123
Perspectives from
Korean Masters
Man Koon SUH
Editor
State of the Art
Rhinoplasty
Techniques
State of the Art Rhinoplasty Techniques
Man Koon SUH
Editor
State of the Art
Rhinoplasty Techniques
Perspectives from Korean Masters
ISBN 978-981-16-5240-0 ISBN 978-981-16-5241-7 (eBook)
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
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189721, Singapore
Editor
Man Koon SUH
JW Plastic Surgery Center
Seoul, Korea (Republic of)
v
Preface
There is no doubt that rhinoplasty is one of the most difficult fields of aes-
thetic plastic surgery. Rhinoplasty is one of the most frequently frustrating
areas for young plastic surgeons.
Consider these two points:
• Rhinoplasty results vary widely based on a doctors experience and skill
• It is difficult to predict changes in shape long after the surgery
Therefore, younger doctors will benefit greatly from the know-how and
experience of established masters of rhinoplasty. Leveraging the observations
presented here will position them well for early success.
“State-of-the-Art Rhinoplasty Techniques” demonstrates the latest tech-
niques of Korean rhinoplasty surgeons. These doctors are not just masters of
this technique; they are long time contributors to the technological develop-
ment of rhinoplasty through research, presentation, and operating room
experience.
Publishing a book in collaboration with plastic surgeons and otorhinolar-
yngologists has been a long time dream of mine. I am thrilled and honoured
to be the editor of this book that my esteemed colleagues have contributed to.
The multispeciality knowledge contained in this book is the culmination of
experience and know-how from plastic surgeons and otorhinolaryngologists.
Surgeons have much digression in selecting techniques and materials for
rhinoplasty operations. Considering that the nose has a functional role as well
as an aesthetic aspect, rhinoplasty should always pursue improvement in
function and aesthetics.
Compared to other procedures, rhinoplasty has a higher rate of revision
surgery. The secondary surgery requires more experience and know-how than
the primary one.
The authors of this book have provided their valuable experience and
knowledge through manuscripts, photos, and illustrations. Each one has con-
tributed a chapter and believe it will allow the reader to experience the latest
in rhinoplasty technology including revision surgery techniques.
This book will be a valuable resource for surgeons wanting to learn the
latest techniques for rhinoplasty. We believe it expands their knowledge on
how to achieve “ideal balance between esthetic and functional outcomes”.
vi
I would like to express my sincere thanks to the authors of the chapters for
their valuable time and effort for the publication of this book. Also, I would
like to express my gratitude to the illustrator, Choi Yun Jung, who expressed
the contents of this book with great illustrations.
Seoul, South Korea
Man Koon SUH
Preface
vii
Preoperative Evaluation and Postoperative Care�������������������������������� 1
Young Seok Kim
Nasal Dorsal Augmentation Using Implant
and Autogenous Tissues������������������������������������������������������������������ 17
Man Koon SUH, Hyesung Lee, and Seunghyun Choi
Nasal Tip Techniques (1): Tip Augmentation Techniques�������������������� 43
Moo Hyun Paik and Lo Shui Chu
Nasal Tip Techniques (2): Bulbous Tip Correction������������������������������ 73
Sung Wan Park
Nasal Tip Technique (3): Tip Shortening����������������������������������������������117
Seong Geun Park
Surgery of Columella, Alar Rim and Alar Base������������������������������������149
Moo Hyun Paik and Lo Shui Chu
Mid-vault Surgery������������������������������������������������������������������������������������227
Jong-Woo Choi
Deviated Nose Correction and Functional Surgery 1��������������������������247
Yong Ju Jang
Functional Surgery 2: Consideration of Internal Valve Problems
in Asian Rhinoplasty, and Turbinate Reduction ��������������������������275
Eun-Sang Dhong
Secondary Rhinoplasty (1): Implant-Related Complications��������������285
Jaeyong Jeong
Secondary Rhinoplasty (2): Mid-vault Correction ������������������������������321
Man Koon SUH
Secondary Rhinoplasty (3): Tip��������������������������������������������������������������347
Keun Cheol Lee
Contracted Nose: My Preferred Technique������������������������������������������413
Hong Ryul Jin
Contents
viii
Contracted Nose and Difficult Complication Cases:
My Preferred Technique������������������������������������������������������������������435
Moo Hyun Paik and Lo Shui Chu
Secondary Cleft Lip Rhinoplasty ����������������������������������������������������������483
Hojin Park and Kyung S. Koh
Injection Rhinoplasty������������������������������������������������������������������������������497
Ik-Soo Koh and Won Lee
Contents
ix
Editor and Contributors
Editor
Man Koon SUH, MD JW Plastic Surgery Center, Seoul, South Korea
Contributors
Jong-Woo Choi, MD, PhD Department of Plastic and Reconstructive
Surgery, Seoul Asan Medical Center, Seoul, South Korea
Seunghyun Choi, PhD Anymedi Inc., Seoul, South Korea
Lo Shui Chu, MD Gok Saem Aesthetic Plastic Surgery Clinic, Seoul, South
Korea
Eun-Sang Dhong, MD, PhD Department of Plastic and Reconstructive
Surgery, Korea University Guro Hospital, Seoul, South Korea
Yong Ju Jang, MD, PhD Department of Otorhinolaryngology-Head and
Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, South Korea
Jaeyong Jeong, MD, PhD THE PLUS Plastic Surgery Clinic, Seoul,
South Korea
Hong Ryul Jin, MD, PhD Dr. Jin’s Premium Nose Clinic, Seoul,
South Korea
Young Seok Kim, MD, PhD Department of Plastic and Reconstructive
Surgery, Yonsei University Gangnam Severance Hospital, Seoul, South Korea
Ik-Soo Koh, MD Koh Ik Soo Aesthetic Plastic Surgery Clinic, Seoul,
South Korea
Kyung S. Koh, MD, PhD Department of Plastic and Reconstructive Surgery,
University of Ulsan College of Medicine, Asan Medical Center, Seoul, South
Korea
Hyesung Lee, PhD Anymedi Inc., Seoul, South Korea
Keun Cheol Lee, MD, PhD Department of Plastic and Reconstructive
Surgery, Inje University Haeundae Paik Hospital, Busan, South Korea
x
Won Lee, MD, PhD Yonsei E1 Aesthetic Plastic Surgery Clinic, Anyang,
South Korea
Moo Hyun Paik, MD, PhD Department of Plastic and Reconstructive
Surgery, Ulaanbaatar Agape Christian Hospital, Ulaanbaatar, Mongolia
Hojin Park, MD, PhD Department of Plastic and Reconstructive Surgery,
University of Ulsan College of Medicine, Asan Medical Center, Seoul,
South Korea
Seong Geun Park, MD, PhD Joseph Aesthetic Plastic Surgery Clinic,
Daegu, Republic of Korea
Sung Wan Park, MD April31 Plastic Surgery Clinic, Seoul, South Korea
Editor and Contributors
1
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,
Preoperative Evaluation
and Postoperative Care
Young Seok Kim
Asian Rhinoplasty
When referring to ethnicity, Asian in general
includes all population from East Asia to
Southwestern Asia. On the other hand, in the field
of plastic surgery, an Asian patient commonly
refers to someone with mongoloid background.
The population of interest is mostly centered in
East Asia such as Korea, Japan, China, or Taiwan,
and Southeast Asia, such as Thailand, Vietnam,
Singapore, Indonesia, or the Philippines. It is
very important to know the characteristics of
their faces and noses in these regions before per-
forming Asian rhinoplasty.
Characteristics of Asian Face
and Nose
Although it is not easy to make a simple defini-
tion of Asian facial features, which bear several
differences compared to a typical Caucasian face,
the following are some of the commonly noticed
characteristics in east Asian faces:
1. Broad facial width
2. Protruded zygoma
3. Straight or concave profile rather than convex
4. Square lower face
5. Geater intercanthal width, presence of epican-
thal fold, and narrow palpebral fissure
6. Thick upper eyelids without supratarsal folds
A typical Asian nose is broader than that of
Caucasians and narrower than Africans. Some of
the distinct characteristics of the Asian nose are
as follows:
1. Low profile with a broad base.
2. Nasal bone is short and thick.
3. Less tip projection, round, and ambiguous tip
defining point.
4. Hypoplasia of anterior nasal spine results in
acute columellar-labial angle, which makes
philtrum appear longer.
5. Nostrils are round and wide-seated with broad
interalar distance.
6. Skin overlying the nasal tip is thick and often
sebaceous.
7. Alar cartilages are small and thin. The medial
crura is small and short.
