Aesth Plast Surg (2007) 31:636642 DOI 10.

1007/s00266-006-0137-1

ORIGINAL ARTICLE

Balanced Rhinoplasty in an Oriental Population

Wen-Chieh Liao Hsu Ma Chiu-Hwa Lin

Received: 27 June 2006 / Accepted: 2 October 2006 Springer Science+Business Media, LLC 2007

Abstract Background: In Taiwan, augmentation rhinoplasty and double-eyelid blepharoplasty are the most popular aesthetic procedures. Although aesthetic concepts vary for different races, the current concept of nasal and facial beauty shows a tendency to correspond to that for white people. The authors present their 10-year experience with a simple and practical approach of simultaneous blepharoplasty and rhinoplasty. Methods: This study enrolled 255 consecutive patients who underwent simultaneous rhinoplasty and blepharoplasty between January of 1996 and December of 2005. All were Chinese in ethnic origin. The patients in the series were predominantly women. Only 10 were men. Five of the cases involved congenital palpebral anomalies including congenital entropion, congenital ptosis, and Down syndrome. A total of 245 patients had an adequate followup period longer than 5 years. The patients satisfaction and postoperative complications were recorded. Results: Among the 245 patients receiving the balanced rhinoplasty, there were no cases of implant extrusion, displacement, or infection. Most of the patients (230/245 cases, 94%) were satised with their nasal and periocular shape. Conclusions: The authors believe that simultaneous blepharoplasty and rhinoplasty are a simple and reliable method for effecting better results for Asians.
W.-C. Liao H. Ma (&) Division of Plastic Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University, 19F, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan e-mail: wjliaw.m1031@msa.hinet.net C.-H. Lin Celebrity Cosmetic Center, Taipei, Taiwan

Keywords

Blepharoplasty Rhinoplasty

Beauty requires a smooth, harmonious, and coordinated blend of facial features. In Taiwan, creation of upper eyelid crease and nasal enhancement is extremely popular and requested with increasing frequency. The common complaints among Taiwanese individuals who want to undergo aesthetic rhinoplasty include a at or low dorsum, a poorly projected tip, an acute nasolabial angle, a short columella, a wide alar base, and a round or ared nostril shape (Fig. 1). The primary aesthetic rhinoplasty usually is focused on augmentation of the dorsum and projection of the tip. The eyelid characteristics of most Asians include the absence of a superior palpebral fold, excessive fat, laxity of a pretarsal fold, and a medial epicanthal fold. The bright-eyed look associated with the double eyelid relative to the size and shape of the face is an aesthetically desirable feature. The surgeon must have an aesthetic sense, which is the ability to see a face and then make appropriate changes to its features. Years of experience have led us to use simultaneous rhinoplasty, blepharoplasty, and epicanthoplasty. Often, many questions are asked about the relation between the eyes and the nose. The goal in balanced rhinoplasty is to proportion the nose so that it complements the graceful curvature, harmony, and attractiveness of the face.

Materials and Methods From January of 1996 to December of 2005, we performed balanced rhinoplasty for 255 patients, who were reviewed

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Balanced Rhinoplasty Fig. 1 Left: Characteristic features of the Asian face. Right: Attractive features of Asian face

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for this study. The average patient age was 24.3 years (range, 2038 years). All the patients underwent augmentation rhinoplasty with silicone implants, double-eyelid upper blepharoplasty, and modied Y-V epicanthoplasty with or without chin augmentation. Preoperative studies included anthropometric measurements, lacrimal system evaluation, and photography. Indications for surgery, patient satisfaction, and postoperative complications were recorded. Operative Method All procedures are performed with the patient under intravenous sedation and local anesthesia (1% lidocaine with 1:200,000 epinephrine) inltration. After the sterile eld has been properly prepared, the various implants can be placed along the nasal dorsum to determine the proper t. The superior aspect of the implant should rest equidistantly between the glabella and the nasion, whereas the inferior aspect should t around the curve of the nasal tip. If the exact implant size cannot be matched, then the next larger size should be used and trimmed along its superior extent to t the desired length. The implant then can be soaked in antibiotic solution during creation of the recipient pocket. In this study, auricular cartilage graft was harvested from the cavum and cymba conchal cartilage, sparing the radix helices, through an anterior approach. Typically, one to three small circular disks of cartilage about 0.5 to 1.0 cm in diameter were fashioned, depending on the tip projection required. We used it as an onlay graft or as a sandwich graft comprising two or three layers of contrabent ear cartilage parts held together using a 6-0 clear nylon suture (Fig. 2).

