbook, with speci c modi cations for Asians.
1 The Changing Face of Aesthetic Facial Plastic Surgery among East Asians
5
tures, such as double eyelids and tall, well-de ned noses.
Fair skin is seen as the marker of class. One ancient saying
in Japanese, Korean, and Chinese societies goes, “A white
complexion overrides three appearance aws,”6 emphasiz-
ing the long-standing importance of light-colored skin in
multiple countries across Asia. This was reinforced during
the Western colonization period, when the Europeans were
present in Asia and enjoyed high social status. In “The His-
tory of White People,” Neil Painter even argued that Cau-
casians produce “the most beautiful race of men” and that
Chinese eyes are an “o ence to beauty.”7 The ideal beauty
of Caucasians was once the well-accepted de nition of
beauty in Asia.
Recently, Asian countries have become stronger and
more in uential economically. Scholars have started to
debate about “Eurocentric” beauty and the phenomenon
in Asia where it has become the norm to alter one’s facial
appearance using plastic surgery to be more Westernized.
With growing con dence within Asian society, however,
Asians have started to embrace their ethnic features. The
fusion of certain desirable Western features with Asian
features is now seen as the ideal form of beauty in Asia.
The key concept now is to blend attractive features rather
than having a certain de ned template, a concept that has
been heavily criticized and is rapidly falling out of favor.
The good-looking features are, of course, those that suit a
person’s facial structure, personality, and the person as a
whole. Enhancement rather than alteration of the facial
features has become the new trend.
Statistics show that up to 58% of women in Korea have
plastic surgery by the age of 50.1,8 The percentage is grow-
ing in their male counterparts too. The desire to obtain
aesthetic plastic surgery is often driven by the psychoso-
cial aspiration of the patient. Rapid development in this
eld is largely driven by the need to appear more attrac-
tive in order to be better accepted in a society that places
a lot of emphasis on beauty and pleasant appearance.
Looking more beautiful becomes an investment to achieve
higher socioeconomic status and to ensure one will nd a
wealthy romantic partner. Thus a new culture or trend has
emerged, unstoppable by past cultural beliefs and taboos,
and strongly driven by novel concept of beauty, wealth, and
a good life. As this concept has grown, the subjects seeking
cosmetic enhancement have become younger and younger.
As Korean dramas and movies have become more popular
throughout Asia, so has the in uence of the Korean de ni-
tion of beauty spread all across Asia. This phenomenon of
“Han Ryu” (the Korean trend) was popular among viewers
of all ages. With attractive actors and actresses portrayed
as heroes and heroines, many fantasized becoming like one
of them, which could be achieved by altering their looks.
This trend became a strong driving force in the devel-
opment of aesthetic surgery in Asia, enabling surgeons to
grow and achieve a new level of understanding of aesthetic
surgeries. However, it is up to the conscience of individual
practitioners to guard the sanctity of this eld, preventing
for Asians are becoming more and more popular, especially
among the more a uent Asians living in the Western coun-
tries. Authors of this book believe there is no better time
than now to have our knowledge and experience gathered
and shared to stimulate more development in this eld.
Many years have passed since the introduction of
speci c techniques for Asian aesthetic surgery. Much has
evolved over the years, and the current focus seems to be
on re ning the techniques to address the stigma faced by
Asian patients. Although we still nd a handful of patients
coming to the surgeon wanting to look like a particular pub-
lic gure, many are steering away from that trend. Patients
these days often request a natural-looking face and wish
to enhance their current appearance while retaining their
facial characteristics, and they especially want to prevent
their plastic surgeries from being noticed by others. While
embracing their existing facial characteristics, patients pre-
fer not to look the same as others who desire the ideal com-
position of a beautiful face, albeit all similar looking. This
has resulted in surgeons reinventing themselves and mov-
ing into the next level of aesthetic facial surgery, combining
less invasive procedures with surgery whenever possible.
The art of combining nonsurgical and surgical techniques
to create a beautiful face will no longer be based on a gut
feeling but w ill be objectively described in this book.
■The Change in Cultural
Beliefs and the Modernization
of Asian Thinking
The Asian desire for a pleasant face is heavily in uenced by
facial physiognomy in the past. The combinations of pleas-
ant-looking features described in the ancient books were
illustrated with pictures of faces that dictated the future of
a person, down to the position of moles on the face and
body.5 There was a realization of the need for an aestheti-
cally pleasing face, but few other than Shusrata ventured
into the aesthetic surgical eld. Individuals with pleasant-
looking faces were more likely to be judged to have a good
life and a good job, and those with unpleasant-looking
features were often associated with socially less respect-
able jobs or even criminality. The latter types of faces were
deemed inauspicious and still very much in uence how
a person is judged in modern society. Despite this, there
was little development in this eld. Few wanted to change
their looks surgically, partly due to the unre ned state of
surgical skills at that time and the strong in uence of Con-
fucianism all over Asia, which emphasized the sanctity of
the physical body as a sacred gift from our parents. Altering
one’s physical appearance was considered disrespectful to
one’s ancestors.1
As globalization and Westernization exerted more
in uence in Asian society via Western media, the de ni-
tion of beauty became associated with white Caucasian fea-
I Introduction
6
5. The narrow and relatively small palpebral aperture
results in small eyes. This has resulted in many
techniques invented and modi ed over the past
decade to increase the palpebral aperture by lateral
canthoplasty. Proper consideration of the anatomy
involved in lateral and medial epicanthoplasty
should be given before the surgery is done to prevent
later complications such as lower eyelid ectropion.
6. A at nasal bridge and a poorly de ned cartilaginous
structure of the nose results in poor projection of the
nose.
7. There is a smaller nasal pyramid with shorter
nasal bone length in Asians compared with other
ethnicities. A study done by Naser and Boroujeni
concluded that the nasal bone length studied in
the skulls of Koreans was smaller than in American
Indians, Anatolians, Iranians, and African Americans.9
The soft and small nasal septum encountered
sometimes poses di culty to the surgeon needing
a cartilage graft from the nasal septum. Due to this,
the use of homologous and autologous rib cartilage
grafts has become popular when synthetic implants
are not suitable or not preferred by patients. Patients
should be adequately counseled, as the likelihood of
needing a rib graft is higher in Asian patients.
8. The nasal skin is thick with abundant sebaceous
glands. This makes maneuvering the nasal tip
substantially more technically demanding.
9. Asians possess di erent skin properties compared
with other racial groups. Asians are known to have
a thinner stratum corneum, the smallest in terms of
pore size and pore numbers, and the highest water
and lipid content in the stratum corneum compared
with other peoples. Their skin is also known
to have the weakest chemical barrier. All these
characteristics signify that topical drug penetration
is the best in Asian skin and that the formation
of wrinkles is less in Asians. Such anatomical
di erences in the epidermal layer of the Asian skin
make management of scars and skin lesions di erent
in the Asian population.
10. Asians have a high malar prominence due to a
prominent zygomatic body or arch.
11. The broad mandibular angle is associated with
masseter hypertrophy.
12. Asians’ hair is thick and coarse, is round in shape, and
grows faster. Asians also have a higher prevalence of
curly hair, but thick and straight hair is predominant
among East Asians. These anatomic di erences in
Asian hair compared with Caucasian hair require
hair transplant equipment and procedures that are
di erent from those that are conventionally used.
To successfully address the above issues, one should
understand the unique anatomic presentation of the Asian
face to properly modify and make re ned adjustments to
the generic techniques presented in earlier textbooks.
the double-edged sword of harm to our patients and to the
practice of aesthetic surgery, by prescribing only appro-
priate and scienti cally sound procedures to patients and
providing the best surgical practices tested by time and
experience.
■Anatomic Di erences and
Their Implications
Most East Asians share the phenotypic features represented
by the Mongoloid pro le. It is currently the most widely dis-
tributed physical type, constituting over a third of the human
species. Therefore, it is not surprising to nd that many living
throughout Asia share the same facial features. Mongoloid
features are typically represented by epicanthal folds and
neoteny. While some of the features, such as the single eyelid
and maxillary retrusion, are not common among Western-
ers, they are widely encountered in Asians, with double-
eyelid surgery being the most popular plastic surgery sought
(Fig. 1.3). High cheekbones, a broad mandibular angle, and
a low nasal pro le are features in Asians that are not highly
favored, and are often associated with aggression or manli-
ness. Generally, a well-projected nose is preferred.
A low nasal bridge is not limited to Mongoloids. The
Malay people found in most of Southeast Asia across
the Philippines, Malaysia, Thailand, and Indonesia often
request changes to address a low nasal bridge and wide
aring ala (Fig. 1.4).
Because the anatomy of the eyelids, nose, and facial
bones in Asians di ers signi cantly from that of Caucasians,
a unique management strategy is required to successfully
improve the aesthetic outcome. The management strategy
should be aimed at handling anatomic issues speci c to the
Asian face such as the following:
1. The pretarsal skin of the upper eyelid is not attached
to the levator palpebrae muscle, leading to a poorly
de ned superior palpebral fold. The construction of a
double eyelid that suits the morphology of an Asian
face is di erent from practice involving Caucasians.
2. Excessive fat is distributed between the orbicularis
oculi muscle and the levator muscle with relatively
thick palpebral skin and orbicularis oculi muscles.
3. Orbits are smaller with a more protruding orbital
margin compared with Westerners. Therefore,
recreating the features of Caucasian eyelids has
proven unsuitable. Aesthetic eye surgery should be
re ned and subtle rather than dramatic, or it can
give rise to a thick, deep upper eyelid, which is not
suitable for smaller orbits.
4. The nasal sclera triangle is rounded due to the
prominent medial epicanthal fold. A variety of
techniques (and their pros and cons) to eliminate
the obtunded angle will be described in detail in the
chapter on epicanthoplasty.
