Asian Facial Cosmetic Surgery

POSTOPERATIVE CARE
151
Figure 15-11
A, Preoperative frontal view. B, Preoperative profile view. C, Postoperative frontal view. D, Postoperative profile view.
A
B
C
D

153
Preoperative Care
With the proper preoperative preparation, the chance of
infection after the sublabial incision does not appear to be
significantly different from other approaches.1,2 Thorough
toothbrushing and vigorous mouthwashing with a strong
alcohol-based (26.9%) antiseptic solution are performed
the night before and the morning of the surgery.
Prophylactic antibiotics are administered preoperatively.
Premedications
Alprazolam(1.5 to 2.0 mg) and propoxyphen napsylate and
acetaminophen 100 mg/650 mg are given 30 minutes
before the surgery.
Anesthesia
A regional block of the infraorbital nerve is done with
0.5 mL of local anesthetic solution at each site. The local
anesthetic solution is composed of 1% lidodocaine with
1:100,000 epinephrine. It is buffered with a 4% sodium
bicarbonate solution mixed in a 1:10 ratio. The injection
is begun at the glabellar area (Figure 16-1, A). Needle
penetration into the upper two-thirds of the external nose
and the glabellar area is less painful to the patient. The
supra- and infratrochlear nerves are infiltrated by passing
the needle along the side of the nose. The plane of
infiltration is just above the periosteum. Next, the needle is
inserted at the exit point of the external nasal branch of
the anterior ethmoid nerve (see Figure 16-1, B and C). The
anesthetic solution is then infiltrated through the mid-
Sublabial Approach
Jung I. Park
segment of the nose. The nasal tip is infiltrated through the
same entry site in the midnose to avoid needle passage
through the thick and painful nasal tip skin (see Figure
16-1, D). The plane of infiltration is just above the peri-
chondrium of the upper and the lower lateral cartilages.
Once the nasal tip is anesthetized, the needle tip is passed
through the nasal dome skin and aimed vertically down-
ward toward the anterior nasal spine (see Figure 16-1, E).
The needle should remain between the two medial crura of
the lower lateral cartilages. Finally, the upper lip is lifted
and the labial frenulum and the premaxillary area are
infiltrated (see Figure 16-1, F). Good anesthesia is the key
to a successful and uncompromised surgery.
Instruments
Necessary instruments include a 30-gauge 1-inch-long
needle; a wide, two-prong, sharp skin hook; a long, pointed,
curved, slender pair of scissors; a Joseph periosteal
elevator, and a curved hemostatic clamp (Figure 16-2).
Sublabial Dissection
The incision is made with the scissors by clipping the
frenulum (Figure 16-3, A). The closed tip of the scissors is
then inserted and aimed at the anterior nasal spine (see
Figure 16-3, B). The tissue is then spread open widely
(see Figure 16-3, C). Once the dissection reaches the
periosteum of the premaxilla, the tip of the scissors is
rotated upward at a 90-degree angle, aiming at the base of
the columella and between the medial crura of the lower
lateral cartilages (see Figure 16-3, D).
16

SUBLABIAL APPROACH
154
A
B
C
Figure 16-1
A, Local anesthetic infiltration begins as glabella at the less painful area. The needle
passes the plane over the periosteum, and the triangular zone is infiltrated. The
nfratrochlear nerve is also blocked. B,The external nasal nerve is infiltrated. C,The
needle passes upward and downward to infiltrate most of the nasal dorsum. The
needle stays close to the periosteum and the upper lateral cartilage.
Continued

SUBLABIAL DISSECTION
155
D
E
Figure 16-1, cont’d
D,The tip is infiltrated through the already anesthetized dorsal skin. The needle
remains deep over the septum and between the dome cartilage. E,The needle
passes downward through the anesthetized tip skin, between the medial columella,
until it reaches the premaxillary bone. F,The gingivolabial frenulum is infiltrated.
F

SUBLABIAL APPROACH
156
Columellar Dissection
The pushing and spreading motion technique is used.
Dissection of each segment is completed before moving
on to the next segment. This technique ensures an even
tunnel creation without segmental constrictions that may
require unnecessary repeated dissection in the same area.
Repeated dissection adds tissue damage, bleeding, infec-
tion, and eventually implant extrusion. The pocket has to
be wide (see Figure 16-3, E) to allow easy passage of
the implant and prevent implant displacement by the
udissected tissue bridges. The columella is the most
constricted area. Surgeons tend to develop a narrow
pocket, which creates a potential bottleneck phenomenon.
Attempts to insert the implant through an inadequate
columellar pocket may add significant surgical time and
tissue damage. As long as the medial crural cartilage
protects the tips of the scissors, skin penetration by the
scissors is not likely. However, the surgeon should strive
to find a balance between creating a large pocket and
penetrating the columellar skin. The medial crura provide
an additional protection for the implant from extrusion.
Often sebaceous material oozes out of the vestibular skin
as a result of compression due to scissor spreading. The
sebaceous material should be wiped away with alcohol
sponges to prevent bacterial contamination.
Tip Dissection
Dissection is performed between the dome cartilages (see
Figure 16-3, F). Because the dome cartilages are present
between the implant and the uninterrupted vestibular skin,
the potential danger of vestibular wound dehiscence,
retrograde infection, and implant extrusion is avoided. The
dissection also bypasses the dome skin because a thick
layer of tissue beneath the skin is not violated. This
thick layer of tissue cushion protects the dome skin from
becoming compressed and devitalized by the upward
thrust of the columellar strut.
Lower Dorsal Dissection
The lower dorsal dissection is performed in the tissue
plane immediately above the upper lateral cartilage and
the septum (see Figure 16-3, G). Every effort is made to
preserve the thick nasal dorsal soft tissue. This thick tissue
provides an adequate blanket for the coverage of the
implant. The pocket should be both wide and unobstruc-
tive. A wide pocket prevents future capsular contracture
that can lead to implant extrusion. Dissection up to the
nasal bone is by scissor dissection (see Figure 16-3, H).
Dissection over the Nasal Bone
The dissection is subperiosteal (see Figure 16-3, I). The
subperiosteal plane provides implant stability and prevents
a floating implant that can be felt through the skin and
even be visible as a pointy bulge in the nasal root area. As
with any other area, the pocket should be wide and free
of tissue bridges. Any undissected tissue remnant could
push the implant to the side and cause potential implant
displacement and asymmetry. As the dissection reaches
the frontonasal suture line, it meets with a strong resist-
ance (see Figure 16-3, J). Although the tip of the implant
does not reach the suture line, the development of an
extra-long pocket prevents future cicatrical capsule
contracture, which could push the implant down toward
the nasal tip and cause eventual implant extrusion (see
Figure 16-3, K).
Implant Handling
Powder should be washed from the gloves. The package
should be opened immediately before implant insertion,
and the implant should be soaked in antibiotic solution.
The implant should not touch the adjacent skin or the
teeth, and a sterile plastic sleeve wrap should be used so
Figure 16-2
Instruments.

