4 Nasal Tip Modification in Asians: Augmentation and Rotation Control
Pearls
For tip surgery in East Asians, projection, rotation, and volume are the three most important factors to consider.
Since inherent tip support is weak and the skin is relatively thick in Asians, tip augmentation is mostly achieved by cartilage grafting rather than suture modification techniques alone.
Patient preference, the character of the tip, and surgeon experience and preference are some of the factors to be considered in choosing the appropriate approach for tip surgery.
For the typical Asian patient, the open approach gives better and more diverse options for modifying the tip shape, while the closed approach is effective in limited cases.
A cap graft with or without a columellar strut and interdomal suture through the endonasal or open approach provides an effective increase in tip projection and rotation.
The septal extension graft is a workhorse used to modify the tip shape, and it should be supported by a strong caudal septum or reinforced with batten or extended spreader grafts.
When designing the septal extension graft, projection and rotation are modified by carefully designing the shape of the graft considering the position of the new dome.
Applying bone as a septal extension graft or overly aggressive application of the septal extension graft should be avoided to prevent pain, hardness, and discomfort at the tip.
Even for relatively thick skin at the nasal tip, tip grafts need to be carefully beveled and carved to keep from showing up in the long term.
To complement modification of the tip shape, cephalic resection, the shield graft, the premaxillary graft, the lateral crural graft, and the alar rim graft are also used.
Introduction
The general goal in tipplasty is to create a naturallooking nasal tip that is in harmony with the nasal dorsum and in balance overall with the facial features. This basic philosophy applies not only to Asians but also to patients from other ethnic backgrounds. Such harmony can only be achieved with a sufficient understanding of the pervading cultural environment and with continuous exposure and dedication to the specific ethnic patient. It is mandatory, therefore, that each operation be highly individualized according to the ethnic background.
For tip surgery in Asians, projection, rotation, and volume are the three most important factors to consider. A harmoniously matched projection of the nasal tip adjusted to the augmented dorsum, with a gentle round shape instead of a well-defined, angulated tip, along with subtle accentuation are the ideals that contemporary Asian nasal tip surgery aspires to achieve.1 One important point that should be kept in mind is that many Asian patients request an increase in tip projection with avoidance of excessive increased tip rotation. The amount of projection and rotation necessary for a case differ according to personal preference, age, sex, occupation, and overall facial features. In general, most patients require and undergo dorsal augmentation, so the amount of tip projection should be balanced accordingly. Nasal tip width should always be evaluated in the context of overall facial anatomy and not as an isolated feature. If the face is relatively wide, a narrow tip can appear conspicuous and demonstrate an operated-on look.
To obtain a more aesthetically pleasing nasal tip in Asians, several procedures are employed. Commonly applied procedures are cartilage grafting techniques, including various tip onlay grafts and septal extension grafts. Theoretically, they may suffice when used individually, but in practice a combination of the various techniques is necessary to achieve the desired goal. Since inherent tip support is weak and the skin is relatively thick in Asians, tip augmentation is rarely achieved by suture techniques alone and is reserved for a select group of patients.2
Patient Evaluation
Current tip shape and support need to be carefully observed and analyzed when planning for tip surgery. A dependent, caudally rotated, less projected tip with good cartilaginous support is relatively easy to treat. The most difficult case is a tip that is already slightly upturned, is poorly projected, and has very weak lower lateral cartilages and a deficient septum (Fig. 4.1). Care should be taken in this case because trying to increase the projection of the tip without proper maneuvers will increase the cephalic rotation and create a short-looking nasal tip.
Tip support is evaluated by palpating the tip, the caudal septum, and the skin because these structures are most important in deciding the tip shape. A nasal tip supported by large lower lateral cartilages and a strong septum is relatively easy to control. However, many Asian patients have the worst combination, rudimentary tip cartilages and a retruded and deficient caudal septum with thick skin.
The patient’s wishes and expectations are discussed. Contour of the tip shape is limited by many factors. Skin and cartilage are most important. The patient’s wishes should be thoroughly addressed because there can be misunderstanding during discussions. A very sensitive patient may complain of very subtle differences in the nostril shape as seen from below. Preoperative photos should always be taken and analyzed before surgery. Increasing the tip projection may exaggerate preexisting slight discrepancies of the rim height or columellar slanting.
Patient preference, the character of the tip, and surgeon experience and preference are some of the factors that are to be considered in choosing the appropriate approach for tip surgery. Many patients strongly demand an endonasal approach to avoid a columellar scar from an open approach. In such cases, advantages and limitations of the endonasal approach should be brought forward during the consultation and thoroughly discussed.