1 The Changing Face of Aesthetic Facial Plastic Surgery among East Asians
7
Fig. 1.3 Typical East Asian woman who had rhinoplasty with blepharoplasty. (a–c) Typical East Asian face, illustrating the wide mandibu-
lar angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip. (d–f) The same
individual after rhinoplasty and blepharoplasty. Her appearance greatly enhanced, the individual seems more approachable and attractive,
with softening of the unfavorable wide angle of the mandible.
a
b
c
d
e
f
I Introduction
8
Such re nement in surgical techniques is also seen in
rhinoplasty surgeries, with more versatile use of alloplas-
tic materials such as Gore-Tex (W.L. Gore & Associates Inc.,
Flagsta , Arizona) and homologous cartilage in reconstruc-
tion of the nose. Nasal augmentation is rarely a need for
the Western patient. In contrast, almost every East Asian
patient requests nasal dorsal augmentation. In the past two
decades, we have seen the popularity of silicone implants
fall and the subsequent increased acceptance of Gore-Tex
as a more versatile implant material. Although the use of
silicone implants is declining due to the higher complica-
tion rate and rigid appearance of the nasal dorsum, we
see a current trend of surgeons carving silicone implants
more judiciously, getting rid of the L-strut and combining
use of the implant with other soft tissue to produce a softer
and natural look and reducing the rate of implant extru-
sion. This allows the surgeon to continue using the silicone
implant, which does have some advantages compared with
other choices of implants. On the other hand, continuous
trials using autologous costal cartilage for dorsal augmen-
tation have shown much improvement over the years with
improved reliability and consistency. We have seen a shift
recently toward the increased popularity of autologous
grafts compared with synthetic grafts due to the superior-
ity of the autologous graft in resisting infection and pre-
venting long-term complications.10,11
Recently, tip surgery in addition to dorsal augm enta-
tion has becom e a standard procedure undertaken dur-
ing rhinoplasty. The tip has to be properly supported and
rotated after dorsal augm entation to produce a natural,
pleasant-looking nose. This is largely achieved by using
■Modi cation and Re nement
of Surgical Techniques
To enhance existing Asian facial characteristics, re nement of
the techniques is often required. Such re nement is well illus-
trated by the various techniques of epicanthoplasty to address
a slightly di erent curve of the medial epicanthus, suturing
techniques to make eyes with ptotic or pu y upper eyelids
appear larger and more relaxed, and lateral canthopexy to
achieve a more attractive and lively appearance of the eyes.
The conventional methods of epicanthoplasty, such as
Y-V, V-W, and W plasty, were noted to give rise to unsightly
scars. As surgeons in Asia accumulated more experience,
many new techniques were developed, such as the pal-
pebral margin incision method (Chen, medial epicantho-
plasty), with others commonly combining blepharoplasty
with medial epicanthoplasty by extending the incision,
resulting in an obscured scar. With the increasing number
of lateral canthoplasties done to widen the palpebral aper-
ture of the Asian eye, complications such as hypertrophic
scars and scar contracture causing the palpebral ssure to
become narrow again are possible. The procedure may also
result in asymmetrical results due to unpredictable scar
formation. In cases where the lateral canthal ligament is
cut to achieve maximal opening of the palpebral aperture,
lower eyelid ectropion and sagging may occur in the future
as the soft tissue and muscular support is weakened. There-
fore, such surgeries are never to be taken lightly and should
be done only after su cient risk and bene t assessment.
Fig. 1.4 (a–c) The face of a typical Southeast Asian woman, with natural double eyelid crease, wide nasal alar, broad nasal bridge and
bulbous nose with a voluminous lip. These are some of the features associated with the Southeast Asian type of face.
a
b
c
1 The Changing Face of Aesthetic Facial Plastic Surgery among East Asians
9
would prove too drastic and destructive. It also plays an
important role as an adjunct to many cosmetic procedures.
Fat grafting techniques have progressed from the use of
crude fat lobules to microfat grafts, giving rise to improved
longevity in the recipient site. The use of fat grafts is also
very popular to improve the contour of facial topography,
proving to be very versatile in creating whatever topogra-
phy is desired. With their expertise in this eld, the authors
of this book are able to share many of their valuable experi-
ences in re ning and perfecting the use of this technique to
improve surgical outcomes.
Hair restoration has also become a popular procedure
done for aesthetic purposes in Asia in recent years. It is
not only popular for males experiencing androgenic hair
loss but also for females who wish to reshape the face
and to soften the outline of the face by altering the hair-
line. More females are seeking hair transplant procedures
to extend the hairline at the temporal region, thus reduc-
ing the muscularity of the face, or to change the face to a
more favorable “oval” shape. Hair transplantation is quite
di erent in Asians. This is due to their thicker and coarser
hair structure, a broader base for the follicles, and a higher
incidence of keloid-forming scars compared w ith Cau-
casians. Therefore, follicular unit extraction and use of a
micropunch designed to minimize scarring and maximize
hair follicle extraction have become more popular than the
conventional single-strip harvesting technique. Due to the
thicker and coarser hair found in Asians, during follicular
unit extraction the direction and depth of the scorings
must be precise and the base has to be broad enough so
that the germinal unit of the hair will not be damaged. As
curly hair is more common in Asians than in Caucasians,
the direction of the implantation has to be considered so as
not to have unnatural hair growing in di erent directions.
These and many other pearls related to hair restoration in
the Asian population will be presented in the correspond-
ing chapters.
We w ill also deal w ith facial hair rem oval using laser
for aesthetic purposes. The w idth of the forehead form s
the shape of the face in the superior third. The forehead
is also the location of the “chakra” w here the third eye
or sixth sense resides as per Sanskrit scriptures. A nar-
row forehead puts too m uch emphasis on the m iddle and
lower parts of the face and is often associated w ith lack
of radiance. A balanced forehead can be created w ith per-
m anent rem oval of the appropriate am ount of hair w ith
least problem of dyspigm entation in Asians, w ho gener-
ally have darker skin tone. Nd:YAG laser has proven to be
a good choice for hair reduction in Asians, compared w ith
conventional diode laser, and was found to be superior in
hair reduction.12 Many studies are still being conducted
on laser hair rem oval regarding the paradoxical e ect of
ne hair grow th postrem oval. An exciting journey lies
ahead, w ith m ore details revealed in the chapter on laser
hair rem oval.
the open approach. Tip rotation achieved w ith a septal
extension graft and the use of m ultiple layers of autolo-
gous m aterial such as m uscle fascia and cartilage cou-
pled w ith som e suture techniques are the m ost popular
options employed now. Both patients and surgeons have
shied away from synthetic m aterial for tip work due to
the high extrusion rate and the subsequent disastrous
sequelae of an infection. Autologous m aterial is tim e
tested and show n to have the least complications and
best results so far. The overaggressive tip work associated
w ith overam bitious m aneuvers is highly advised against,
as too m uch of a good thing in any circum stances w ill only
result in the opposite of the desired e ect. Overprojec-
tion and rotation of the tip is associated w ith a deform ed
tip in the long run as a certain degree of resorption of
the cartilage graft used and scarring of soft tissue w ill
cause instability of the tip constructed. Therefore, from
our experience, judicious adjustm ent of the dorsum w ith
a m atching tip should be the lim it to such augm entation
procedures, although it m ay be very inviting intraopera-
tively to achieve a m axim um e ect.
Understanding the speci c anatom ic di erences
in Asians has enabled us to com bine the use of various
adjunctive surgeries and procedures w ith rhinoplasty to
produce a m ore favorable outcom e than is possible w ith
just rhinoplasty alone. Som e of these procedures include
paranasal implant, chin implant, nasal alar resection, and
colum ella-lengthening aps to address issues like m axil-
lary retrusion, retrognathia, w ide nasal ala, and short col-
um ella, respectively, w hich are com m on problem s found
in Asians. Asian surgeons have also perfected their skills
in m alar reduction, w hich is a m ore com m on procedure
in the East compared w ith the West. Previous experience
has resulted in som e cases of facial sagging, facial asym -
m etry, and dow nward m ovem ent of the m alar point. The
reduction of the angle of the m andible is also a com m on
aesthetic surgery in Asia as opposed to the West, as a
softer look and a “V-shaped” face are strongly favored
in Asia. Asian surgeons have substantially m ore expe-
rience w hen it com es to this kind of skeletal reduction
work. Other skeletal alteration surgeries that are popu-
lar in Asia include orthognathic surgery such as bim ax-
illary advancem ent/reduction or m andibular reduction/
advancem ent, w hich can be solely for cosm etic purposes.
These surgeries were originally intended to correct con-
genital deform ities related to functional problem s such
as m alocclusion. As the appearance of a protruding m an-
dible or retruding m axilla is unattractive, patients these
days are w illing to undergo surgeries even w ithout func-
tional problem s, and even w hen the risk of associated
complications outweighs the bene t.
The growing popularity of fat grafting has improved
patient satisfaction tremendously. Fat grafting produces a
long-lasting e ect in facial rejuvenation. This is especially
true in the younger patients in whom a surgical face lift
I Introduction
10
■Conclusion
New trends, concepts, and techniques are rapidly appearing
in Asia for aesthetic facial plastic surgery. This trend can-
not be ignored and will become our strength as experience
grows. Many of the new techniques should be reviewed
judiciously and meticulously and used carefully. Therefore,
this new book is opening up a whole new chapter in aes-
thetic facial surgery for East Asians.
References
1. Holliday R, Joanna EH. Gender, globalization and aesthetic
surgery in South Korea. Body Soc 2012;18(2):58–81
2. Weeks DM, Thomas JR. Beauty in a m ulticultural world. Fa-
cial Plast Surg Clin North Am 2014;22(3):337–341
3. Rawlings AV. Ethnic skin types: are there di erences in
skin structure and function? Int J Cosm et Sci 2006;28(2):
79–93
4. Rhee SC, Lee SH. Attractive composite faces of di erent
races. Aesthetic Plast Surg 2010;34(6):800–801
5. Tempark T, Shwayder T. Chinese fortune-telling based on face
and body mole positions: a hidden agenda regarding mole
removal. Arch Dermatol 2012;148(6):772–773
6. Wagatsum a H. Color and race: the social perception of skin
color in Japan. Daedalus 96(2);1967:407–443
7. Zhang L. Eurocentric Beauty Ideals as a Form of Structural
Violence: Origins and E ects on East Asian Wom en, in Vio-
lence and Su ering in the Contemporary World (Spring
2013). 4–11
8. 90% of Korean wom en would have plastic surgery, poll
shows. Chosun Ilbo 2009 (October 26): 11
9. Asieh ZN, Mariyya PB. CBCT evaluation of bony nasal pyra-
m ic dim ensions in Iranian population: a comparative study
with ethnic groups. International Scholarly Research No-
tices 2014:1–5
10. Jin HR, Won TB. Nasal tip augm entation in Asians us-
ing autogenous cartilage. Otolaryngol Head Neck Surg
2009;140(4):526–530
11. Park JH, Jin HR. Use of autologous costal cartilage in Asian
rhinoplasty. Plast Reconstr Surg 2012;130(6):1338–1348
12. Wanitphakdeedecha R, Thanomkitti K, Sethabutra P, Eim -
punth S, Manuskiatti W. A split axilla comparison study
of axillary hair removal with low uence high repetition
rate 810 nm diode laser vs. high uence low repetition
rate 1064 nm Nd:YAG laser. J Eur Acad Derm atol Venereol
2012;26(9):1133–1136
13. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers
A. Blindness caused by cosm etic ller injection: a review
of cause and therapy. Plast Reconstr Surg 2014;134(6):
1197–1201
■Procedural Techniques
Facial cosmetic procedures can no longer rely on surgery
alone. Many practitioners can no longer a ord to shun the
use of laser, intense pulsed light (IPL), and many other non-
surgical techniques to achieve better outcomes. Although
many of these techniques do not provide long-term e ects
as good as surgical intervention, they often complement
the surgical outcome or delay surgical intervention appro-
priately. Examples are the use of thread lifting for younger
patients where a surgical face lift is too drastic and unnatu-
ral, laser or high-frequency focused ultrasound (HIFU) in
face lifting for mild soft tissue sagging, laser and/or IPL in
resurfacing various types of scars and reconstructed aps,
and ller injection for speci c facial contour augmenta-
tion in limited areas. Various types of ller injection, rang-
ing from collagen, hyaluronic acid, and calcium hydroxyl
apatite to poly-L-lactic acid and platelet-rich plasma, are
becoming more and more accessible to patients as they are
noninvasive, are technically easier to apply, and provide
a reasonable outcome for a nonsurgical procedure. At the
time this book is being prepared, hyaluronic acid remains
the most widely used ller due to its longevity and its safety
pro le compared with the other types of llers. It is impor-
tant, however, that the reader be able to discern the ben-
e t of the ller injection and verify that it outweighs the
risks of its usage, which include, in the worst-case scenario,
blindness due to embolism of the retinal vessels.13 Although
not as severe as blindness, other complications, such as skin
necrosis of the injected area, should not be overlooked as
reconstruction of the a ected area can be very troublesome
if it involves a large area requiring complex reconstructive
techniques. The rst sign of the grievous complications just
mentioned (pain in the patient postinjection) should not
be simply disregarded, and prompt usage of hyaluronidase
w ith or without hyperbaric oxygen is called for.
