Asian Facial Cosmetic Surgery

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
98
A
B
Figure 10-22
The Uchida method.
Figure 10-23
The Uchida method. A, Preoperative view. B, Marking. C, Postoperative view.
C
A
B

LATERAL CANTHOPLASTY
99
A
B
C
D
Figure 10-24
The Flowers split V-W advancement flap is a modification of the Uchida method.
Figure 10-25
The Flowers method. A, Preoperative view. B, Postoperative view.
A
B

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
100
B
A
C
A
B
Figure 10-26
The Von Ammon method. A, Design. B, Skin incision, splitting of conjuctiva, and
lateral displacement. C, Postoperative view.
Figure 10-27
The Blair method for lateral lengthening of the palpebral fold. A, Design.
B, Postoperative view.

LATERAL CANTHOPLASTY
101
A
B
C
a
c
b
b
a1
ac
b
a1
ac
Figure 10-28
The Fox method for lateral canthal lengthening. The desired lateral canthal angle
position is b. A. V-shape marks c between aa and b. B. Incision and repositioning of
V-shaped skin flap to point a. C, Suturing conjuctiva to lateral canthal skin.
Figure 10-29
Modification of the Fox method used in lateral epicanthoplasty.
A
B
A
B
Figure 10-30
The Blaskovics method. A, Design. B, The V-shaped skin flap is repositioned to the
upper part of the horizontal incision line. C, Donor defect of lower portion was
closed and final appearance.
C

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
102
A
B
C
D
Figure 10-31
The Uchida method. A, Marking a 5-mm transverse incision and 2- to 3-mm lateral
arm. B, Resected area; design of resected portion. C, Resection of skin and suturing
of flap at the level of lateral canthal tendon. D, Tip of triangular flap and conjuctiva is
sutured by nylon 7-0 or silk 7-0.
Figure 10-32
The Uchida method.
Figure 10-33
A case of complication: hypertrophic scar.
A
B
A
B

LATERAL CANTHOPLASTY
103
References
1. Park JI: Z-epicanthoplasty in Asian eyelids, Plast Reconstr
Surg 98:602, 1996.
2. Converse JM, Smith B: Nasoorbital fractures and traumatic
deformities of the medial canthus, Plast Reconstr Surg
38:147, 1966.
3. Speath EB: Further consideration of the surgical correction
of belphalophimosis and epicanthus, Amer J Ophthalmol
41:61, 1956.
4. Mustarde JC: Repair and reconstruction in the orbital
region, ed 2, New York, 1980, Churchill Livingstone,
pp 332-344.
5. Yoon KC: Modification of Mustarde technique for
correction of epicanthus in Asian patients, Plast Reconstr
Surg 92:1182, 1993.
6. Hughes WL: Surgical treatment of congenital phimosis: the
V-Y operation, Arch Opthalmol 54:586, 1955.
7. Iliff WJ: Congenital defects. In Heilmann K, Paton D, eds:
Atlas of ophthalmic surgery, Tokyo, 1985, Thieme Maruzen,
pp 1103-1125.
8. Fuente del Campo A: Surgical treatment of the epicanthal
fold, Plast Reconstr Surg 73:566, 1984.
9. Mulliken JB, Hoopes JE: W-epicanthoplasty, Plast Reconstr
Surg 55:435, 1975.
10. Park DH: The correction of entropion using skin-tarsal
fixation with epicanthoplasty, Korean Aesthet Plast Reconstr
Surg 1:1, 1995.
11. Flowers RS: Surgical treatment of the epicanthal fold
(invited essay), Plast Reconstr Surg 73:571, 1983.
12. Fox SA: Ophthalmic plastic surgery, ed 5, New York, 1976,
Grune & Stratton, pp 223-225.
13. Park DH: Epicanthoplasty using Z-plasty, Korean Aesthet
Plast Reconstr Surg 8:71, 2002.
14. Park DH: Epicanthoplasty using the modified Park’s
method, Korean Plast Reconstr Surg 27:641, 2000.

105
Why Epicanthoplasty?
Just as with the single eyelid, the epicanthal fold is a unique
feature of the East Asian population. The medial canthal
area shows distinctive anatomic variations based on the
presence or absence of the epicanthal folds. The eyelid
without the epicanthal fold is classified as Type I. In a Type
II eyelid, the epicanthal fold partially covers the lacrimal
lake, and the fold ends at the margin of the lacrimal lake. In
Type III, the lacrimal lake is almost completely covered by
the epicanthal fold, and the fold curves laterally to blend in
with the lower eyelid. Type IV is a rare anomaly of reversed
epicanthal fold (Figure 11-1). Types II and III are
commonly encountered in Asian blepharoplasty (Figure
11-2).
Epicanthoplasty can enhance the aesthetic result of the
double eyelid surgery by lengthening the palpebral fissure,
thus producing the image of a larger and more open eye. A
long parallel fold from the nasal end to the lateral canthal
end brings out the natural beauty of the eye. It may also
prevent an undesirable change in the epicanthal area
caused by the double eyelid surgery. The natural epicanthal
fold curves smoothly from the medial canthus to the rest of
the eyelid. As the pretarsal upper eyelid skin is drawn up
higher after the double eyelid surgery, the skin of the
epicanthal fold becomes tightly stretched. This vertical
tightening of the normally relaxed epicanthal fold creates a
sharp skin ridge similar to that of traumatic web formation
(Figure 11-3). The palpebral fissure then turns into an
undesirable round eye with a somewhat startling
appearance (Figure 11-4).
Park Z-Epicanthoplasty
Jung I. Park
Why Z-Epicanthoplasty?
Many surgeons are reluctant to perform epicanthoplasty
for fear of creating a visible scar in the medial canthal area.
Even a minor scar is not tolerated in this area. Problems
associated with the various epicanthoplasty designs
include complex incisions extending beyond the eyelid skin
and tension across the suture line generated by pulling the
tissue to advance the flap. The purpose of many classical
English-written epicanthoplasties was to correct a
congenital anomaly or traumatic epicanthal web in which
minor scarring is not so critically scrutinized. The beauty
of the Z-epicanthoplasty is that the incisions are within the
thin eyelid skin, the incisions are able to incorporate with
the incision for the double eyelid procedure, and the
technique provides for a tension-free closure.1-4 The design
follows clear and fixed landmarks and reference points
such as the medial margin of the lacrimal lake, incision line
for the double eyelid procedure, and fusion point between
the epicanthal fold and the lower eyelid skin.
Consultation
Despite its sound principle and design, the execution of the
procedure is highly sensitive to surgical technique. The
benefit of a widely open eye with a long, beautiful, parallel
double eyelid fold versus the risk of possible redness and a
visible scar should be thoroughly discussed. Although this
procedure leaves a minimal scar when performed exactly
as designed, some patients may not tolerate even the
slightest scar.
11

PARK Z-EPICANTHOPLASTY
106
Marking
In the majority of cases, Z-epicanthoplasty is performed in
conjunction with the double eyelid procedure. In a small
number of cases, the procedure is used for patients who
have already had double eyelid surgery without epicantho-
plasty. Markings are made using a fine felt-tip marker as
the patient is seated with the eyes in the primary gaze
position. The first marking is placed on the surface of the
epicanthal fold. A point is marked as a surface representa-
tion of the most medial point of the lacrimal lake (Figure
11-5). This point is designated as point A. Point B is the
point of confluence of the epicanthal fold with the lower
eyelid skin (Figure 11-6, A). This point is quite distinctive
in most patients. However, some patients have a poorly
defined confluence. The surgeon then has to determine the
point that allows the flap to close without tension and is
adjacent to the lacrimal lake. Point D is the most medial
end of the lacrimal lake (see Figure 11-6, B). When viewed
from the front through a transparent layer of the epicanthal
fold, A and D should be the same point. Thus lines A–B
and D–B should be the same length and line when viewed
from the front. When flap ABD is elevated, incisions A–B
and D–B should close without any tension (see Figure 11-
6, C and D). Point E is on the line drawn for the double
eyelid incision. The line for the double eyelid should run
parallel to the tarsal margin. As the patient’s eyes are in a
primary gaze position, marking for the double eyelid
procedure is extended medially, aiming at point A. The line
shows a slight tendency to converge toward the tarsal
margin. Next, a second line is drawn as a medial continua-
tion of the double eyelid incision. This time the line
maintains a parallel relationship with the tarsal margin.
Then a line is drawn from point A horizontally or angled
superior medially to join the upper line. The cross point
becomes point C. At point E, the two lines diverge from the
main double eyelid incision to meet points A and C,
respectively. In the modified Z-epicanthoplasty (Figure 7-8,
A and B), the angled line A–C maintains point C closer
to the eyelid and seems to achieve a better parallel
relationship. Line A–C can be as much as 45 degrees from
the horizontal line. One critical issue is to determine point
A in a more conservative lateral location that is closer to
TYPE I
TYPE II
TYPE III
TYPE IV
Figure 11-1
Medial canthal anatomy. Types I to IV.

DISSECTION
107
the eye than to the nose. When point A is marked more
medially to point D than is appropriate, point A has to be
stretched laterally to meet point D during the closure,
which will create tension on the closure and result in a
thicker scar.
Anesthesia
Local anesthetic is infiltrated after the markings to avoid
distortion. Efforts should be made to avoid wetting the
incision with the solution because the solution may blur or
erase the lines. If the line is erased, the surgeon may choose
not to perform the epicanthoplasty. Surgery without an
exact design is a guarantee of closure with tension and a
thick scar. Local anesthetic should be injected deep into the
surface of the medial canthal ligament. This is one area in
which the patient often experiences pain if the amount of
anesthetic is not adequate.
Dissection
The incision for the Z-epicanthoplasty is made before the
incision for the double eyelid because of the need for
precision in this critical and small area. The skin of triangle
A
B
Figure 11-2
A,Type II. B,Type III.
A
B
Figure 11-3
A, Aesthetically acceptable Type II epicanthal fold in a single eyelid. B, As the upper eyelid skin is lifted to create a supratarsal crease, tension develops on the epicanthal fold.

