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88986Rhinoplasty for Southeast Asian noses: Open andclosed approachesCORAZON COLLANTESJOSE, EDUARDO C YAP and KONRAD P AGUILAAsia is a big continent and the characteristic noses can be very dierent from the Middle East to Far East.is chapter will concentrate its discussion on Southeast Asian noses. e common features of Southeast Asian noses are the following: bulbous tip, thick skin, low dor-sum, weak cartilages, short and upturned tip and hanging and wide ala.Most noses need dorsal augmentation, lengthening, tip projection, columellar show, hanging ala correction and alar base plasty.DORSUMe nose can be divided into thirds. e dorsum com-prises the nasal bones as the upper third and the dorsal septum with the attached upper cartilages (UCs) as the middle third (see Figure 86.1).Most aesthetic deformities of the nasal bone are low radix and wide nasal bone base. A low radix can be aug-mented with so-tissue material such as fascia or soened cartilage or synthetic material, e.g. silicone or expanded polytetrauoroethylene (e-PTFE) (popularly known as Gore-Tex). A wide nasal bone can be corrected with medial and lateral osteotomies.e junction of the upper and middle third of the nose is the rhinion. It corresponds to the dorsal hump. A prominent hump can be corrected by direct trimming of the UC with the dorsal septum and humpectomy of the nasal bones using a chisel or rasp. e majority of humps are cartilaginous.Internal valve collapse is not common in low dorsum noses because of the wider relationship of the septum and the UCs. In the presence of a caudal deviation of the septum, support gras, e.g. spreader and septal extension gras (SEGs), can be used to straighten the deviation. A deviated dorsal septum needs splitting the UC from the septum and reinforcement with spreader gra (see Figure86.2).e dorsum for most Southeast Asian noses is low and almost always needs augmentation. Dorsal augmentation is performed aer tip projection surgery is completed. e tip projection surgery oen utilizes a support system of SEGs. e augmented dorsum is used to blend the new tip with the radix (see Figure 86.3). For noses that have a good tip and need only dorsal augmentation, a silastic implant either an I-shape or an L-shape can be used. It is inserted via a closed approach (bilateral marginal incision). e dissection is sub-SMAS (supercial muscular aponeurotic system) at the UC and lower cartilage, and subperiosteal at the nasal bones. e dissection should just be limited in order to avoid mobility of the silicone implant. e under-surface of the implant should be carved well in a concave manner to allow full surface contact with nasal bones and the UCs. Healing is via brous encapsulation. Most silicone implants heal well; however, there are some that heal with capsular contracture aer several years needing revision surgery. Silicone is also prone to calcication with time.e-PTFE, popularly known as Gore-Tex, has gained pop-ularity because of its better aesthetic outcome. It is initially introduced in the market as sheets; however, recently many CONTENTSDorsum 889Tip 891Alar rim 891Alar base 892Technique for open structural rhinoplasty (OSR) 892Augmentation rhinoplasty using conchal cartilage via closed approach 893 890 Rhinoplasty for Southeast Asian noses: Open andclosed approachescompanies produced preformed e-PTFE of various shapes and sizes. is implant is now preferred because it is more natural looking and heals with tissue adhesion. Despite it being less visible as an implant, there are times that it may show under a thin skin. In order to make e-PTFE implant better looking, the sides of the Gore-Tex should be cut and carved well to avoid cornering appearance (see Figure 86.4). Make certain implant placement is midline and in full contact with undersurface. Since e-PTFE is so, it is not used in tip support surgery. One dreadful complica-tion of e-PTFE is infection. Infection can be avoided by diligently observing the sterility, e.g. soaking the implant in gentamicin solution when not in use and avoidance of prolonged air exposure. Implant package should be opened only when it is time for insertion. e caudal edges of the implant should be cleared and away from the inci-sion line since the incision wound can be the site of entry of microorganisms (see Figure 86.5).Cartilage may also be used in dorsal augmentation. Cartilage source may be from the septum, ear or rib. Mostly the source is from the ear. Scoring the cartilage in the concave portions