Regarding the character of the tip, two factors should be considered in deciding the right approach. The first is tip support. When the size and strength of the lower lateral cartilages are adequate, an endonasal approach can be a good choice. When the cartilages are weak and support is minimal, however, endonasal tipplasty techniques become ineffective.3 The second factor is the status of tip projection and rotation. Inserting a columellar strut, converging the lower lateral cartilages, and placing a cap graft will project the tip together with slight cephalic rotation. This increase in rotation may create an excessively overrotated appearance in patients who already have a borderline short nose. A septal extension graft via an external approach is more appropriate for these patients. The best indication, therefore, for the endonasal approach is when the tip is slightly droopy with lower lateral cartilages that are large and strong. It is also best used in patients who do not have thick skin and severe deformities or asymmetry of the tip cartilage.
Surgical Techniques
Augmenting Tip Projection via the Endonasal Approach
Cap Graft via the Endonasal Approach
The site where the graft will be placed is marked on the tip skin. After the harvest of cartilage from the nasal septum or the cymba concha, two to three pieces are overlapped and sutured, taking into consideration the degree of augmentation needed and the existing tip size. The size of the graft is designed so that it does not exceed the usual interdomal distance, which is 6 to 8 mm, and the margins are carefully trimmed. One or two knots are made, and the threaded needles are left uncut. The margins of the graft are trimmed to make a smoother transition with the surrounding tissue or are morselized using Brown-Adson forceps. Failure to do this may lead to graft visualization. Using an infradomal marginal incision, the insertion pocket is made slightly larger than the graft (Fig. 4.2). The needles of a 5–0 PDS suture are introduced through the incision site, coming out through the previously marked dots on the tip. By pulling on the suture, the graft can be placed at the center of the pocket (Fig. 4.3). The incision site is closed while gentle traction is maintained on the suture. The pulled-out suture is fixed with tape to the skin and removed after a week.
Utilizing Columellar Strut, Interdomal Suture, and Onlay Graft via the Endonasal Approach
Cartilage harvested from the nasal septum or the ear is designed according to the planned procedure (e.g., cap graft, shield graft, or columellar strut). The incision can be modified based on the size and the nature of the intended graft, but bilateral infradomal marginal incisions extending to the lateral columella are usually employed to expose and dissect both lower lateral cartilage domes and the medial crura. An intradomal suture is done at the lower lateral cartilage to produce a slight increase in projection. This suture begins from the upper part of the medial crus medially, passing through the intermediate crus to exit at the lateral crus.
The suture is then done in reverse, from the lateral to the medial crus and the knot thrown medial to the medial crus. Care should be taken to maintain symmetry of the domes and to avoid excessive medialization of the lateral crura or lateral crural steal. If this happens, complications such as deformity of the lower lateral cartilage or an overly narrowed medial and lateral crural angle can occur. To reinforce tip support, a pocket is made between the medial crura, followed by insertion of the columellar strut (Fig. 4.4). The columellar strut, harvested from the nasal septum, should be straight with adequate length and strength. An interdomal suture, incorporating the columellar strut by passing the needle from side to side, is done (Fig. 4.5). Alternatively, both domes are pulled out to one side of the nostril and sutured as necessary. The excess portion of the columellar strut that projects over the dome is trimmed. An onlay cap graft is placed above the dome as described previously, if necessary. The dome is relocated to its natural position, the tip is positioned, and the dorsal height is cross-checked from the lateral and basal views.
Tip Projection and Rotation Control Using the Septal Extension Graft
Concept
The septal extension graft is the workhorse for tipplasty in the Asian nose. By providing a firm foundation upon which the lower lateral cartilages can be repositioned, tip projection and rotation are effectively controlled. By changing its shape and location, the graft can be efficiently used to augment, rotate or de-rotate, or lengthen the nose, or to correct the nasolabial angle.4
A septal extension graft is designed with the degree of tip projection and rotation taken into consideration. Lower lateral cartilages are repositioned and sutured to the newly formed caudal septum, resulting in immediate tip elevation and rotation. This technique is useful in short nose cases or to increase tip projection in patients who lack tip support, since strong support of the tip can be achieved. However, it would be prudent not to overuse the septal extension graft when other methods of increasing tip projection are available (e.g., columellar strut or cartilage tip graft), because the septal extension graft involves a more invasive procedure requiring more tissue dissection compared with other methods. One drawback is decreased tip elasticity resulting in a stiff nasal tip, which, however, tends to improve over time. Another drawback is that the extension graft can bend when excessive tension is applied.5 This usually happens when the caudal septum is weak or the repositioned lower lateral cartilage and the draping skin and soft tissue exert too much tension on the new tip. The surgeon should be conscientious in informing the patient of all these possibilities preoperatively.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
