The Clinical Problem
In recent years, young Asian women have often described their ideal nose as having a thin, gentle lateral curve and a slightly upward nasal tip. They also desire a narrower tip and ala than their present nose. Generally, the nasal tip is round and the skin is thick in Asians, especially in northeastern Asians. In addition to this, the most significant point is the lower part of the nose.
Surgical Preparation and Technique
Augmentation of Dorsum Nasi
Many Asians have an inferiority complex about their physical characteristics in comparison to Westerners, typically because of their flat noses. In a clinical setting, patients hesitate to choose foreign materials such as silicone due to media bias. Foreign material implantation is commonly used in Asian noses to augment the profile.
Silicone Implant
The design and customized carving of a silicone block is one of the most important processes for making the desired profile shape of the nose. It is not so complicated to incise from the nostril to make a pocket on the dorsum of nose for implantation. An implant that has an I -shaped implant solely on the dorsum of the nose is relatively stable when it is implanted. However, the implant that has an L -shaped strut implant that underlies the subcutaneous tissue of the nasal tip tends to increases the risk of complications ( Fig. 19.1 ).
Autografting the Dorsum of the Nose
Autografts are harvested from various donor sites and include cartilage, dermofat, and fascia. These grafts have their advantages and disadvantages.
Cartilage grafting
Costal cartilage grafting.
We frequently use costal cartilage for posttraumatic reconstruction surgery. This can be collected in large amounts and processed easily.
Ear cartilage grafting.
Ear cartilage is collected from the back of the ear to avoid auricular deformity. Although it is difficult to collect long, linear strips of cartilage for augmentation of the entire dorsal back of the nose, multiple strips of cartilage are combined to offset the wavy configuration. These cartilage grafts should be placed linearly anteriorly and laterally, adaptable to any uneven contours of the dorsum nasi. We combine two pieces of these grafts. Absorption of the graft remains a problem, however, and fine surgical manipulations are required ( Fig. 19.2 ).
Dermofat grafting
Dermofat grafting is highly significant for the restoration of subcutaneous soft tissues at the back of the nose because of its high bioavailability. However, the supportability is poor when an excess amount is used. This is probably beneficial for patients with subcutaneous soft tissue damage (e.g., a history of long-term implantation of foreign materials) and patients with skin thinning due to aging.
Fascia grafting
The fascia is not thick and is predominantly used in combination with other graft materials according to the requirements of augmentation and restoration. When grafting cartilages alone, late complications include palpable grafted cartilages and visibly apparent edges associated with thinning of the skin and subcutaneous tissues. The combination of multiple fascial grafts is effective for prevention. The concomitant use of multiple fascial grafts is also effective for the prevention of the so-called warping deformity.
Temporal fascia is frequently used as a donor site. When it is used with cartilage, this works as a wrapping and prevents spontaneous absorption of the cartilage.
Nasal Tip Surgery
Narrowing of the Nasal Tip to the Back of the Nose
This is a method that was developed in the 19th century by Joseph. This procedure, which resects the medial aspect of the lateral crus, has been used until recently. A noncartilage region between the lower lateral cartilage (LLC) and upper lateral cartilages (ULCs) and the central crus is shifted posterosuperiorly. This is effective when performed concurrently with the technique described above ( Fig. 19.3 ).