helps make the implant to bend to a straight looking piece; however, sometimes warping can still occur. Resorption and warping are high in cartilage for dorsal augmentation.Dermofat from the sacrococcygeal area may sometimes be used as augmentation material. e advantage is the natural look, however, resorption is high. is material is usually reserved for secondary rhinoplasty of patients with thin skin.Figure 86.1 Nasal framework.Spreader graftSeptal extensiongraftFigure 86.2 Support grafts: Spreader graft and septal extension graft.Support graftSeptal extension graft(SEG) - openTip grafts (shield,backstop, onlay)Contour graftsExtended spreadergraft - openColumellar strut graft- closed or openFigure 86.3 Common support and contour grafts. Alar rim 891Homogra materials such as cartilage and dermis are gaining popularity nowadays because of least reaction; however, the cost is prohibitive.TIPMost Asian tips are bulbous which is due to thick skin or convex lower lateral cartilage (LLC), or a combina-tion of both. e dome portion of the lower cartilage may not be well formed too. e medial crura are usu-ally muchsmallerand weak causing the inadequate tip support.Many simple procedures such as transdomal and inter-domal suture techniques are good enough to dene the tip; however, most oen, tip gras such as shield and onlay gras are needed for a more dened tip. A too convex LLC may need cephalic trimming, making sure that enough 5–8 mm of LLC is le behind for support and patency of external nasal valve.e whole shape of the lower cartilage can be changed when the dome is pulled anteriorly and xed to the ante-rior angle of SEG for a total new dimension of tip projec-tion. SEG is the usual support gra used for lengthening a short nose and projecting a low tip (see Figure 86.6).An additional procedure to improve the tip in a thick skin is to perform defatting, especially at the supratip area.ALAR RIMe rims in some Asian noses are hanging and need li-ing procedure. A triangular tissue is excised at the inner lateral portion of the nasal vestibule. e triangular tissue is shaped like a sail of a sailboat with two irregular sides and a base. e inferior side is the inner rim of the ala, and the cephalic side is a skin groove in the vestibule which is a depression marked by transition of thin and thick vibris-sae. e alar rim is then sutured to the inner vestibular skin like a ap (see Figure 86.7). e sail excision is usually done as the rst procedure in rhinoplasty in order to allow the maximum exibility of manoeuvring the ala from marking, incision, excision and suturing.Figure 86.4 e-PTFE 2 layered sheets and shaved tapered at all sides.Figure 86.5 e-PTFE implant. Note the caudal edges of the implant are within the line of incision.Figure 86.6 New projected position of lower cartilage via xation to SEG.Figure 86.7 A piece of triangular tissue shaped like a ‘sail’ is excised from the inner lateral portion of the nasal vestibule.The alar rim is rolled in and sutured to close the defect. 892 Rhinoplasty for Southeast Asian noses: Open andclosed approachesALAR BASEA wide alar base may sometimes improve when tip is projected; however, further narrowing can be achieved by a wedge excision of the sill. e wedge sill excision is a three-dimensional analysis and can be in continuum to the lateral alar groove for correction of alar are. e inci-sion at the lateral alar area is made 0.5–1.0 mm above the alar groove for better wound healing and coaptation (see Figure 86.8).TECHNIQUE FOR OPEN STRUCTURAL RHINOPLASTY (OSR)Depending on the severity of deformity, either closed or open approaches are used. e general rule is the simpler the correction, the simpler the approach.Closed technique is used commonly in noses that need minor surgical manoeuvres such as dorsal augmentation and tip suture with or without graing. It is also the choice of approach in minor touch-up procedure in secondary rhinoplasty.Open approach is used when there is a need to explore and repair the cartilaginous structures under direct vision, e.g. crooked nose, asymmetric tips, moderate-to-severe bulbous tip deformity, short noses and cle lip noses. It is also commonly used in dicult secondary rhinoplasty.e septum is the most stable structure to hold the tip, so it is the principle of structural rhinoplasty that the lower cartilage is repositioned to a new projection via a support gra, e.g. SEG (see Figure 86.9). Since the septum is small in majority of noses, there is almost always a need to harvest conchal cartilage for tip contour gras while