Nonsurgical facial rejuvenation is often overlooked by
many surgeons due to its relatively brief history. However,
with the growing number of clients preferring nonsurgical
intervention to surgical intervention and its de nite role in
complementing surgical outcomes, nonsurgical interven-
tion has survived and is rapidly being reinvented and diver-
si ed in providing solutions to facial rejuvenation. Although
these techniques need to be further proven with more stud-
ies and research, surgeons should be aware of the nonsur-
gical techniques available in the market because ultimately
patients who need surgery may be those who have expe-
rienced complications from these nonsurgical techniques.
In certain circumstances, these nonsurgical techniques can
also be e ectively combined with the use of surgical tech-
niques to achieve better results.
II
Rhinoplasty
(Trang không có chữ)
13
2 Augmentation Rhinoplasty Using Silicone Implants
In-Sang Kim
■Introduction
The noses of East Asian people are di erent in many
aspects from Caucasian noses. Augmentation rhinoplasty
is one of the most common aesthetic procedures in Asian
countries because of the relatively at and wide Asian nose.
However, augmentation rhinoplasty should be conserva-
tive, preserving the ethnicity to make the nose appear very
natural and harmonious with other facial units. In Asian
countries, augmentation rhinoplasty is not a major recon-
structive operation. It is regarded as one of the uncompli-
cated common cosmetic procedures. It is often regarded as
a trendy operation, and the aesthetic standard of patients
is generally high. People want short recovery times and a
quick return to the job, although major augmentation is
frequently required.
In this situation, a practical and cost-e ective option
for a surgeon is rhinoplasty using an alloplastic implant.
Pearls
• For East Asian noses, major augmentation is
frequently required for the nasal dorsum and the tip.
• The silicone implant is widely used in Asian
countries because it is easy to use, limitless in
volume, cost-e ective, and superior to the auto- or
homograft from the aesthetic viewpoint.
• There are two sources of problems related to the
alloplastic implant. One is the problems inherent
in the material itself, which can be minimized. The
other is problems from technical or judgmental
errors, which are more common and must be
avoided.
• Infection is a serious problem though uncommon.
Thorough sanitization of the operation eld,
including the nasal vestibule and anterior nasal
cavity, is important. Care should be taken not to tear
the mucosal barrier using atraumatic techniques.
Operation time should be reduced to decrease
the chance of infection. The implant must be
immersed in antiseptic solution before and after any
manipulation.
• Designing an implant must be individualized. The
surgeon should have in mind the desired shape of
the nose. Individual anatomic characteristics must
be considered such as the nasofrontal angle, dorsal
contour, and tip projection.
• Proper selection of a tip technique is important.
According to the tip technique, the design of an
implant varies. The implant should be connected to
the augmented tip smoothly and seamlessly.
• Do not try to augment the tip with the implant.
Unlike the relatively immobile dorsum, the tip
is highly mobile. Therefore, only autologous
cartilage must be used for the tip, with appropriate
techniques to prevent extrusion and skin problems.
An implant placed on the tip is aesthetically
unpleasing because it always leads to a rotated tip
with an unnaturally thick infratip lobule.
• With the use of only autologous cartilage for the
tip, skin problems are prevented and more natural
outcomes are ensured.
• Stacking of multiple layers of onlay grafts is
commonly required for su cient tip projection
in Asians. The wing graft should be used in
combination with the stacked onlay graft to prevent
noticeability of the onlay graft and pinching
deformity.
• Complication rates of alloplastic implants are
medically acceptable. Complications are more
frequently the result of the surgeon’s technical and
judgmental errors, rather than the fault of inherent
characteristics of the material itself.
Amounts of autologous materials except for costal cartilage
are limited for the usual large-volume augmentation. How-
ever, with the use of costal cartilage, economic and psycho-
logical burdens are heavy for patients. Other disadvantages
include postoperative scarring on the chest, rigidity of the
tip, prolonged operation time, and a long recovery period.
In addition, the use of costal cartilage is not free of com -
plications. Problems of warping and resorption are well
known. Infection is rare but is possible. Therefore, costal
cartilage is reserved as a last resort by many surgeons.
On the other hand, alloplastic implants are ready to
use, easy to carve, varied in size, and superior to autolo-
gous materials from an aesthetic viewpoint. Also, they are
not subject to resorption or warping. Among the most com -
monly used alloplastic materials are silicone, expanded
polytetra uoroethylene (Gore-Tex), and porous high-den-
sity polyethylene (Medpor, Stryker, Kalamazoo, Michigan).
Silicone is the most frequently used material in Asian
countries. It is nonporous, in contrast to the other two
II Rhinoplasty
14
Professional recommendations should be given to the
patient after a thorough analysis of the face. The relation-
ship of the nasal dorsum, tip, philtrum, lips, and mentum
with the vertical facial axis should be investigated. In ana-
lyzing the face, any facial asymmetry must be noted and
revealed to the patient before the surgery, because the
augmentation rhinoplasty may worsen or accentuate a
pre-existing facial asymmetry. When the vertical facial
axis is skewed or de ected, the augmented nose cannot
be absolutely vertical and straight. In patients with signi -
cant facial asymmetry, it is better to augment the nose in a
di erent vertical axis from the anatomic dorsum. In these
patients, nasal bones on the two sides are frequently asym -
metric in terms of the width and the slope. When the bony
asymmetry is signi cant, the bottom of the implant is bet-
ter carved asymmetrically accordingly.
Facial asymmetry commonly accompanies asymmet-
ric nasal alae. Pre-existing alar asymmetry makes the nose
look deviated even after augmentation to the correct axis.
Asymmetric alar resection in these patients may not cor-
rect the problem satisfactorily. Alar asymmetry relating to
facial asymmetry is di cult to correct because of its multi-
dimensional nature.
A systemic examination of the nose is performed from
top to bottom (Fig. 2.1). The relationship of the forehead
with the nasal root is important for a successful dorsal aug-
mentation. The Asian forehead is relatively at and less pro-
truding. Generally, Caucasians are more dolichocephalic
materials, with no tissue ingrow th or vascularization
seen after implantation. Because of its nonporous nature,
it is nonadhesive to surrounding tissue and enclosed in a
brous capsule. Also, it is free from deformation, easy to
sterilize, and easy to remove when necessary. It is relatively
cheap and available in a range of softness values.
Expanded polytetra uoroethylene (ePTFE) is com -
posed of nodules of Te on interconnected by brils of
polytetra uoroethylene and has a microporous architec-
ture, with pore sizes ranging from 10 to 30 mm. Its poros-
ity makes it easily malleable and susceptible to long-term
compression, resulting in volume decrease or deformation
of the implant. Its hydrophobic and porous nature makes
the sterilization process using an antiseptic or antibiotic
solution di cult. Relatively high cost is another disadvan-
tage. For the revision cases, sometimes it is very di cult
to remove the previous ePTFE implant, especially when the
implant is thin, and the duration of implantation is long.
When the surrounding soft tissue is removed together
w ith the implant, the resulting soft tissue irregularity is
extremely di cult to repair.
Porous polyethylene (Medpor) consists of a continuous
system of interconnecting pores of size 125 to 250 mm. The
vascular and brous ingrow th leads to integration and sta-
bilization of the implant. The tensile strength of the mate-
rial is very high, contrary to the case for ePTFE. Because of
its sti nature, it should be used with utmost caution in
mobile areas such as the membranous septum or tip.
Synthetic implants in rhinoplasty have been a topic of
great controversy. In particular, silicone, which is the single
most commonly used implant material in Asian countries,
is a point of worldw ide contention.1 Asian noses are consid-
ered more receptive to alloplastic implants because of their
thick skin.2 This is true to some extent, but even thicker
skin cannot resist long-term thinning, extrusion, in am -
mation, and infection. Therefore, proper techniques using
an adequately designed implant must be executed.
When an experienced surgeon uses proper techniques,
the complication rate for alloplastic implants is surpris-
ingly low and in a medically acceptable range. Recent stud-
ies about the complication rates of alloplastic implants for
augmentation rhinoplasty show that they are much lower
than those in studies from the 1960s and 1970s.3 These
changes are due to improvements in implant design, con-
servative surgical techniques, surgeons having more expe-
rience, and the use of softer silicone.
■Patient Evaluation
The shape and pro le of the nose requested by the patient,
and their feasibility or desirability are discussed in this
section. Advantages and disadvantages of using alloplastic
implants and possible alternatives to alloplastic materials
are also discussed.
Fig. 2.1 Key areas that should be considered for successful aug-
mentation rhinoplasty: forehead slope, nasofrontal transition, pro-
jections of the nasal tip, premaxilla, and chin.
2 Augmentation Rhinoplasty Using Silicone Implants
15
with the patient, because it is unrealistic to try to make the
sides of the alae completely symmetric. In patients with
underdevelopment of the maxilla or premaxilla, paranasal
or premaxillary augmentation may be considered as ancil-
lary procedures of the augmentation rhinoplasty.
However, it should be taken into consideration that
acute nasolabial angle is not uncommon in Asians. Some
Asian noses are beautiful enough even with the acute naso-
labial angle, and in some patients acute nasolabial angle is
not a concern at all.
Patients with protruding lips can bene t from the com -
bination of rhinoplasty, maxillary augmentation, and chin
augmentation. This combination of surgeries will dramati-
cally enhance the facial pro le in selected patients.
■Surgical Techniques
Skin Marking
Skin marking for the augmentation must be done in the
sitting position. Marking a vertical line for the dorsal aug-
mentation is important, because frequently the glabella,
nasal dorsum, and nasal tip are o the same vertical axis,
and Asians are more brachiocephalic. Brow ridges in Asians
are also not as prominent as in Caucasians. As a result,
the nasofrontal angle in Asians is like a gentle and grace-
ful curve rather than an angle. Augmentation rhinoplasty
in Asians must preserve this gentle curvaceous transition
from the forehead to the nasal dorsum. And the augmented
nose must harmonize with the relatively at forehead.