8. Smaller and thinner septal cartilage.
Preoperative Evaluation
For a successful rhinoplasty, meticulous preop-
erative evaluation with surgical planning is
essential.
Y. S. Kim (*)
Department of Plastic and Reconstructive Surgery,
Yonsei University Gangnam Severance Hospital,
Seoul, South Korea
e-mail: psyskim@yuhs.ac
2
General Preoperative Consideration
Initial Consultation
It is important to objectively evaluate the patient’s
present condition, expectations, or any concerns
related to the procedure. It is preferable to explain
in plain language rather than using excessive
medical terminology for better communication
between a patient and the surgeon. Patients may
acquire biased understanding and memory of the
consultation because they tend to focus on what
they want to hear. If sufficient explanation of
realistic expectations and the possibility of com-
plications is not guaranteed, both the patient and
the
surgeon
may
encounter
undesirable
consequences.
Patient Expectations and Suitability
for Rhinoplasty
Each patient has his or her own expectations
regarding
postoperative
appearance.
Most
patients do have realistic expectations and can
understand the limitations of rhinoplasty with
adequate preoperative consultation. Therefore, it
is desirable to review preoperative photographs
with the patient, discuss present problems, and
what can and cannot be achieved. If the patient
insists on unrealistic goals or displays certain
psychiatric issues in the process, the surgeon
should be able to decline the request. Appropriate
candidates for rhinoplasty are realistic, emotion-
ally stable, secure, well-informed, and under-
stand the limitations. The acronym SYLVIA
describes an appropriate female rhinoplasty
patient who is secure, young, listens, verbal,
intelligent, and attractive. The acronym SIMON
refers to a patient who is single, immature, male,
overly expectant, and with narcissistic traits.
These patients with unrealistic expectations are
highly likely to be disappointed postoperatively
regardless of the result. In addition, patients with
the following “Danger signs” may not be suitable
candidates for a rhinoplasty.
History
Thorough history taking is crucial to decide if a
patient is physically or psychologically suitable
for a rhinoplasty. First, evaluate a patient’s gen-
eral medical condition, and check for any comor-
bidity, including hypertension, diabetes, or
“Danger signs” may indicate the patient
has underlying psychological issues.
1. Minimum disfigurement
2. Delusional distortion of the body
image
3. An
identity
problem
or
sexual
ambivalence
4. Confused or vague motives for the
surgery
5. Unrealistic expectations of change in
life situations as a result of the surgery
6. A history of poorly established social
and emotional relationship
7. Unresolved grief or a crisis situation
8. Present misfortunes blamed on physi-
cal appearance
9. Older neurotic man overly concerned
about aging
10. A sudden anatomic dislike, especially
in older men
11. A hostile, blaming attitude toward
authority
12. A history of seeing multiple physicians
and being dissatisfied with them
13. The indication of paranoid thoughts
(From Rohrich RJ, Janis JE, Kenkel
JM. Male rhinoplasty. Plast Reconstr Surg.
2003;112: 1071–1085.)
Y. S. Kim
3
allergy. Also, check for any medication such as
antihypertensives, analgesics, dermatologic pre-
scriptions, or health supplements. Especially if
the patient is on anticoagulants like aspirin, war-
farin, or health supplements like red ginseng or
omega-3, it is advisable to hold the medication 1
week before the surgery since they may cause
perioperative coagulation problems.
Any history of facial trauma should be taken
into consideration. For instance, if a patient with
deviated nose has a history of prior treatment,
photographs before and after the trauma and
radiologic studies such as computed tomography
should be collected and reviewed.
Ask how many prior rhinoplasties were done,
what kind of implant was used, and which part of
cartilage was utilized. Depending on the availabil-
ity of septal, conchal, or costal cartilage, surgical
planning should vary. If the patient has a history of
filler injection or thread insertion into the nose,
check when and how many times the procedure
was done, and also inspect the material’s brand
name and whether it is absorbable or not.
Commonly, patients do not mention nasal
obstruction in the preoperative consultation. If the
nasal obstruction is present, the possibility of sep-
tal deviation, hypertrophic inferior turbinate, or
internal valve collapse should be considered. In
case of allergic rhinitis or underlying sinusitis, the
condition may worsen following the surgery, and
the patient should be informed of this beforehand.
Therefore, try to check for nasal congestion or
stuffiness, snoring, nasal blockage, rhinitis, or
sinusitis. The utilization of objective tools like the
“NOSE Scale” may help in the process (Fig. 1).
Smoking is a known risk factor for postopera-
tive wound healing delay and airway problems,
so surgeons should provide adequate explanation
and advice.
Preoperative Evaluation
Inspection
The facial symmetry should be evaluated first
when inspecting the patient. Most patients with
facial asymmetry complain of nasal deviation,
but they often do not realize their faces are asym-
metric and the vertical axis of the face has devi-
ated and canted. The patient needs to understand
this concept since the poor understanding of
one’s facial symmetry will leave the patient
unsatisfied with the result. Most people have
asymmetric faces to varying extents, but few
have good insight about it. It is the surgeon’s role
to explain any facial asymmetry through preop-
erative photographs or a mirror and the limita-
tions of correcting the deviation. In the case of
hemifacial microsomia, further explanation about
nostril and alar size discrepancy should be pro-
vided (Fig. 2).
In addition, the relationship of the nose with
surrounding facial features, including eyes, lips,
and overall facial proportions, should be care-
fully examined, observing both static and
dynamic appearance. Standardized photography
should be used in the process.
Physical Examination
Physical examination for rhinoplasty must
include evaluation of skin envelope, nasal frame-
work, internal nasal structures, identification of
potential cartilage donor sites, and nasal airway
function test.
1. Skin
The skin thickness and characteristics of nasal
dorsum and tip tend to vary greatly among indi-
viduals, so careful examination is required for each
case. Compared to Caucasian patients, Asians have
relatively thick nasal skin envelope. When the skin
overlying the nasal tip is thicker, continuous pres-
sure on the underlying cartilage framework may
result in relatively unsuccessful nasal tip plasty.
Also, when the skin is thick and sebaceous, edema
resolves slowly, and rearranged alar cartilage or
grafted cartilage can be less noticeable. On the
other hand, when the skin is thinner, we can expect
the edema to resolve quickly, and even little manip-
ulation of cartilage is more conspicuous. Repeated
surgery or history of acne problem can thicken the
skin envelope of the nasal tip, and the surgical
result may be less satisfactory.
Preoperative Evaluation and Postoperative Care
4
To predict the extent of nasal lengthening, the
surgeon can do a pinching test or stretch the nos-
trils with cotton tips. When the nasal tip appears
bulbous, it is necessary to check whether the skin
or cartilage is actually bulky.
2. Nasal framework
The structures of the nasal dorsum and nasal
tip can be evaluated by palpation of the nose.
This step includes palpating the nasal bone and
Nasal Obstruction Symptom Evaluation (NOSE) Instrument
Physician AAO-HNS#:
Today’s date:
Please help us to better understand the impact of nasal obstruction on
your quality of life by completing following survey. Thank You!
Not a
problem
Very mild
problem
Poor
0
Please mark on this line how troublesome is your difficulty in breathing through your nose:
moderate
problem
fairly bad
problem
severe
problem
Over the past 1 month, how much of a problem were the following conditions for you?
Please circle the most correct response
To the Patient:
0
1. Nasal congestion or stuffiness
2. Poor sense of smell
3. Snoring
4. Nasal blockage or obstruction
5. Trouble breathing through my nose
6. Trouble sleeping
7. Having to breathe through my mouth
8. Unable to get enough air through my
nose during exercise or exertion
9. Feeling panic that I cannot get enough
air through my nose
11. In general, my health is
None
Medium
Severe
10. Embarrassment around friends and
coworkers because I have trouble
breathing through my nose
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
Fair
1
Good
2
Very good
3
Excellent
4
Fig. 1 Nasal Obstruction Symptom Evaluation (NOSE) instrument (from the NOSE Scale © 2003, the American
Academy of Otolaryngology–Head and Neck Surgery Foundation)
Y. S. Kim
5
examining its solidity, projection, symmetry,
deviation, or hump. Especially in the case of sec-
ondary cases, this step is crucial. The size and
integrity of upper lateral cartilage and dorsal sep-
tum should be noted, and see if there is a devia-
tion of the dorsal septum. When the nasal tip is
gently pushed in a cephalic direction, the caudal
septal angle may be visible or palpable, aiding
detection of septal deviation. Also, for secondary
cases, the integrity of the keystone area where the
nasal bone and upper lateral cartilage come in
contact, dislocation of an implant, or the condi-
tion of prior grafts at the nasal tip should be
scrutinized.
