Understanding the surgical anatomy of the Ethnic nose is essential for successful Dorsal Augmentation in Ethnic Rhinoplasty. The Layers of the Ethnic Nose include: 1. SMAS or fibromuscular layer. Periosteal and perichondrial layers.

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Objective: The authors propose a classification system for aesthetic correction of the Asian-American nose and outline surgical techniques with general application to this patient population. Methods: Patients were classified into 3 categories based on morphologic characteristics, as follows: type I vertical deficiency , type II vertical deficiency and broad nasal width , and type III type I or II with glabella deficiency. The treatment protocol included cartilaginous augmentation of the tip, columella, and dorsum for type I patients, using the ear as a donor site.

Type II patients underwent similar augmentation and also reduction of the tip and nasal bone, and in some cases reduction of the nasal base. Type III patients received the same treatment as type I or II cases, but in addition required glabella augmentation with hydroxylapatite.

Results: Representative case studies and results are illustrated for each of the 3 types of patients. Augmentation of vertical deficiencies is essential to an aesthetic outcome, while glabella correction can be crucial to the overall result in type III patients. One of the more definitive Asian morphology reviews is that of Aung et al.

Type A exhibits a prominent alar lobule and a full nasal tip. In type B, the alar lobule is less prominent and the tip is more defined. Type C exhibits the least prominent alar lobule, with a relatively straight slope from the tip to the alar base. Because the Asian-American nose incorporates many nationalities, the morphologic features can be expected to be more diverse. A diversity of features has been identified in other non-Caucasian noses, such as African-American and Hispanic Mexican-American noses.

The purpose of this study was to analyze and categorize if possible the Asian-American nose and then determine common surgical techniques that have general application to this particular population of patients. Methods Classification We reviewed our last 23 Asian-American patients who underwent rhinoplasty.

The patients were divided into 3 morphologic categories. Type I most common—12 patients is the patient who is deficient in overall vertical nasal height, so that the nose appears relatively broad. The basal view is essential to determine whether this problem is caused by a deficient columella, a deficient tip, or both.

Occasionally, this type of patient also exhibits thick skin and slightly enlarged alae. But the predominant physical finding is an insufficient overall vertical height. The apparent broad nasal features nasal bones and nasal base are relative to the vertical deficiency. This type of patient does not have a significant, absolute increase in nasal base width or nasal bone width. Figure 1 A basal view is best to demonstrate A tip deficiency, B columella deficiency, or C tip and columella deficiency.

Figure 1 Open in new tab Download slide A basal view is best to demonstrate A tip deficiency, B columella deficiency, or C tip and columella deficiency. The ala itself can be somewhat enlarged and the skin may be thick.

Type III occasional—4 patients is the patient who has features characteristic of type I and sometimes II but in addition has a glabella deficiency. The root of the nose is usually diminutive, so that in some of these patients the eyelids are anterior to the nasal root. Surgical treatment General principles The choice of using an open versus a closed approach in treating all 3 of these morphologic types of Asian-American noses can vary according to particular circumstances.

In our series of cases, the open approach was usually preferred because it provided better visualization. Because aesthetic correction of the Asian-American nose was typically an augmentation rhinoplasty, the skin was brought under slight stretch. Therefore, potential problems of late postoperative edema and fibrosis caused by an inability of the skin envelope to accommodate the new, larger nasal framework were not significant. The closed approach was generally reserved for patients who preferred not to have an external scar and when deemed more appropriate because of other factors, such as local circulatory conditions eg, scarring of the skin, smoking, etc.

Type I patients Type I patients received a surgical correction to each nasal component that contributed to the overall unaesthetic appearance. Dorsal deficiency including radix was generally treated by placement of a dorsal graft using ear cartilage. The specific technique for harvesting concha cymba and cavum, and structuring it into a tandem unit that can provide substantial dorsal augmentation, has been described in detail elsewhere.

Columella deficiency was treated with a columellar strut preferably autogenous septal cartilage, but, when necessary, ear cartilage.

If ear cartilage was used and happened to have an undesirable curvature convexity , a mattress suture was used to straighten it out Figure 2. Tip deficiency was corrected with an anatomic tip graft and support graft. Note that the suture enters the cartilage perpendicular to the longitudinal direction of the cartilage. Figure 2 Open in new tab Download slide An abnormally curved columellar strut graft eg, from the ear can be straightened by applying a mattress suture of nylon to the convex side of the graft.

Excessive nasal base width was corrected with a conservative excision mm of the medial aspect of the ala or the nostril sil, depending upon which contributed more to the excessive width of the nasal base. In some instances, the entire nasal base width was reduced further by undermining the entire nasal base which includes ala, sil, and columellar base and adjacent premaxillary pyriform tissue.

After this undermining, a pair of large sutures nylon was passed from one ala to the other spanning sutures in order to narrow the overall nasal base even further Figure 3. The details of this type of nasal base reduction procedure are provided elsewhere.