Therefore, excessive augmentation of the radix area should
be avoided in patients with a at forehead. The proximal
end of the implant should be carefully tapered to accom -
modate to this area and not be visible or palpable. Despite
the retruded forehead, if the patient wants a substantial
amount of dorsal augmentation, combined forehead aug-
mentation should be considered. Forehead augmenta-
tion surgery is rarely performed in the West; however, it
is a common surgery in Asian countries, using alloplastic
implants or microfat injection.
In patients with excessive skin and soft tissue crowding
in the glabellar and nasal root area, the brow lift should be
considered. That is because augmentation rhinoplasty may
make this area look heavier and thicker and may worsen
the masculine look in these patients, leading to unsatisfac-
tory outcomes. Aged patients tend to have brow ptosis and
a thick soft tissue load in the glabellar area. Therefore, a
combined brow lift surgery should be considered in aged
patients and augmentation of the radix area should be
minimized, focusing more on tip augmentation. However,
even in young patients having a short distance from gla-
bellar area to nasion, dorsal augmentation may further
shorten the distance, making the nasal root area unnatural
and attened. Therefore, a combined brow lift surgery may
be considered in these young patients also. The endoscopic
brow lift is the best option for young patients considering
the e ect on the medial brow and minimizing postopera-
tive scarring.
The glabellar and nasal root region shows a wide range
of variation even in Asians. Therefore, the proximal implant
should be carved carefully according to individual anatomy
to t in this area. Preoperative X-ray may be helpful for
visualization of the bone and soft tissue anatomy of this
area (Fig. 2.2). Examination by manual palpation of this
area before or during the operation is also very important.
Careful dorsal examination precedes the design of an
implant. The nasal bone is examined for its length, width,
and asymmetry. Manual palpation along the dorsum is
helpful in revealing soft tissue thickness, presence of hump,
or dorsal irregularity.
Skin thickness of nasal tips is quite variable in Asians.
For the thin-skinned patients, visibility of grafts or the
implant might be problematic. On the other hand, for the
thick-skinned patients with bulbous tips, it is very di cult
to obtain a ne de nition of the tip.
Wide alae are common in Asians. For the enhanced
outcome of dorsal augmentation, alar resection may be
required in some patients. If alar asymmetry and asymmet-
ric maxillary development are present, they are discussed
Fig. 2.2 A preoperative X-ray helps in planning by visualizing the
bone and soft tissue anatomy of the nose.
II Rhinoplasty
16
is required. Any blood or secretion in the oral and pharyn-
geal cavity is sucked out repeatedly using a suction catheter
through the oral airway during the operation. To reduce the
secretion, intravenous injection of glycopyrrolate before
the surgery is recommended. Oxygen supplementation
through the oral airway also can be helpful.
Preparation of the Implant
Before local anesthetic injection, an implant is prepared
and tried on the dorsum (Fig. 2.4). The surgeon must check
whether it is suitable for the desired height and desired
nasal pro le, whether it is well tted for the nasofrontal
angle, and the dorsal con guration. Then initial carving is
performed using a no. 15 surgical blade before the surgery.
A correctly designed implant is crucial for a successful
outcome. Any single implant must be customized accord-
ing to individual anatomy. The thickness of the implant is
decided rst. Implants with 4 to 5 mm of thickness are most
frequently chosen among the 2 to 10 mm thickness range.
However the thickness is not uniform and varies along the
dorsum after carving according to the individual’s ana-
tomic characteristics. In general, when the nose is low in
radix and the tip is well projected, the implant is carved
proximally thick and distally thin. On the contrary, when
the nose is adequately high in radix and the tip is low, the
implant is carved proximally thin and distally thick. When
a hump is present, the implant is often carved thinner in
the rhinion area (Fig. 2.5).
The implant’s shape, especially the distal portion, is
also variable according to the preferred tip augmentation
technique.
The initially carved implant is immersed in antiseptic
solution such as hypochlorous acid until its later use. The
and augmentation rhinoplasty may accentuate the devi-
ated look of the nose.
Therefore, the surgeon must set a vertical line for the
augmentation. The line that looks the straightest is care-
fully chosen for the line of augmentation (Fig. 2.3). When
the dorsum and tip are vertically misaligned, usually a ver-
tical line extended upward from the tip is more appropriate
for the line of augmentation, rather than the line along the
dorsum, although this is not always the case.
The nasal starting point is set and a horizontal line is
marked, usually at the height of the ciliary margins. In gen-
eral, when the patient wants a higher dorsum, the line may
be drawn at the height of the supratarsal crease. When the
patient wants a more natural look, then the line is drawn
between the ciliary margin and the pupil. However, it is
individualized according to the patient’s facial character-
istics. This horizontal line also provides a landmark for the
cephalic extent of the subperiosteal dissection.
Anesthesia and Positioning
The patient is put under anesthesia in a supine position
and draping is done. Augmentation rhinoplasty using allo-
plastic implants is done under general anesthesia or intra-
venous anesthesia with sedation. When it is done under
intravenous anesthesia, close monitoring of the respiration
is crucial. Maintaining the oral airway during the surgery
Fig. 2.3 Skin marking is done in a sitting position using a straight
wooden stick. A vertical line is drawn. The nasal starting point,
rhinion, and nasal tip are marked.
Fig. 2.4 The implant is tried on the dorsum for the initial carving.
2 Augmentation Rhinoplasty Using Silicone Implants
17
for later closure and there is no risk of notching deformity.
The columellar ap is elevated in the conventional man-
ner. Elevation of the skin ap from the tip is on the supra-
perichondrial plane for the thin-skinned patients as usual.
However, for the thick-skinned Asian patient, the defatting
procedure is frequently required for debulking the thick
soft tissue and for better de nition of the tip. For the defat-
ting procedure, a layer of soft tissue is deliberately left on
the cartilage surfaces elevating the skin ap (Fig. 2.6).
Because the tip soft tissue is arranged in a layered
fashion, it is not quite as di cult to raise the ap w ith an
even thickness. This technique is better for smooth and
even removal of the soft tissue along the cartilage surfaces
than defatting from the undersurface of the skin ap after
supraperichondrial elevation. There is thick soft tissue on
the supratip area also, and it can be removed or preserved
depending on the situation. On the cartilaginous dorsum,
the plane is changed to the supraperichondrial plane.
Creation of the Periosteal Pocket
As dissection proceeds on the nasal bone, the plane is
changed again to the subperiosteal plane (Fig. 2.7). It is
very important to accurately raise the periosteal ap from
the nasal bone. When the implant is not correctly placed in
the subperiosteal space, the implant tends to be more mov-
able and more visible. To elevate the periosteum precisely,
it is better to use a sharp and narrow tip elevator, such as
the Joseph elevator, at rst. When the subperiosteal space is
correctly raised partially, then a wider elevator is inserted
and the space is widened. If a wide and blunt instrument is
used from the start, the periosteum is easily torn.
Close to the nasofrontal suture line, bleeding is likely
to ensue because of proximity of vessels to the suture line.
hypochlorous acid is suitable for this purpose because it is
clear in nature and relatively less toxic, nonirritating, and
potent.
Harvest of Ear Cartilage
After local anesthetic injections at the nose and the ear,
conchal cartilage is harvested rst when it is expected to
be necessary. Conchal cartilage is harvested commonly
through a postauricular incision. And it is harvested from
the cavum concha and cymba concha separately, leaving
the crus of helix as a bridge. This valuable anatomic land-
mark of the auricle is best preserved for aesthetic purposes
and structural support, and to maintain the abundant neu-
rovascular supply of this area. The harvested conchal carti-
lages are preserved in the antibiotic solution.
Incision and Elevation of the Skin Flap
For an open rhinoplasty, transcolumellar and marginal
incisions are marked rst. In Asian patients, occasionally
the caudal margins of the alar cartilages are not prominent
through the vestibular skin. Therefore, marking for mar-
ginal incision is helpful for a precise and symmetric inci-
sion. The marginal incision is placed 1 mm anterior to the
caudal margin of the alar cartilages, because this is better
Fig. 2.5 The initial carving is done using a no. 15 surgical blade.
The three most common shapes of implants are shown (top, proxi-
mally thin and distally thick; middle, proximally thick and distally
thin; bottom, anatomically carved). Implants are further custom-
ized during the surgery.
Fig. 2.6 Elevating the skin ap. A thin layer of soft tissue on the
alar cartilage is deliberately left for the defatting procedure.
II Rhinoplasty
18
The soft tissue on the surface of the alar cartilages and
in the supratip area that was left deliberately during ap
elevation for the defatting procedure is now removed. Clear
identi cation and delineation of the cartilage margins are
important at this stage for later procedures (Fig. 2.8). Mar-
ginal incisions are extended laterally as needed, especially
when the tension on the augmented tip is expected to be
high. The piriform ligaments may also be further released as
necessary. For more release of tension, the scroll area may
be dissected. However, the dissection should be as conser-
vative as possible, because more dissection will cause more
distortion, scar formation, and unpredictability.
Harvest of Septal Cartilage
Next the membranous septum is dissected and the caudal
margin of the septum is identi ed. The septal cartilage is
harvested, leaving the L-strut. In Asians, the septal cartilage
is frequently weak and small. In those patients with a weak
septum, more of the septal cartilage should be preserved
than the conventional 1 cm width for the dorsal and cau-
dal strut to maintain the structural stability. Therefore, the
amount of harvested septum is frequently very small. Even
when the harvested amount of septal cartilage is enough,
the caudal septum is too weak and frail to provide long-
term stable support for the septal extension graft. In this
regard, tip surgery using septal cartilage only has clear
limitations in many Asian patients. However, despite these
drawbacks, the septal extension graft is still one of the most
reliable tip techniques for Asians. It provides tip projection
and rotation/derotation itself, as well as providing strong
medial support for combined onlay grafts (Fig. 2.9). How-
If this bleeding is not controlled correctly, hematoma can
arise postoperatively on the nasal root. Hematoma is a seri-
ous complication, because if not adequately treated, it will
be accompanied by bacterial infection. The position of the
implant may also be changed by a hematoma.
Therefore, it is better not to dissect overly extensively
in the cephalic direction if it is not necessary. Excessive
cephalic dissection may also lead to cephalic migration of
the implant.
The subperiosteal pocket is widened laterally as needed.
The space should be close to symmetric and adequately
wide for the implant to be snugly placed inside. When the
subperiosteal pocket is too small, the implant may not be
placed properly and may later be displaced or deviated. On
the other hand, an overly wide pocket is also a common
cause of early postoperative displacement of the implant.
Defatting and Release of
Ligamentous Attachments
After the dissection along the dorsum is nished, the tip
surgery is initiated. A successful dorsal augmentation can-
not be accomplished without a successful tip augmentation.