PARK Z-EPICANTHOPLASTY
108
ECA is excised and discarded (see Figures 11-6, C and 11-
9, A to E). Next, flap ABD is elevated (see Figure 11-6, D).
This flap actually begins at point E as the epicanthal flap
EABD. Incision D–B should be a straight line. A #15 Bard-
Parker blade is inserted with the blade up and facing the
surgeon. The tip of the blade touches the medial canthus
immediately above the conjunctiva. While the assistant
spreads and flattens the epicanthal fold with the fingers, the
surgeon should push the blade gently but forcefully along
line D–B (see Figure 11-9, F). If the surgeon is not careful,
the incision may curve laterally on the lower eyelid skin
side. This will create a gap in closure between lines A–B
and D–B, which causes tension across the suture line.
Next, the incision EAB is made down to the medial
canthus. Atraumatic forceps are used to tightly grasp and
lift up flap EABD. The remaining adherence of the flap to
the medial canthal ligament is severed with the knife, using
a pushing and sweeping motion over the surface of the
A
B
Figure 11-4
Views of double eyelid surgeries. A, Preoperative view. B, Postoperative view.
Epicanthoplasty was not performed in this case, and epicanthal folds have
transformed into unsightly vertical ridges. C, Postoperative view with persistent and
unsightly epicanthal folds.
C
A
B
Figure 11-5
A,The dot is a surface representation of the medial end of the lacrimal lake. B, Relationship between the dot and lacrimal lake.

DISSECTION
109
e
c
a
b
e
c
b
d
E
e
c
b
d-a
F
e
c
D
C
e
c
a
b
A
e
c
a
b
d
B
Figure 11-6
A,The Park Z-epicanthoplasty design. Point A is the surface representation of point D. At point B, the epicanthal fold meets the skin of the lower eyelid. B, Point D is the most
medial point of the lacrimal lake. C, Triangle EAC is removed. D, Flap EABD is lifted. E, The flap is rotated and sutured. F, Long-term scar.

PARK Z-EPICANTHOPLASTY
110
ligament. The surgeon will feel a sudden release of the flap
from the ligament (see Figure 11-9, G). A pair of sharp,
pointed tenotomy scissors may be used for this purpose.
This step is one of the most important aspects of the
dissection to ensure a tension-free flap rotation and
closure. Once this is accomplished, the rotated flap fills the
recipient triangle ECA; the flap is completely relaxed
without any gaping of the wound (see Figure 11-9, H). This
maximizes the healing of line E–C, which is one of the
most sensitive incision lines. Because the flap is tension
free, a deep fixation suture to hold it in place is not
necessary. If the surgeon desires a more distinctive medial
crease, incision E–C is undermined, and an anchoring
suture can be placed between the rotated EAB flap and the
deep soft tissue at the nasal side below incision EC. A 6-0
or 7-0 clear nylon suture is used with buried knots. Every
effort should be made to prevent superficial placement of
the suture; otherwise the suture may create prolonged
e
c
c
a
d
b
Original Z - Epicanthoplasty
Modified Z - Epicanthoplasty
a
b
e
c
a
b
c
a
d
b
Figure 11-7
Original and modified Z-epicanthoplasty.
A
B
Figure 11-8
A, Marking for a modified Z-epicanthoplasty. B, When the eyelid is stretched, line B–D is visible.

DISSECTION
111
C
A
B
E
D
e
c
b d
F
Figure 11-9
A to C, The tiny triangle EAC is removed. Even slightly larger removal may cause a scar
in this critical area. If the surgeon decides not to remove the triangle, the excess tissue
will adapt quite well without causing a redundancy. D and E, If a strip of pretarsal skin
should be removed, the triangle is incorporated with the pretarsal skin excision. F, The
tip of the #15 Bard-Parker blade touches the medial canthal ligament (point D). Line
B–D is incised by pushing the blade gently but firmly toward point B.
Continued

PARK Z-EPICANTHOPLASTY
112
redness and occasionally even granuloma formation. If the
epicanthal fold is excessively large, the edge of the flap
along EAB may be trimmed conservatively. However, this
is not necessary in most cases. The EAC angle is about 135°
degrees in the original Z-epicanthoplasty with a horizontal
A–C and as much as 90 degrees in the modified Z-epi-
canthoplasty with an oblique A–C. Incisions A–B and D–B
should be in complete alignment to allow a tension-free
closure. At times, suturing between points D and A
presents a technical challenge. If suturing is not easy or the
suture needle cuts through the ligament, then the suture
may be made through the eyelid skin close to points D and
A (see Figure 11-9, I). For patients with abundant fat in the
medial canthal area, defatting under the incision A–B is
necessary to match the thinness of line D–B, which has
very little soft tissue at point D. Otherwise a step formation
develops at the closure site. The skin is closed with 6-0
fast-absorbing gut sutures. The original and modified Z-
epicanthoplasties result in distinctively different closure
patterns (Figure 11-10). As an alternative, triangle EAC
may be trimmed at a later stage using a freehand technique
(Figure 11-11). Scar formation is the most critical issue
associated with the epicanthoplasty. The common causes
of unsightly scar formation is closure with tension (Figure
11-12) and poor design (Figure 11-13). Exact placement of
point A and complete detachment of the flap at point D are
two critical steps of the surgery. Extremely conservative
excision of triangle EAC is an important method to avoid
scar formation.
Postoperative Care
Additional care is not necessary after the surgery.
Recovery
A judicious use of triamcinolone acetonide injections
eliminates the occasional red, thick scar.
Figure 11-9, cont’d
G, Line B–D is transected, and the base of flap ABD is completely released from the
medial canthal ligament. The tip of the flap may be lifted with a pair of forceps,
applying tension as the flap is freed. Often a sudden release of the flap is felt at the
end of dissection. H, The flap should be freed until it sits comfortably in the recipient
site without fixation suture. The incision lines are in perfect approximation without
fixation. The only fixation in this view is the supratarsal sutures. I, A single layer of
absorbable fine sutures are placed. D–B and A–B approximation should be precise in
both the depth and length on each side. Even a tiny step formation may cause a
significant patient dissatisfaction.
Epifold
a
d
G
H
I

RECOVERY
113
Case Studies
See Figures 11-14 to 11-17.
A
B
Figure 11-11
A to C,The triangle EAC may be trimmed later using a freehand technique. Excision
of the triangle should be conservative. Otherwise, gaping tension closure and a thick
scar sequence develops.
A
B
C
Figure 11-10
A, 1-week postoperative view of original Z-epicanthoplasty. B, Modified Z-epicanthoplasty.

PARK Z-EPICANTHOPLASTY
114
Figure 11-12
Inadequate detachment of the flap at point D with forceful pull and closure of the
flap may cause a thick scar. A large triangle EAC may also cause a scar.
Figure 11-13
This poor design will lead to scar formation.
A
B
Figure 11-14
A, Preoperative view. B, 1-week postoperative view.
A
B
Figure 11-15
A, Preoperative view. B, 2-month postoperative view.

RECOVERY
115
References
1. Park JI: Z-epicanthoplasty in Asian eyelids, Plast Reconstr
Surg 98:602, 1996.
2. Park JI: Modified Z-epicanthoplasty in the Asian eyelid, Arch
Facial Plast Surg 2:43, 2000.
3. Yoo WM, Park SH, Kwag DR: Root Z-epicanthoplasty in
Asian eyelids, Plast Reconstr Surg 109:2067, 2002.
4. Park JI: Root Z-epicanthoplasty in Asian eyelids. In
correspondence and brief communications, Plast Reconstr
Surg 111:2477, 2003.
A
B
Figure 11-16
A,The patient returned 1 year postoperatively for revision of relapsed double eyelid. The Park epicanthoplasty scar was not detected until the chart was reviewed. B, Marking
was necessary to trace the invisible scar.
A
B
Figure 11-17
A, Double eyelid surgery without epicanthoplasty. B, 8-month postoperative view of double eyelid surgery with Z-epicanthoplasty.

117
Lateral Canthoplasty in Asian Eyelids
The lateral canthus is an integrated anatomic unit that
defines the geometric pattern of the lateral aspect of
eyelids. Lateral canthoplasty is a technique used to
lengthen the palpebral fissure by dividing the lateral
canthus, which produces a longer and more open eye.
Anatomy of the Lateral Canthus
In the lateral canthus, the upper and lower preseptal
orbicularis oculi muscles form a raphe. The raphe consists
of loops of muscle bundles that are firmly attached to the
skin of the lateral canthus.1 The upper or lower pretarsal
muscles insert into the orbital tubercle, which is situated
behind the orbital rim on the lateral orbital wall, through
the intermediary of the lateral canthal tendon. The lateral
palpebral artery, a branch of the lacrimal artery, passes
through the space between the tendon and the raphe
(Figure 12-1). This space deepens laterally.2
Indication
The degree of scleral exposure is evaluated by pulling the
lateral canthus laterally. Lateral canthoplasty is indicated
when the sclera is exposed widely. The patient who has
small eyeballs or extreme enophthalmos will have a poor
outcome. Contraindications for the procedure include
patients with excessively high expectations. When lateral
canthoplasty is performed in conjunction with the double-
eyelid operation, it enhances the aesthetic result by
lengthening the palpebral fissure. This causes the eye to
appear longer and larger.
Lateral Canthoplasty
Jong-Hak Lim
Markings
A fine felt-tipped marker is used to make the markings.
Point A is marked as the patient is in a seated position with
the eyes looking forward in the primary gaze position
(Figure 12-2). Point A becomes the position of the new
lateral canthus. Then the markings are continued with the
patient in a supine position with the eyes opened. The
markings are continued throughout the operation. Bu and
Bl are marked at the points above and below the lateral
canthus in the upper and lower eyelids. Cu and Cl are
marked about 1 cm from Bu and Bl on the gray line of the
12
f
a
b
g
e
d
c
Figure 12-1
Periocular arterial anatomy.