POSITIONING
157
that only the inserting end of the implant is exposed. The
area surrounding the incision site should be covered with
sterile gauze. Whenever possible, the implant should be
inserted in only one attempt. Sufficiently wide pocket
preparation is crucial for easy insertion.
Insertion
The upper lip is lifted with the left thumb and index
fingers. The implant is inserted with a clamp and pushed
upward along the curvature of the tunnel (Figure 16-4, A
and B). The implant is guided with the left fingers to
prevent it from flipping during the pushing maneuver.
Positioning
Once the implant is inserted, the surgeon should confirm
the midline placement of the implant and check for
implant mobility and the absence of any tethering soft
tissue that can push the implant in one direction or
another. Supralobular and infralobular tip pressure points
are thoroughly checked for the presence of any excessive
Figure 16-3
A, The frenulum is cut with the scissors. B, The tip of the scissors is introduced. C, The frenulum is spread open widely. This step is repeated until the periosteum of the anterior
nasal spine is exposed. D, The tip of the scissors is tilted upward to enter the intercolumellar space.
Continued
A
B
C
D

SUBLABIAL APPROACH
158
Intradomal ligament
Figure 16-3—cont’d
E, The columellar cavity is spread as wide as possible. Make sure that the columellar cartilage protects the medial vestibular skin from being punctured. As the columellar skin
expands, sebaceous materials ooze out of the glands. These materials need to be cleanly wiped away to avoid bacterial contamination. E-2, Illustration of E-1,. F, The tip of the
scissors glides over the anterior septal angle rather than passing the subcutaneous tissue of the nasal tip skin. The vestibular skin is protected by the dome cartilage. This passage
ensures preservation of thick nasal tissue. F-1, Illustration of F.
Continued
E-1
E-2
F-1
F-2

POSITIONING
159
G-1
G-2
H
Figure 16-3—cont’d
G, Dissection over the upper lateral cartilage remains close to the perichondrium. The
left fingers guide the tips of the scissors. The pocket should be wide and even.
A small pushing and spreading-wide motion continues. G-1, Illustration of G-2.
H, Scissor dissection continues to the tip of the nasal bone.
Continued

SUBLABIAL APPROACH
160
Periosteum
I-1
I-2
Figure 16-3—cont’d
I, The Joseph periosteal elevator is introduced. The periosteum is elevated from the
nasal tip. Firm and small scrapings of the nasal bone at the tip are very effective.
I-1, Illustration of I-2.
Continued

POSITIONING
161
J-1
J-2
K
Figure 16-3—cont’d
J, The subperiosteal plan is developed to the frontonasal suture line. Every effort
should be made to prevent tissue bands from remaining within the pocket. Once the
pocket is formed, it is much harder to remove the tissue band. J-1, Illustration of
J-2. K, Implant in place. The pocket should be slightly longer than the length of the
implant.

SUBLABIAL APPROACH
162
A
B
Figure 16-4
A,The implant is properly guided and oriented to the point just beyond the nasal tip.
Once the tip enters the lower dorsal pocket, the implant will slide smoothly. B, A
sterile 4×4 gauze patch protects the implant from salivary contamination. C,The
implant is squeezed into a proper position, with the fingertips placed at the nasal root
and tip. Tension against the infralobular tip is carefully tested with the fingertip.
D,Tension against the supralobular tip is tested by gently compressing the implant and
pushing it upward with the hemostat at the bottom of the columellar portion of the
implant. E,The bottom of the columellar implant is amputated if too much tension is
present against the supralobular tip skin. However, amputation is not necessary in
most occasions. F,The sublabial incision is closed with a single-layer horizontal
mattress suture, taking a deep bite, using 4-0 chromic catgut.
D
C
F
E

DRESSING
163
tension (see Figure 16-4, C and D). If the surgeon has any
doubts on this point, the pocket should be widened or
lengthened at the nasofrontal junction.
Columellar Strut Shortening
Although the columellar strut is quite long, it rarely
requires shortening. The distal end of the columellar strut
simply sits on the surface of the premaxillary bone. It
supports the nasal tip gently but without a thrusting force.
Once the implant is inserted, the degree of upward tension
produced by the implant against the nasal tip skin is
carefully evaluated. The columellar strut is partially
amputated only when excessive upward tension against the
dome skin exists (see Figure 16-4, E).
Implant Modification
The L-shaped full dorsocolumellar implant is used. Any
necessary implant modification should be performed
before it is inserted, using calculated measurements to
prevent repeated insertions. The undersurface of the
implant can be carved to accommodate a small hump
(Figure 16-5, A), or the dorsal portion can be shortened
to augment only the distal half of the nose and the tip
and thus camouflage a small hump without rasping it (see
Figure 16-5, B). A rasp can be used to partially lower the
dorsal hump through this approach, although its effective-
ness is somewhat limited.
Closure
The wound is closed with 4-0 chromic catgut in a water-
tight, horizontal mattress fashion (see Figure 16-4, F).
Dressing
The author does not use splint or tape dressings. Zealous
taping, anchoring of the implant by creating multiple
holes,3 or use of an implant that allows tissue in growth
have been advocated to ensure immobilization of the
implant. Implant displacement occurs well before any
tissue in growth. Anchorage of the implant by tissue in
growth after the implant displacement has occurred will
simply fixate the implant in a malposition and complicate
future implant removal because the nasal tissue will have to
be removed. Preservation of the nasal tissue is critical in
case revisional surgery is needed in the future. The implant
shift also occurs as a result of scar contracture that forces
the implant toward a certain direction. This force is far
stronger than any thin strands of in-growth tissue can
withstand. If the pocket creation is adequate, the author
Figure 16-5
A,The undersurface may be carved from a full dorsocolumellar implant. B, Partial
dorsal implant.
A
B