3. Internal nasal structures and Nasal airway
In order to find out the extent or cause of nasal
obstruction, examination of external nasal valve,
internal nasal valve, and nasal cavity is necessary.
Either nasal speculum or dynamic maneuver can
be useful, but adequate instruments and lighting
systems are prerequisites. Cottle maneuver is
performed by lateral traction of the cheek at the
level of the internal valve on the affected side. If
the nasal airflow is improved with the maneuver,
nasal obstruction is thought to be at the level of
the internal valve. Alternatively, one can apply a
cotton-tipped applicator at the nostril and
manually open the valve with lateral traction, and
then see if the symptom improves (Fig. 3).
Intranasal examination with nasal speculum
should be done for every patient expecting rhino-
plasty (Fig. 4). The examination enables visual-
ization of the anterior nasal cavity, including the
inferior turbinate, and abnormal findings such as
mucosal hypertrophy, turbinate hypertrophy, sep-
tal deviation, spur, or perforation can be noted if
present. The patient must be informed of any pre-
existing synechiae, septal deformities, or perfora-
tion
preoperatively,
or
he
or
she
may
inappropriately blame the surgeon afterward.
Also, consultation of septal or turbinate problems
should precede the surgery (Fig. 4).
Photographic Analysis
It is advised to take and analyze every patient’s
standardized photography preoperatively. The
surgeon can objectively evaluate the patient’s sta-
tus at varying angles, which is helpful in convey-
ing the surgical plan to the patient and adjusting
his or her expectations. These photographs can be
Fig. 2 A case of facial asymmetry. A frontal view and 3D CT views show right mid-face hypoplasia causing vertical
midline canting and deviation to right
Preoperative Evaluation and Postoperative Care
6
used to let the patient see the difference made
with the surgery. Also, certain facial dispropor-
tion, subtle asymmetry, or deformity may not be
obvious upon physical examination but can man-
ifest on the photographic analysis. Conveying
such information to the patient before the surgery
is of paramount importance. These photographs
should be kept securely since they are valuable
medical records in case of any dispute.
Standard photography for rhinoplasty includes
a frontal view, right and left lateral views, right
and left three-quarters oblique views. In addition
to the five standard views, high and low basal
views provide crucial information of the dorsal
curvature and the alar–columellar complex. It
may also be helpful to obtain an overhead view
for evaluation of the nasal dorsum and smiling
views to check dynamic changes of the nasal tip
due to tip ptosis or overactive depressor septi
muscle (Figs. 5 and 6).
It is essential to take these standardized photo-
graphs accurately. The Frankfort horizontal line,
which extends from the top of the tragus to the
infraorbital rim, is useful as a reference for proper
head positioning. The head should be positioned
so that the Frankfort horizontal line is parallel to
the ground. A low basal view is best achieved by
Fig. 3 Cottle maneuver (left) and alternative method with cotton-tipped applicator (right)
Fig. 4 Using a nasal speculum to inspect the intranasal
examination
Y. S. Kim
7
aligning the nasal tip to the medial canthus. This
alignment allows the surgeon to recognize the
relationship between nasal tip and dorsum. A
high basal view considered a true basal view can
be attained by aligning the nasal tip evenly with
the glabella, which allows good visualization of
the alar–columellar complex (Figs. 5 and 6).
Imaging Analysis
1. CT scans
CT scans are not routinely ordered for aes-
thetic rhinoplasty. Most clinically significant
anatomical problems can be identified by physi-
cal examination. However, if the patient has
symptomatic nasal deviation, severe facial asym-
metry, traumatic deformity, or sinus issues, CT
scan images would be helpful in preoperative
planning (Fig. 7).
2. Endoscopic examination
When a more detailed study of internal nasal
structures and the nasal airway is required upon
nasal speculum examination, endoscopic confir-
mation may be needed (Fig. 8). Recently, flexible
Fig. 5 Five standard views for photography used for facial plastic surgery procedures. This standard photography
includes a frontal view, right and left lateral views, right and left three-quarters oblique views
Preoperative Evaluation and Postoperative Care
8
endoscopes with 3–4 mm diameter are commonly
used to examine the nasal cavity, nasopharynx,
and larynx instead of traditional rigid sinuscopes.
Endoscopes are also handy in detecting any nasal
abnormalities such as chronic rhinitis, polyps, sep-
tal deviation, or choana bulbosa (Fig. 8).
Systematic Nasal Analysis
After thoroughly evaluating the patient’s present
state by inspection, physical examination, photo-
graphic, and imaging analysis, the surgeon should
study the balance and harmony of the patient’s
facial proportions. Aesthetic facial and nasal anal-
Fig. 6 Two basal views and smiling views for rhinoplasty. Low basal view (above left), and high basal view (above
right). Smiling lateral views can check dynamic changes of the nasal tip (below)
Y. S. Kim
9
ysis in a rhinoplasty patient should be performed
systematically, as Rohrich suggested (Fig. 9).
Postoperative Management
Postoperative management is as important as sur-
gery and preoperative planning. Beginners tend
to focus on the surgery itself and not so much on
postoperative management, but they gradually
realize its importance after encountering unex-
pected situations and outcomes over the years.
Postoperative management is an essential part of
any surgery.
Postoperative management includes dress-
ings, medications, and patients care and instruc-
tions. There is no strict rule regarding this step,
and most surgeons have a choice of several treat-
ment options through their experiences, but some
of the basic principles are as follows.
Fig. 7 Axial CT scan images of deviated nose patients
Fig. 8 Intranasal endoscopic images after septoplasty. Preoperative (left) and postoperative (right) views
Preoperative Evaluation and Postoperative Care
10
Immediate Postoperative
Management
Dressings
It is crucial to think of the postoperative dressing
as the last step of the surgery and try to put in as
much effort to maintain the shape of a nose.
1. Nasal Packing
Nasal packing is unnecessary in general and is
uncomfortable for the patient. However, in cases
involving septal or inferior turbinate procedures,
nasal packing can be helpful to achieve adequate
hemostasis and stabilization of the septum.
Excessive intranasal packing is also undesirable.
Especially in the case of osteotomy, too much
packing may cause deformation of the bones.
Extra cautions should be taken when septal com-
pression is needed after septal cartilage harvest.
Too much pressure may cause rebleeding upon
removal or cause a septal perforation by strangu-
lation of the mucosa.
There are various packing materials avail-
able, so the surgeon himself needs to be famil-
iarized with them through enough experience.
Traditional nasal packing is Vaseline® ribbon
gauze which can be easily manipulated into
position. Hydrocolloid gauze which promotes
wound healing can be a good alternative to
Vaseline gauze. Hygroscopic foam pack-
ing (e.g., Merocel®, Medtronic Xomed Inc,
Jacksonville, Fla) has been widely used follow-
ing rhinoplasty. More recently, various biode-
gradable nasal packing materials are introduced,
which can easily fit to the nasal cavity and pro-
vide hemostasis and support without excessive
pressure. They also dissolve naturally and are
easily removed with gentle irrigation and aspi-
ration (Fig. 10).
Systematic Nasal Analysis
Frontal
View
Facial proportions
Fitzpatrick type; thin or thick; sebaceous
Midline; C-; reverse C-; S- or S-shaped deviation
Narrow or wide; asymmetrical; short or long nasal
bones
Narrow or wide; collapsed; inverted-V deformity
Straight; symmetrical or asymmetrical; well- or ill-
defined; narrow or wide
Ideal, bulbous, boxy, pinched; supratip; tip-defining
points; infratip lobule
Gull-wing–shaped facets; notching; retraction
Long or short; dynamic depressor septi muscle; upper
lip crease
Width
Skin type and quality
Symmetry and nasal deviation
Bony vault
Midvault
Dorsal aesthetic lines
Nasal tip
Alar rims
Alar base
Upper lip
Lateral
Acute or obtuse; high or low radix
Long or short
Smooth; hump; scooped out
Break; fullness; pollybeak
Overprojected or underrotated
Overprojected or underprojected; columella-to-lobule
ratio
Symmetrical or asymmetrical; long or short
Septal tilt; flaring of medial crura
Width
Overrotated or underrotated
Hanging or retracted alae; hanging or retracted
columella
Maxillary or soft-tissue deficiency
Normal; deficient
Nasofrontal angle
Nasal length
Dorsum
Supratip
Tip projection
Tip rotation
Alar-columellar relationship
Periapical hypoplasia
Lip-chin relationship
Basal
Nasal projection
Nostril
Columella
Alar base
Alar flaring
Characteristics
Fig. 9 Systemic nasal
analysis (From Rohrich
RJ, Ahmad
J. Rhinoplasty. Plast
Reconstr Surg. 2011
Aug;128(2):49e-73e)
Y. S. Kim
11
Nasal packing is usually removed on day 1 or
2. Lengthy maintenance of packing is undesir-
able since it may cause an unusual event of olfac-
tory dysfunction or unexpected systemic infection
such as toxic shock syndrome. Intranasal cleans-
ing after removal is essential for symptom relief
and respiratory improvement for patients who
received septoplasty or turbinoplasty. The patient
should be educated to take care of intranasal
hygiene for at least 2–4 weeks.