LATERAL CANTHOPLASTY
118
upper and lower eyelids. The length of line A–Bu, which is
equal to line A–Bl, is 3 to 5 mm. The length of line Bu–Cu
is equal to line Bl–Cl. Lines A–Bu and A–Bl are one half to
one third the length of the lines Bu–Cu and Bl–Cl.
Bu–A–Bl forms a small triangular skin flap. Point D on the
line Bu–Cu is determined during surgery (Cu–D ≥Bu–D).
Point E is also determined during surgery and is located on
the line drawn 90 degrees to the line Bu–Cu from point D
(Figure 12-3).
Anesthesia
Eyedrops containing 0.5% proparacaine hydrochloride are
placed in the conjunctival sac. A solution containing 1%
lidocaine with 1:100,000 epinephrine local anesthetic is
injected into the lateral canthal area with a 27-gauge
needle.
Operative Procedure
Lines A–Bu and A–Bl are incised with a #11 blade.
Next, Bu–Cu and Bl–Cl are incised on the gray lines. A
triangular skin flap is developed by dissecting tissue
through the incision line Bu–A–Bl and down to the lateral
canthal tendon (Figure 12-4). During this part of the
procedure, it is very important to avoid injury to the lateral
palpebral artery, which lies between the raphe and the
tendon (see Figure 12-1). The conjunctival flap, line Bu–Cu
and Bl–Cl, is dissected with a #11 blade and scissors. The
skin-conjunctival flap are formed by the line Cu–A–Cl
(Figure 12-5). The use of forceps with traction on the
triangular skin flap helps facilitate the skin-conjunctival
flap dissection (Figure 12-6). When the conjunctival flap
Bu–Cu is gently pulled toward point A (i.e., the new lateral
canthus), mild tension will develop. To eliminate this ten-
sion, a back cut is made with scissors from point D (Figure
12-7). Point D is near the midpoint between Bu and Cu.
Cu
B
A
Bl
Cl
Cu
D
B
A
Bl
Cl
Figure 12-2
Markings of lines A–Bu–Cu and A–Bl–Cl.
Figure 12-3
Lines A–Cu and D–E.
Figure 12-4
Preoperative marking.
Figure 12-5
View of skin-conjunctival flaps.

CONCLUSIONS
119
The back cut from point D is made at a 90-degree angle to
the line Bu–Cu. Point E is the end point of the back cut. The
length of line D–E is determined after the tension is com-
pletely released (Figure 12-8). Point D is rotated, advanced
(Figure 12-9), and sutured to point A (Figure 12-10). Points
D and A are sutured with 6.0 monofilament black nylon.
The suture through points A and D should include lateral
canthal tendon tissue to help anchor the flap (point A–
tendon–point D). Next, the redundant triangular conjunc-
tival tissue is trimmed along line E–Cu (Figure 12-11). A
continuous running suture is made along the line Cu–E–DA
with 6.0 monofilament black nylon. The small triangular
redundant skin flap on line Bu–A–B? is excised (Figure
12-12). A continuous running suture is made along line AD–
Bul–Cul with 6.0 monofilament black nylon (Figure 12-13).
Postoperative Care
The sutures are removed on the seventh postoperative
day.
Conclusions
Lateral canthoplasty with skin-conjunctival flap elevation
and the back cut rotation–advancement technique (Lim’s
method) is an easy and reliable method to lengthen the
palpebral fissure. The technique leaves no scars on the
lateral canthus (Figure 12-14).
A
Bu
Cu
Figure 12-6
A triangular skin-conjunctival flap is lifted using forceps with tension.
Cu
D
Bu
E
Figure 12-7
The conjunctival flap is divided from point D to point E.

LATERAL CANTHOPLASTY
120
Cu
D
A
E
Figure 12-8
Rotation and advancement of point D to point A.
Figure 12-9
The small triangular skin flap of Bu–A–Bl.
Cu
D
A D
E
Figure 12-10
Suture through points A and D.

CONCLUSIONS
121
Cu
D
E
Figure 12-11
Trimming the redundant triangular conjunctival flap of the upper eyelid on the line
E–Cu.
Figure 12-13
Immediate postoperative view of the lateral canthoplasty.
Figure 12-14
Preoperative view (A) and 6-month-postoperative view after Lim’s lateral canthoplasty with the double-eyelid operation (B).
A
B
Figure 12-12
The upper eyelid after the conjunctival flap and the small redundant triangular skin
flap on the lower eyelid were trimmed.

LATERAL CANTHOPLASTY
122
References
1. Jones LT: Levator resection. In Callahan A: Ptosis associated
with congenital defects: blepharophimosis, epicanthus, and
other syndromes. Symposium on surgery of the orbit and
adnexa, Trans New Orleans Acad Ophthalmol, St Louis,
1974, Mosby.
2. Jelks GW, Smith BC: Reconstruction of the eyelids and
associated structures, Philadelphia, PA, 1990, McCarthy,
p 1677.

123
Is There an Asian-Specific Forehead
Lift?
Although the forehead lift technique is the same as in
Caucasian patients, the rationale and indications are quite
different for Asian patients. Forehead lift for the non-Asian
population is performed to eliminate frown lines and
lateral hooding of the upper eyelids. Asian women rarely
have frown lines; when frown lines are present, they are
not as deeply grooved as in Caucasians. As a result, Asian
women are not as concerned about frown lines. More often
the forehead lift is performed for Asians as an adjunctive
procedure to double eyelid surgery. The public under-
stands and accepts the fact that the eyelids remain puffy
and unnatural for a long time and that this side effect may
be permanent after the double eyelid surgery in the
middle-aged or older patients with redundant upper eyelid
skin (Figure 13-1). This is partially caused by the inherent
thickness of the Asian upper eyelid skin1-4; more
Forehead Lift for the Asian
Upper Eyelid
Jung I. Park
important, it is because the double eyelid fold is created by
this thicker upper eyelid skin. The eyelid skin becomes
thicker as it approaches the eyebrow.5 After the thin lower
part of the upper eyelid skin is resected, the skin remaining
to create the double eyelid is the thicker skin in the
upper part of the eyelid. Contrary to the layperson’s belief,
puffiness of the upper eyelid after double eyelid surgery is
caused by the creation of the fold by the thick skin and
muscle, not the presence of excess fat. Forehead lift in the
Asian patient helps create a delicate double eyelid by lifting
thick, redundant upper eyelid skin from the pretarsal area.
It is indicated in nearly all middle-aged or older Asian
patients who seek upper eyelid surgery.
Consultation
Generally, patients who request double eyelid surgery are
not well informed about the beneficial effect of forehead
lifts. The beneficial effect is best demonstrated by asking
the patient to raise the eyebrows in front of a mirror
(Figure 13-2, A and B) or by lifting the patient’s forehead
with the fingers. This demonstrates lessening of the
fullness in the upper eyelids (see Figure 13-2, C). For those
patients who already have double eyelids and redundant
overhanging eyelid skin, lifting the lid skin demonstrates
thinning of the double eyelid fold. Although a forehead lift
is highly beneficial, a surgeon should be well prepared to
accept the patient’s desire to proceed with only a simpler
double eyelid procedure. When the forehead lift is chosen,
13
Figure 13-1
Persistent postoperative puffy double eyelid folds.