SUBLABIAL APPROACH
164
A
B
Figure 16-6
A, Preoperative view. B, 8-day postoperative view. Edema of the nasal root and the
nasal tip is evident. C, 6-month postoperative view showing a smooth, well-defined
nasal bridge and tip.
C

CASE ANALYSIS
165
does not feel that external fixation of the implant is
necessary.
Postoperative Care
A 10-day regimen of pre- and postoperative broad-
spectrum oral antibiotics is prescribed. The patient is
allowed to drink with a straw and eat with a spoon for
the first 3 days. The patient is advised to prevent food from
lodging in the gingivolabial sulcus and to practice bulb
syringe irrigation with a mixed solution of water and
hydrogen peroxide. Gentle toothbrushing and use of a
mouthwash are recommended. The patient should not
blow the nose for 4 weeks.
Recovery
The recovery is quick and uneventful. Soft tissue swelling
is most marked in the frontonasal angle area. Most swelling
subsides within 1 week. The patient may go back to work
within 1 week unless the work requires excessive straining.
Ecchymosis is either very minimal or does not occur at all.
However, final refinement of the nasal shape may not be
apparent until after several months (Figure 16-6).
Case Study
In the patient who has a shallow dorsum with a projected
tip, only the dorsal implant may be used (Figure 16-7). The
dorsocolumellar implant is an excellent tool for the patient
with a deviated nose from previous augmentation through
the vestibular approach (Figure 16-8). Because of its long
columellar portion, it is a simple and effective implant to
improve retrusive columellar and an acute columellolabial
angle and narrow the nasal base (Figures 16-9 and 16-10).
A small hump or deprojected tip can be corrected with
the use of a partial dorsal implant (see Figure 16-5, B, and
Figure 16-11).
A
B
Figure 16-7
A, Preoperative view showing a shallow dorsum. B, Postoperative view showing a well-defined, balanced dorsum.

SUBLABIAL APPROACH
166
A
B
Figure 16-8
A, Preoperative view showing a sharp, deviated dorsum from a previous augmentation. B, Postoperative view showing a straight,
well-defined dorsum.

CASE ANALYSIS
167
A
B
Figure 16-9
A, Preoperative view with retrusive columellar show and an acute columellolabial angle. B, Postoperative view with an improved columellar show and
columellar angle.

SUBLABIAL APPROACH
168
A
B
Figure 16-10
A, Preoperative view showing a broad alar base. B, Postoperative view showing a narrowed alar base, vertical orientation of the nostrils, and reduced alar flaring.
A
B
Figure 16-11
A, Preoperative view showing a small nasal hump. B, Postoperative view. Better harmony has been achieved.

CASE ANALYSIS
169
References
1. Flowers RS: Nasal augmentation by the intraoral route, Plast
Reconstr Surg 54(5):570-578, 1974.
2. Deva AK, Merten S, Chang L: Silicone in nasal augmentation
rhinoplasty: a decade of clinical experience, Plast Reconstr
Surg 102(4):1230-1237, 1998.
3. Regnault P: Nasal augmentation in the problem nose,
Aesthetic Plast Surg 11:1, 1987.

171
Incision
The transcolumellar incision includes a horizontal limb
and an inverted V. Bilateral marginal incisions are then
connected to the transcolumellar incision (Figure 17-1).1,2
Nasal Dome Skin Flap Development
The nasal columellar and dome skin is elevated from the
lower lateral cartilage. Sharp, pointed, iris-type scissors are
used in a spreading motion to help dissect the skin from
the delicate cartilages. The fatty tissue of the dome should
remain attached to the skin flap to ensure a thick dome
skin flap. The assistant should lift and hold the flap with a
wide, two-prong, sharp skin hook to expose the dome
cartilages.
Open Rhinoplasty
Jung I. Park
Pocket Creation
The dissection is continued over the upper lateral
cartilages and up to the nasal bone, using the same sharp
pointed scissors in a spreading motion. A Joseph periosteal
elevator is then used to elevate the periosteum off the nasal
bone. A wide pocket is created up to the nasofrontal suture
line. Next, a pocket is developed between the medial crura.
The pocket should reach the premaxillary bone. This
deep pocket allows the elevation of the columellar and the
nasal tip without stretching the columellar skin itself
(Figure 17-2, A). When the pocket is limited to the
columella itself, tip elevation must be accomplished by
lengthening the columellar skin (see Figure 17-2, B). Tip
elevation by stretching the columellar pocket is inefficient
and increases the tension on the tip tissues compared
with the same amount of upward tip movement by the
columellar lift. When the entire columellar structure is
lifted, upward tension to the nasal tip is shared by the
columella, which reduces the tension to the nasal tip skin.
Implant Insertion
The dorsal portion of the L-shaped full dorsocolumellar
implant is pushed into the dorsal pocket. The columellar
segment of the implant is inserted into the columellar
pocket and pushed down to the premaxillary bone. The
dome/knee portion of the implant is then sandwiched
between the medial crurae. The knee portion of the
L-shaped implant may be thinned with a knife to prevent
widening of the nasal tip. The medial crurae and the
cartilaginous dome are gently lifted to judge the necessary
17
Figure 17-1
Inverted V transcolumellar incision.