the central septum harvested is used solely as support gra.e cut starts as a marginal incision just as one is per-forming a closed approach rhinoplasty. e cut is along the caudal border of the LLC. e dissection is supraperi-chondrial in the lower cartilages. At this point, a trans-columellar incision is made to completely access the plane to elevate the skin and so-tissue envelope (SSTE). e dissection at the lower cartilage and the UC is above the perichondrium whereas the dissection in the nasal bone is beneath the periosteum. e dissection should be wide up to nasomaxillary bone.Tip denition procedures may be carried out at this time using the domal and interdomal sutures. Depending on the strength of the medial crura, a columellar strut gra and a tip shield or onlay gra can be used. Osteotomy can be performed at this time. If there is a need of a dorsal augmentation, a gra is used in order to blend the bridge with the new tip. e material for dorsal augmentation can be autologous using conchal cartilage or septum, or it can be synthetic using Gore-Tex or silicone. e dorsal aug-mentation material should be just appropriate in size and shape. Usually implant thickness ranges from 2 to 5 mm. e cephalic end of the implant should blend well with the radix whereas the caudal end should just end at the UC or over the LLC. If the implant caudal end rests on the LLC, the implant end should be sutured to the cartilage for sta-bility (see Figure 86.10).Figure 86.8 Incisions should be made 1 mm above the alar crease for better wound coaptation during suturing. Figure 86.9 Septal extension graft. A piece of cartilage harvested from the central portion is sutured at the caudal strut for added length and height for tip support.Figure 86.10 Final appearance of the Gore-Tex dorsal implant and the multiple layered tip grafts for tip denition. Augmentation rhinoplasty using conchal cartilage via closed approach 893If the tip needs elongation (counter-rotation) or ante-rior projection, a more structured graing is needed. is time the membranous septum is dissected using sharp scissors till it reaches the caudal margin of the septum. A subperichondrial dissection is made bilaterally up to the bony portions of the septum. A submucous removal of the central portion of the septal cartilage is performed leaving a 10 mm of caudal and dorsal strut. Any bony spurs are removed using rongeur forceps. e removed cartilage is fashioned into an SEG and is sutured to the caudal strut using PDS 5-0 sutures. e dome of the lower cartilage is sutured to the anterior end of the SEG (see Figure 86.9). e medial crura are also xed to the SEG for stabiliza-tion of the lower cartilage (see Figure 86.3). e mucosa of the membranous septum and the cartilaginous septum is sutured in a quilt manner using vicryl 5-0.Further tip enhancement can be achieved using a tip shield gra or onlay gra. e dorsum can be augmented this time using autologous cartilage or synthetic implants, e.g. silicone, e-PTFE (Gore-Tex) or Medpor. Most com-monly Gore-Tex is used nowadays because it heals by adhesion and not by encapsulation. It also gives a more natural look over silicone. Gore-Tex however is prone to infection if not properly sterilized and handled. It should be opened just before use to prevent long air exposure. It should be soaked in an antibiotic solution, e.g. gentamicin, just before inserting. Fixation sutures should be applied in the caudal end of implant to prevent deviation. Preformed implant should be well carved, especially in the rhinion area, in order to ensure maximal adhesion of the implant to the underlying bone and cartilages (see Figure 86.11). Make sure to ll up any gap in the undersurface of the Gore-Tex with cartilage or a thin sheet of Gore-Tex. is is to prevent collapse of the caudal portion causing supra-tip depression. e dorsal augmentation should be just enough to blend the new radix to the new tip, making sure the implant is not palpable.A trial closure may be tried and checked for the tip pro-jection. Additional tip gras may be used if deemed nec-essary. Closure of the columella is bilayer. e muscle and so tissue is closed using vicryl 6-0 and the skin is closed using nylon 6-0. e marginal incision in the vestibule is closed using vicryl 6-0.Palpation is very important aside from the looks imme-diately post-op. Whatever is the form you see on the operat-ing table is the form the patient will have. Any irregularity should be corrected.External dressing includes putting on Steri-Strip and a thermal cast for 5–7 days. Sutures