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
124
the patient should be informed that the surgery on the
upper eyelid is also necessary to create a double eyelid or
eliminate residual skin redundancy if preexisting double
eyelid folds are present. The patient should be informed
and warned about the necessary overcorrection of brow
elevation that may be persistent and gradually decrease
within 2 years. The double eyelid operation can be per-
formed at the same time. In that case, the eyelid surgery
should precede the forehead lift. Although a conservative
skin excision may be performed at the same stage, excision
of redundant eyelid skin is best deferred for at least 1 to 2
years, until the brow takes a final position. Forehead lift is
not indicated for those with high eyebrow position.
Preoperative Preparation
A hair shampoo with antiseptic soap is recommended.
Otherwise, the general preoperative care with monitored
anesthesia care (MAC) or general anesthesia is advised. For
the endoscopic forehead lift, the scalp hairs are combed
and shaved 1.5 cm posterior to the hairline, 0.5 cm wide,
1.5 cm long. Two paramedian locations about 3 to 4 cm
apart and two lateral locations at the level of the lateral
canthi are shaved for the incisions (Figure 13-3). An arbi-
trary line is drawn on the forehead skin above the lateral
aspect of the eyebrow. The forehead skin is lifted so that
the surgeon can view the effect of brow elevation on the
eyelid skin. Fullness of the upper eyelid disappears as the
brow fat is displaced. The amount of desired brow eleva-
tion is then determined by reading the movement of the
marked line along the vertically placed ruler (Figure 13-4).
A similar maneuver is used for the midline lift. The
measured length of the necessary elevation is then written
on the forehead skin as a reference, using a marking pen.
Measurements are made at each lateral eyebrow and the
midline. The midline elevation is in the range of 5 to 7 cm,
and the lateral elevation is 8 to 11 cm.
Anesthesia
Although monitored anesthesia care or general anesthesia
is preferred, local anesthesia with sedation can be used in
selected cases. A solution of 150 mL of diluted 0.1% lido-
caine and 0.05% marcaine with 1:1,000,000 epinephrine
is adequate to block and infiltrate the anterior scalp and
forehead area. A 30-gauge needle is used to block the
supraorbital, supratrochlear, and zygomaticotemporal
nerves (Figure 13-5) with 1 cc of 0.5% marcaine with
1:100,000 epinephrine solution. Next, local infiltration is
performed across the forehead and temple at the level of
the supraorbital ridge using a 27-gauge needle. The rest
of the forehead and the anterior scalp are infiltrated with
a 22-gauge spinal needle. Regardless of the anesthesia
technique, the use of tumescent technique helps lessen
bleeding and postoperative periorbital ecchymosis.
Instruments and Equipment
Endoscopic forehead lift equipment, a monitor, and an
instrument set are required (Figure 13-6).
Figure 13-2
A, Lateral hooding is the first sign of upper eyelid laxity. B,The patient lifts the
eyebrows to simulate the effect of forehead lift. This maneuver helps identify
asymmetric brow elevation that may lead to dynamic asymmetry postoperatively.
C,The full effect of the forehead lift on a double eyelid fold is demonstrated. This
maneuver is an excellent educational tool to the patient who otherwise would prefer
a simple, inexpensive eyelid surgery.
A
B
C

ENDOSCOPIC DISSECTION
125
Endoscopic Dissection
Vertical incisions down through the periosteum are made
in the shaved area using a #5 Bard-Parker blade. Next, the
periosteum is elevated over the entire forehead between
the linea temporalis and from the eyebrows up to the area
3 cm behind the incision area in the scalp (Figure 13-7).
The periosteal elevation does not require the use of an
endoscope. This dissection is done easily, quickly, and
without bleeding by using a curved periosteal dissector. A
linear area of resistance across the forehead, approximately
2.5 cm from the supraorbital ridge, is present. Careful and
forceful pushing of the periosteal elevator can break this
resistance without difficulty. The tip of the elevator should
always stroke the bone to prevent premature penetration of
the periosteum. The supraorbital foramen or notch should
be identified by palpation. The periosteal elevation should
stop about 1 cm above the supraorbital ridge to prevent
injury to the supraorbital nerve. The periosteum is laterally
elevated to the linea temporalis. The endoscope is then
introduced through the left paramedian incision. The tip of
the shield of the endoscope is advanced to approximately
1 cm above the supraorbital ridge. A dissecting knife or
heavy, dull-tipped, curved dissector is inserted through the
Figure 13-3
A, Incisions. B,Two paramedian and two lateral incisions.
1.5 cm incisions
A
B
A
B
Figure 13-4
A, A dot is plotted at the lateral end of the eyebrow. B,The brow is lifted upward and the displacement of the dot is measured. This number becomes a guideline for the
advancement of the forehead.

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
126
right paramedian incision. The periosteum is then incised
horizontally and parallel to the supraorbital ridge all the
way across the forehead, from one linear temporalis to
another (Figure 13-7). The periosteum is spread using a
dull-tipped curved dissector (Figure 13-8) to ensure move-
ment of the periosteum of the forehead and eliminate
tethering to the lower supraorbital periosteum. The sur-
geon should take care to consider the extent of separation
to prevent tearing of the supraorbital neurovascular
bundle. If desired, the corrugator supercilli muscles are
exposed through the periosteal incision by shearing off the
soft tissue surrounding the muscle, and the muscle is
divided (Figure 13-9).6,7 The endoscope is then moved to
the area of the linea temporalis. The periosteal attachment
to the linea temporalis is severed by a sharp dissection. The
forehead periosteum is further freed from the attachment
to the linear temporalis with a blunt, teasing motion. Care
should be taken to avoid severing or avulsing the frontal
branch of the facial nerve. The nerves run deeply in this
area and enter from beneath the frontalis muscle. Two
periosteal incisions are connected at the superolateral
orbital margin. At this time the forehead periosteum is
completely freed from its adhesion to the bone and is ready
for upward movement. If additional mobility of the
periosteum is needed, an additional periosteal incision may
be made superiorly from the upper aspect of the linea
temporalis on the lateral forehead (see Figure 13-7). The
skin of the forehead and the eyebrow moves upward as the
periosteum is lifted. Movement of the eyebrow and temple
is tested, and the necessary periosteal release is repeated
until free movement is accomplished. The location of the
fixation screw is determined by the preoperatively
estimated degree of brow elevation and the determination
of a new brow position after manually lifting the forehead
flap (Figure 13-10). A self-tapping screw is then inserted
into the skull bone at the incision site. Four screws are
placed in a similar fashion at each incision site. A KLS
Martin Hexa-HeadTM 1.5-mm × 6-mm embedded per-
manent brow screw is used for a permanent fixation. The
Supratrochlear n.
Supraorbital n.
Zygomaticotemporal n.
Figure 13-5
Sensory innervations of the forehead skin.
Figure 13-6
Instruments.

PRETRICHIAL INCISION
127
forehead flap is then advanced a measured distance and
fixated to the screws with 2-0 permanent sutures. The
suture is passed through the tunnel in the head portion of
the screw (Figure 13-11, A). Then the suture needle is
entered into the undersurface of the periosteum, 1 cm
inferior to the lower end of the incision, and exited through
the scalp skin. The needle is reentered into its exit point,
where it penetrates the scalp and passes below the level of
the hair bulb in the subcutaneous tissue plane parallel to
the periosteum until it is exited through the incision site
(see Figure 13-11, B). Two ends of the suture are tied
together and tightened. As an alternative, a removable
11-mm self-tapping screw may be used. The suture needle
then is passed through the full thickness of the scalp,
approximately 1 cm inferior to the lower end of the incision.
The suture is tied around the base of the screw (Figure
13-11, C). If a removable screw was used, both the screw
and suture are removed after 1 month. One possible
problem with the through-and-through suture technique is
a temporary or even permanent hair loss in a 1-cm2 area.
If hair loss is permanent, the bolded area could be easily
excised and reapproximated during an in-office procedure.
The benefits of the forehead lift outweigh its minimal
inconvenience. The scalp is closed with 4-0 nylon in an
interrupted fashion.
Pretrichial Incision
A hairline incision8-10 is used for patients with high fore-
heads. A full thickness of the forehead tissue strip is
removed to elevate the eyebrow. The incision is extended
between the temples along the frontal hairline. The scalp
incision is beveled inferiorly to shave a thin layer of epi-
dermis. The scalp, which bears one or two rows of hairs, is
deepithelized. After the dissection passes the hair-bearing
scalp, the knife is turned 80 degrees to bevel superiorly and
parallel to the direction of the hair shafts. The width of the
strip of the forehead tissue to be removed is based on the
preoperative measurement as previously described. The
lower incision is also beveled 2 mm inferiorly to develop an
epidermal flap, and then beveled superiorly at the same
1 cm
Hairline
Scalp
Galea
Periosteum
Periosteal elavator
3 cm
Figure 13-7
Extent of periosteal elevation.
A
B

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
128
angle as the beveling of the upper incision (Figure 13-12,
A).11 Both the upper and lower incisions are made in a
zigzag hairline pattern, which allows for better camouflage
(Figure 13-13).12 The skin island between the incisions is
removed and discarded. Periosteal elevation, periosteal
incision, and dissection along the supraorbital rim and the
linea terminalis are completed in a fashion similar to the
endoscopic procedure. Despite the long incision, the use
of the endoscope facilitates dissection to overcome limited
exposure. The corrugator supercilli muscle bundles are
then divided (Figure 13-14). The subperiosteal forehead
flap is pulled up, the fixation points are marked along the
upper incision line, and four screws are inserted. The flap
is fixated to the screw using 2-0 permanent suture. The
needle is passed through the periosteum, galea, and
frontalis muscle. The forehead is pulled up, and the suture
is tied to the screw with a buried knot (Figure 13-15). Each
suture needle should take at least 1 cm or more of the
periosteal and galeal tissue to prevent the suture material
from tearing. Additional deep periosteal/galeal sutures
are placed at 2-cm intervals between the scalp and the
forehead flap. Subcutaneous sutures are then placed to
bring the wound edges into complete approximation. The
epidermal flap of the lower incision covers the denuded
upper incision. The hair shaft under the epidermal flap
grows through the scar tissue. These hairs help conceal the
scar (see Figures 13-12 and 13-16, A and B).13 The skin is
closed with 6-0 fast-absorbing plain gut sutures.
Cut edge of periosteum
Supraorbital nvb.
Corrugator supercilii m.
Dissector
Endoscope
Procerus m.
Corrugator supercilii m.
Supraorbital n.
Dissector
Endoscope
Figure 13-8
A, Incision of the periosteum 1 cm above the superior orbital rim. B,Wide separation of the periosteum, and exploration of the corrugator
supercillim.
A
B