Insertion of the Implant The external rhinoplasty technique is the only way to gain exposure (Fig. 3). The incision we use is at the level of the midcolumella to break up the line of the scar and prevent notching. The horizontal incision extends to meet a vertical marginal incision. The dissection proceeds in the subperiosteal plane, with a Joseph elevator inserted to create a pocket. The implant is placed into the created pocket, and symmetry is conrmed by visual inspection and palpation. The immobility of the implants superior aspect that resides under the tight subperiosteal pocket also should be veried. The incision is closed with a 6-0 nylon suture, which is removed on the third to fth postoperative day. The postoperative care is same as for any other nasal procedure. Double-Eyelid Blepharoplasty and Modied Y-VEpicanthoplasty The patient determines the height and shape of the desired crease (Fig. 3). In general, the height of the fold should be approximately 6 to 8 mm above the ciliary margin or naturally established line. The excessive skin is marked out in an elliptical fashion. A skin incision is made on the upper eyelid according to the usual method. Portions of the orbicularis oculi muscle, the connective tissue, and the pretarsal fat with or without excessive orbital fat are removed by careful clamping, cutting, electrocautery, and reinspection for bleeding points. After removal of the fat, the levator is identied and attached to the lower border of the ocularis muscle with three sutures along the entire edge of the tarsus, placed 5 to 6 mm apart. The skin closure is accomplished using 7-0 nylon in a running fashion.

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638 Fig. 2 The auricular cartilage and design of onlay graft

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Fig. 3 The surgical design of balanced rhinoplasty

Epicanthoplasty With the Modied Y-V Advancement Procedure (Fig. 4) Point A is on the skin of the medial canthus overlying the apex of the lacrimal lake. On the web, points B and C are marked crossing the lacrimal lake. The three points form a triangle. The nasal skin then is tracted medially, exposing the lacrimal lake completely to make point A at the apex of the lacrimal lake. Two periciliary lines, AD and AE, are made. The lengths of these two lines can be adjusted to correct residual skin deformities after approximation of points A and A. The V-shaped skin from A, B, C, D, and E, to A is resected. Excessive orbicularis oculi muscles and subcutaneous tissues are trimmed, and all adhesion bands are subsequently released. Finally, a deep buried suture using 6-0 prolene is performed by plicating the periosteum of nasal bone or medial canthal ligament to point A. Alar Base Surgery The decision for alar base surgery (Fig. 3) is made at the end of all the procedures. At this time, the general appearance of the nose may be assessed, and alar sculpturing may be selected and performed either in the sidewall of the alar are or in the nostril oor.

Results A total of 245 patients underwent balanced rhinoplasty. The postoperative follow-up period ranged from 5 months to 10 years (average, 5 years). The results were evaluated considering postoperative complications, displacement of implant, and preservation of the shape of the nose. With few exceptions, the patients in our series had an uneventful postoperative course. The shape of the nose and double eyelids was maintained, with both patients and surgeons judging the results to be satisfactory. Moreover, scarring from all the incisions was invisible. There were two cases of delayed implant extrusion, both of them secondary to trauma. In one patient, an infection developed after several months, which resolved with oral antibiotics.