are removed in 5–7days. Oedema may still persist for the next few weeks, but usually the nose is good looking 4–6 weeks post-op. Improvement and wound maturation will gradually improve in 6 months to a year.AUGMENTATION RHINOPLASTY USING CONCHAL CARTILAGE VIA CLOSED APPROACHClosed rhinoplasty approach is considered a minimally invasive type of surgery. is approach is commonly uti-lized for nasal contour enhancement or aesthetic purposes.Conchal cartilage is the autologous gra of choice used for augmentation rhinoplasty because it is readily acces-sible. e average thickness of ear cartilage is 1.5 cm and is capable of increasing the height of the nasal dorsum from 3 to 5 cm by suturing 2–3 layers of cartilage together.e ear cartilage is harvested via posterior auricular inci-sion. is will give the surgeon a better surgical eld to har-vest the whole conchal cartilage, i.e. the cymba and cavum concha as a single piece (see Figure 86.12). To prevent defor-mity of the pinna, a 5-mm margin along the antihelix, anti-tragus and inferior crura should be preserved. is serves as the framework of the external ear. e incision is then closed via interrupted or simple continuous suture using nylon or prolene 5-0. e contour of the concha is preserved using two peanut cotton balls serving as splinting device in the concavity, which is then kept in place by surgical tape.Figure 86.11 The ventral portion of a preformed e-PTFE (Gore-Tex) should be well carved in order to avoid mobility of implant post op because of the cantilever-fulcrum at the rhinion. Carving the ventral side ensures maximal contact of implant with the bones and cartilages.Figure 86.12 Conchal cartilage is harvested via posterior auricular approach. 894 Rhinoplasty for Southeast Asian noses: Open andclosed approachesTo design the nasal gra, a spindle-shaped portion is cut from the harvested cartilage to form the rst part of the gra (see Figure 86.13). e length of the spindle-shaped cartilage is based on the measured length of the nasal bone with a width of 8 mm. From the longest portion of the remaining harvested cartilage, another straight piece with 3-mm width is also obtained. e two pieces are sutured together with straight cartilage positioned under the con-cave side of the spindle-shaped material. is will serve as the frame of the gra. Additional layers are sutured to the gra frame according to the height needed for dorsum augmentation (see Figures 86.14 and 86.15).For nasal augmentation, a marginal or infracartilagi-nous incision is done. Unlike in open columellar approach, there is no transcolumellar incision done and the columella is preserved. Dissection is done along the suprachondrial plane of the LLC and the upper lateral cartilage. Upon reaching the rhinion, the dissection is carried down to the subperiosteal plane of the nasal bone area. As much as possible, the width of the dissection should be limited to 1 cm. It should be straight, midline and free of so- tissue webs. e fabricated cartilage implant is inserted as dorsal onlay gra. Additional height of the gra may be achieved by inserting a piece of cartilage underneath the gra (seeFigure 86.16).For tip augmentation, an interdomal suture is per-formed to strengthen the tip or the dome of the LLC that will serve as the base for the tip gra. A single or double layer of shield gra is inserted to dene the tip and add projection. A columellar strut gra may be inserted to achieve rotation of the tip if desired. e incision is then closed and an external splint is applied to keep the gra in place.Closed rhinoplasty approach is eective in improving the height and appearance of an oriental nose. is mini-mally invasive procedure allows the surgeon to perform the surgery under local anaesthesia and may be performed as an ambulatory minor surgical procedure.Top tips • Always ensure that your patient’s expectations are realistic. • When using an implant to augment contour, the soft-tissue pocket should be just enough to accommodate the implant to prevent its later migration. • When using augmentation materials, always discuss their nature with the patient. Some patients will have religious or cultural objections to some materials.Figure 86.13 A spindle shaped portion is obtained from the harvested cartilage.Figure 86.14 The pieces of cartilages are sutured together to fabricate the dorsal onlay graft.Figure 86.15 Picture showing 3 layers of cartilage to obtain 5 mm thickness.Figure 86.16 Schematic diagram showing how the con-chalcartilage ts inside the nose for augmentation.