OPEN RHINOPLASTY
172
tip projection. The cartilage complex is lifted an additional
2 to 3 mm to place the dome higher than the final desired
height. This will compensate for the false appearance of tip
projection secondary to edema and the future deprojection
secondary to the weight and pressure of the dome tissue
and scar contracture. As this position is maintained, the
medial crura are sutured to the columellar segment of the
implant with a 6-0 clear nylon (Figure 17-3, A and B). The
tip elevation is accomplished by the thrust of the implant to
the sutured columellar cartilage. The dome cartilages are
then sutured together in a horizontal mattress fashion to
narrow the tip above the upper surface of the knee/dome
of the dorsocolumellar implant (Figure 17-4). Thus the
dome skin does not have direct contact with the implant.
Placement of the dorsal segment is readjusted.
Autograft
The septal or auricular cartilage can be used as a shield
graft or an onlay graft. The graft is sutured to the medial
crura so that the graft projects 3 to 4 mm higher than the
implant (Figure 17-5, A and B). When the dome skin is re-
draped, the graft invariably bends over without assistance
and covers the dome segment of the implant (see Figure
17-5, C). The dome skin is completely shielded from the
implant. A layered shield graft, an onlay, or both enhances
tip projection (Figures 17-6 to 17-8). When major refine-
ment in the nasal tip is necessary, a procedure that
combines the use of the columellar implant, dorsal implant,
and autograft is required (Figures 17-9 to 17-11).
Implant Fixation
The foot portion of the columellar segment may slip to one
side of the premaxilla, especially when the tip projection
requires excessive upward thrust. In selected cases, a screw
fixation of the foot portion of the columellar implant is
necessary to maintain the midline position and upward
thrust of the columellar segment. (See Chapter 18 for more
information.)
Preoperative
A
B
Postoperative
Shallow pocket
Interdomal
ligament
Deep pocket
Figure 17-2
A, A deep columellar pocket allows free upward movement of the columellae. B, A shallow columellar pocket stretches the columellar soft tissue in both directions.
Thus tip elevation is only half as effective.

CLOSURE
173
Closure
After satisfactory placement of the implant and adequate
tip projection are confirmed, the columellar flap is pulled
down to re-drape the nose. First, a 5-0 Vicryl buried suture
is placed through the tip of the inverted V, taking a deep
dermal bite to allow an adequate eversion of the wound
edge. The entry and exit of the needle near the skin should
be as close as possible to the surface and symmetric to
achieve a perfect, tight approximation of the skin edges.
Two more subcuticular sutures are placed at the junction
between the transcolumellar and marginal incision. These
two sutures help to spread the columellar skin tightly and
allow a perfect alignment of the columellar closure. A
frequent and unsightly result at this stage involves a step
formation at the corners of the columellar closure. Every
effort should be made to confirm a perfect approximation
of the skin edge at the corners. Alignment of the skin at the
marginal incision is accurately adjusted. The skin closure of
the columellar incision is executed with a 6-0 black nylon
suture using an interrupted ring type fashion to avoid
tension on the skin. The vestibular dome is closed with an
absorbable 4-0 chromic catgut suture. The closure step
Figure 17-3
A, Medial crurae are sutured to the implant in an uplifted position. B, Illustration of this procedure.
A
B
Figure 17-4
A, Approximately 50% of the dome portion of the implant is thinned. The cartilage domes are sutured together with 6-0 clear nylon. B, Illustration of this procedure.
A
B

OPEN RHINOPLASTY
174
Figure 17-5
A, An extra-long shield graft is carved from the septal or auricular cartilage. B, The L-shaped full dorsocolumellar implant is in place. Cartilage graft is sutured to the caudal
edges of the columellar cartilages at three locations with 6-0 nylon sutures. C and D, The shield graft bends over and covers the implant.
A
B
Shield graft
D
Dorsocolumnellar implant
C

CLOSURE
175
Implant
Double shield graft
A
B
Figure 17-6
A, An additional layer of shield graft is added to strengthen the projection of the shield graft. B, Illustration of this procedure.
A
B
Figure 17-7
A, Preoperative view showing tip deprojection. B, Postoperative view showing that a well-defined narrow tip, a subtle cephalic
rotation, increased nostril show, and narrowing of the alar base have been accomplished.

OPEN RHINOPLASTY
176
A
B
A
B
Figure 17-8
A, Preoperative view. B, Postoperative view showing an increased tip projection and columellolabial angle.
Figure 17-9
A, A long columellar implant is used for an adequate tip projection. B, A silicone columellar strut is shown within the columellar pocket. The pocket is made narrow and deep
down to the anterior maxilla.
Continued

CLOSURE
177
C
D
E
F
G
Figure 17-9, cont’d
C, The medial crural cartilages are sutured to the columellar implant. D, The dome
cartilages are sutured to the columellar strut and rest above the tip of the implant.
E, The silicone dorsal implant is carved. F, The dorsal implant is inserted.
G, Double-layered conchal cartilages are placed caudal to the columella. H, An
additional layer of conchal cartilage graft is wedged between the dorsal implant
and double-layered shield graft. The grafts project far beyond the implant.
Continued
H

OPEN RHINOPLASTY
178
should be considered an important part of the surgery and
should not be done in a casual manner. The patient may
judge the surgical outcome based on the result of this one
last step.
Dressing
Taping is applied in the usual fashion with benzoin,
SteriStripsTM (3M, St. Paul, MN) and external splinting of
the surgeon’s choice. The nasal vestibule is packed lightly
with folded TelfaTM (Kendall, Mansfield, MA) gauze that
is covered with bacitracin ointment. A nasal drip pad is
applied.
Postoperative Care
High-dose broad-spectrum antibiotics are used for 10 days.
The patient is not allowed to blow the nose for 1 month.
Sniffing is allowed to clear any nasal discharge. Pinching
and twisting the nose are avoided indefinitely.
Recovery
The sutures are removed after 1 week. Healing periods for
nose swelling and columellar incision redness vary among
patients. The incision is barely visible after a meticulous
closure. Exposure to extreme cold may cause redness of the
nasal tip.
Figure 17-9, cont’d
I, Illustration of the procedure shown in H. J, The dorsal implant is sutured to the
upper lateral cartilage at two locations to prevent lateral migration, inferior
migration, or both.
I
J

RECOVERY
179
Implant sutured to
upper lateral cartlages
Shield graft
Dorsal implant sutured
to nasal septum
Figure 17-9, cont’d
K, Illustration of the procedure shown in J.
K

OPEN RHINOPLASTY
180
A
B
Figure 17-10
A, Preoperative view showing thick skin and a broad amorphous tip. B, Postoperative view showing a sharply defined and projected
tip.