Internal splints can also be helpful to avoid
hematoma, support and stabilize the septal struc-
tures, and prevent the formation of synechiae.
The internal nasal splints should be placed using
nasal speculum under direct visualization not to
damage and possible perforation of the muco-
periosteum. When applying trans-septal sutures
to prevent septal hematoma, it is important to
avoid excessive tension resulting in strangulation
of the septum. Furthermore, make sure to remove
sutures after splint removal since remnant sutures
may cause septal perforation or inferior turbinate
synechia (Fig. 11).
2. Taping
Simple soft tissue taping itself can reduce edema
and is effective in shaping the nose. The soft tissues
are taped with 1/2-in. Micropore™ surgical tape
(3M™, Saint Paul, MN) or 1/2-in. Steri-Strips™
(3M™, Saint Paul, MN). Pieces of tapes are applied
transversely over the nose. Taping begins at the
nasal root and ends up to supratip break in an over-
lapping fashion so as to drape the soft tissue inti-
mately to the underlying nasal skeleton. 1/4-in.
width strip may be applied longitudinally along the
caudal aspect of the nasal lobule to provide support
to the new tip (Fig. 12). An excessive pressure as an
effort to prevent hematoma or edema is not advis-
able. This is because too much pressure may cause
other problems such as nasal envelope compromise.
Do not expect to eliminate a hematoma with a
dressing (Fig. 12).
a
b
c
d
e
Fig. 10 Various nasal packing materials. A. MEROCEL®
(Medtronic Xomed Inc, Jacksonville, FL), B. Nasopore®
(Polyganics, Groningen, Netherland), C. RAPID RHINO◊
NASASTENT◊ (Smith&Nephew orthopaedics GmbH,
Tuttlingen, Germany), D. PosiSep® X (Hemostasis LLC,
St. Paul, MN), E. Physiotulle® (Coloplast, Humlebaek,
Denmark). Merocel is a hygroscopic foam nasal packing.
Nasopore®, RAPID RHINO◊ NASASTENT◊, and
PosiSep® X are biodegradable packing materials.
Physiotulle® is hydrocolloid gauze dressing material
Fig. 11 Endoscopic views of internal nasal splints with trans-septal suture
Preoperative Evaluation and Postoperative Care
12
3. External splints
External splints are generally applied following
nasal osteotomies. Denver Splint (Shippert Medical
Tech Corp. Denver, CO) or thermoplastic splints are
commonly used for external splints. It should be
carefully applied over the upper two-thirds of the
dorsum, and its lateral edges are compressed medi-
ally to keep the osteotomized nasal bone in position.
The distal end of the splint should be placed cepha-
lad to the supratip area (Fig. 12). Otherwise, this
may result in loss of supratip break. Excessive pres-
sure when applying it can lead to the medial dis-
placement of osteotomized bony segments. When
using a thermoplastic splint, care must be taken not
to have a burn injury to the underlying skin.
Fig. 12 Immediate postoperative dressings. Merocel® nasal packing followed by soft tissue taping (Joseph dressing).
Denver external splint was applied to provide stabilization of the nose after osteotomies
Y. S. Kim
13
Medications
1. Prophylactic antibiotics
Controversy over the use of antibiotics after
surgery still exists. However, prophylactic antibi-
otic use can reduce the postoperative infection
rate, especially in patients with implants or oste-
otomies. In order to prevent surgical site infection,
the first-generation intravenous cephalosporine
can be injected within 1 h before incision and be
given as postoperative antibiotic prophylaxis
until 24 h. It is widely recommended that periop-
erative antibiotic prophylaxis should be discon-
tinued within 24 h after surgery completion.
However, oral cephalosporin can be given for 3
days postoperatively in cases of implant usage or
osteotomies. It can be maintained for up to 7 days
for high-risk patients such as secondary or
infected cases.
2. Steroids
Steroid use reduces postoperative edema and
ecchymosis
associated
with
rhinoplasty.
Perioperative intravenous methylprednisolone
succinate (Solu-medrol™; Pfizer, New York,
NY) is commonly used for patients having
osteotomies because it is relatively safe as a
short-acting corticosteroid. In a meta-analysis
study, preoperative administration is superior to
postoperative, and extended dosing is superior to
singular. However, steroid administration is not
always harmless and should not be given for a
prolonged period without considering patient-
specific medical factors. Especially, steroids
MUST not be given to diabetic patients because
they can increase their blood sugar level and lead
to dangerous situations. In general, perioperative
steroids are enough to be administered up to 2
days after rhinoplasty.
3. Pain medications
Most patients state that pain after rhinoplasty
is minimal to moderate, even though it depends
on the person. Nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen are sufficient
in most cases, but using opioids can be consid-
ered for patients having osteotomies or being
sensitive to pain. Pain at any intensity will usu-
ally last for only 48–72 h but may last longer if
the nose is much manipulated or nasal packing is
maintained. However, some patients’ noses may
remain tender or sensitive to touch for up to 3
months, but most of the symptoms disappear
after months.
Postoperative Care and Instructions
for Patients
Edema and Ecchymosis
It is important to instruct patients to keep the
head elevated, such as semi-Fowler’s position,
for 2–3 days postoperatively. During this period,
instruct the patient to frequently apply an ice bag
to the eyes and cheeks to minimize edema.
Reducing postoperative edema also helps with
the patient’s anxiety. Postoperative edema is usu-
ally at its peak at 48–72 h. In osteotomy cases or
correction of the deviated nose, it is acceptable to
maintain the external splint for up to 2 weeks.
Most postoperative edema resolves within 3–4
weeks. As previously described, using periopera-
tive steroids helps relieve edema.
Postoperative ecchymosis may persist for 2–4
weeks in patients with thin skin or easily bruised.
Quite a few patients are worried that their return
to their daily lives will be delayed due to ecchy-
mosis after surgery. Therefore, it is necessary to
check their past history, menstruation cycle, or
health status before surgery and explain that
ecchymosis may appear for a couple of weeks
after surgery. Recently, topical agents which can
be utilized to reduce postoperative ecchymosis
are introduced, but controversy over their effec-
tiveness remains.
Epistaxis and Hematoma
Postoperative epistaxis is a rare complication,
even if any osteotomy performed during a rhino-
plasty may cause postoperative bleeding. A major
Preoperative Evaluation and Postoperative Care
14
cause is a damage to branches of the facial artery
or anterior ethmoidal artery. The incidence of
excessive bleeding is less than 1%, but special
caution must be taken when it is found. Bleeding
can occur immediately after surgery or any time
following for up to 1 week. Treatment is usually
conservative with nasal packing for 24–48 h; in
rare cases of recurrent bleeding, surgical explora-
tion and cauterization with endoscopic identifica-
tion are required. In the case the identification
would not be possible and refractory to all proce-
dures, angiographic embolization should be
considered.
Dorsal or peri-implant hematoma can occur
immediately after the surgery, especially in the
case of osteotomies. It should be removed within
2 weeks. If a hematoma is observed upon removal
of the external splint, careful aspiration should be
tried. Septal hematoma can occur after septo-
plasty or septal cartilage harvest and is a serious
complication. Its symptoms include nasal
obstruction, severe pain, and, occasionally, fever.
Separating the mucoperichondrium from the sep-
tal cartilage is a routine part of septoplasty or
septal cartilage harvest, and bleeding between
these two mucoperichondrial flaps creates a sep-
tal hematoma. Usually, within 2–3 days after sur-
gery, swelling and protruding of the septum may
occur with blocking the airway. If nasal packing
was done, the diagnosis could be delayed after
the removal of packing materials.
Incision and drainage should be considered as
soon as it is found. These include widely opening
the septal mucosa, removing the entire hema-
toma, and internal nasal packing for 24–48 h
combined with parenteral broad-spectrum antibi-
otics. It is crucial to recheck it the day after drain-
age to see if there is any remaining hematoma.