POSTOPERATIVE CARE
129
Biplanar Forehead Lift
The hairline incision is the same as the pretrichial forehead
lift. The forehead skin is freed from the underlying frontalis
muscle approximately 4 cm inferior to the hairline (Figure
13-17, A). The subperiosteal plane is developed through
the exposed frontalis muscle.14,15 Two paramedian and two
lateral locations are used to gain access to the subperiosteal
plane, as described in the preoperative preparation. The
supraorbital and supratrochlear nerve branches, which are
seen above the muscle, are avoided. The rest of the sub-
periosteal dissection and muscle ablation are identical to
the other two approaches using the endoscopic forehead
lift principles. As the frontalis muscle and the periosteum
are lifted, the degree of eyebrow elevation is determined.
Next, the lifted frontalis muscle is plicated over the entire
width of the forehead using multiple horizontal mattress
3-0 Vicryl sutures (see Figure 13-17, B). The plication is
made with somewhat exaggerated eyebrow elevation. The
redundant forehead skin is then marked for conservative
resection to ensure a tension-free skin closure (see
Figure 13-17, C). The same beveling technique used in the
pretrichial incision is followed. The subcutaneous tissue
and dermis are closed in a vertical mattress fashion with
buried knots using 4-0 vicryl sutures. The epidermal flap is
carefully placed over the denuded scalp dermis. The skin
is closed with a continuous running 5-0 or 6-0 plain gut
suture. This procedure is particularly beneficial to the
patient with excessive forehead horizontal wrinkles caused
by a hyperdynamic frontalis muscle.
Postoperative Care
A forehead compression dressing with a soft gauze roll and
elastic bandage is applied for hemostasis. The dressing is
used for 2 days. Gentle shampooing is allowed on the
fourth postoperative day. Hair may be styled after 1 week.
The temporary screws are removed in 4 weeks.
Supratroclear n.
Periosteum
Supraorbital n.
Figure 13-9
Division of the corrugator supercillim.
Figure 13-10
Testing the mobility of the brow.

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
130
A
B
De-epithelization
Hair grows through scar
Beveled parallel to hair follicles
B
A
Figure 13-12
A, Beveling of the scalp and the forehead flap. B, Hair grows through the scar tissue and
camouflages the scar.
Figure 13-11
A, Forehead flap fixation to the retainable screw. B, Forehead flap fixation to the
removable screw.

RECOVERY
131
Case Study
See Figures 13-18 to 13-21.
Recovery
Periorbital ecchymosis and swelling peak during the third
and fourth postoperative days. At times the patient is
unable to open the eyes due to swelling. Swelling subsides
rapidly and becomes almost normal in 1 week. The brow
position remains higher than the ideal position for 2 years
postoperatively. For ideal long-term results, overcorrection
is necessary.
A
B
Figure 13-13
A, Pretrichial forehead lift is an excellent alternative to a traditional four-hole endoscopic forehead lift. The amount of forehead to be lifted is marked on the forehead. The
incision is made in a zigzag pattern to camouflage the postoperative scar. B, Modified pretrichial incision. The incision is avoided in the midline area in which the patient may
part the hair.
Figure 13-14
Subperiosteal dissection is completed, and multiple parallel bundles of the
corrugator supercilli muscle are shown.
Figure 13-15
Suture fixation of the pretrichial forehead flap.

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
132
A
B
Figure 13-16
A, Immediate postoperative view. B, Invisible postoperative scar due to hair growth through the incision scar.
Dissector
Endoscope
A
Figure 13-17
A, Biplanar forehead lift. Skin elevation.
Continued

RECOVERY
133
Horizontal mattress
sutures
B
C
Figure 13-17—cont’d
B, Frontalis muscle plication with multiple horizontal mattress sutures. C, Excess
forehead skin excision.
A
B
Figure 13-18
A, Preoperative view shows heaviness of the upper eyelid skin. B, Postoperative view shows that a distinctive definition of the brow fat was lifted and settled over the
supraorbital ridge.

FOREHEAD LIFT FOR THE ASIAN UPPER EYELID
134
A
B
Figure 13-19
A, Preoperative lateral view. B, Postoperative lateral view shows that upper eyelid fullness has been eliminated.
A
B
Figure 13-20
A, Despite the distinctive double eyelid fold, the patient was not happy with the surgery because of the upper eyelid fullness. B, Postoperative view shows a lively appearance of
the periorbital area.

RECOVERY
135
References
1. Fernandez LR: Double eyelid operation in the oriental in
Hawaii, Plast Reconstr Surg 25:257-264, 1960.
2. Zubiri JS: Correction of the oriental eyelid, Clin Plast Surg
8:725-736, 1981.
3. Liu D, Hsu WM: Oriental eyelids. Anatomic difference and
surgical consideration, Ophthalmic Plast Reconstr Surg
2:59-64, 1986.
4. Lee Y, Hwang K: Skin thickness of Korean adults, Surg
Radiol Anat 24:183-189, 2002.
5. Lee JS: Simplified anatomic method of double-eyelid
operation: septodermal fixation technique, Plast Reconstr
Surg 100:170, 1997.
6. Park JI, Hoagland TM, Park MS: Anatomy of the corrugator
supercilii muscle, Arch Facial Plast Surg 5(Sept-Oct):412-
415, 2003.
7. Bernstein L, Park J: Letter to the editor, Arch Facial Plast
Surg, in press.
8. Uchida JJ: A method of frontal rhitidectomy, Plast Reconstr
Surg 35:218, 1965.
9. Su CT, Morgan RF, Manson PN, et al: Technique for
division and suspension of the orbicularis oculi muscle,
Clin Plast Surg 8:673, 1981.
10. Guyuron B, Davies B: Subcutaneous anterior hairline
forehead rhytidectomy, Aesth Plast Surg 12:77, 1988.
11. Kerth JD, Toriumi DM: Management of the aging
forehead, Arch Otolaryngol Head Neck Surg 116:1137-1142,
1990.
12. Benito J: Aesthetic incision in the subcutaneous forehead
lift, Aesthetic Plast Surg 17:239, 1993.
13. Mayer TG, Fleming RW: Fleming-Mayer flap (modified
after Juri) forehead lifting. In Mayer TG, Fleming RW:
Aesthetic and reconstructive surgery of the scalp, St Louis,
1992, Mosby.
14. Oslin B, Core GB, Vasconez LO: The biplanar
endoscopically assisted forehead lift, Clin Plast Surg
22:633, 1995.
15. De Cordier BC, de la Torre JI, Author Name, et al:
Endoscopic forehead lift: review of technique, cases,
and complications, Plast Reconstr Surg 110:1558-1568,
2002.
A
B
Figure 13-21
A, Preoperative oblique view. B, Postoperative oblique view.

II
137
Asian rhinoplasty is predominantly an augmentation
procedure that uses preformed silicone rubber implants.
Less frequently, autologous cartilages such as the rib are
also used for the augmentation rhinoplasty. Another
emerging trend is to combine alloplastic implants with
autologous cartilage. The use of silicone or polytetra-
fluoroethylene for the nasal dorsal augmentation with
modification of the tip using septal or auricular cartilage is
an alternative to the traditional augmentation.1-3As early as
the 19th century, attempts were been made to enhance
nasal height using paraffin injections.4 Naturally, use of
paraffin created major complications (Figure 14-1). The
use of ivory, acrylic, polyethylene, and silicone injections
are also associated with significant complications.5
Beekhuis first introduced the silicone rubber implant for
nasal augmentation in 1964.6 Skepticism about the use of
silicone implants in rhinoplasty began when initial reports
in the 1960s–1970s showed a high extrusion rate.7-9 Based
on the occasional case of terrifying skin loss from silicone
implants, augmentation rhinoplasty gained a negative and
persistent reputation among Western plastic surgeons.
Despite the severe criticism, it has remained the implant of
choice for nasal augmentation in Asian patients. Contrary
Introduction to
Augmentation Rhinoplasty
Jung I. Park
to the widespread belief among Western surgeons, large
series performed by experienced Eastern surgeons have
reported a low extrusion rate (i.e., less than 2%).10-13 Almost
from the outset of silicone implant use, the development of
this complication was thought to be due to surgical
technique error.7,14 Dramatic lowering of extrusion rates is
a result of a better understanding of the implants and their
tissue interaction. Another factor that helped lower the
occurrence of implant extrusion was early detection of
impending extrusion and removal of the implant in a
timely manner. Infection goes hand in hand with implant
extrusion by either preceding or following the latter event.
Just as in the case of extrusion, a low incidence of infection
has been reported (i.e., less than 3%).11,13 Flowers and Deva
et al reported a 0% rate of infection in their primary
augmentation rhinoplasty series.10,12
Silicone Implant
Strengths
Unlike the autograft, the supply of silicone implant
material is unlimited. It is inexpensive, and its safety has
14
Augmentation
Rhinoplasty

INTRODUCTION TO AUGMENTATION RHINOPLASTY
138
been proven. The rigidity of the implant can be chosen to
suit the needs of the surgeon. Silicone is easy to contour
and it comes as a preformed, ready-to-use implant. It
requires a minimal amount of dissection to insert the
implant, and a secondary incision to harvest grafts is not
required. Additionally, it is extremely easy to remove in
case of implant problems. Cosmetic outcome is excellent
with the proper choice of candidates.
Weaknesses
Although implant extrusion and infection are serious
concerns, these complications are somewhat inherent to
the implant surgery in general. With a better understand-
ing of why these complications occur and the use of
meticulous technique, the nasal implant surgery can be as
safe as breast augmentation or hip replacement surgery.
Implant malposition is the most common complication of
nasal implant surgery.11-13 It is often the result of technical
imperfections. Although the nasal implant can enhance the
projection of the nasal tip, its ability to change the shape of
the nasal tip is limited. The implant can be visible under a
certain light as a transparency when a transparent implant
is used.15 Use of an opaque or a flesh-colored implant
eliminates this problem.14,15 In colder temperatures or in
cases in which the implant places excessive pressure on the
skin, certain types of skin may turn reddish.
Implant Shape
The shape of the nasal implant varies depending on the
area to be enhanced. Implant shapes include the following
(Figure 14-2, A to E):
Dorsal
Dorsocolumellar
Full dorsocolumellar
Partial columellar
Partial dorsal
Columellar
The dorsal implant is used for the patient who has a
shallow dorsum and root of the nose but good tip
projection. The dorsocolumellar implant consists of a
dorsal and a columellar portion. The full dorsocolumellar
type is designed to assist tip projection10 and also act as a
solid stabilizer15 for the dorsal portion by keeping it in
the midline orientation. Extreme caution is required with
this type of implant to prevent undue pressure to the
supralobular dome skin. Although the full dorsocolumellar
type is superior in achieving tip projection, the partial
columellar type is safer. The partial columellar type has
a full dorsal component and a vestige of the columellar
portion. This is one of the most popular types used in East
Asian countries. The idea behind this design is to avoid
Figure 14-1
Paraffinoma.
Figure 14-2
A, Dorsal implant. B, Dorsocolumellar implant. C, Partial columellar implant.
D, Partial dorsal implant. E, Columellar strut implant.