RECOVERY
181
References
1. Goodman WS, Charles DS: Why external rhinoplasty?
J Otolaryngol 7(1):6-8, 1978.
2. Jung DH: Approach to rhinoplasty. In Jung DH (Ed.):
Rhinoplasty, Seoul, 2002, Greenbook, p 83.
A
B
Figure 17-11
A, Preoperative oblique view. B, Postoperative view.

183
The nasal base and the columella have unique charac-
teristics in the Asian nose.1 The columella tends to be at an
even height with or somewhat retrusive to the nasal ala.
The columellolabial angle is acute. The nasal tip has a
tendency toward a subtle deprojection in some patients.
Premaxillary augmentation with alloplastic material,
cartilage-plumping grafts, nasal tip cartilage modification,
and onlay or shield grafts may improve some of these
conditions. However, a simpler and possibly more effective
solution that directly addresses these problems is the use of
a columellar strut.2,3 The columellar strut can increase the
nasal tip projection and improve the columella show and
columellolabial angle. The implant provides the necessary
volume to achieve a desired result that may not be
attainable with an autograft unless a rather extensive graft
harvesting is performed. Two potential problems are
associated with the use of the columellar strut implant.
First, forceful elevation of the columella and tip results in
excessive tension on the supratip lobule. This concern is
largely resolved by developing a partial columellar pocket.
By leaving the upper third of the columellar tissue
undisturbed, the nasal tip is shielded from the implant
pressure2,3 (Figure 18-1). Second, slippage of the bottom of
the implant toward one side as the result of downward
pressure may cause a slanted nasal columella, an asym-
metric nostril, and an annoying and palpable protruding
implant in the upper gingivolabial sulcus.2 Suture fixation
of the implant at the premaxillary periosteum may resolve
the problem of the implant slippage. However, it is difficult
and ineffective to suture the implant through a small
incision. The implant often relapses with time. The use of
Columellar Strut Implant
Jung I. Park
screw fixation ensures a long-term, forceful upward lift and
prevents implant slippage (Figure 18-2).
Consultation
Occasionally, the patient with a small hump desires tip
elevation as a way to minimize the appearance of the
hump. These patients are less aware of the columellar
retrusiveness or the acuteness of the columellolabial angle.
After the anatomic features are viewed and compared with
ideal features, the patients are eager to improve the
anatomy. The patient with a retracted alae is not a candi-
date for the columellar implant because it may enhance the
appearance of an exposed nostril (“pig nose”). Alternative
18
Figure 18-1
Partial columellar pocket.

COLUMELLAR STRUT IMPLANT
184
techniques should be discussed before the procedure is
chosen. The patient is informed of the presence of the
metallic screw and reassured that it will not set off a metal
detector and is compatible with magnetic resonance
imaging (MRI).
Preoperative Care, Medications,
Anesthesia, and Instrument
The reader is referred to Chapter 16, “Sublabial Approach.”
Procedure
After local anesthesia is administered, the sublabial
dissection is carried out in a manner identical to that
described in Chapter 16, “Sublabial Approach.” The nasal
base should be dissected widely above the periosteum
to free it from the premaxillary bone (Figure 18-3). The
columellar strut can now lift the nasal base without a
tethering force. Dissection is then continued into the
medial columellar space as described in Chapter 16.
However, the pocket should remain narrow so that the
columellar strut fits tightly into the pocket. The pocket
should be developed only up to the lower two-thirds of the
columella (see Figure 18-1). If the pocket is too shallow,
then the implant may not effectively project the nasal tip.
Instead, some of the force may be diverted anteriorly,
which causes an unsightly columellar bulge and excessive
cephalic rotation of the nasal tip. Alternatively, diversion of
the force to the sides may lead to a slanted columella and
even extrusion of the implant through the nasal vestibule.
On the other hand, if the pocket is too deep and reaches
close to the nasal tip, the implant may apply pressure to the
nasal dome skin (Figure 18-4). The columellar strut may be
prepared from a dorsocolumellar implant by amputating
the dorsal part of the implant (Figure 18-5). To achieve
significant nasal tip projection and an improved columello-
labial angle, the implant may be customized into the shape
of the Eiffel Tower with a broad base. The customized
implant with a broad base guarantees stability when fixated
with one or two screws at the base. The desired length of
the columellar strut is determined by manipulating the
nasal base as the implant is inside the pocket. By lifting
the implant with the forceps, the surgeon is able to
estimate the implant length required to obtain an ideal
tip elevation. Overcorrection is necessary to compensate
for a transient increase in tip projection caused by swelling
from the anesthetic solution. The tip deprojection
Figure 18-2
Screw fixation. The screw penetrates the implant and the bone. A partial vertical slit
incision through the columellar strut helps engage the screw through the rubbery
silicone material.
Figure 18-3
The nasal base is freed from the premaxillary bone.

OPEN RHINOPLASTY APPROACH
185
secondary to cicatrical contracture and tissue compression
should also be considered. A partial slitlike incision is made
through the lower portion of the columellar strut to allow
penetration of the screw only with a twisting motion. The
slit should be incomplete. The tip of the screw is allowed to
penetrate the implant and the bone just far enough to
reveal the tip that is partially buried in the implant. The
thickness of the implant at the base is carved to a thickness
of 4 mm. The implant is inserted into the pocket. The nasal
tip and columellar complex is gently lifted to the desired
height with an upward thrust of the columellar strut
implant. The screw is inserted through the implant into the
premaxillary bone, approximately 3 mm deep, and the
head of the screw is buried into the implant. A 1.5 × 7-mm
self-tapping titanium screw is used (Figure 18-6).
Depending on the hardness of the implant, the thickness
of the implant can be adjusted.
Open Rhinoplasty Approach
The columellar strut may also be inserted into a columellar
pocket using the external rhinoplasty approach. The
external rhinoplasty incision is made, and the columellar
and dome cartilages are exposed. The columellar pocket is
created between the medial crura. To maintain implant
position, the pocket does not extend beyond the limit of
the medial crura. A tight pocket prevents lateral movement
of the implant and posterior slippage of the implant into
the membraneous septum. A tunnel is then created
inferiorly to reach the premaxilla. The anterior tip of the
Compressed
interdomal ligament
Deep pocket compresses
nasal dome skin
A
B
Figure 18-4
An implant in a deep pocket compresses the skin of the nasal dome and may
predispose implant extrusion.
Figure 18-5
A, This columellar strut was prepared from dorsocolumellar implant. B, Slight overcorrection is achieved.