Fig. 2.7 The dissection plane is supraperichondrial on the carti-
laginous dorsum and subperiosteal on the nasal bone.
Fig. 2.8 Cartilage margins are clearly delineated after the defat-
ting procedure.
2 Augmentation Rhinoplasty Using Silicone Implants
19
Preparation of the Stacked
Onlay Graft
According to the estimated amount of tip projection,
onlay grafts using septal or auricular cartilage are pre-
pared. Because the amount of septal cartilage is limited in
Asians usually, auricular cartilage is generally used for this
purpose.
Stacking of multiple onlay grafts is frequently neces-
sary because the required amount of tip augmentation is
commonly substantial in Asians.4 Stacking of two or three
layers of auricular cartilage is usually required, although
the number is variable. The layered cartilages may be
sutured together. Three layers of auricular cartilage will be
around 5 mm in thickness.
The graft should be cephalo-caudally long enough to be
placed over the domes of the alar cartilages. The margins
of the graft are meticulously trimmed to be devoid of any
sharp edges.
When the stacked onlay grafts are prepared, the same
cephalo-caudal length as used for the graft is resected
from the distal implant (Fig. 2.11). The removed part of
the implant is replaced by the onlay graft, which is sutured
to the cut end of the implant. By suturing the graft to the
implant, an unbroken, seamless transition from the dorsum
to the tip is ensured. Tip mobility is mildly decreased but
not restricted by suturing the graft to the implant. How-
ever, when the septal extension graft is used, decreased
tip mobility is an inevitable trade-o . The thickness of the
distal end of the implant is adjusted to match the thickness
of the onlay graft. The distal part of the implant may be
beveled according to the inclination of the lateral crura of
the alar cartilages.
The stacked onlay graft is supported medially by the
septal extension graft. Without strong medial support, the
ever, excessive tension from overzealous tip augmentation
relying only on the septal extension graft will be a cause of
septal buckling, long-term resorption or weakening of the
caudal septum, and tip drooping. Therefore, a minimal to
moderate amount of tension should be applied, consider-
ing the strength of the individual septal cartilage.
After harvesting the septal cartilage, osteotomies are
performed if required. Although the osteotomy is not a
contraindication for alloplastic dorsal augmentation, the
osteotomy should be as atraumatic as possible and muco-
sal tearing should be minimized to exclude the chance of
ascending bacterial infection.
Insertion of the Implant
The prefabricated implant is now inserted in the dorsal
pocket (Fig. 2.10). The excessive length outside the pocket
is trimmed. The pro le of the nose is closely examined and
compared with the planned shape. The conformity of the
implant on the nasal dorsum is closely checked. The proxi-
mal end should not be visible, readily palpable, or mov-
able. The dorsum should be smooth and straight, or mildly
concave in women. To obtain the desired shape and dorsal
smoothness, repeated carving and trials of the implant may
be necessary.
The projection and rotation of the tip, which is tem -
porarily form ed by the distal tip of the implant, is care-
fully exam ined. The implant m ay be used as a dum my for
the tip surgery. The surgeon can estim ate the required
am ount of projection by the thickness of the implant tip.
And also the surgeon can estim ate the desired am ount of
rotation/derotation by m oving the tip of the implant back
and forth.
Fig. 2.9 Septal extension grafting is done on the caudal septum
as an overlapping pattern.
Fig. 2.10 The prefabricated implant is inserted into the dorsal
pocket.
II Rhinoplasty
20
cases of alar rim retraction, because it is securely xed to
the onlay graft to provide strong support against retraction,
compared with the alar rim graft.
In a widely used technique for alloplastic augmentation
in Asia, the tip of the implant (straight or L-shaped) is placed
on top of the alar cartilages, and then a piece of autologous
cartilage is laid on top of (onlay-like) or in front of (shield-
like) the distal implant in an attempt to decrease the risk of
skin problems such as extrusion. These techniques provide
tip projection and rotation with relative ease, and produce
fair outcomes in selected cases, especially in those with
under-projected and under-rotated nasal tips. However,
these techniques have apparent disadvantages. The resul-
tant tip tends to be over-rotated and unnatural, because
the projection and rotation increase without proportional
elongation of the tip. The infratip lobule becomes unnatu-
rally thick with a decreased columellar-lobular ratio. Fine
tip modi cation is also di cult using these techniques, and
the tip often looks sharp and pointed. In addition, the piece
of cartilage on the distal implant is likely to become con-
spicuous with time.
In contrast, for the previously described technique
using the stacked onlay graft, it is easy to elongate the tip.
Fine tip shaping is possible with additional carving and
grafting. Combining the wing grafts, it is more naturally
smooth in shape, and there are no visibility or conspicuity
problems of onlay grafts over time.
Variant Techniques
The aforementioned procedures can be done using the
endonasal approach. However, generally this makes it more
di cult to manipulate the grafts and to control the tension
on the tip skin. For more visualization and more release
e ect of the graft w ill abate with the collapse of columella
and membranous septum, requiring more amounts of car-
tilage, and the columellar-lobular ratio will deteriorate.
Insertion of the Uni ed Graft and
Implant Hybrid
The uni ed graft and implant hybrid is inserted into the
dorsal pocket, and the pro le is closely examined again.
The surgeon has to examine the nose carefully, temporar-
ily closing the incision by pulling down the columellar ap,
because the pro le can be changed due to the tension on the
skin. Repeated carving may be required at this stage also.
When the desired shape of the nose is nally obtained,
the onlay graft is xed to the alar cartilages with sutures.
The nal ne modi cation of the tip and tip lobules is
done by carving and additional grafting. A shield graft in
front of the graft or additional onlay grafts can be added
as necessary.
Placement of the Wing Grafts
After obtaining a nal tip shape, so-called wing grafts are
applied bilaterally on the lateral sides of the onlay graft
(Fig. 2.12). The wing graft is shaped to assimilate the lat-
eral crura of the alar cartilages, to correspond with the
dome newly created by the stacked onlay graft. Auricular
cartilage is best suited to this purpose because of its natu-
ral curvature. The purpose of the wing graft is to prevent
the collapse or pinching deformity on the lateral sides of
the onlay graft. Without the wing grafts, the tip is centrally
prominent only near the onlay graft, and laterally tip lob-
ules are collapsed and pinched. The wing graft provides a
smooth transition from the tip to the lobules, softens the
margins of the onlay graft, and acts as a structural support
against soft tissue collapse. The wing graft is also helpful in
Fig. 2.11 The same length of the silicone implant as the stacked
onlay cartilage tip graft is cut out from the caudal end.
Fig. 2.12 The wing grafts are applied on both sides of the onlay
graft.
2 Augmentation Rhinoplasty Using Silicone Implants
21
Closure and Splinting
For the nal procedure, meticulous suture closure is done.
Then irrigation with antibiotic and antiseptic solutions is
performed using a syringe after the closure.
Taping is done to decrease the edema and to decrease
the mobility of the implant and grafts. Then a thermo-
plastic splint is applied on the dorsum. The splinting is
important to immobilize the implant and to prevent edema
and hematoma on the radix area in the immediate post-
operative period. The splint should be applied along the
pre-marked vertical line of the augmentation. The splint is
maintained for at least 7 days.
■Key Technical Points
1. Designing an implant is the rst and most critical
step. Based on the desired shape and individual
anatomy, the implant should be carved correctly.
2. The subperiosteal pocket is created. The pocket
should be symmetric and appropriately wide for
the implant to be snugly placed inside and not be
excessively mobile.
3. For the septal extension graft, excessive tension on
the graft is undesirable, especially when the septal
cartilage is frail. It provides a stable platform for
the onlay tip graft, which is used for further tip
projection and de nition, commonly required in
Asian patients.
of tension, a marginal incision is extended medially over
the footplate to the nasal sill, and laterally to the piriform
ligaments.
When the height di erence between the tip and the
anterior septal angle is signi cant and the inclination of
lateral crura is considerable, a variant technique can be
used (Fig. 2.13). The substantial tip-to-septum height dif-
ference and lateral crural inclination are commonly created
by the strong tip projection with the septal extension graft;
however, a considerable tip-to-septum height di erence is
present even prior to surgery in some patients. In this situ-
ation, the distal implant is carved in a wedge shape with
appropriate thickness to t in the cephalic divergence of
alar cartilages. The implant may be sutured to the cephalic
margins of the alar cartilages.
For some patients, only the low nasal bridge, not the
tip, is the problem and their concern. Then only a correctly
carved implant according to the individual dorsal anatomy
will su ce. The implant is inserted through the marginal
or intercartilaginous incision. Inadequately narrow, small,
or asymmetric dorsal pockets will predispose to extrusion.
For the symmetry of the dorsal pocket, bilateral incision
and dissection are recommended. The distal end of the
implant is tapered to be paper thin to smoothly continue
to the cephalic portion of the alar cartilages. An implant
of excessive length, in a small or asymmetric pocket, may
extrude, especially when the distal implant is in direct con-
tact with the incision site. In this regard, marginal incision
is more appropriate for the alloplastic implantation. With
the marginal incision, additional tip grafting or other tip
manipulations are also possible.
Fig. 2.13 (a,b) When the gap is signi cant between the tip and the anterior septal angle, the implant may be carved in a wedge shape
and suture xed to the cephalic margins of the alar cartilages.
a
b
II Rhinoplasty
22
Problems Caused by Inherent
Physical Characteristics of
Alloplastic Implants
Capsule Formation
In cases where complications such as contraction do not
occur, the brous capsule prevents the implant from bond-
ing with skin, prevents skin damage, and maintains the
thickness of the skin and soft tissue to some degree. On the
other hand, the brous capsule has a side e ect of making
the area susceptible to infection by preventing antibiotics
from e ectively penetrating the area around the implant
and by letting the silicone implant create dead space within
the capsule as it moves inside.
In certain situations, the capsule causes severe compli-
cations, most notably the contracted nose.6 Creation of an
excessively thick and w ide capsule and contraction is usu-
ally caused by additional factors such as bacterial infection
and excessive tissue damage.
Therefore, to avoid overproduction of capsules and its
ensuing complications, the surgeon must take care to pre-
vent in ammation or infection from occurring during or
after surgery, while minimizing tissue damage and bleed-
ing by surgery.
Skin and Mucosal Damage
Stimulation of the skin, damage to skin and appendages,
skin thinning, skin contraction, and telangiectasis are long-
term complications. The slight yet repetitive damage caused
by the solid implant can harm the mucous membrane and
create recurring chronic in ammation, possibly by ascend-
ing bacterial infection through small mucosal defects. To
minimize such physical damage from silicone implants,
the implant should be of appropriate length and width,
and it must be well tted and immobile. Additionally, using
a softer material for the implant can help reduce physi-
cal stimulation. Suturing a layer of dermis or dermofat on
the outer surface of the implant is helpful in thin-skinned
patients or revision cases to decrease mechanical stimula-
tion, and mobility and visibility of the implant (Fig. 2.14).
