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Rhinoplasty in Small Bulbous Asian Noses: Some Special Surgical Techniques to Consider

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Eduardo C. Yap, MD

Consultant, Facial Plastic Surgery
Belo Medical Group
Manila, Philippines
https://www.belomed.com/blog/dr-eduardo-yap

Email: edcyap88@gmail.com
Phone: +63-917-7068796

Introduction

Asia is a big continent, nose morphology changes from different regions.  Often times when Asian rhinoplasty is the topic, it is the Eastern Asian nose that is talked about. East Asia is geographically divided into Far East Asia and South East Asia; and the South East Asian noses are one of the smallest noses in the world.1

Rhinoplastic surgery in small Asian noses requires improving the bulbous tip, elongating the dorsum, counter rotation and projection of the tip.  To achieve this goal a strong support system of the dorsal and caudal strut should be achieved.  The support grafts that works well are the extended spreader graft (ESG) and septal extension graft (SEG).  Columellar strut graft when used alone will not give longevity of result because of weak lower cartilage coupled with the weight of the thicker fibrofatty skin. Improving the nasal morphology involves aggressive soft tissue contouring too by trimming the fibrofatty tissue. The ala is usually wide and hanging; this deformity has to be corrected as well.  Therefore, in dealing with small Asian noses, 2 main surgical categories are considered: 1. Structural framework surgery e.g. support and contour grafts, and 2. Soft tissue contour surgery e.g. defatting the tip, alar lift and alarplasty.2 

Structural framework surgery

In the structural framework surgery, grafts are taken from septum.  It is the SEG that is the strongest and has the longevity of tip support.  There are many ways to design a SEG.  Most commonly known are the “side to side” and “end to end”. See Figure 1 and 2. 

The side to side SEG can be a full or partial overlap of the caudal strut depending on the strength of the caudal strut. If the caudal strut is weak, then a full side to side SEG is used to serve as a batten graft also.  If the caudal strut is strong, then a smaller side to side SEG can be used.  Extended spreader graft (ESG) is used when the dorsal strut is weak or deviated. See Figure 3.  

Figure 1.  Septal Extension Graft, side to side
Figure 1.  Septal Extension Graft, side to side
Figure 2.  Septal Extension Graft, end to end
Figure 2.  Septal Extension Graft, end to end
Figure 3. Extended Spreader Graft
Figure 3. Extended Spreader Graft

Sometimes when the harvested septum is small, the ear cartilage is fashioned as extender of the support grafts.3,1    Occasionally the bony septum is used as support for weak SEG.4 See Figure 4, 5, 6,7

Figure 4.  Folded conchal cartilage placed as sandwich support below the SEG.
Figure 4.  Folded conchal cartilage placed as sandwich support below the SEG.
Figure 6.  A folded conchal cartilage fixed at the anterior caudal end of SEG
Figure 6.  A folded conchal cartilage fixed at the anterior caudal end of SEG
Figure 5.  A long folded conchal cartilage with a slit is interposed with the SEG.
Figure 5.  A long folded conchal cartilage with a slit is interposed with the SEG.
Figure 7.  Bony septum as support for weak septum
Figure 7.  Bony septum as support for weak septum

Synthetic material like polycaprolactone (PCL) can be used as support and template for cartilage growth whenever the septum is weak or small. See figure 8.

PCL mesh is a new absorbable synthetic material that has tissue regenerative property.  PCL should be covered with cartilages in order to prevent extrusion or erosion to mucosa and to allow cartilage cells ingrowth.  

The dorsal and tip grafts are fashioned after the framework structure is done.  Synthetic dorsal implant is still the preferred choice because of volume and ease of shaping. 

Figure 8.  PolyCaproLactone (PCL), a new synthetic absorbable mesh that acts as support and template for cartilage tissue regeneration.
Figure 8.  PolyCaproLactone (PCL), a new synthetic absorbable mesh that acts as support and template for cartilage tissue regeneration.

Soft tissue contour surgery

In the soft tissue contour surgery, attention is mainly at the fibrofatty skin of the tip, subtip and ala.  The fibrofatty tissues at the supratip and alar crease are trimmed using sinus thru cut forceps at the end of the procedure. See figure 9.

Figure 9a.  Sinus Tru-cut forceps for defatting the supratip
Figure 9a.  Sinus Tru-cut forceps for defatting the supratip
Figure 9b.  Before and immediately after defatting
Figure 9b.  Before and immediately after defatting

If the subtip area is still big at the end of the surgery, an ellipse of skin in the subtip is excise,  this maneuver somehow raised the nostril apex hence improving the nostril shape as well.5  See figure 10.

Figure 10a.  A piece of triangular skin tissue in the subtip area is excised following the imaginary border of the ala and the columella.  Make sure to leave a 1.0-1.5mm of rim margin to prevent notching.
Figure 10a.  A piece of triangular skin tissue in the subtip area is excised following the imaginary border of the ala and the columella.  Make sure to leave a 1.0-1.5mm of rim margin to prevent notching.
Figure 10b.  Before and immediately after excision.
Figure 10b.  Before and immediately after excision.