Septal hematoma can lead to septal perfora-
tion or abscess of the nasal septum if untreated,
and hematoma underlying the skin flap leads to
fibrosis and deformed nose.
Activity Restriction
It is recommended that the patient stay indoors
and rest for 2–3 days after the surgery, and light
walking is desirable after that for the resolution
of edema. Regular activity should be gradually
resumed at this point. Stressful activities and
intense exercise should be avoided for a month.
Care should be taken not to get trauma or pres-
sure on the nose until 4–6 weeks after surgery.
Wearing glasses is not allowed for 4 weeks.
Instead, glasses should be taped to the forehead,
or contact lenses can be worn right after the reso-
lution of eyelid edema.
Dressings and Stitch Removal
Regular dressing every 2 or 3 days helps keep the
wound clean, and the splints and tapes are
removed after 5–7 days postoperatively. Tapes
should be gently removed to minimize the
patient’s discomfort and avoid damaging the
underlying framework during the removing pro-
cess. Betadine and alcohol may irritate, so simple
saline or diluted chlorhexidine are used for inci-
sion site cleansing, followed by antibiotic oint-
ments such as mupirocin or bacitracin. Diluted
hydrogen peroxide is useful to remove dry crust
or scab over the incision. Particular caution
should be taken to intranasal cleansing to avoid
mucosal injury.
Sutures on columellar incisions are removed
in the outpatient clinic on days 5–7. Some of the
alar base sutures may be left for up to 10 days. If
absorbable intranasal sutures do not dissolve
within 2 weeks, it is advised to remove them for
intranasal hygiene.
Further Reading
Gorney M, Martello J. Patient selection criteria. Clin Plast
Surg. 1999;26(1):37–40.
Hatef DA, Ellsworth WA, Allen JN, et al. Perioperative
steroids for minimizing edema and ecchymosis
after rhinoplasty: a meta-analysis. Aesthetic Surg J.
2011;31(6):648–57.
Jeong JY. Rhinoplasty-rebuilding nose. MedicMedicine:
Seoul; 2016.
Liew S, Wu WT, Chan HH, et al. Consensus on chang-
ing trends, attitudes, and concepts of Asian beauty.
Aesthetic Plast Surg. 2016;40(2):193–201.
Nuyen B, Kandathil CK, Laimi K, et al. Evaluation of
antibiotic prophylaxis in rhinoplasty: a systematic
review and meta-analysis. JAMA Facial Plast Surg.
2019;21(1):12–7.
Y. S. Kim
15
Rohrich RJ. Streamlining cosmetic surgery patient
selection–just
say
no.
Plast
Reconstr
Surg.
1999;104(1):220–1.
Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg.
2011;128(2):49e–73e.
Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast
Reconstr Surg. 2003;112:1071–85.
Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP. Dallas
rhinoplasty. 3rd ed. St Louis: Quality Medical
Publishing; 2014.
Stewart MG, Witsell DL, Smith TL, et al. Development
and validation of the Nasal Obstruction Symptom
Evaluation (NOSE) scale. Otolaryngol Head Neck
Surg. 2004;130(2):157–63.
Suh MK. Atlas of Asian rhinoplasty. Singapore: Springer;
2018.
Swamy RS, Most SP. Pre- and postoperative portrait pho-
tography: standardized photos for various procedures.
Facial Plast Surg Clin North Am. 2010;18(2):245–52.
Preoperative Evaluation and Postoperative Care
17
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,
Nasal Dorsal Augmentation Using
Implant and Autogenous Tissues
Man Koon SUH, Hyesung Lee,
and Seunghyun Choi
Low nasal dorsum is one of the common features
of East Asian noses. Because of this, nasal dorsal
augmentation is the most frequently performed
procedure in Asian rhinoplasty.
Materials for nasal dorsal augmentation are
classified into two types: alloplastic implants and
autogenous tissues.
Dorsal Augmentation Using
Implants
When it comes to the dorsal augmentation mate-
rials, there is a distinct difference in preference
between Western and Asian surgeons. Autogenous
tissues are preferred by Western surgeons, and
there is no doubt that the autogenous materials
are superior to implants in terms of complica-
tions. However, autogenous tissues have several
disadvantages: lesser satisfaction in the aesthetic
aspect because of unexpected graft absorption,
donor site morbidity and a more complex surgi-
cal procedure.
Unlike Westerners, Asians have thicker and
fibrotic nasal skin envelope, so the implant visi-
bility or operated looking appearance after dorsal
augmentation is significantly less likely than that
of Westerners. For these reasons, implants con-
tinue to be popular for dorsal augmentation in
Asia. Appropriate surgical technique and a high-
quality implant placed in appropriate location
surely minimize the frequency of complications.
Implant can be relatively safe and bring aestheti-
cally beautiful results for Asians with the skin
that is not thin, so long as surgery is performed
using a safe method, suggested as follows:
Selection of Implants
The most commonly used implant for Asian nasal
dorsal augmentation is silicone implants, fol-
lowed by e-PTFE (Gore-Tex®) implants (Fig. 1).
Each implant has unique characteristics,
advantages and disadvantages.
Silicone is characterized in that the height of
implant does not change over time, it forms a
capsule, and the frequency of calcification on the
surface of implant is higher than that of an
e-PTFE implant over a long period.
e-PTFE implant has micropores into which
tissue ingrowth occurs. With tissue ingrowth, the
implant is less likely to be movable, and no cap-
sular formation occurs, which makes capsular or
scar tissue contracture less likely than it is with a
silicone implant. However, the height of an
e-PTFE implant decreases by about 5–20% over
time, with less reliable dorsal height predictability.
M. K. SUH (*)
JW Plastic Surgery Center, Seoul, South Korea
H. Lee · S. Choi
Anymedi Inc., Seoul, South Korea
18
In addition, tissue ingrowth makes for a difficult
implant removal.
Currently, silicone implants are more widely
used because of the high predictability in postop-
erative dorsal height. Nevertheless, an e-PTFE
implant is still used in some selected cases.
Operative Techniques
Preoperative Design
The cephalic starting and caudal end points of an
implant are marked on the midline of dorsum
(Fig. 2). The starting point at the radix area is
usually marked between eyelash line and double
eyelid fold. This starting point would be more
cephalic for patients with a protruding forehead,
with the point marked more caudally for patients
with flatter forehead or long nose.
The distal end of an implant should not extend
to the nasal tip, and the nasal tip should be pro-
jected using various tip plasty techniques (Fig. 3).
The nasal tip of a female should be slightly
higher than the dorsal line so as to form the natu-
ral curvilinear line (Fig. 4). In male patients, the
lateral profile of the dorsum should form a
straight line from the radix to the nasal tip.
Incision and Dissection
The endonasal approach would be sufficient for
simple dorsal augmentation, for which inframar-
ginal incision provides adequate exposure (Fig. 5).
The incision begins initially along the inferior
margin of the medial crus, 2–3 mm inward from
the columella border of the midpoint of the colu-
mella. Near the dome area, the incision is extended
a
b
Fig. 1 Implants for nasal dorsal augmentation. (a)
Silicone implant, (b) e-PTFE (Gore-Tex®) implant
a
b
Fig. 2 Starting and ending points of nasal dorsal implant (a, b)
M. K. SUH et al.
19
laterally along the inferior border of medial crus.
The inferior margin of the lateral crus can be visu-
alized by everting the alar rim inside out.
Implant pocket refers to the dissected space to
be used for implant placement, and the creation
of this pocket to be straight and symmetric is the
most important step during dorsal augmentation.
When an implant pocket is created through a
right-sided endonasal approach, the radix portion
of the pocket can easily deviate toward the left
side. To prevent asymmetric pocket formation,
pocket dissections should be performed through
bilateral endonasal incisions.
Open approach is needed in cases requiring
various tip plasty.
The dissection is performed at supraperichon-
drial plane in the lower and upper lateral cartilages.
And in the nasal bone area, the dissection should be
carried out under the periosteum to prevent the
mobility of an implant and to reduce the visibility
of the implant countour. Metzenbaum scissors are
utilized for the supraperichondrial dissection, while
preserving the maximum amount of soft tissues
attached to the skin envelope. Then, a Joseph eleva-
tor is used to lift the periosteum (Fig. 6).
Fig. 3 Caudal end of the implant does not extend beyond
the cartilage onlay graft
Fig. 4 The preferred
dorsal profile for Asian
female is a slight
curvature from the
dorsum to the nasal tip.
Asian men usually
prefer a straight dorsal
line
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
20
The author recommends the slightly larger
pocket size than implant width.