Calci cation
When removing a long-seated implant, the surgeon may
come across calci cation of the implant. A calci ed implant
forms a harder and rougher surface, increasing stimulation
to the overlying skin and letting the irregular surface show
through the skin. Calci cation may worsen with time.7 Cal-
ci cation also relates to mechanical stimulation and dam -
age to surrounding tissue.
4. The pre-carved implant is inserted in the pocket
and the dorsal pro le is carefully checked. Repeated
carving may be necessary. Using the distal implant
as a dummy for the tip augmentation allows
the amount of tip projection and rotation to be
estimated.
5. The onlay graft is prepared. It is com m only
stacked in m ultiple layers for sufficient tip
projection. The sam e length as the onlay graft is
excised from the distal implant. The onlay graft is
sutured to the cut end of the im plant.
6. The wing graft is prepared mimicking the lateral
crus. It is placed on both sides of the onlay graft to
prevent the pinching deformity of tip lobules, to
decrease the conspicuity of the onlay graft.
7. Further ne tip shaping is achieved by delicate
carving and the use of additional onlay or shield
grafts.
8. Meticulous closure and irrigation using antibiotic
and antiseptic solutions are done. Use of a
compressive dressing with a thermoplastic splint is
important to immobilize the implant and to prevent
edema and hematoma.
■Complications and
Their Management
Negative reactions toward alloplastic implants for rhino-
plasty were common in the Western part of the world. This
may stem from experience with injectable materials such
as para n oil, liquid silicone, and early implants of exces-
sive size.5 Interestingly, recent research shows much lower
complication rates from silicone implants compared with
reports published in the 1960s and 1970s. These changes
are thought to be due to improvements in implant design,
conservative surgical techniques, physicians having more
experience, and use of softer silicone. Many physicians in
Asia perceive the complication rates of silicone implants
as acceptable, in part due to more experience with rhi-
noplasty using silicone implants compared with Western
physicians.
Complications from silicone implants can be largely
grouped into two categories, those caused by inherent traits
of silicone itself and those resulting from the surgeon’s
technical or judgmental errors. For a successful surgical
result, it is essential to minimize the inevitable problems
from inherent physical characteristics of the material and
to make e orts to reduce technical and judgment errors.5
Common complications, such as deviation, tip skin
problems, and infection, are more frequently related to
technical errors that are avoidable, and less frequently to
the physical characteristics of the material itself.
2 Augmentation Rhinoplasty Using Silicone Implants
23
implant for immobilization by tissue ingrow th. It is helpful
to immobilize the implant; however, it is di cult to cor-
rect when the implant is xed but deviated. And it is said
to be the cause of sudden hematoma or bleeding in the late
postoperative period, because a sudden trauma or move-
ment of the implant w ill disrupt the blood vessels of the
ingrown tissue.
Constant movement by the malpositioned implant can be
a cause of chronic skin irritation and chronic in ammation.
Infection
Alloplastic implants are susceptible to infection and, when
infected, exhibit typical symptoms such as erythema, swell-
ing, and purulent secretion. However, temporary erythema
and swelling in the form of subclinical infection can occur
repeatedly. Subclinical infection is thought to occur when
the number of bacteria is small, or if bacteria are present in
the form of bio lm on the surface of silicone.
Thorough sterilization of the surgical eld is necessary
for reducing infection, especially in the nasal vestibule and
the entrance part of the nasal cavity. During surgery, it is
important to prevent disruption of natural barriers such as
the mucous membrane. A lengthy surgical time may reduce
blood ow to the tissue and increase the risk of infection.
Implants must be immersed in sterilizing solution during
procedures.8
■Case Studies
Case 1
A 22-year-old female visited the clinic for a rhinoplasty
(Fig. 2.15). She showed typical Asian facial features such as
a at forehead, shallow nasofrontal angle, at nasal bridge
with weak tip projection, and maxillary retrusion.
Considering the shallow nasofrontal angle and under-
projected tip, a silicone implant was carved to be proxi-
mally thin and distally thick. Bilateral medial and lateral
osteotomies were performed. For su cient projection,
a three-layer stacked onlay graft with wing grafts using
conchal cartilage, and a septal extension graft were used
in combination for the tip. For more de nition of the tip,
defatting of the soft tissue on the tip was done.
One-year postoperative pictures show adequate tip
projection, a more de ned nasal tip, and an augmented,
narrowed nasal bridge. The stigma of rhinoplasty, including
the unnaturally at nasofrontal transition, visible implant
contour in the radix, and sharp pointed tip, are barely
noticeable.
Problems Caused by Technical or
Judgmental Errors of the Surgeon
Extrusion and Thinning of Tip Skin
Extrusion rates of silicone implants reportedly vary from
0.48% to 50%, probably due to the di erences in surgi-
cal technique, implant shape, and the surgeon’s level of
experience.3 When excessive tension is applied to the
nasal tip’s skin w ith the intention of giving a tent-pole
e ect using the implant, especially the L-shaped silicone
implant w ith a long colum ellar segm ent, the risks of skin
dam age and implant extrusion increase. An implant of
excessive length m ay thin the nasal tip skin over tim e,
and m ay eventually extrude. The implant can also
extrude into the nasal cavity through the m ucous m em -
brane. Chronic in am m ation and infection are also com -
m on causes of extrusion. Extrusion is a complication that
can be avoided by using an appropriately sized implant,
tip grafting w ith autologous cartilages, and infection and
in am m ation protection.
Implant Displacement and Movement
Implant deviation is a frequent side e ect. To prevent
displacement, the implant should be placed in the sub-
periosteal pocket. Silicone implants have a higher risk of
movement compared with materials with pores, such as
Gore-Tex. Therefore, it is important to immobilize the sili-
cone implant for the period of time using a splint after sur-
gery. Some surgeons make wedge excisions or holes on the
Fig. 2.14 The outer and lateral surfaces of the silicone implant are
covered with a dermal graft.
II Rhinoplasty
24
Bilateral extended spreader grafts using rib cartilage
and stacked onlay tip grafts with wing grafts using auricular
cartilage were employed. Auricular cartilage has advantages
over rib cartilage for the onlay or shield graft and the wing
graft, because of its natural curvature and less sti nature.
The dorsum was augmented with a silicone implant, which
was covered with a dermal graft from the postauricular skin.
Use of the silicone implant is usually safe even in secondary
cases. In contrast to case 1, the implant was designed to be
proximally thick and distally thin. One year after the revi-
sion operation, the result remained stable.
Case 2
A 25-year-old female visited the clinic for revision rhi-
noplasty (Fig. 2.16). She had developed an infection
after silicone implantation in the previous surgery. She
showed severe contraction, a at dorsum with low radix,
an over-rotated tip, and irregular deformed tip skin with a
depressed scar. Septal cartilage was used for the tip-plasty
in the previous surgery.
Fig. 2.15 Case 1: Primary dorsal augmen-
tation with tip-plasty. (a,c) Preoperative
frontal and lateral views show at forehead,
shallow nasofrontal angle, at nasal bridge
with weak tip projection, and maxillary
retrusion. (b,d) One-year postoperative pic-
tures show adequate tip projection, a more
de ned nasal tip, and an augmented, nar-
rowed nasal bridge.
a
b
c
d
2 Augmentation Rhinoplasty Using Silicone Implants
25
5. McCurdy JA, Lam SM, eds. Cosm etic Surgery of the Asian
Face. London, UK: Thiem e Medical Publishers; 2005
6. Jung DH, Moon HJ, Choi SH, Lam SM. Secondary rhino-
plasty of the Asian nose: correction of the contracted nose.
Aesthetic Plast Surg 2004;28(1):1–7
7. Jung DH, Kim BR, Choi JY, Rho YS, Park HJ, Han WW. Gross
and pathologic analysis of long-term silicone implants in-
serted into the hum an body for augmentation rhinoplas-
ty: 221 revision cases. Plast Reconstr Surg 2007;120(7):
1997–2003
8. Jang YJ, ed. Rhinoplasty and Septoplasty. Seoul, South Ko-
rea: Koonja Publishing; 2014
References
1. Lee MR, Unger JG, Rohrich RJ. Managem ent of the nasal
dorsum in rhinoplasty: a system ic review of the literature
regarding technique, outcom es, and complications. Plast
Reconstr Surg 2011;128:538e–550e
2. Lam SM, Kim YK. Augm entation rhinoplasty of the Asian
nose with the “bird” silicone implant. Ann Plast Surg
2003;51(3):249–256
3. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use
of alloplastic m aterials in rhinoplasty surgery: a m eta-
analysis. Plast Reconstr Surg 2008;121(3):85e–92e
4. Ahn J, Honrado C, Horn C. Com bined silicone and cartilage
implants: augm entation rhinoplasty in Asian patients.
Arch Facial Plast Surg 2004;6(2):120–123
Fig. 2.16 Case 2: Correction of the postop-
erative contracted nose. (a,c) Preoperative
photos show severe contraction, at dor-
sum with low radix, over-rotated tip, and
irregular deformed tip skin with a depressed
scar. (b,d) One-year postoperative photos
show elevated dorsum, decreased tip rota-
tion, and improved tip skin dimpling.
a
b
c
d
26
3 The Use of Costal Cartilage for Dorsal
Augmentation and Tip Grafting
Victor Chung and Dean M. Toriumi
■Patient Evaluation
The initial patient consultation starts with a complete his-
tory and physical examination to diagnose the structural
problems that cause the undesirable aesthetic features of
the patient’s nose. In addition, the consultation should
elucidate any history of nasal obstruction or complicat-
ing history: previous surgery, infection, or foreign bod-
ies, including implants and injectable llers. The physical
exam will con rm characteristic anatomic features of the
East Asian nose, including: at glabella; low nasal dorsum
with caudally placed nasal starting point; thick, sebaceous
skin overlying the nasal tip and supratip; weak lower lat-
eral cartilages; small cartilaginous septum; foreshortened
nose; retracted columella; and thickened, hanging alar lob-
ules (Fig. 3.1).2
■Introduction
Aesthetic rhinoplasty of the East Asian face requires a dif-
ferent approach than that used for the Caucasian face. This
alternative approach is due to di erences in nasal anatomy,
patient expectations, and surgical techniques. Regardless
of the approach, the principles of structure rhinoplasty
remain the same: surgical manipulation of the nasal con-
struct causes weaknesses susceptible to scar contracture.
For a long-term aesthetic and functional outcome, aug-
mentation must withstand the distorting forces of tissue
healing.1 Supporting the nose by augmentation requires a
signi cant amount of grafting material. Autologous costal
cartilage provides a bountiful source of material that can
be used to produce a lasting aesthetic and functional result
in the East Asian face.
Pearls
• Rhinoplasty in an East Asian patient requires
attention to a di erent set of aesthetic goals than
for a Caucasian patient. Digital image morphing
software is very important to be able to communicate
proposed changes to the patient population.
