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Aesth Plast Surg (2007) 31:636–642 DOI 10.

1007/s00266-006-0137-1

ORIGINAL ARTICLE

Balanced Rhinoplasty in an Oriental Population
Wen-Chieh Liao Æ Hsu Ma Æ Chiu-Hwa Lin

Received: 27 June 2006 / Accepted: 2 October 2006 Ó 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 satisfied 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 Á 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 Á 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 flat or low dorsum, a poorly projected tip, an acute nasolabial angle, a short columella, a wide alar base, and a round or flared 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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3 years (range. Double-Eyelid Blepharoplasty and Modified Y-VEpicanthoplasty The patient determines the height and shape of the desired crease (Fig. the various implants can be placed along the nasal dorsum to determine the proper fit. the height of the fold should be approximately 6 to 8 mm above the ciliary margin or naturally established line. The dissection proceeds in the subperiosteal plane. then the next larger size should be used and trimmed along its superior extent to fit the desired length. The incision we use is at the level of the midcolumella to break up the line of the scar and prevent notching. one to three small circular disks of cartilage about 0. The incision is closed with a 6-0 nylon suture. The horizontal incision extends to meet a vertical marginal incision.5 to 1. Right: Attractive features of Asian face 637 for this study. The superior aspect of the implant should rest equidistantly between the glabella and the nasion. The skin closure is accomplished using 7-0 nylon in a running fashion. Portions of the orbicularis oculi muscle. which is removed on the third to fifth postoperative day. and photography. The implant then can be soaked in antibiotic solution during creation of the recipient pocket. Typically. 123 . and reinspection for bleeding points. All the patients underwent augmentation rhinoplasty with silicone implants. the levator is identified and attached to the lower border of the ocularis muscle with three sutures along the entire edge of the tarsus. lacrimal system evaluation. Indications for surgery. 3). A skin incision is made on the upper eyelid according to the usual method. with a Joseph elevator inserted to create a pocket. 2). and the pretarsal fat with or without excessive orbital fat are removed by careful clamping. Preoperative studies included anthropometric measurements. After removal of the fat. and postoperative complications were recorded. In general. through an anterior approach.000 epinephrine) infiltration.Balanced Rhinoplasty Fig. 1 Left: Characteristic features of the Asian face. Operative Method All procedures are performed with the patient under intravenous sedation and local anesthesia (1% lidocaine with 1:200. and symmetry is confirmed by visual inspection and palpation. auricular cartilage graft was harvested from the cavum and cymba conchal cartilage. The average patient age was 24. cutting. double-eyelid upper blepharoplasty. Insertion of the Implant The external rhinoplasty technique is the only way to gain exposure (Fig. If the exact implant size cannot be matched. depending on the tip projection required. patient satisfaction. placed 5 to 6 mm apart. 3). sparing the radix helices. The postoperative care is same as for any other nasal procedure. electrocautery. The implant is placed into the created pocket.0 cm in diameter were fashioned. whereas the inferior aspect should fit around the curve of the nasal tip. the connective tissue. The excessive skin is marked out in an elliptical fashion. and modified Y-V epicanthoplasty with or without chin augmentation. 20–38 years). The immobility of the implant’s superior aspect that resides under the tight subperiosteal pocket also should be verified. 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. In this study. After the sterile field has been properly prepared.