Irrigation of Pocket
Washing the inner pocket with a mix of povidone-
iodine solution and an antibiotic is helpful for
prevention of infection.
Implant Carving
Select one that best fits the patient’s dorsal line
and the desired height among the various shaped
implants. And then, implant is carved via the fol-
lowing steps (Fig. 7):
1. The cephalic portion of the implant is placed
on the starting point marked on the radix
2. Distal end of implant is marked.
3. The implant is cut to the length marked by the
end point. Then, the thick distal end is thinly
carved.
4. The bottom of the implant is carved and
trimmed to the curvature of the dorsum.
Uneven thickness of the nasal dorsal skin enve-
lope can lead to a mismatch between the carved
implant and the skeletal framework. Because of
this, the implant should be placed within the
pocket and re-carved until the revised implant
results in the desired shape of the dorsum.
Implant Insertion
While dorsal skin envelope and periosteum are
retracted by Aufricht retractor, the implant is
introduced into the pocket through an inframar-
ginal incision. It is important to make sure that
the implant is positioned in the centre of the
pocket without deviation.
There is no need to fix the caudal end of
implant, but if the operator cannot be sure that the
implant position is stable, the distal end can be
fixated to the septal angle.
Wound Closure and Dressing
An absorbable suture material is used to repair
the intranasal incision. Drain is not necessary.
Joseph dressing is applied to stabilize the dor-
sal implant and nasal tip (Fig. 8). The author
applies compression to the dorsum with an Aqua
splint (Thermosplint), which helps to minimize
postoperative swelling.
The aqua splint and paper dressing are
removed 5–7 days after surgery. For the first 2
weeks, the implant should be monitored closely
for any deviation. During this time, implant
deviation can be corrected by external manipula-
tion of the implant.
Figure 9 demonstrates dorsal augmentation
using silicone implant in male patient.
Fig. 5 Inframarginal incision
M. K. SUH et al.
21
a
b
c
d
Fig. 6 Dissection and pocket formation through bilateral endonasal incision. (a, b) Dissection over the upper lateral
cartilages, (c, d) Periosteal elevation
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
22
a
b
d
e
c
f
Fig. 7 Silicone implant carving. (a) Placement of the
implant on the nasal dorsum, (b, c) The implant is cut at
the cephalic end, (d) Thinning of the cephalic tip of
implant, (e) Carving of the implant undersurface to match
the dorsal contour, (f) Final shape of the implant
Dorsal Augmentation with 3D Printing
Technology
Because ready-made silicone used for implanta-
tion sometimes does not exactly match the nasal
dorsal contour for each patient in spite of sophis-
ticated carving, it is easy to create a dead space at
the glabellar and supratip area, which can lead to
seroma formation, inflammatory reaction and
formation of thick capsule leading to contracture
(Fig. 10).
The rapid development of 3D medical imag-
ing and 3D printing technology has led to a
M. K. SUH et al.
23
a
b
Fig. 8 Joseph dressing (a) and aqua splint (b)
a
d
e
b
c
f
Fig. 9 Dorsal augmentation using silicone implant (5.0 mm in height) and tip projection using conchal cartilage onlay
graft (closed approach). (a–c) Before operation, (d)–(f) After operation
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
24
paradigm shift of patient-specific treatment in
plastic surgery, enabling patient-specific surgical
planning and implant manufacturing.
Especially in augmentation rhinoplasty, prior to
3D printing, surgeon had to manually carve ready-
made implants during the intra-operation step to fit
the patient’s dorsal contour. However, with 3D
printing technology, in the pre-operation step, the
surgeon can produce the desired implant that fits
accurately patient’s dorsal contour. Not only does
the implant fit the surface structure of the nasal
bone and upper lateral cartilages where the implant
is to be inserted, the implant can precisely match
the desired height and profile line curvature cre-
ated by the patient through simulation application.
Also, the implant reflects the asymmetry and irreg-
ularity of the nasal bone and upper lateral carti-
lages. Patients’ satisfactions are high, because they
can participate in the determination of the desired
height and profile line before surgery through the
simulation application and this facilitates commu-
nication between the surgeon and the patient,
allowing consensus on desired goals.
Design and Manufacturing Process
Patient-specific 3D printing nasal implants are
manufactured through communication between
patient–surgeon–manufacturer.
A. Patients can participate through virtual plas-
tic surgery software based on 3D medical
images rather than surgeon explaining the
surgery plan to the patient in 2D (Fig. 11).
• Through the provided virtual plastic sur-
gery software, the patient can present the
desired dorsal height and profile line shape
and can check the postoperative shape
reflecting the proposed shape in 3D.
a
b
Fig. 10 (a) Conventional ready-made nasal implant. (b) Patient-specific 3D printing nasal implant (innofit®). Shape of
the implant exactly fits to the nasal dorsal contour
M. K. SUH et al.
25
• Surgeon can develop patient-specific sur-
gical plans by applying patient opinions
and conditions.
• The manufacturer designs patient-specific
implants according to the shared surgical
plan reflecting tip plasty, and the surgeon
confirms it.
B. The fabrication of patient-specific nasal
implants is as follows (Fig. 12):
1. Acquisition of 3D information of human
tissue through medical images such as CT
or MRIs
2. Segmentation of specific area from the
patient medical image.
• Bone including nasal and orbital parts,
and nasal cavity must be segmented.
• Segmentation can be processed by both
manually by technicians and automati-
cally using such as geodesic active con-
tour algorithm.
• Nowadays, Artificial Neural Network
technology such as hybrid U-net con-
volutional neural network and wavelet
based neural network is applied for
automatic image segmentation.
• Virtual molding technology provides
relatively more accurate information on
the expected shape as it can acquire 3D
information on the expected shape.
3. Implant design reflecting the surgical plan
and the shape required by the patient and
surgeon.
• Calculate the required implant capacity
from the predicted outcome after sur-
gery, which is a two-dimensionally
sketched outline above on the picture of
patient taken from the front and the lat-
eral view.
• The result from the virtual surgery can
offer more accurate numerical informa-
tion than the 2D sketched outline.
• The implant is designed considering the
calculation result, operation plan and
the requested specification such as the
shape type like an L-type or a boat
type, whether tapered or not, angle of
nasofrontal slope and size, etc.
Patient
Imaging
Surgery consultation with
virtual surgery result
Virtual Surgery
Software
3D visualization of
patient’s needs
3D facial model
Reconstruction
Design
request
Participation in planning
Operation
Planning
Confirmation
request
Operation
Patient-specific
implant design
Implant fabrication
Before
After
-
-
Hospital visits
Medical image
Order
Medical image
segmentation
Surgeon
Virtual surgery
Manufacturer
Fig. 11 Process of 3D printing implant manufacturing
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
26
4. The implant is fabricated using a 3D
printer.
Figure 13 is the result of dorsal augmenta-
tion using patient-specific 3D implant.
Advantages and Disadvantages of 3D
Printed Nasal Implant
The advancement of 3D imaging and 3D printing
technology in rhinoplasty has enabled the patient’s
opinion to be reflected through virtual plastic sur-
gery software, and patient-specific nasal implant
fabrication based on the patient’s 3D medical image.
Advantages of 3D printed patient-specific
nasal implant are as follows:
First, Implants that exactly fit the patient’s nasal
dorsal contour can be manufactured. Nasal dorsum
is not a straight line, and there are irregularities and
asymmetry, and it is impossible to carve an implant
that exactly matches this contour. 3D printing
implants can be manufactured to match nasal dor-
sal irregularity and asymmetry (Fig. 14). Implant
carving is unnecessary or significantly reduced
compared to ready-made implants. In the intra-
operation process, the time and effort required to
carve an implant can be significantly reduced.
As the shape of the implant is consistent
with the patient’s nasal dorsal irregular con-
tour and asymmetry, it is expected that the
possibility of implant deviation and migration
can be reduced.
Second, since the patient can participate in
simulation surgery and accurately reflect his or
her intention in determining the dorsal height and
profile line, the postoperative satisfaction is high
and the possibility of subjective complaints can
be significantly reduced.
a
b
c
e
d
f
Fig. 12 Fabrication of patient-specific nasal implants. (a)
Acquisition of 3D information of human tissue through
medical images such as CT or MRIs and segmentation of
specific area from the patient medical image. (b, c)
Implant design reflecting the surgical plan and the shape
required by the patient and surgeon. (d, e) The implant is
fabricated using a 3D printer. (f) Final product
M. K. SUH et al.
27
b
a
c
e
d
Fig. 13 Patient-specific
nasal
implant
(innofit®,
Anymedi Inc., Seoul, Korea) application case. (a) Surgery
planning through virtual surgery software (Anymedi Inc.).