IMPLANT SHAPE
139
undue pressure to the supralobular dome. The tip projec-
tion is supposedly achieved by cantilever action of the
dorsal portion of the implant.14,16 However, due to the soft
and malleable nature of the silicone implant, the cantilever
effect is not very effective. Rather, tip enhancement achieved
with the partial columellar type may be caused by the
mass of the implant as a volume enhancer at the dome.
Occasional subtle tip deprojection found after augmenta-
tion with partial columellar type could be due to the lack of
tip support. The function of the columellar portion as a
stabilizer is also limited because of its short columellar
extension. The partial dorsal type is designed to support
and enhance the nasal tip, but only for the patient with a
deprojected tip and a small hump. Extreme caution should
be exercised to avoid excessive tension with this implant.
The columellar implant is designed to provide tip
projection without the implant reaching the tip itself. The
implant may be carved to accommodate the need for the
particular patient (Figure 14-3).
Full Dorsocolumellar Implant
Because of its long columellar strut, the full dorsoco-
lumellar implant enhances the columellar-labial angle and
increases the columellar show by forward displacement of
the columella itself. The bottom of the implant is located
anterior to the anterior nasal spine and acts as a plumping
graft. This is an important aspect of this particular type of
implant for many Asian noses that have a sharp columellar-
labial angle.
In the author’s practice, three sizes of implants are used,
including medium “A” and sizes 1, 2, and 3 in “F.” Size 1 is
the thinnest, and size 3 is the thickest implant (Figures
14-4 and 14-5, Tables 14-1 and 14-2). For the rare patient
with an extremely short or long nose, a short or long
implant in “A” is ordered on a custom-made basis.
Implant Choice
The size and shape of the implant can be chosen based on
the surgeon’s judgment and the implant sizer. Computer
imaging or moulage can be used to choose the implant.
However, implant choice based on a thorough consultation
is most crucial to satisfy the patient. Hardness of the
implant is described in terms of durometers. The average
nasal implant is in the range of 20 to 30 durometers. An
implant that is too soft is difficult to handle, tears during
A
B
C
Figure 14-3
A,The full dorsocolumellar implant is amputated to make a partial dorsal implant.
B,The undersurface of the dorsal portion of the dorsocolumellar implant may be
carved either to reduce the height at the root area or to accommodate a small hump.
C,The implant is carved to lessen the supratip bulge.

INTRODUCTION TO AUGMENTATION RHINOPLASTY
140
the insertion, and is unable to support the nasal tip. Hard
implants give an unnatural feel, and it is easy to traumatize
the overlying skin secondary to pressure or accidents.
Although manufacturer-packaged presterilized implants
are available, the implant can also be steam sterilized. The
use of an implant with multiple holes for stability is not
recommended. It is the author’s belief that adequate pocket
creation and correct placement of the implant dictate the
ultimate location of the implant. The holes simply make
the implant more difficult to remove in case of complica-
tions. Examination of silicone implants at the time of
revision surgery typically reveals a well-formed capsule
encasing the implant (Figure 14-6).
a
f
g
c
e
i
d
b
e
h
Figure 14-4
Dimensions of the dorsocolumellar implant.
b
a
Figure 14-5
Dimensions of the dorsal implant.
Table 14-1. Park Dorsocolumellar Implant
A-B angle
80 degrees
A
Short
4.0 cm
Medium
5.0 cm
Long
5.5 cm
B
3.2 cm
C
1.15 cm
D
1.0 cm
E
0.6 cm
F
Size 1
0.25 cm
Size 2
0.4 cm
Size 3
0.55 cm
G
0.7 cm
H
0.4 cm
I
0.4 cm
A, May customize to adapt for an excessively long or short nose.
B, May lengthen to enhance tip projection.
C, May broaden to give the nose a broader, natural-looking Asian nose.
May be narrowed if the patient has a sharp bridge or desires a chiseled
look.
D, The average Asian noses have a broad nasal tip. Dome design is made
broader than the columellar portion to conform to the natural nasal tip.
A broader surface also diffuses the upward tension to the dome skin.
E, The columellar strut is made narrower than the dome but thick enough
to support the dome without bending.
F, The main concern for most patients is the expected enhanced height of
the nasal dorsum. This is the single most important parameter for the
patient’s consideration.
G, Posterior extent of lateral flanges of the dorsal portion.
H, Thickness of the implant at the supratip lobular area. The tip projection
is manipulated by B. H remains the same, but it can be carved thin if
needed.
I, The columellar strut is made in a rectangular shape to reduce the
thickness between the medial crura.
Table 14-2. Park Dorsal Implant
A
Short
4.0 cm
Medium
5.0 cm
Long
5.5 cm
B
Size 1
0.25 cm
Size 2
0.4 cm
Size 3
0.55 cm
C
1.15 cm
Mirror image to the tapering tip.
Tapering begins from the nasofrontal angle.
A, Same dimension as A in Table 14-1.
B, Same dimension as F in Table 14-1.
Note: Each end tapers gradually. The nasofrontal angle is made thickest.
Tapering is more acute toward the forehead and very gradual as it
approaches the nasal tip.

SURGICAL APPROACHES
141
Preoperative evaluation
A thorough preoperative evaluation is essential to deter-
mine the operative indications, understand the patient’s
expectations, explain the limitations in achieving a certain
result, and finally choose the correct implant. Symmetry of
the external nose should be carefully evaluated. The patient
must be informed that preexisting asymmetry is not
correctable with the implant. In fact, the implant may give
an illusion of worsening of the deviation by augmenting the
nose. The depth of the nasofrontal angle and the height of
the nasal bridge determine the thickness of the nasal
implant. A mild tip deprojection can be managed by the
use of a full dorsocolumellar implant. Moderate to severe
tip deprojection is best corrected with use of dome
cartilage modification or the shield or onlay cartilage graft.
The patient with a double bubble tip due to a strong dome
cartilage is not a candidate for nasal augmentation using
the implant unless only the dorsum is enhanced. Unsightly
projection of the implant tip within the double bubble
dome is quite unacceptable. The upturned nose is a relative
contraindication for augmentation with implants. The
implant may accentuate the appearance of excessive
cephalic rotation of the nasal tip and worsen the nostril
exposure. Alar flaring and a wide base can be improved
with judicious use of the full dorsocolumellar implant
(Figure 14-7). A sharp columellar-labial angle is often
improved with the use of the full dorsocolumellar implant
through the sublabial approach (Figure 14-8).
Surgical Approaches
Implant Augmentation Rhinoplasty
Vestibular Incision
The vestibular approach is the
most popular technique and is easier to perform through a
direct route. Concerns include the close proximity of the
incision site to the final location of the implant. It is an
accepted principle that the incision should be made at a
distant site from the intended location of the implant to
Figure 14-6
Capsule formation around the implant.
A
B
Figure 14-7
A, Preoperative wide nasal base. B, Postoperative narrowed nasal base with a full dorsocolumellar implant.

INTRODUCTION TO AUGMENTATION RHINOPLASTY
142
avoid extrusion of the implant secondary to a disruption of
the skin barrier (i.e., the skin incision). Development of
asymmetry, which is one of the most common complica-
tions, is a concern with this technique due to the off-
midline approach. The implant tends to deviate to the
opposite side of the vestibular incision.11-13 The vestibular
incision is a less effective approach to inserting the full
dorsocolumellar implant.
Sublabial Incision
The sublabial approach ensures
symmetry because of its midline approach. Because it is
fixated by the columellar strut as a part of the L-shaped
implant, the position of the dorsal segment of the implant
is stable. The nasal tip support is accomplished with less
tension to the tip skin for a given amount of tip elevation.
First, this approach bypasses the dissection under the
dome skin by undermining the tissue low at the dome area,
away from the dome skin and subcutaneous tissue. Unlike
the vestibular dissection, the skin of the dome maintains a
thicker protective layer of tissue against the upcoming
implant. Second, in sublabial dissection, the nasal base is
completely freed before the tunnel is created. In other
words, tethering between the columella and the
premaxillary bone is not required. The tip is thus elevated
along with the nasal base without a drag. Another
beneficial aspect of the sublabial approach is that the
incision site is away from the location of the implant. The
maxim to be applied to all implants is that the approach
should be as far as possible from the implant, either by
some distance or by the tissue thickness.17 The distance
between the incision and the end of the implant is
approximately 1 cm. Pressure vectors created by the
implant are at a 90-degree angle to the direction of the
incision. These two factors make it almost impossible for
the implant to extrude through the incision. The dissection
is more difficult because of the need to follow a double-
angled plane. The distance to the farthest point at the
nasofrontal angle is long. This approach is technically more
difficult. In the author’s practice, the vestibular incision is
reserved for dorsal augmentation only.
External Rhinoplasty Incision
The external incision
uses a standard combination of precolumellar and
marginal incisions. It allows an easy and full access to the
nasal tip and dorsum. Modification of the tip and hump
removal are easily and safely accomplished. The implant
can be covered by the biologic material or fixated with the
medial crura in such a way that the implant is not in direct
A
B
Figure 14-8
A, Preoperative sharp columellolabial angle. B, Postoperative increased columellar show and a more obtuse columellolabial angle.