Discussion Our balanced rhinoplasty technique consists of three procedures: (1) augmentation rhinoplasty with an onlay auricular cartilage graft for underdeveloped nasal root and decreased tip projection, (2) an incision method of double-eyelid blepharoplasty for creating a supratarsal

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Balanced Rhinoplasty

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Fig. 4 The illustration of modied Y-V advancement epicanthoplasty

fold, (3) modied Y-V epicanthoplasty to enhance the aesthetic result by lengthening of the palpebral ssure, (4) and alar base surgery. Augmentation rhinoplasty is performed to correct the underdeveloped nasal root and make a good image of the eyes [9]. But augmentation alone cannot decrease the intercanthal distance [1]. Maximal augmentation of the nasal root can cause a slight improvement, but it makes a straight nasofrontal junction, which appears too unnatural on an Asian face. In most circumstances, an Asian epicanthoplasty is used as an ancillary procedure to a double-eyelid operation to make the eyes more beautiful [4]. If the epicanthal web and widened distance between the eyes (female, >35 mm; male, >37 mm) is presented, the modied Y-V epicanthoplasty is indicated [4]. According to our experience, the intercanthal distance can be shortened about 4 to 6 mm, resulting in a hypertrophic scar, which has been unnoticeable in all patients. Double-eyelid blepharoplasty can eliminate puffy upper eyelids and give the appearance of a wider palpebral ssure. However, for individuals with epicanthal folds,

removing the upper eyelid skin without addressing the epicanthal fold creates additional tension along the fold and accentuates its appearance. Nevertheless, removal of the epicanthal fold often leads to undesirable scarring. The modied Y-V epicanthoplasty can minimize the scar extending nasally by advancement instead of ap transposition. It also averts scarring above and/or below the medial canthus by the placement of less noticeable supraciliary and subciliary incisions [4]. The standards of beauty vary tremendously among individuals, among racial groups, and according to socioeconomic mores. With rapid development of aesthetic plastic surgery, augmentation rhinoplasty and double-eyelid blepharoplasty have become the most frequent operations in Taiwan [6]. The typical Asian nose is characterized by a relatively decient bony structure and a natural saddling of the dorsum. Most Asian upper eyelids lack a pretarsal fold, exhibit laxity of the pretarsal skin, and have a medial epicanthal fold, which is caused by hypoplasia of the nasal bones and redundancy of skin [5]. More than 50% of Taiwanese have a single or hidden eyelid. A medial epicanthal fold is found in 45% of males and 62% of females [6]. They believe that the double-eyelid operation and augmentation rhinoplasty ought to have a great effect on beauty. The goal of balanced rhinoplasty is to improve the harmony of the facial features with a dramatic tridimensional change. As mentioned earlier, the eyes and the nose are inseparable. But many questions are asked about double-eyelid blepharoplasty together with augmentation rhinoplasty. For example, if the distance between the eyes decreases after rhinoplasty, if the epicanthal fold disappears after the rhinoplasty, if rhinoplasty and double-eyelid blepharoplasty can taken together, and if they are, which surgery should be performed rst? Our experience with Oriental upper eyelid blepharoplasty and rhinoplasty has resulted in the following ndings. For a patient with a very wide intercanthal distance and a low nasal root, balanced rhinoplasty is recommended (Figs. 5 and 6). A patient who has a normal intercanthal distance with a low nasal root can get an attractive correction with balanced rhinoplasty (Fig. 7). A patient with a narrow intercanthal distance (Fig. 8) requires more caution in the technique because the eyes may look even more closed after surgery. Using our balanced rhinoplasty, the augmentation rhinoplasty should be performed before double-eyelid blepharoplasty and medial epicanthoplasty, considering the possibility of silicone implant contamination. In contrast to our priority of rhinoplasty, some surgeons perform blepharoplasty, epicanthoplasty, or both rst for the swelling of skin [3]. If a patient wishes the

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640 Fig. 5 A 20-year-old woman with a wide intercanthal distance. Left: Preoperative view. Right: Postoperative 5year view