COLUMELLAR STRUT IMPLANT
186
implant is allowed to project well beyond the projection of
the dome cartilage (Figure 18-7, A). The medial crura are
sutured to the implant. The lower lateral cartilages are then
medially brought over the projecting tip of the implant and
sutured to the implant with a 6-0 clear nylon for fixation
(see Figure 18-7, B). The dome skin is thus protected from
the implant. The nasal skin is then draped over the sutured
dome cartilage.
A
B
Figure 18-6
A, A columellar implant is visible inside the deep sublabial pocket. B, The implant is
grasped by a pair of forceps. C, 6- to 8-mm self-tapping screws (KLS®) are used.
D, The implant is fixated with a self-tapping screw.
C
D

PATIENT PHOTOGRAPHS
187
Closure, Dressing, Postoperative Care,
and Recovery
The reader is referred to Chapter 16, “Sublabial Approach.”
Case Study
See Figures 18-8 to 18-10.
A
B
Figure 18-7
A,The columellar implant projects well above the dome cartilage. B,The lateral curae are gathered medially and sutured to the implant. The cartilage projects beyond the
implant in such a way that the implant does not have direct contact with the nasal dome skin.

COLUMELLAR STRUT IMPLANT
188
A
B
Figure 18-8
A, Preoperative view. B, Postoperative view showing a subtle tip elevation and masking of the dorsal hump.

189
Figure 18-9
A, Preoperative view. B, Postoperative view. Exaggerated tip
elevation, cephalic rotation, and shortening of the nose have
been achieved. C, 1-year postoperative view.
A
B
C

190
A
B
Figure 18-10
A, Preoperative view. B, 1-month postoperative oblique view.
C, 1-year postoperative oblique view.
C

PATIENT PHOTOGRAPHS
191
References
1. Han KW: Rhinoplasty. In Lee YH: Aesthetic plastic surgery,
Seoul, 1998, Gunja, p 173.
2. Webster RC, Hopping SB, Hall B, et al: Intraoral insertion of
grafts to project the nasal tip, Arch Otolaryngol 108:187-193,
1982.
3. Lawson W, Reino AJ, Seidman D: The silicone columellar
strut, Plast Reconstr Surg 97:938-943, 1996.

193
Because surgeons realized that the injection of paraffin or
silicone had terrible consequences (Figure 19-1), augmen-
tation rhinoplasty with silicone implant has become
widely popular during the past four decades due to its
effectiveness and simplicity. However, it is associated with
many complications (Boxes 19-1 and 19-2). Although
Complications of Implant
Augmentation Rhinoplasty
and Critical Analysis
Jung I. Park and Dong Hak Jung
implant malposition (Figure 19-2, A) is the most common
complication,1-3 infection (Figure 19-3) and implant extru-
sion and the resulting cicatrical deformity (Figure 19-4) of
the nose are more serious complications. Implant malposi-
tion is usually the result of a misdirected pocket creation
after the unilateral vestibular incision (see Figure 19-2, B).
19
A
B
Figure 19-1
A, Paraffinoma. B, Intraoperative view.

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
194
Contrary to the widespread belief among Western
surgeons, large series performed by experienced surgeons
reported a low extrusion rate (i.e., less than 2%).1-4 Almost
from the outset of silicone implant use, the development of
extrusion was thought to be caused by surgical technique
error.5 Dramatic improvement in long-term results and
lower extrusion rates are a result of better understanding of
implant and tissue interaction. Other factors that helped to
lower the occurrence of implant extrusion were early
detection and timely removal of the implant (Figure 19-5).
Infection goes hand in hand with the implant extrusion by
either preceding or following the latter event. The reported
incidence of infection is approximately 3%.1-4 Despite the
low rate of serious complications reported, revision rates
range from 5% to 10%.1-3 The discrepancy is mainly due
to a large number of implants removed for various
cosmetic reasons, particularly implant displacement of the
implant or patient dissatisfaction related to the size of
the implant.2
Infection may develop as a result of wound or implant
contamination, the presence of systemic infection, skin
penetration during the surgery, wound dehiscence, or
contamination by sebaceous material evacuated during
the manipulation of the oily nasal tip skin. Unresolved
infection leads to abscess formation and implant extrusion.
The best treatment for infection is prevention. This is
particularly true with any implant surgery. Administration
A
B
Figure 19-2
A, Deviated nose secondary to implant malposition. B, Illustration demonstrating
misdirection of the implant as a result of unilateral vestibular incision.
Box 19-1
Medical Complications
Infection
Extrusion
Persistent redness
Wound dehiscence
Scar
Box 19-2
Cosmetic Complications
Nasal tip deprojection
Pollybeak deformity
Deviated nose
Asymmetric nostril
Cephalic rotation
Triple dome
Rotated implant
Movable implant
Transparent implant

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
195
Figure 19-3
Infection.
Figure 19-4
Depressed scar of the infratip lobular area after the removal of an infected implant.
Figure 19-5
A, Persistent redness and mild swelling as a result of infection. B, Early removal prevents cicatrical contracture deformity.
A
B