SURGICAL APPROACHES
143
contact with the nasal tip skin. Those maneuvers help
prevent implant extrusion. The external incision is a better
approach to obtain symmetry. Concerns with the scar,
complexity of dissection, and potential exposure of the
implant at the incision site are the disadvantages of this
procedure.
Autograft Augmentation Rhinoplasty
The main goal of nose augmentation using an autologous
graft is to avoid the extrusion and infection associated with
alloplastic implants. Options for autologous cartilage
include nasal septal, auricular, or rib cartilage and iliac,
mastoid, or skull bone. Those grafts share common
characteristics of being biologic material and not being
subject to extrusion. They also share the long-term
sequelae of resorption and possible contour changes such
as warping.18,19 Secondary incision and dissection are
necessary to harvest the grafts. The scars are well hidden
and relatively pain free in nasal septal or auricular cartilage
grafts and in mastoid or skull bone grafts. The iliac bone
graft harvesting is very painful. Rib cartilage harvesting is
painful and also causes a potentially unsightly scar. Auri-
cular cartilage, nasal septal cartilage, and mastoid bone
grafts are relatively simple and safely obtained with the
proper training. The harvesting of skull bone or rib cartilage
grafts carries potential serious risks. For the purpose of
the average augmentation, the auricular and nasal septal
cartilages do not have sufficient volume and the contour is
not ideal for augmentation, excepting the nasal tip. When
these cartilages are vertically stacked for volume, surface
irregularity and malpositioned grafts become a concern.
The rib cartilage graft is a preferred method of augmen-
tation rhinoplasty because of the availability of large
volume and ease of contouring (Figure 14-9). Although
warping is a main concern with this graft, proper treatment
of the graft may reduce the chance of warping, and a low
resorption rate makes it the graft of choice.19,20
Augmentation Rhinoplasty Using Autograft
and Alloplast Combination
Combination procedures take advantage of both implant
volume and the safety of autologous grafting material.1-3
Relatively large volumes are required to enhance the nasal
bridge. The alloplastic implants are well tolerated in the
nasal dorsum or root area but not in the nasal tip area. The
silicone rubber implant or PTFE provides the necessary
volume and optimal contouring in the nasal bridge.
However, the most common site of implant extrusion is
through the nasal tip or the vestibular skin at the incision
site.14,15,21Therefore the possibility of implant extrusion can
be avoided by using tip modification and the cartilage graft.
Nasal tip augmentation requires a smaller and easily
obtainable cartilage graft without relying on the more
complex secondary graft harvesting sites such as the rib.
References
1. Rizzo M: The Filipino and Polynesian patients. In Matory
WE Jr: Ethnic considerations in facial aesthetic surgery,
Philadelphia, 1998, Lipppincott-Raven, pp 285-306.
2. Jung DH: Rhinoplasty. In Jung DH Ed. Rhinoplasty, Seoul,
2002, Greenbook, p 175.
3. Ahn J, Honrado C, Horn C: Combined silicone and
cartilage implants. Augmention rhinoplasty in Asian
patients, Arch Facial Plast Surg 6:120-123, 2004.
4. Gersuny R: Ueber eine subcutane prothese, Z Heilkunde
1:199, 1900.
5. Furukawa M: Oriental rhinoplasty, Clin Plast Surg
1(1):129-155, 1974.
6. Beekhuis GJ: Silicone rubber implants in nasal
reconstructive surgery, Laryngoscope 74:1405, 1964.
7. Lipshutz HA: Clinical evaluation of subdermal and
subcutaneous silicone implants, Plast Reconstr Surg 37:249,
1966.
8. Davis PKB, Jones M: The complication of silastic implant,
Br J Plast Surg 24:405-411, 1971.
9. Milward TM: The fate of silastic and vitrathene nasal
implants, Br J Plast Surg 25:276, 1972.
10. Flowers RS: Nasal augmentation by the intraoral route,
Plast Reconstr Surg 54(5):570-578, 1974.
11. Hiraga Y: Complication of augmentation rhinoplasty in
Japanese, Ann Plast Surg 4(6):495-499, 1980.
12. Deva AK, Merten S, Chang L: Silicone in nasal
augmentation rhinoplasty: a decade of clinical experience,
Plast Reconstr Surg 102(4):1230-1237, 1998.
Figure 14-9
Rib.

INTRODUCTION TO AUGMENTATION RHINOPLASTY
144
13. Lam SM, Kim YK: Augmentation rhinoplasty of the Asian
nose with the “Bird” silicone implant, Ann Plast Surg
51(3):249-256, 2003.
14. McCurdy JA Jr: The Asian nose: augmentation rhinoplasty
with L-shaped implants, Facial Plast Surg 18:(4)245-252,
2002.
15. Mutou Y: The complication of augmentation rhinoplasty in
Orientals, Br J Plast Surg 28:160-163, 1975.
16. Arons MJ: The application of cantilever bridge principle to
silastic nasal support, Br J Plast Surg 33:404, 1980.
17. Regnault P: Nasal augmentation in the problem nose,
Aesth Plast Surg 11:1, 1987.
18. Mowlem R: Bone and cartilage transplants, their use and
behaviour, Br J Surg 29:182, 1941.
19. Boyce RG, Toriumi DM: Considerations in the use of
biologic grafts and alloplastic implants in facial plastic and
reconstructive surgery, J Long-Term Effects Med Implants
2:199-220, 1992.
20. Gibson T, Davis WB: The distortion of autogenous cartilage
grafts: its causes and prevention, Br J Plast Surg 10:257-274,
1958.
21. Han KW: Rhinoplasty. In Lee YH: Aesthetic plastic surgery,
Seoul, 1998, Gunja, p 209.

145
The endonasal (vestibular) approach to augmentation
rhinoplasty achieves superior access to the nasal lobule and
dorsum and allows precise pocket preparation. This
approach also facilitates accurate intraoperative modifica-
tion of alloplastic prostheses (or autografts, if indicated)
because prostheses can be easily removed, modified, and
replaced during surgery for inspection and tailoring to “fit”
each patient’s individual anatomy.
Preoperative Care
Prophylactic antibiotics (e.g., cephalexin) are initiated the
evening before surgery and continued for 3 days post-
operatively. The vestibule is prepared with 5% povidone-
iodine solution before the nasal vibrissae is trimmed.
Preoperative Medication
Other than prophylactic antibiotics, preoperative medica-
tion is not routinely used. As described in the following
section, intravenous medications provide adequate
sedation when administered immediately before local
anesthetic infiltration. The local anesthetic provides
continuing analgesia during the immediate postoperative
period; discomfort is rarely an issue after this time.
Anesthesia
Direct infiltration of local anesthetic into
the surgical site is preferred to specific attempts to block
regional nerves such as the infraorbital nerve.
The nasal vibrissae are trimmed before local anesthetic
is infiltrated, and the vestibule is re-prepped with 5%
povidone-iodine solution. Intravenous propofol (10 mg/mL)
Vestibular Approach
John A. McCurdy, Jr.
is titrated in 1-mL increments to the point of early
hypnosis; the patient’s clinical response and pulse oximetry
should be used to determine the appropriate level of
sedation. The usual required volume of propofol is 4 to
6 mL (40 to 60 mg). The patient is rarely completely
hypnotic but is always amnesiac. The nasal dorsum is
injected through the vestibular skin, and then the marginal
incision sites and lobule, including the columella, are
infiltrated. Direct supplemental infiltration of the nasion, if
required, is performed percutaneously. Care is taken to
inject sufficient anesthetic to provide adequate hemostasis
while preventing tissue distortion.
Surgery is deferred until at least 10 minutes after anesthetic
infiltration to allow the achievement of a hemostatic
(vasoconstrictive) effect.
The local anesthetic solution is prepared as follows:
1. Equal portions of plain 1% lidocaine and plain 0.5%
bupivacaine are mixed, and a volume of epinephrine
1:1000 that is sufficient to achieve a final concentration
of 1:50,000 is added (i.e., 10 mL of anesthetic solution +
0.2 mL epinephrine 1:1000, or 20 mL anesthetic
solution + 0.4 mL epinephrine 1:1000 = an epinephrine
concentration of 1:50,000). This preparation of local
anesthetic provides a hemostatic effect superior to that
of commercially premixed local anesthetic/epinephrine.
2. Sodium bicarbonate is not used as a buffer because
this substance impairs the hemostatic activity of the
anesthetic/epinephrine solution. Intravenous sedation
with propofol before anesthetic infiltration, as
previously described, obviates conscious perception of
pain during injection.
15

VESTIBULAR APPROACH
146
Instruments
Essential instruments include a double ball retractor, small
scissors for lobular and columella dissection, and standard
rhinoplasty dissection scissors (Foman or Metzenbaum
type) to undermine the dorsum and aid in periosteal
shredding over the nasal bones (Figure 15-1). If Gore-Tex
is to be used for nasal augmentation, its insertion is faci-
litated with use of a Gore-Tex–passing forceps designed by
Dr. Dong-Hak Jung of Seoul, South Korea (Figure 15-2).
Operative Technique
The procedure is as follows:
1. Incisions: Access to the dorsum and lobule is obtained
through a marginal incision (i.e., an incision along the
inferior border of the lower lateral cartilage, as opposed
to the rim incision recommended by many Asian
surgeons) that extends into the superior half of the
columella (Figure 15-3).
2. Dorsal pocket dissection: Dissection of a precise
subcutaneous midline pocket is facilitated by initiating
the dissection through the columellar aspect of the
incision (Figure 15-4). The lower lateral cartilages are
freed from the lobular skin but are not otherwise
modified because the implant will rest on their anterior
surfaces. Dissection of an ample pocket is performed in
the lobular region; the pocket should become more
glove-like over the dorsum but remain sufficiently large
to avoid tension. The right-handed surgeon has a
Figure 15-2
Gore-Tex–passing forceps.
Figure 15-4
Midline pocket dissection is initiated through the columellar aspect of the marginal
incision.
Figure 15-1
Instruments used for augmentation rhinoplasty.
Figure 15-3
A marginal incision at the inferior border of the lower lateral cartilage is used instead
of a rim incision.