One aspect in soft tissue contour surgery is the Ala.   The ala should be approached in 3 dimensions. Alarplasty addressed the 2 dimension of the alar flare and alar width.  See figure 11.

Figure 11a.  Alar flare to be corrected via wedge excision only. Note the small nasal sill.
Figure 11a.  Alar flare to be corrected via wedge excision only. Note the small nasal sill.
Figure 11b.  A two-dimensional analysis of alar base and flare.  Correction is via combined excision.
Figure 11b.  A two-dimensional analysis of alar base and flare.  Correction is via combined excision.

The 3rd dimension is the alar rim which has to be raised since most Asian noses have hanging ala. The alar rim lift is done internally via sail excision.6,7 See figure 12.

Figure 12a.  Sail Excision for alar lift.  The skin together with the subcutaneous fats and muscles are removed and the alar rim is flipped inwards as a flap.
Figure 12a.  Sail Excision for alar lift.  The skin together with the subcutaneous fats and muscles are removed and the alar rim is flipped inwards as a flap.
Figure 12b.  The vestibular groove should not be mistaken as the caudal margin of the lower lateral cartilage.
Figure 12b.  The vestibular groove should not be mistaken as the caudal margin of the lower lateral cartilage.

This procedure involves removal of a triangular skin tissue with its subcutaneous fats and muscles then the alar rim skin is rolled in to close the defect. The fixed landmarks to follow are the vestibular groove and the inner margin of the alar rim.  The alar rim lift via sail excision is done as initial step before rhinoplasty while the alar base and flare surgery is done as final step when rhinoplasty is done. 

Conclusion

In conclusion, surgery of small Asian bulbous nose needs a strong structural framework and an aggressive soft tissue contouring surgery.  See figure 13 and 14

Figure 13a Pre op postop. Front view.  N
Figure 13a Pre op postop. Front view.  N
Figure 13b  Preop Postop Oblique.
Figure 13b  Preop Postop Oblique.
Figure 13c.  Preop postop.  Lateral view.  Note the improvement in tip counterrotation and projection, columellar show, alar rim, premaxilla and nasal dorsum.
Figure 13c.  Preop postop.  Lateral view.  Note the improvement in tip counterrotation and projection, columellar show, alar rim, premaxilla and nasal dorsum.
Figure 13d.  preop Postop Basal view.  Note the projection and improvement in alar flare.
Figure 13d.  preop Postop Basal view.  Note the projection and improvement in alar flare.
Figure 14a Preop Postop. Frontal view
Figure 14a Preop Postop. Frontal view
Figure 14b Preop Postop Oblique view.
Figure 14b Preop Postop Oblique view.
Figure 14c Preop Postop Lateral view.  Note the general improvement in nasal dorsum, tip projection, alar-columellar relationship, and premaxilla.
Figure 14c Preop Postop Lateral view.  Note the general improvement in nasal dorsum, tip projection, alar-columellar relationship, and premaxilla.
Figure 14d. Preop postop.  Basal view.  Note the improvement in tip projection, nostril shape and alar flaring.
Figure 14d. Preop postop.  Basal view.  Note the improvement in tip projection, nostril shape and alar flaring.

References

  1. Yap, EC. Aesthetic Rhinoplasty for South East Asians, In: Jin HR. Aesthetic Plastic Surgery of the East Asian Face.    2016. 108-121
  2. Yap, E.C. Principles of Structural Rhinoplasty in South East Asian Noses. Philipp J Otolaryngol Head Neck Surg 2014; Jul-Dec 29(2): 41-44
  3. Pernia, N E, Galvez, JA, Victoria, FA. The Dimensions of the Nasal Septal Cartilage: A Preliminary Study in Adult Filipino Malay Cadavers.  Phil Journal of ORL-HNS. Vol 26, No. 2, July-December 2011, 10-12
  4. Que-Ansorge, C., Yap, EC. The Use of Bony Septum as an Extended Spreader Graft in Primary and Secondary Rhinoplasty.  Philipp J Otolaryngol Head and Neck Surgery 2019. Jan-Jun 34(1) 20-25
  5. Yap, EC, Rhinoplasty for South East Asian Nose. In: Jang, YJ. Rhinoplasty for the Asian Nose. Facial Plastic Surgery Clinics of North America. Aug 2018, 26(3) 389-402
  6. Baladiang DE, Olveda MV, Yap EC. The “sail” excision technique: a modified alar lift procedure for Southeast Asian noses. Philipp J Otolaryngol Head and Neck surgery 2010 Jan-Jun; 25(1): 31-37
  7. Yap, EC. Improving the hanging ala.  Facial Plast Surg.  2012 Apr; 28(2): 213-217

Disclosure:  There are no financial or other relationships, that might lead to a conflict of interest.