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
196
of prophylactic antibiotics, vigorous use of antiseptic
mouthwash, face and nasal prepping, aseptic implant
handling, and minimally traumatic surgery are important
precautions. After infection develops, an aggressive anti-
biotic regimen should be administered for 1 month. The
implant should be removed immediately whenever the
signs of infection progress despite adequate antibiotic
treatment or if the infection has not resolved after 1 month
of antibiotics. When the infection is associated with
marked redness and moderate swelling, the surgeon should
consider immediate removal of the implant. Any delay
will advance the development of abscess formation, skin
thinning, implant extrusion, wound dehiscence, and
permanent and serious scar formation. Understanding the
cause of implant extrusion is the best way to prevent it. The
cause of implant extrusion is found in the relationship
between the skin thickness and the pressure exerted on the
skin by the implant. Too thin skin or too much pressure by
the implant creates a condition in which a series of tissue
reactions occur: diminished capillary perfusion as demon-
strated by blanching, avascular necrosis, perforation,
retrograde infection, and implant extrusion. When the
pressure is marginal, compensatory and reactive hyperemia
causes a persistent redness. Persistent redness (see
Figures 19-5, A, and 19-6) may range from an innocuous
intermittent occurrence (especially associated with cold
weather) to the more serious early signs of infection,
extrusion, or both. Three vulnerable pressure points result
in implant extrusions. When the incision is placed close to
the location of the implant, tension on the newly healing
wound with low tensile strength creates a condition for
wound breakdown and implant extrusion. Thus extrusion
most frequently occurs in the vestibular or columellar skin
incision site (Figure 19-7). 4,6-8 The sublabial incision was
designed so that the incision is far from the location of the
implant and the risk of implant extrusion is significantly
reduced.2,4 Two other pressure points are the supratip and
infratip lobules of the nose. Supratip lobular pressure is a
result of the tent-pole effect caused by excessive tension
from the columellar implant (Figure 19-8). Infratip lobular
pressure is caused by either an excessively long implant
(Figure 19-9) or an insufficient pocket in the nasal root area
and capsule contracture that lead to downward pressure
to the infratip area. Despite the universal condemnation
of the ill effect of silicone columellar strut, the majority of
the reported implant extrusions occur in the vestibular or
infratip lobular area (see Figures 19-7 and 19-10).1,7,9-11
When the surgeon uses sound judgment, the columellar
strut can provide the necessary tip projection without
compromising the skin. A safe way to reduce the risk of a
falling nasal tip is to modestly support the columellar
segment without causing a tent-poling effect. However, the
majority of surgeons prefer to avoid using the columellar
segment of the nasal implant. As a result, tip deprojection
or pollybeak deformity (Figure 19-11) is an occasional
source of cosmetic dissatisfaction because of the lack of
tip support. The dorsal pocket should be large and long
enough so that the implant can be pushed up and down
without restriction. Although a large pocket helps avoid
extrusion, it creates room for the implant to move around
and settle into an undesirable location. The implant can
Figure 19-6
Persistent redness.
Figure 19-7
Impending implant extrusion through a vestibular incision.

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
197
Figure 19-8
Supratip lobular redness caused by a long columellar implant.
Figure 19-9
An excessively long dorsal implant.
Figure 19-10
Infratip lobular redness caused by a long implant or short
dorsal pocket.
Figure 19-11
Pollybeak deformity.

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
198
shift to the side, causing a deviation (see Figure 19-2, A),
or ride up high to cause tip deprojection or an unsightly
pollybeak deformity of the nasal tip (see Figure 19-11). An
implant without a columellar segment is especially
vulnerable because the columellar segment functions as a
stabilizer.7 A long columellar strut resists a cephalic migra-
tion, side-to-side shift of the dorsal segment, or both. How-
ever, the long columellar strut should be designed to act as
a support rather than a tent pole. Every effort should be
made to prevent excessive tip thrust by the columellar strut.
An excessively long columellar segment may also create an
exaggerated double break (Figure 19-12) or unsightly
cephalic rotation (Figure 19-13) of the nasal tip or asym-
metric nostrils due to a slanted columella implant. In
patients with a strong and broad cartilage dome, the tent-
pole effect of the columellar strut may create a triple dome
deformity. On rare occasions, the implant inserted in a
narrow dorsal pocket may cause the implant to become
twisted so that the lateral edge projects forward, resulting
in a razor-sharp nasal bridge. The same result can be
caused by the capsule contracture (Figure 19-14). Because
the tolerance of the Asian nasal skin to the implant is
based on skin thickness, it is prudent to avoid the use of
nasal implants in Asians with thin skin (Figure 19-15). The
implant can also be seen as a transparency in a patient
with thin skin. The use of a flesh-colored implant could be
one solution to this problem.7,8 The pocket should be
developed as deeply as possible to ensure sufficient tissue
coverage. The plane is above the perichondrium of the
upper lateral cartilage and in the subperiosteal plane over
the nasal bone. An excessively superficial implant place-
ment can cause transparency and surface irregularity. The
silicone implants may also undergo calcification after 10
to 20 years (Figure 19-16).11 Although the expanded
polytetrafluoroethylene (e-PTFE) nasal implants, due to
their soft malleable nature, do not present the same
concerns relating to the pressure effect as do silicone
implants, they are not immune to inflammatory reactions
at the tissue implant interface. Both implants may share the
same sequence of events resulting in implant removal.
They may also cause an implant displacement because of
asymmetric pocket creation, scar contracture, or both
Figure 19-12
An exaggerated double break.
Figure 19-13
Excessive cephalic rotation.

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
199
Figure 19-15
The implant is visible in this patient with thin skin.
Figure 19-16
A calcified silicone implant.
A
B
Figure 19-14
A, A rotated implant. B, An intraoperative view of the rotated implant.