(b) 3D model of patient-specific implant and nasal profile.
(c, d) Before and after operation. (e) A patient-specific
nasal implant is implanted to fit the patient’s nose
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
28
If a male patient wants the formation of dorsal
hump or if a patient wants to form brow-dorsal
aesthetic line, this is not possible with conven-
tional ready-made implants, but 3D printing
implant makes them possible.
Nevertheless, disadvantage of this technique
is that it takes several days for the implant to be
manufactured before surgery.
Dorsal Augmentation Using
Autogenous Tissues
Autogenous tissues are appropriate for dorsal
augmentation in the following cases:
1. Patient having thin nasal dorsal skin.
2. Secondary operation for implant-related com-
plication, such as dorsal skin thinning, visible
implant contour, dorsal skin redness or capsu-
lar contracture.
3. Patient preference against implant material.
The most commonly used autogenous grafts
in Asian patients are dermofat, and costal
cartilage.
Dorsal Augmentation with Dermofat
Dermofat graft is the most commonly used autog-
enous tissue for dorsal augmentation in Asian
countries. Compared to cartilage grafts, graft vis-
ibility through thin dorsal skin is less common
with dermofat graft. Therefore, dermofat graft is
appropriate for patients with very thin dorsal skin
and for secondary rhinoplasty for skin thinning
or redness from implant.
Graft Harvest
A graft is harvested from one side of the buttock
close to the intergluteal crease. The medial mar-
gin of the graft is located about 2–3 mm lateral to
the crease (Fig. 15). The design of dermofat
should incorporate larger-than-needed dimen-
sions to account for the shrinkage after harvest-
ing. For the purpose of dorsal augmentation, the
author harvests the dermofat that is 60 mm long,
10–12 mm wide. The skin is incised without
exposing the subcutaneous fat. The dermis is
deepithelized using a No. 10 blade. After deepi-
thelization, the dermal incision is carried down
into the subcutaneous tissue. Once the incision is
at an adequate depth, the whole graft is elevated
en bloc.
a
b
c
Fig. 14 Various shapes of 3D printing implants (innofit®)
M. K. SUH et al.
29
Dorsal Augmentation Technique
Unlike silicone implant, dermofat grafts are
placed in the supraperichondrial and supraperios-
teal planes.
Before insertion, the dermofat should be
trimmed to appropriate width and shape, and this
should be tailored to each individual nose.
Regarding the orientation of dermofat, the con-
ventional practice is to place the dermis side up;
however, the author thinks that the orientation of
dermofat placement does not affect the resorption
of the graft. Placing the graft such that the fat
layer is on top facilitates the shaping the graft
more easily (Fig. 16). For insertion and fixation,
the cephalic end of dermofat graft is secured
using a pull-out suture between the eyebrows. At
the caudal end, the graft is fixated to the septal
angle or the dome of lower lateral cartilage using
a 5-0 PDS suture. The pull-out suture is removed
a week after the operation.
The dermofat graft can undergo partial resorp-
tion after the operation. The resorption rate
increases with the amount of fat tissue.
Approximately 40–60% or higher resorption rate
is generally considered to be average. Thus, over-
correction should be performed in consideration
of this resorption rate. Resorption occurs until
approximately 18 months after surgery, but there
is not much change thereafter (Fig. 17).
Vertically-Oriented Folded Dermal
Graft Technique
To retain the maximum amount of dorsal aug-
mentation, the thickness of dermal layer should
be maximized, while minimizing the thickness of
the fat layer. The technique which enables much
a
c
d
b
Fig. 15 Harvest of dermofat graft. (a) Graft is harvested
from one side of the buttock close to the intergluteal
crease. (b) After the skin incision along the designed line,
deepithelization is performed. (c) The dermis and fat layer
are harvested. (d) Wound closure
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
30
higher dorsal augmentation is a vertically-
oriented folded dermal graft technique.
Harvest of the Graft
The graft is designed in the sacrococcygeal area
as shown in Fig. 18. The inferior endpoint of
graft is located 2 cm superior to the coccyx.
Incision through half the thickness of dermis
is made (Fig. 19). Then, deepithelization is per-
formed. Thereafter, the incision is carried into the
deeper dermis. The graft is elevated while incor-
porating a minimal amount of the fat into the
graft. The dermal layer is closed using no. 3-0
suture vicryl sutures, and the skin is closed using
no. 3-0 nylon sutures. Drains are not necessary.
Fabrication of the Harvested Graft
The graft fabrication uses multiple sutures to fold
the graft such that it becomes more compact hori-
zontally and provides maximal height.
The harvested graft is fixated to a thick paper
plate with a pin on each end. A portion of the sub-
cutaneous fat is trimmed to leave minimal amount
of fat (Fig. 20). The graft is folded along the cen-
tral line by placing five 6-0 nylon sutures. The
folded edges are brought together in four places
using 5-0 nylon sutures, and this becomes the graft
base. Next, the graft is made more compact by the
use of multiple outer vertical or horizontal sutures
(5-0 nylon). If bulging of the graft’s base occurs
due to these sutures, the base is trimmed until it is
c
d
a
b
Fig. 16 Insertion of the dermofat graft. (a) Placing the
dermofat graft with fat side up. (b) A pull-out suture is
used to fix the cephalic end of the graft to the area between
the eye brows. (c) The caudal end of the graft is fixed to
the septal angle or dome of the lower lateral cartilage by
using an absorbable suture
M. K. SUH et al.
31
flat. Next, the outer circular sutures are placed
using 5-0 nylon. At this point, the graft should
stand vertically on its base. The final height of the
fabricated graft can be around 10–12 mm.
The vertically-oriented folded dermal graft
augments the dorsal height not by the thickness
but by the folded height of the graft.
Placing the Graft on the Dorsum
The cephalic end of the graft is fixated to the
radix using a pull-out suture. The caudal end is
fixed to the septal angle or to the dome of lower
lateral cartilages.
Dorsal Augmentation with Costal
Cartilage
Costal cartilages are abundant in graft volume,
and the resorption rate is very low compared to
dermofat graft, enabling significant augmenta-
tion of nasal dorsum. Surgeon should have
elaborate skill for using costal cartilage for
dorsal augmentation to avoid graft warping,
contour visibility, deviation due to graft migra-
tion, etc.
Block costal cartilage graft can be a good
choice for Asians with a very low dorsum,
a
d
e
b
c
f
Fig. 17 Pre- and postoperative views of dorsal augmentation using the dermofat graft. (a)–(c) Preoperative view, (d)–
(f) Three years after dorsal augmentation with dermofat and tip projection with conchal cartilage onlay graft
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
32
requiring major dorsal augmentation of 5 mm or
more.
Harvesting the Costal Cartilage
In most cases, the graft for dorsal augmentation is
harvested in either the sixth or seventh rib. The
inframammary fold incision allows access to the
fifth and sixth rib cartilage. In patients with lower
inframammary crease, the incision allows access
even to the seventh rib. The seventh rib is rela-
tively longer and straight. As such, the seventh rib
cartilage is usually preferable for the purpose of
dorsal augmentation. Because the seventh rib is
often inaccessible from the inframammary fold,
the incision is usually made directly over the sev-
enth rib cartilage to be harvested. It is necessary to
confirm the signs of calcification and ossification
through chest X-ray prior to surgery. During sur-
gery, an operator should probe the costal cartilage
for any signs of calcification using a 25-gauge
needle, prior to making a skin incision in the chest
wall. It also plays the role of confirming the exact
location of the osseochondral junction.
Carving the Costal Cartilage
Carving of the costal cartilage is the most impor-
tant, difficult and time-consuming step for suc-
cessful dorsal augmentation. A graft must be
precisely carved to fit in to the dorsal contour.
The most common complication in block cos-
tal cartilage graft for dorsal augmentation is graft
warping.
Concentric Carving Technique
In an attempt to minimize warping of the costal
cartilage, the operator must obtain a graft, with
which balanced intrinsic stresses are symmetri-
cally maintained. A graft with balanced intrinsic
stress can be obtained by using the core portion
of the cartilage. In practice, it is impossible to
carve out a perfectly symmetric costal cartilage
graft for dorsal augmentation. Respecting the
principle of balanced cross section, however, one
can minimize graft warping by the concentric
carving of the core cartilage (Fig. 21).