• The East Asian nose is de cient in structural
support. Augmentation is necessary to achieve the
desired re nement. A structural approach to East
Asian rhinoplasty allows the surgeon to accomplish
the established goals.
• Although alloplastic implants have been widely used
in East Asian rhinoplasty, autologous costal cartilage
is being used more frequently in the East Asian nose
as a desirable alternative.
• A thorough history, including previous surgery,
infection, implants, or injectable llers, is necessary
to elucidate factors that will increase the complexity
of the surgery.
• For safe and successful costal cartilage harvest, the
surgeon must be familiar with the anatomy of the
rib cage to select the rib with the best contour for
the necessary grafts.
• The barrier to mastering costal cartilage grafting is
learning to judge where to use each potential graft
and how to properly prepare the grafts.
• Age is the most important factor to consider when
carving costal cartilage.
• One of the most important concepts in successful
costal cartilage grafting is to carve the material
sequentially with repeated cycles of carving, soaking,
and drying the graft to identify its natural bend.
• Although cross-hatching and splinting are useful,
it is important to understand that these techniques
cannot overcome the selection of an inappropriate
piece of costal cartilage.
• In the setting of East Asian dorsal augmentation,
osteotomies are usually unnecessary.
• Serial carving, perichondrium camou age, and rigid
xation are key strategies in performing dorsal
augmentation.
• Tip augmentation, accomplished with shield or
horizontal onlay grafts, creates projection and
re nement; however, a stable foundation is required
to control length and rotation.
• In the East Asian nose, with its wide airway and
thicker lateral sidewalls, alar batten and alar rim
grafts are infrequently indicated.
• After structured rhinoplasty with autologous costal
cartilage augmentation, technically di cult base
reductions may be required to balance the nose.
3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
27
Preoperative Discussion and
Counseling
Further preoperative counseling should include inci-
sion placement (columellar and alar for base reduction),
increased sti ness of the nose, extra operative time for
costal cartilage harvest, complications (pneumothorax and
warping), and postoperative course (swelling, follow-up
schedule). This is the time to tell the patient that to achieve
the goals of dorsal augmentation and tip re nement in the
setting of thick skin, a large amount of grafting material will
be used, essentially making the nose bigger. This is neces-
sary in East Asian rhinoplasty, as the primary cases will
often be lacking in septal cartilage. Similar to the quality
of the upper and lower lateral cartilages, the septum is thin
and weak. According to the principles of structure rhino-
plasty, destabilizing the already weak cartilage by reducing
the structural components will allow scar contracture to
have an even more dramatic and often undesirable e ect.
This emphasizes the need for augmentation. To address the
lack of material, it is the authors’ opinion that autologous
costal cartilage can provide the best aesthetic and func-
tional results in the East Asian patient’s nose. Costal car-
tilage is inherently stronger and, therefore, can be carved
thinner, avoiding bulk in the nose. The vascular demand is
less than for auricular cartilage, decreasing rates of resorp-
Preoperative Evaluation
The preoperative evaluation continues with the photod-
ocumentation of these anatomic features in standardized
views (frontal, lateral, three-quarter, and base views).
Three-dimensional stereophotogrammetry can be per-
formed at this point to provide a baseline for postoperative
comparison and measurements.3
Digital im age m orphing software provides an oppor-
tunity for a frank discussion between the patient and
surgeon. Photographic m anipulation is a transparent
m edium for the com m unication of expectations, priori-
tization of goals, and identi cation of potential pitfalls.
Typical goals for the East Asian nose include elevation of
the nasal dorsum , re nem ent of the nasal tip, narrow ing
of the nasal base, and correction of colum ellar retraction.
Furtherm ore, the software can prompt subjective prefer-
ences (Westernized versus natural) and objective param -
eters: nasal length, dorsal height, projection, rotation,
w idth, and tip re nem ent. Throughout this exchange,
the surgeon needs to counsel the patient that the fron-
tal view is the rst priority. Improvem ents w ill be m ade
regarding the pro le and base views; however, the fron-
tal view w ill not be sacri ced for such improvem ents.
Agreem ent on the planned outcom e is necessary prior to
the operative date.
Fig. 3.1 Native East Asian characteristics: thick skin, wide and low dorsum, retracted columella, underprojected and amorphous tip.
(a) Frontal view; (b) lateral with midpupillary horizontal line; (c) base view.
a
b
c
II Rhinoplasty
28
The nasal septum is exposed by lateral retraction of the
lower lateral cartilages and sharp dissection to the anterior
septal angle. Bilateral mucoperichondrial aps are raised
in the appropriate subperichondrial plane to decrease the
risk of septal perforation. Again, as most Asian patients do
not require a hump reduction, a submucous resection may
be performed at this time, while preserving 15-mm caudal
and dorsal struts. The septal cartilage harvest will provide
a small volume of grafting stock that is not particularly
strong but is at low risk for warping.
After deconstructing the nasal framework, the surgeon
surveys the nose and reviews the grafts anticipated to be
necessary to resupport the nose, augment the dorsum, and
re ne the nasal tip before changing gloves and turning to
the chest.
Costal Cartilage Harvest
Prior to the costal cartilage harvest, the surgeon must con-
sider several patient factors, including age, breast anatomy,
and excessive scarring. Despite variability in nasal anatomy,
costal cartilage anatomy is relatively consistent across dif-
ferent ethnic backgrounds. The most important factor is
the age of the patient.6,7,8 Younger patients are at higher
risk for graft warping. Older patients are at higher risk for
fracturing during harvest or graft manipulation. Patients
between the ages of 30 and 50 are generally at lower risk
of warping, and fracturing can usually be prevented with
careful handling of the grafts. In the East Asian patient
population, the average volume of breast tissue obligates
the surgeon to minimize the incision length for the sake of
a smaller scar that cannot be hidden in an inframammary
crease (Fig. 3.3).
With the increased prevalence of breast augmentation,
incisions hidden in the inframammary crease may risk
puncture or trauma to the breast implant. Furthermore,
ribs directly under an implant (typically rib 6) provide
tion. Costal cartilage is available in greater volume, provid-
ing all of the necessary grafts from a single donor site. As
there is less cautery required for hemostasis at the rib com -
pared with the ear, donor site pain is also less.4 Postopera-
tive complications seen with synthetic implants—wound
infection, graft extrusion, injured skin envelope—are rare;
however, the risk of complications remains for a lifetime
(Fig. 3.2). For these reasons, autologous costal cartilage is
ideal for the East Asian nose and is the focus of this chapter.
■Surgical Techniques
The senior author (DMT) performs augmentation rhino-
plasty through a standard external rhinoplasty approach
under general anesthesia with endotracheal intubation in
an outpatient surgicenter. The surgeon injects the chest
and nose with 1% lidocaine with 1:100,000 epinephrine
prior to prepping and draping to allow for optimal vaso-
constriction. While injecting the septum, the surgeon can
initiate the elevation of mucoperichondrial aps via hydro-
static dissection. At the same time, needle palpation can
di erentiate cartilaginous versus bony nasal septum, for
an estimation of available material for grafting. The nose
is packed with cotton pledgets soaked in 0.05% oxymetazo-
line, for further vasoconstriction.
Opening the Nose
By opening the nose rst, the surgeon can make a clear
assessment of the amount of cartilage grafting material
required to complete the case. A midcolumellar inverted-V
incision is demarcated with anticipation of the tip projec-
tion outcomes. If there is a planned increase of projection,
the incision is drawn slightly (1 mm) posterior to the mid-
columella. The columellar incision is made with a no. 11
blade scalpel. Marginal incisions and columellar incision
extensions are made bilaterally with a no. 15 blade scal-
pel. Using Converse scissors, the incisions are connected
sharply. Particular attention is directed to preserving the
soft tissue triangles as well as maintaining an adequate cu
of tissue separating the marginal incision from the alar rim,
~ 3 mm. Carelessness here can result in notching of the alar
margin. Using three-point retraction, the skin envelope is
raised sharply. Preserving the subdermal plexus by mini-
mizing blunt spreading improves hemostasis and mini-
mizes postoperative edema. Sharp dissection continues
from the lower lateral cartilages superiorly to the cartilagi-
nous dorsum and bony-cartilaginous junction. A key point
is to use the Joseph periosteal elevator in a limited fashion,
preserving a tight pocket in anticipation of a dorsal graft. A
tight pocket will restrict graft movement and aid in rapid
xation to prevent warping.5 Additionally, as most Asian
patients do not require a hump reduction, wide subperios-
teal dissection is not warranted.
Fig. 3.2 L-shaped silicone implant removed in revision surgery.
3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
29
3.75-cm (1.5-in), 27-gauge needle localizes the osseocar-
tilaginous junction and determines the degree of ossi ca-
tion. Be forewarned: Blind needle pokes may puncture the
pleura and lung parenchyma, resulting in a closed tension
pneumothorax.
Once the ideal rib has been selected and characterized,
the overlying skin is marked and the surrounding area is
injected with 1% lidocaine with 1:100,000 epinephrine.
Costal cartilage from the right side is preferred to avoid
injury to the pericardium and confusion of postoperative
important structural support to the breast implant. Harvest
of a supporting rib may result in undesired asymmetries of
the breast position or discomfort from the weight of the
implant lying on the manipulated rib. Hypertrophic scar-
ring and keloid formation should be elucidated from the
patient’s history for appropriate counseling preoperatively.
Abnormal chest wall anatomy and elevated body mass
index may also increase the complexity of the harvest.
When selecting a rib to harvest, one must be familiar
with the relationships of the individual ribs to one another.
The fth rib has a free superior and inferior margin; how-
ever, it can lie underneath breast tissue or pectoralis mus-
cle. It is also relatively short and curved and may not be of
adequate size for dorsal augmentation. The sixth rib typi-
cally has a free superior margin, but the inferior margin is
connected to the seventh rib medially. The sixth rib is usu-
ally at an ideal depth, but it has a slight genu that may not
be ideal if a long straight segment is needed (Fig. 3.4).
The seventh rib is straighter and will usually have con-
nections with the surrounding ribs on both the superior and
inferior borders. The eighth and greater non oating ribs
will have signi cant connections to surrounding ribs and
are thinner and may not be of adequate width for a dorsal
graft. The seventh and eight ribs are located slightly deeper
underneath the skin compared with the sixth rib. As the ribs
are followed medially, they course deeper under the subcu-
taneous tissue. Ultimately, the rib with the best contour for
the necessary grafts should be selected, but generally the
cartilage component of the seventh rib has the best contour.
After these considerations, the surgeon should manu-
ally palpate the chest wall around the potential ribs for
harvest. Once oriented, careful needle palpation with a
Fig. 3.3 Scar comparison. (a) Harvested costal cartilage and chest incision intraop-
eratively. (b) Right scar marked with two dots is the costal cartilage harvest site after
5 years. Left scar is a breast augmentation scar (arrow).