COMPLICATIONS OF IMPLANT AUGMENTATION RHINOPLASTY AND CRITICAL ANALYSIS
200
(Figure 19-17). Persistent swelling without the presence
of infection is also a potential complication.11 Cartilage
grafts are vulnerable to graft shift, surface irregularity,
and resorption, especially in the dorsal segment. Costal
cartilage concerns include potentially serious complica-
tions of pneumothorax, hypertrophic scarring of the chest
wall, and warping (Figure 19-18).11
References
1. Hiraga Y: Complication of augmentation rhinoplasty in
Japanese, Ann Plast Surg 4(6):495-499, 1980.
2. Deva AK, Merten S, Chang L: Silicone in nasal
augmentation rhinoplasty: a decade of clinical experience,
Plast Reconstr Surg 102(4):1230-1237, 1998.
3. Lam SM, Kim YK: Augmentation rhinoplasty of the Asian
nose with the “Bird” silicone implant, Ann Plast Surg
51(3):249-256, 2003.
4. Flowers RS: Nasal augmentation by the intraoral route,
Plast Reconstr Surg 54(5):570-578, 1974.
5. Lipshutz HA: Clinical evaluation of subdermal and
subcutaneous silicone implants, Plast Reconstr Surg 37:249,
1966.
6. Davis PKB, Jones M: The complication of Silastic implant,
Br J Plast Surg 24:405-411, 1971.
7. Mutou Y: The complication of augmentation rhinoplasty in
Orientals, Br J Plast Surg 28:160-163, 1975.
8. McCurdy JA, Jr: The Asian nose: augmentation rhinoplasty
with L-shaped implants, Facial Plast Surg 18(4):245-252,
2002.
9. Shirakabe Y, Shirakabe T, Kishimoto T: The classification of
complication after augmentation rhinoplasty, Aesth Plast
Surg 9:185-192, 1985.
10. Han KW: Rhinoplasty. In Lee YH: Aesthetic plastic surgery,
Seoul, 1998, Gunja, p 210.
11. Jung DH: Rhinoplasty. In Jung DH (Ed.): Rhinoplasty, Seoul,
2002, Greenbook, p 122.
Figure 19-17
This deviated nose is the result of a displaced e-PTFE nasal
implant.
Figure 19-18
Warping of the costal cartilage nasal graft.

201
To accomplish successful nasal augmentation, the rhino-
plastic surgeon must thoroughly understand the anatomy
of the external nose, nasal aesthetics preferred by Asians,
materials available for augmentation, and various surgical
techniques.
Ideal Shape of the Nose
Patients always request the natural appearance without the
“surgical look.” Often they ask for minimal augmentation.
They like to conform to the general public and maintain
harmony with the rest of the face (e.g., minimal augmenta-
tion in those patients with narrow intercanthal distances).
Radix
The ideal nasofrontal angle in Asian is between 135 and
140 degrees.1 The sellion is the most posterior or the
“lowest” point of the external nose. The ideal location of
the sellion should be at the level of the eyelid fold.
Although the ideal height of the sellion is measured as the
distance from the cornea in Caucasian patients, this rule
does not apply to Asian patients because of the variable
degree of eye protrusion among Asians.2 Rather, the ideal
height of the sellion is determined by the relationship
between the nasofrontal angle and the degree of protrusion
of the glabellar area.
Augmentation Rhinoplasty
with Autograft/Alloplasty
Combination
Dong Hak Jung
Nasal Bridge
The ideal nose presents a curvilinear line along each side of
the nose, from the eyebrow to the tip.1,3 Although the
narrowest distance between the two lines should be about
10 mm, this may vary depending on the intercanthal
distance, facial characteristics, and the patient’s preference.
A single dorsal line following augmentation gives a
“surgical look.” The nasal tip has a better appearance when
it is 1 to 2 mm higher than the dorsum.3
Nasal Tip
The nasal tip of the Asian is often amorphous because of
weak cartilage and thick skin. The ideal nose should have
tip-defining points (TDPs) (Figure 20-1). The nasolabial
angle in Asians is between 90 and 95 degrees.1 The height
of the implant should vary at different points on the radix,
nasal dorsum, or tip. The patient should demonstrate a low
glabella, adequate nasal width, and well-defined TDPs
(Figure 20-2).
Augmentation Using Gore-Tex™ and
Cartilage
Implant Preparation
Implant thickness is determined after a review of the
profile view. The choice of autograft versus alloplast is
20

AUGMENTATION RHINOPLASTY WITH AUTOGRAFT/ALLOPLASTY COMBINATION
202
determined during the patient consultation. Expanded
polytetrafluoroethylene (e-PTFE, Gore-TexTM [W.L. Gore
and Associates, Inc., Newark, DE]) or silicone is chosen for
augmentations that are less than 7 mm. The author uses
costal cartilage for augmentations greater than 7 mm to
avoid excessive tension on the skin. The use of an implant
is best avoided in the tip area because of the high incidence
of complications. A combination of autograft and alloplast
is used instead (e.g., dermis and e-PTFE or e-PTFE and
auricular cartilage) (Figure 20-3).4 Although silicone
implants are available in various shapes and sizes, the sur-
geon may sculpt an implant for a precise fit. At times the
surgeon may use a block of silicone. Although preformed
e-PTFE blocks are available, the author prefers to fashion
the implant by layering the sheets (Figure 20-4). The edges
of the implant are tapered to avoid irregularity. The
implant is fashioned wider in the root area to provide two
parallel lines and narrower between the lower lateral
cartilages (LLCs) (Figure 20-5). Slight overcorrection is
necessary to compensate for the natural shrinkage of
e-PTFE. The implant is immersed in antibiotic solution
before its placement.
Anesthesia
Most cases are performed under local anesthesia with
intravenous sedation. Initial doses of ketamine hydro-
chloride (0.5 to 0.7 mL) (25 to 35 mg, 0.5 to 1.0 mg/kg) and
propofol (5 mL) are followed by propofol in 5-cc
Figure 20-1
Rhomboid-shaped tip-defining points (TDPs) are composed of the
domes of the medial crura and the supratip and infratip breakpoints.
Figure 20-2
A, This preoperative view reveals an adequate nasal width and well-defined TDPs. B,
The supratip break and infratip lobular contour are well demonstrated on the profile
view.
A
B

DORSAL AUGMENTATION USING IMPLANTS
203
A
B
C
E
D
Figure 20-3
E-PTFE is sandwiched between the cartilages (A). Preoperative (B and D)
and postoperative views (C and E).