Figure 3 Open in new tab Download slide Nasal base reduction is performed by first resecting either a portion of the ala or a portion of the nostril sil. A, The periosteum and soft tissue of the ala is then elevated from the bone with a Freer elevator. B, A tunnel is made from one alar wound to the other. C, A pair of nylon sutures approximates the dermis of one ala to the other ala. D, Slight overcorrection is performed when tightening the suture.

Because the bulbous or broad tip cannot be camouflaged very well by a tip graft, type II patients required a tip-plasty open or closed , which included cephalic trim of the lateral crura leaving a 6-mm wide lateral crus and then application of the suture algorithm suggested elsewhere 10 for the bulbous or broad nasal tip.

This algorithm includes 1 the transdomal suture, 2 the interdomal suture, 3 the lateral crural mattress suture to eliminate convexity of the lateral crus and, if needed, 4 the columella-septal suture to secure the tip complex to the caudal septum. Lateral osteotomies were performed by the buccal sulcus approach. A small incision was made within the hairline of the central forehead, and a pocket was developed with a periosteal elevator over the glabella region.

Hydroxylap-atite mixed as prescribed by Hobar et al 12 was placed within the pocket until the glabella exhibited a smooth contour. Usually, 5 mL was required. Care was taken to maintain a separate pocket for the glabella so that no granules of hydroxylapatite migrated into the nasal dorsum. During the early postoperative course when the hydroxylapatite was still malleable , digital molding of the glabella area was necessary in some cases in order to maintain a smooth contour that was free of irregularities.

Results Case study results are illustrated for each of the 3 morpholobibgic types treated in our series. The physical examination revealed an overall vertical deficiency dorsal deficiency, tip hypoplasia, and columella deficiency.

There was an involuted hemangioma on the left side of the nose dating from childhood, which the patient did not want treated, and an ill-defined supratarsal fold. Using an open approach, the dorsum was augmented with a tandem graft from the ear. The septum was used for a tip graft and columellar strut. At 10 months postoperatively, the nose had an appearance of greater vertical height and an overall more aesthetic appearance Figure 4.

Figure 4 Open in new tab Download slide A, C, E, Preoperative views of a year-old woman with type I vertical deficiency dorsal deficiency, tip hypoplasia, and columellar deficiency. B, D, F, Postoperative results 10 months after patient received a tip graft, columellar strut, and dorsal graft using an open approach. She also received an upper blepharoplasty.

The result demonstrates that augmentation of the vertical deficiencies is the key to a successful outcome.

The physical examination revealed a broad nasal base primarily the nostril sil and vertical deficiency a short columella, tip deficiency, and dorsal deficiency. Surgical correction included a tip graft, columellar strut, and dorsal augmentation with a tandem ear graft. A nasal base reduction was performed in which a section of the nostril sil was excised, the soft tissue of the alar was freed from the premaxillary pyriform region, and a pair of nylon spanning sutures was used to reduce the nasal base width even further.

At 13 months postoperatively, the nose width was improved because part of the nose was literally narrowed and because the overall vertical height of the nose was increased Figure 5.

Figure 5 Open in new tab Download slide A, C, E, Preoperative views of a year-old man with type II vertical deficiency and increased absolute nasal width of the nasal base.

He also has an acute columella-labial angle. B, D, F, Postoperative views show satisfactory improvement 13 months after placement of a tip graft, dorsal graft, and columellar strut using an open approach. He also received a nasal base reduction, including wedge excision of the nostril sil and spanning sutures from one ala to the other.

Type III This year-old woman requested more prominence to her dorsum, including the nasal bridge. The physical examination revealed a lack of vertical height a short columella, tip deficiency, and dorsal deficiency. She also exhibited severe glabella deficiency, with the eyelids anterior to the nasal root. Surgical correction included a tip graft, columella graft, and dorsal tandem graft the ear was the donor site.

The glabella was augmented with 5 mL of hydroxylapatite. She also received an upper blepharoplasty, chin augmentation, and submental lipoplasty. At 2 and one-quarter years postoperatively, there was significant improvement in the nasal appearance, particularly the glabella deficiency Figure 6. Figure 6.



Although these techniques are well developed and documented in Asian languages, there are relatively few English-language articles on the subject, and even fewer on current debates and controversies among plastic surgeons. Knowledge of these different techniques is essential to perform an adequate rhinoplasty in Asians. For Western patients, reduction rhinoplasty with dorsal hump rasping and lower lateral cartilage resection is classic. In contrast, silicone implant augmentation rhinoplasty is the most commonly used technique in Orientals. This article focuses on current rhinoplasty practices and controversies in Asia. It reviews morphologic differences between the Oriental and Western noses, as well as common patient requests.


Asian Rhinoplasty Techniques

Kekree J Cosmet Laser Ther. D, Appearance 2 years after intradermal injection of 0. Flow chart illustrating that HA gel injections can be considered for most patients requesting nasal reshaping. Carolina Edwartz on behalf of Galderma.



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