Incision
Inframammary fold
1
2
3
4
5
6
Fig. 3.4 Harvest incision placement.
a
b
II Rhinoplasty
30
Having opened the nose, the surgeon should have in
mind the grafts that will be used to structure the nose. The
harvested costal cartilage should be taken in dimensions
appropriate for the planned grafts. Usually 3 to 4 cm of cos-
tal cartilage is harvested. To ensure an intact harvest site
and avoid violation of the pleura, the rst incision should
start by using the sharp end of the Freer elevator to cut 0.5
mm from the superior and inferior margins of the rib. After
50% penetration through the depth of the cartilage, the
incision is completed with the blunt end of the Freer eleva-
tor. The goal is to maintain a protective cu of cartilage that
guides the dissection into a safe plane above the posterior/
deep perichondrium and pleura. Medial and lateral bound-
aries of the cartilage are rst sharply incised with a no. 15c
blade through 10% of the thickness, followed by a sharp
Freer elevator through 70%; the blunt Freer elevator com -
pletes the nal 30%. Once mobilized on inferior, superior,
lateral, and medial borders, the undersurface of the rib is
freed with a Freer elevator using a lifting motion (Fig. 3.5).
Following the harvest, the medial and lateral edges of the
remaining cartilage are smoothed with Takahashi forceps.
The wound bed should be inspected for violations of
the perichondrium or pleura, with potential injury to the
lung parenchyma and a resulting pneumothorax. The
wound bed is lled with saline. A Valsalva maneuver con-
rms an intact harvest site, if the saline volume is constant
and there are no bubbles. Any defects should be repaired
immediately. To repair such defects, the lung is de ated
and a catheter is placed in the defect. A purse-string stitch
should be placed around the defect and tied after the cath-
discomfort with angina. The donor site is a separate sterile
eld, and cross-contamination with nasal ora should be
avoided by changing gloves and using a separate set of sur-
gical instruments.
Due to the senior author’s experience, he is able to
start with a 10-mm incision that may stretch to a nal
length of 12 or 13 mm. The chest incision is made small
to minimize the visible scar and morbidity to the patient.
For patient safety, surgeons should continue to use a larger
incision until they are familiar with the dissection.5 After a
skin incision is made, sharp dissection continues through
the subcutaneous fat to the fascia overlying the muscle. For
hemostasis, bipolar cautery is used to minimize postop-
erative pain. A no. 15c scalpel is used in the small window
to sharply incise the muscle fascia. The muscle is bluntly
spread to decrease bleeding and postoperative pain. The
keyhole perspective is maintained with retractors to view
the perichondrium overlying the rib. This window can be
translated medially and laterally along the course of the
rib. Recall that the rib’s course is not a straight line, but
an oblique and three-dimensional arc that changes depth
as it curves from lateral to medial. Through the process of
exposing the rib, the boundaries of the rib should be con-
rmed by careful needle palpation.
Once exposed, the anterior perichondrium is incised
w ith a no. 15c scalpel along the lateral limit, superior bor-
der, and inferior border of the rib. The perichondrium is
mobilized with a Freer elevator and harvested sharply. The
rest of the perichondrium will remain intact to ensure the
integrity of the harvest site.
Fig. 3.5 Costal cartilage harvest technique. (a) Blunt dissection through
muscle to the perichondrium on the anterior surface of the rib. (b) Lifting-
technique with Freer elevator to preserve the posterior perichondrium.
(c) Removal of costal cartilage en bloc. (Used with permission from Tori-
umi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37:335–352.)
a
b
c
3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
31
less than the peripheral slices; however, it may be brittle
and prone to fracture in older patients. With the properties
of the central and outer/ brous component in mind, the
surgeon may begin to carve the costal cartilage.
One of the most important concepts in successful cos-
tal cartilage grafting is to carve the material sequentially.
Repeating soaking and drying cycles between carvings
encourages the cartilage to reveal any tendency to bend in
30 to 60 minutes. First the harvested segment is cut into
three pieces along the longest axis, creating anterior, cen-
tral, and posterior slices. These pieces are allowed to soak
and then they are carved into thinner pieces. After allow-
ing the freshly carved cartilage to show its natural bend,
the key is to utilize that bend when selecting individual
pieces for speci c grafts. Most grafts require some degree
of curvature for optimal function. The inherent strength of
costal cartilage allows it to be carved very thin to decrease
the bulk in the nose; however, a thickness less than 1 mm
increases the risk of torquing. Attempting to carve the car-
tilage into a straight piece is not advised, as it may result in
unpredictable warping after xation.
Limited manipulation of the costal cartilage is possible
and is particularly useful if warping is a concern. The two
techniques available to the surgeon are cross-hatching and
splinting, which may be used separately or in combination.
Cross-hatching consists of partial-thickness cuts into the
concave side of a curved piece of cartilage to release the
bowing forces on the graft. The degree of release is di -
cult to predict, and overzealous cross-hatching may result
in overcorrection and curvature in the opposite direction.
Partial-thickness cuts on the convex side increase the exist-
ing curvature. Splinting involves the summation of curves.
Two curved pieces are sutured together with opposing con-
cavities to create a single straight graft (Fig. 3.6). Although
cross-hatching and splinting are useful, it is important to
understand that these techniques cannot overcome the
selection of an inappropriate piece of costal cartilage.
Management of the Bony Vault
The importance of addressing the bony vault in the East
Asian nose lies in setting the foundation for dorsal aug-
mentation. Mismanagement of the bony vault will result
in failure to create a natural-appearing dorsum. Starting
with a low, wide nasal dorsum, it seems counterintuitive
to forgo narrowing osteotomies. In fact, the existing wide
bony dorsum will create a desirable pyramidal shape when
a dorsal augmentation graft is stacked on top of it. A bony
vault narrowed by aggressive osteotomies w ill provide ver-
tically oriented sidewalls and create an unnatural tubular
shape when combined with a dorsal augmentation graft
(Fig. 3.7). Additionally, excessive narrow ing of the bony
upper third may prove to be too much for the anatomic lim -
itations of the nasal base, creating an imbalance between
the widths of the cephalic and caudal portions of the nose.
eter is placed on suction, and removed when the lung has
been maximally reexpanded. A repeat inspection and Val-
salva maneuver are warranted. Injury to the lung paren-
chyma may require a chest tube insertion.
The chest harvest site remains open for the duration of
the operation as a contingency for more graft material or peri-
chondrium. The site is protected with an antibiotic-soaked
gauze sponge and blue towel. After completing the rhino-
plasty, the surgeon again changes gloves. The rib harvest site
is irrigated and inspected. Closure begins with 3–0 PDS suture
to reapproximate the muscle and its fascia. Careful attention is
paid to this layer of closure to ensure the separation of muscle
and fascia from the overlying subcutaneous tissue. A suture
spanning the two layers will result in tethering of the overly-
ing tissue to the deeper fascia, inhibiting independent motion.
The subcutaneous fat is reapproximated with 4–0 PDS suture.
The deep dermal layer is closed with 5–0 PDS suture. The
subcuticular layer is closed with 6–0 Monocryl suture. The
cutaneous layer is reapproximated and everted with 5–0
fast-absorbing gut suture. Finally, cyano acrylate adhesive is
applied super cially to seal the wound.
The senior author recommends routine postoperative
chest X-ray and a period of observation after costal cartilage
harvest until the surgeon is familiar with the procedure.
For patients with a propensity for keloids or hypertro-
phic scars, Kenalog (10 mg/mL) may be injected at the cos-
tal cartilage harvest site. After the skin glue falls o , silastic
sheeting may be utilized to help minimize the visibility of
an unsightly scar.
Costal Cartilage Carving
At this point of the procedure, the surgeon needs to focus
on the critical step of cartilage carving. Regardless of the
amount of energy expended on the harvest or complica-
tions encountered during the harvest, the surgeon cannot
lose concentration. The barrier to mastering costal carti-
lage grafting is learning to judge where to use each poten-
tial graft and how to properly prepare the graft. Prior to any
carving, the surgeon should repeat the survey of the nose
and plan all of the necessary grafts; one should not carve
the grafts as they are needed in the procedure. If a large
dorsal augmentation is planned, an appropriately thick
piece of costal cartilage stock needs to be preserved for the
dorsal graft, starting with the rst cut into the costal car-
tilage. Improper carving, selection, or xation of the costal
cartilage grafts could potentially create more deformity
than the de ciency one is trying to repair.
Again, age is the most important factor to consider
when carving the costal cartilage. The cartilage will have
a whiter-appearing outer portion, which contains a brous
component. In the younger patient, the outer portion of the
rib has an increased tendency to bend. In the older patient,
the outer brous component is less prone to fracture, in
which case it is preserved.9,10 The central piece may bend
II Rhinoplasty
32
Conservation of a low, wide nasal dorsal foundation
should not preclude the surgeon from manipulating the
nasal bones. Osteotomies to address bony deviation may
be necessary. Excessive width may require judicious nar-
rowing osteotomies. Depressed bony segments may need
outfracture. Avoiding medial osteotomies will help prevent
excessive narrowing. If thick cortical bone is preventing
back fracture from the lateral osteotomy sites, laterally fad-
ing medial osteotomies may be necessary. Lateral osteoto-
mies are performed in a high-low-high fashion. The senior
author prefers to use a straight 3-mm osteotome to limit
soft tissue trauma. And the surgeon should limit the force
applied by the dominant hand when manually adjusting
the nasal bone to avoid a telltale “thumbprint” sign.
Management of the Middle Third
After setting the bony vault at an appropriate width, the
surgeon proceeds caudally to address the middle third of
the nose, continuing a rm structural foundation for dorsal
grafting. The most commonly used technique is spreader
grafting. In the East Asian nose, spreader grafts open the
internal nasal valve and aid in setting and preserving nasal
length and projection. By resisting the cephalic pull on the
tip complex, strong spreader grafts prevent over-rotation
and nasal shortening. They strengthen the dorsum, pre-
venting saddling. They can be tucked under an outfractured
nasal bone to prevent postoperative recollapse.
Spreader grafts may be placed traditionally or in sub-
mucosal pockets (Fig. 3.8). By keeping the upper lateral
cartilages attached to the septum, the surgeon does not
need additional time to reconstruct the middle nasal vault,
Fig. 3.6 Graft splinting technique. (a) A curved graft is matched
with a sliver of cartilage with opposing curvature.The graft and
sliver are sutured together with 6–0 Monocryl. (b) Final graft with
multiple splints.
Plane of
illustration
Osteotomy
Fig. 3.7 Dorsal augmentation graft without osteotomies. (a) Plane of Illustration. (b) When the dorsal augmentation graft is placed on
a wide base the outcome is a favorable contour with a smooth transition from graft to maxilla. Osteotomies that inappropriately narrow
the base disrupt this transition, creating a vertical drop-o from the graft to the cheek. (Used with permission from Toriumi DM, Pero CD.
Asian rhinoplasty. Clin Plast Surg 2010;37:335–352.)
a
b
a
b