IMPLANT DESIGN
147
natural tendency to underdissect the lobular portion of
the pocket on the right side (and for the left-handed
surgeon, vice versa); the surgeon must be aware of this
tendency and modify the dissection accordingly.
3. Columellar dissection: After the skin of the lobule and
dorsum is undermined, the tips of the scissors are
directed into the columella, where a pocket that is
continuous with the dorsal pocket is dissected between
the medial crura. This allows the columellar segment of
the prosthesis to be placed (Figure 15-5).
4. Periosteal dissection: After the subcutaneous pocket is
dissected, the periosteum of the nasal bones is shredded
with the tips of a blunt dissecting scissors to encourage
its growth around the implant, thus assisting in
stabilization of the prosthesis (Figure 15-6).
Implant Design
The author has designed and currently uses a silicone
implant (Table 15-1) that consists of three segments
with distinctive characteristics and functions: a dorsal
component, a lobular component, and a columellar
strut (Figure 15-7). All three components are made of soft
silicone elastomer, which is of particular importance
because softness and flexibility (Figure 15-8) translate into
diminished pressure at the tissue-prosthesis interface,
resulting in less stress on the overlying skin. The first
generation of silicone nasal implants designed in Asia were
fabricated from hard elastomer and tended to be
excessively large, factors that contributed to complications
such as implant exposure.
Figure 15-5
The columellar pocket is dissected continuous with the dorsal pocket.
Figure 15-6
The dorsal periosteum is shredded with the tips of blunt dissecting scissors.
Table 15-1. Design of the L-Shaped Silicone Implant
Segment
Characteristics and Features
Dorsal component
Soft and flexible (translates into
decreased pressure at the
tissue-prosthesis interface)
Groove for apposition to dorsum
Tapered edges to minimize
palpability and visibility
Lobular component
Soft and smooth
Broad (neither sharp nor pointed)
2-mm greater projection than that
of dorsum
Cantilevered action
Columellar strut
Inferiorly inclination to maximize
columella sculpturing
Broad, posterior flare for stabilization
between caudal septum and
columellar skin
Soft and flexible
Figure 15-7
The L-shaped soft silicone prosthesis.

VESTIBULAR APPROACH
148
The soft, flexible dorsal component has a groove on its
posterior surface that allows apposition to the dorsum. All
edges are tapered to facilitate inconspicuous blending, thus
minimizing prosthesis palpability or visibility.
The soft lobular component is smooth and broad (as
opposed to narrow and pointed), a configuration designed
to minimize and diffuse pressure on the overlying lobular
skin. Anterior projection of the lobular component is
2 mm greater than that of the dorsal component. The final
relative projection of these two components is generally
adjusted on an individual basis with intraoperative
sculpting of the prosthesis. Lobular projection is achieved
with a cantilever mechanism of the combined dorsal and
lobular components, rather than a tent-pole mechanism
involving the columellar strut.
The most misunderstood component of the L-shaped
nasal implant is the columellar strut. Surgeons who use
struts of autogenous material may teach that postoperative
lobular position is a function of the thrusting action of
these struts; perhaps because of this theory, it is assumed
that the alloplastic strut functions in a similar manner.
However, use of the strut as a tent pole to increase tip
projection is a prescription for disaster. In actuality, the
columellar strut has two functions. First, it stabilizes the
proximal (lobular) segment of the implant in the midline,
thus providing resistance against displacement and mal-
position. Second, the strut allows sculpturing of the
columella by inferiorly displacing the characteristically
retracted columella of the Asian nose, thus increasing its
“show.” An understanding of these two functions of the
columellar strut allows the surgeon to resist any temptation
to extend the strut to the full length of the columella,
thereby producing an undesirable “tent-pole” effect; to
perform its two functions, the columella strut need only
extend to 50% to 75% of the columellar length.
In earlier years the author preferred a columellar strut
fabricated from firm elastomer because the strut could be
relatively short and thin due to the fact that the firm
elastomer resisted deformation. However, this belief
proved to be erroneous because contraction of the fibrous
capsule that naturally forms around the prosthesis often
exerts a rotational force, which occasionally results in
lateral displacement of the strut. Pressure from such
displacement may result in perforation in the vestibular
aspect of the columella (i.e., the site of the incision), which
is by far the most common site of implant exposure. The
rotational forces are less likely to be effectively transmitted
to a columellar strut fabricated from soft elastomer
because of the flexibility at the lobular-columellar junction
of the implant. However, this flexibility will result in
superior displacement of the strut (by columellar tension)
unless the strut has sufficient breadth to allow it to be
wedged between the caudal septum and columellar skin/
medial crura. Intraoperatively the flared strut is carefully
trimmed to fit gently between the medial crura and caudal
septum at the most anterior point that allows aesthetically
sufficient inferior displacement of the columella (producing
columellar “show”). The inferior inclination (i.e., angula-
tion) of the columellar strut with respect to the dorsal
component assists in the achievement of this goal. Other
commercially available nasal implants are constructed so
that the columellar strut projects at a 90-degree angle from
the dorsal component, a situation that renders the
strut virtually useless in producing columellar “show” and
reinforces the improper notion that the strut is of value in
increasing tip projection.
It cannot be overemphasized that after the final trimming,
the columellar strut never extends posteriorly for a
distance of greater than 75% of the length of the columella.
Allowing the strut to contact the nasal spine, maxilla, or
both results in a “tent-pole” effect—an invitation to disaster
in the form of implant extrusion secondary to pressure
necrosis of the lobular skin. It cannot be sufficiently
stressed that the function of the strut is not to project the
lobule; lobular projection is achieved by the cantilever
effect of the rounded, slightly elevated lobular and
contiguous dorsal segment in a fashion analogous to the
Figure 15-8
The flexibility of the soft prosthesis is demonstrated.

CLOSURE
149
cantilever action of bone grafts used for total nasal
reconstruction.
Because of complaints that clear silicone implants may be
visible through the nasal skin with bright indoor lighting,
an implant of a neutral color (e.g., beige or flesh toned)
should be considered, especially if the patient has a fair
complexion.
Implant Placement and Modification
After the pocket dissection is completed, the L-shaped
implant is inserted (Figure 15-9). The prosthesis is not
premeasured but is individually tailored at the time of
surgery. The effect of the prosthesis is observed, and then
the prosthesis is removed and sculptured according to the
requirements of each individual patient. Implant insertion,
observation, removal, and resculpturing are repeated as
many times as is necessary to achieve the desired aesthetic
result. The ease of removing and replacing the prosthesis
for this task is a major advantage of the endonasal
approach. During sculpturing, it is important to maintain
the broad configuration of the lobular component (i.e., it
should not be too narrow or pointed) and taper the edges
of the implant as needed, avoiding sharp projections.
The distal (glabellar) end of the prosthesis terminates at a
point approximately halfway between the infrabrow and
intercanthal lines and should be sculptured to blend
inconspicuously with the nasion while preserving the
nasofrontal angle.
If the surgeon experiences difficulty when freeing both
lower lateral cartilages with a single marginal incision, a
corresponding incision should be made on the opposite
side to facilitate proper pocket preparation, which is
required for symmetry of the implant in the lobular region.
If resistance is encountered over the dorsum after the
implant is placed, the pocket is too small and should be
enlarged to prevent tension on the nasal skin. If a small
dorsal hump is present, it is generally easier to rasp the
dorsum than to modify the implant to accommodate the
hump.
After the dorsal and lobular components are placed, the
columellar strut is coaxed into the columellar portion of
the pocket with forceps (Figure 15-10). The strut is
generally trimmed before the first implant insertion, and
further sculpturing is undertaken as required. Care must
be taken to ensure that the strut does not contact the nasal
spine or maxilla and that tension is not applied to the
columellar skin as columellar “show” is produced.
Closure
The marginal incision is closed with two sutures of 5-0
chromic. Before suture placement, columellar tissue and
the lobular portion of the flap are mobilized to ensure that
the closure is tension free. Antibiotic ointment is placed
over the incision, and the nostril is occluded with a small
piece of cotton, which is removed on the first postoperative
day. An external tape dressing is then applied and left in
place for 5 to 7 days.
Figure 15-9
The dorsal component of the prosthesis is inserted.
Figure 15-10
The columellar portion of the prosthesis is inserted.