It is important that the bottom surface of graft
accurately matches the dorsal contour (Fig. 22).
a
b
Fig. 18 Design of the vertically-oriented folded dermal
graft. The graft is located at the midline of the sacrococ-
cygeal area, and the caudal end of the graft is located 2 cm
above the coccyx. The length of the graft is 6 cm, while
the width of the cephalic area is 3–4 cm and that of the
caudal area is 1.6–1.8 cm
M. K. SUH et al.
33
a
b
c
d
e
Fig. 19 Harvest of the vertically-oriented folded dermal
graft. (a) Incision is made into the half-thickness depth of
the dermis. (b) The deepithelization is performed. (c) A
deeper dermis incision is made. (d) Dermis layer has been
harvested. (e) Wound closure
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
34
Fig. 20 Fabrication of the graft. (a) Marking for five
inner sutures. (b) Five inner sutures were placed using a
No. 6-0 nylon suture. (c) Four base sutures were placed
using a No. 5-0 nylon suture. (d) Multiple outer horizontal
sutures were placed using a No. 5-0 nylon suture. (e) The
graft base was trimmed to remove the bulging after outer
horizontal sutures. (f) The outer circular sutures were
placed. (g) The graft is erected in a vertical orientation
after all the sutures have been placed
a
b
c
e
f
d
M. K. SUH et al.
35
Multilayered Costal Cartilage Graft
Technique
Harvested costal cartilage is sliced into thin
pieces and then submerged in a saline-filled
container for at least 15 min to expose the warp-
ing tendencies. Several pieces of thinly sliced
cartilage were piled up according to the desired
height (Fig. 23). A block of piled up, multilay-
ered cartilages margin is trimmed with a No. 15
blade scalpel. This technique can make it easier
to carve the graft to more accurately fit in to the
dorsum and minimize the complication of graft
warping.
Placing the Graft on the Dorsum
To prevent the graft deviation, the follow key
points should be respected:
1. The size of the subperiosteal pocket, into
which the graft is placed, should not be wide.
The graft must fit into the pocket tightly to
minimize graft movements.
2. Toriumi et al. suggested the “perichondrial
fixation method”, using a costal cartilage
dorsal graft and interpositional costal peri-
chondrial graft. According to his technique, a
strip of costal perichondrium is sutured to
the undersurface of the upper third of the
dorsal graft to create a costal/perichondrial
interface. Then multiple holes are made in
the bony dorsum of the nose using a 2-mm
straight osteotome or a narrow rasp is used to
create a rough surface on the bony dorsum.
And then, the dorsal graft with intervening
costal/perichondrial graft is placed on top of
the bony dorsum. The raw surface of the
bony dorsum and intervening costal peri-
chondrium, together with the tight subperi-
osteal pocket, prevents slippage, movement
or deviation of the graft.
3. Caudal portion of the graft is fixed to the dor-
sal septum and upper lateral cartilage using
5-0 PDS sutures. Two sutures should be
placed to the cephalic and caudal portions of
the dorsal septum and upper lateral
cartilage.
On the thin-skinned nose, a diced cartilage is
packed loosely along the both margins of the dor-
sal graft to avoid any lateral step-off. Temporal
fascia or crushed costal perichondrium of the
costal cartilage can be used alternatively.
Figure 24 shows the example of dorsal augmen-
tation using a solid costal cartilage graft.
Dorsal Augmentation with Diced
Cartilage Wrapped in Fascia
The harvested cartilage is diced and wrapped
within a fascia and placed in the dorsal pocket
(Fig. 25). The costal cartilage is a preferable
source when a great quantity of cartilage is
g
Fig. 20 (continued)
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
36
required and the deep temporal fascia is the pre-
ferred envelope.
Operation is not technically demanding and
can be easily performed even by inexperienced
surgeons. Compared to costal cartilage block
graft, diced cartilage graft tends not to cause the
problem of graft contour becoming visible
through the thin dorsal skin. It also avoids the
problem graft warping. Even if it is difficult to
completely avoid absorption, but absorption is
much less than that of dermofat graft, so it can be
used for major dorsal augmentation.
Operative Technique
Harvest of Temporal Fascia
Temporal fascia can be harvested between the tem-
poral crest and superior root of ear helix (Fig. 26).
A 3–4 cm skin incision is made 1 cm anterior
and 3 cm superior to the superior root of ear helix
(Fig. 27). The incision is carried down through the
subcutaneous tissue. Upon opening and retracting
the superficial temporal fascia, the glistening
membrane observed is the deep temporal fascia.
The deep fascia is incised and separated from the
temporal muscle. It is essential to harvest the fas-
cia as large as possible, up to 5 × 4 cm fascia.
Hematoma formation is possible after temporal
fascia harvest, which should be prevented by dili-
gence in haemostasis and by compression dress-
ing above the donor site. Drain is unnecessary.
Dicing the Cartilage
All types of cartilage (conchal, septum, costal) can
be used, however, major dorsal augmentation can
be performed using costal cartilage. Cartilages are
diced into small pieces of less 0.2 mm in diameter,
using No. 11 or dermatome blade. Instillation of a
small amount of gentamicin solution, which acts
as a carrier for the adhesive forces, will turn the
diced cartilage into a paste-like mixture.
Fig. 22 Graft must be carved to fit in to the contour of the
dorsum
a
b
Fig. 21 Concentric carving technique of the costal cartilage (a, b)
M. K. SUH et al.
37
Packing the Diced Cartilage in the Tube-
Shaped Fascia
The diced cartilage is packed into a 1-cc insulin
syringe, and the hub of syringe is cut off. The fas-
cia is wrapped around the syringe, and the longi-
tudinal margins of the fascia are closed by
continuous running suture using an absorbable
suture. The distal end of the fascia is also closed
with an absorbable suture (Fig. 28).
The diced cartilage within the syringe is
slowly injected into the fascial tube and the
syringe is slowly withdrawn from the tube. After
completing the infusion of the cartilage particles,
the fascial sleeve on the opposite side is also
a
b
c
e
d
Fig. 23 Multilayered costal cartilage grafts. (a)
Harvested costal cartilage is sliced into thin pieces. (b)
Top layer piece is being carved. (c) Two pieces of thinly
sliced cartilages are gathered by absorbable sutures. (d)
Several pieces of thinly sliced cartilage are piled up
according to the desired height. (e) Final result with good
contour without warping
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
38
a
b
c
e
f
g
d
h
Fig. 24 Dorsal augmentation with solid costal cartilage
graft. (a)–(d) This female patient has a flat dorsum and
upturned tip due to contracture from previous failed rhino-
plasty. (e)–(h) Six months after surgery. Solid costal carti-
lage was placed on the dorsum for nasal dorsal
augmentation. Tip revisional surgery for caudal rotation
and columella projection was performed by bilateral
extended spreader type of septal extension graft combined
with columellar strut graft using costal cartilage
M. K. SUH et al.
39
Fig. 25 Diced cartilage wrapped in temporal fascia
Fig. 26 The temporal fascia is harvested between the
temporal crest and superior root of ear helix
a
b
c
d
Fig. 27 Operative procedures for harvesting the deep
temporal fascia. (a) A 3-cm vertical incision is made
between the temporal crest and superior root of ear helix,
while avoiding injury to the superficial temporal vessels.
(b) The suprafascial dissection should be extended wide
enough to expose the fascia as much as possible. (c)
Elevation of the deep temporal fascia. (d) The harvested
deep temporal fascia
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues
40
sutured with an absorbable suture, closing the
fascia tube.
Insertion of the Diced Cartilage in Fascia
to the Pocket
Dorsal pocket for the graft is placed in the supra-
perichondrial and subperiosteal plane. The
cephalic end of the graft is fixed with a pull-out
suture, while the distal end is sutured to the septal
angle.
The graft is moulded to the desired contour by
finger manipulations using both hands. Then, a
paper tape and a thermoplastic splint are used for
fixation.
The Fig. 29 shows an example case of dorsal
augmentation using the diced cartilage wrapped
in temporal fascia.
a
b
c
Fig. 28 Procedure of diced cartilage wrapped in tempo-
ral fascia. (a) 1 cc syringe without a hub is wrapped with
the temporal fascia. (b) Diced costal cartilage. (c) The
diced cartilage particles in the syringe is slowly infused
and packed into the fascial tube
M. K. SUH et al.
41
f
e
d
c
b
a
Fig. 29 Dorsal augmentation using diced cartilage
wrapped up in the temporal fascia. (a)–(c) This female
patient has a flat dorsum, especially on the mid-vault.
(d)–(f) Nose maintains well-defined dorsum 8 months
after surgery
Nasal Dorsal Augmentation Using Implant and Autogenous Tissues