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Fig. 6 A 12-year-old boy with a cleft lip. Left: Preoperative view. Right: Postoperative 9year view

staged operations, we suggest that either blepharoplasty or rhinoplasty be performed rst. The second stage will be performed after the proper interval about 1 month later. Augmentation rhinoplasty of the Asian nose may be effectively accomplished with either alloplastic or autogenic materials [9]. The use of silicone implants has a long legacy of safety among Orientals [9]. However, poor surgical technique and overaggressive augmentation with hardened versions of silicone implant have led to the problems of higher infection rates, contraction, displacement, and even possible extrusion [7]. The relatively low rate of infections seen in our patients has been attributed to characteristically thick skin. Implant shifting or misalignment can occur from creation of too large a pocket, constant midface movement, and repetitive microtrauma.

Extrusions, seen most commonly with the use of the silicone graft and caused by pressure exerted on the skin by the implant, usually take place at the columella and can be devastating when they occur at the tip [8]. To augment the nose fully and minimize the risk of extrusion, the onlay graft technique of contoured auricular cartilage placed at the nasal tip has been used successfully in our series. Cartilage is adequately nourished via direct diffusion and thus may be positioned safely in the nasal tip and other areas of little soft tissue coverage. Our complication rate of 3% with combined allogenic/autologous materials is similar to the 4% rate in the largest published Asian series by Endo et al. [2], who used only autologous grafts. We believe that autologous material at the nasal tip, an area of substantial mechanical stress, functions as a buffer to reduce the risk of

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Balanced Rhinoplasty Fig. 7 A 23-year-old woman with a normal intercanthal distance. Left: Preoperative view. Right: Postoperative 5year view

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extrusion. The technique combining silicone and auricular cartilage that we describe appears to be a safer way to augment Asian noses than the use of silicone alone. Alar base surgery often is indicated for Asians. In our series, the decision for alar base surgery was performed as the nal step. Classically, the alar base width should approximate that of the intercanthal distance. If the alar base appears disproportionate or inordinately wide before or at the end of balanced rhinoplasty, alar base reduction or modication should be considered in a conservative and symmetric manner. Alar reduction or modication of any type must be based on the relative anatomy and the aesthetic appearance to achieve a symmetric, balanced outcome with minimal scar. There is an inseparable link between the eyes and the nose in terms of aesthetic surgery. A perfect result achieved in one operation is difcult. Much depends on the

experience and skill of the surgeon. Our balanced rhinoplasty heightens the satisfaction with surgery and the effect of cosmetic improvement, as compared with rhinoplasty or blepharoplasty performed alone. We believe our approach can achieve a graceful harmony between the nose and the remainder of the face for Asians.

References
1. Cho BC, Lee KY (2002) Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids. Plast Reconstr Surg 110:293300 2. Endo T, Nakayama Y, Ito Y (1991) Augmentation rhinoplasty: Observations on 1,200 cases. Plast Reconstr Surg 87:5459 3. Jung DH (2006) Relationship of rhinoplasty and blepharoplasty. In: Proceedings of the 43rd Shimmian Rhinoplasty Hands-On Course, Seoul, Korea

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642 Fig. 8 A 38-year-old woman with a narrow intercanthal distance. Left: Preoperative view. Right: Postoperative 5year view

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4. Kao YS, Lin CH, Fang RH (1998) Epicanthoplasty with modied Y-V advancement procedure. Plast Reconstr Surg 102:18351841 5. Lee Y, Lee E, Park WJ (2000) Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: Do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:18721880 6. Liao WC, Tung TC, Lin CH, et al (2005) Celebrity arcade suture blepharoplasty for double eyelid. Aesth Plast Surg 29:540545

7. Shirakabe Y, Shirakabe T, Kishimoto T (1985) The classication of complications after augmentation rhinoplasty. Aesth Plast Surg 9:185192 8. Shirakabe Y, Suzuki Y, Lam SM (2003) A systematic approach to rhinoplasty of the Japanese nose: A thirty-year experience. Aesth Plast Surg 27:221231 9. Tham C, Lai YL, Weng CJ, et al (2005) Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg 54:15

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