Excessive orbicularis oculi muscles and subcutaneous tissues are trimmed. Moreover. points B and C are marked crossing the lacrimal lake. Two periciliary lines. In one patient. D. and preservation of the shape of the nose. and all adhesion bands are subsequently released. (2) an incision method of double-eyelid blepharoplasty for creating a supratarsal 123 . The shape of the nose and double eyelids was maintained. There were two cases of delayed implant extrusion. 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. 3 The surgical design of balanced rhinoplasty Epicanthoplasty With the Modified Y-V Advancement Procedure (Fig. which resolved with oral antibiotics. B. the patients in our series had an uneventful postoperative course. C. exposing the lacrimal lake completely to make point A’ at the apex of the lacrimal lake. 3) is made at the end of all the procedures. to A’ is resected. The lengths of these two lines can be adjusted to correct residual skin deformities after approximation of points A and A’. and alar sculpturing may be selected and performed either in the sidewall of the alar flare or in the nostril floor. 5 years).-C. Liao et al. 2 The auricular cartilage and design of onlay graft W. The postoperative follow-up period ranged from 5 months to 10 years (average. scarring from all the incisions was invisible. and E. displacement of implant. With few exceptions. A’D and A’E. The nasal skin then is tracted medially. a deep buried suture using 6-0 prolene is performed by plicating the periosteum of nasal bone or medial canthal ligament to point A. 4) Point A is on the skin of the medial canthus overlying the apex of the lacrimal lake. an infection developed after several months.638 Fig. The three points form a triangle. are made. The V-shaped skin from A. with both patients and surgeons judging the results to be satisfactory. Results A total of 245 patients underwent balanced rhinoplasty. Fig. Finally. At this time. the general appearance of the nose may be assessed. both of them secondary to trauma. The results were evaluated considering postoperative complications. On the web. Alar Base Surgery The decision for alar base surgery (Fig.

(4) and alar base surgery.Balanced Rhinoplasty 639 Fig. With rapid development of aesthetic plastic surgery. 5 and 6). The modified Y-V epicanthoplasty can minimize the scar extending nasally by ‘‘advancement’’ instead of flap ‘‘transposition. which surgery should be performed first? Our experience with Oriental upper eyelid blepharoplasty and rhinoplasty has resulted in the following findings. 7). Using our balanced rhinoplasty. augmentation rhinoplasty and double-eyelid blepharoplasty have become the most frequent operations in Taiwan [6]. some surgeons perform blepharoplasty. (3) modified Y-V epicanthoplasty to enhance the aesthetic result by lengthening of the palpebral fissure. an Asian epicanthoplasty is used as an ancillary procedure to a double-eyelid operation to make the eyes more beautiful [4]. among racial groups. Nevertheless. For a patient with a very wide intercanthal distance and a low nasal root. They believe that the double-eyelid operation and augmentation rhinoplasty ought to have a great effect on beauty. If a patient wishes the 123 . but it makes a straight nasofrontal junction. for individuals with epicanthal folds. If the epicanthal web and widened distance between the eyes (female. and according to socioeconomic mores.’’ It also averts scarring above and/or below the medial canthus by the placement of less noticeable supraciliary and subciliary incisions [4]. Double-eyelid blepharoplasty can eliminate puffy upper eyelids and give the appearance of a wider palpebral fissure. male. As mentioned earlier. >37 mm) is presented. Augmentation rhinoplasty is performed to correct the underdeveloped nasal root and make a good image of the eyes [9]. removing the upper eyelid skin without addressing the epicanthal fold creates additional tension along the fold and accentuates its appearance. A patient with a narrow intercanthal distance (Fig. For example. However. the intercanthal distance can be shortened about 4 to 6 mm. the modified Y-V epicanthoplasty is indicated [4]. resulting in a hypertrophic scar. The goal of balanced rhinoplasty is to improve the harmony of the facial features with a dramatic tridimensional change. exhibit laxity of the pretarsal skin. epicanthoplasty. and have a medial epicanthal fold. which is caused by hypoplasia of the nasal bones and redundancy of skin [5]. In most circumstances. A patient who has a normal intercanthal distance with a low nasal root can get an attractive correction with balanced rhinoplasty (Fig. In contrast to our priority of rhinoplasty. The standards of beauty vary tremendously among individuals. But many questions are asked about double-eyelid blepharoplasty together with augmentation rhinoplasty. the eyes and the nose are inseparable. if rhinoplasty and double-eyelid blepharoplasty can taken together. Most Asian upper eyelids lack a pretarsal fold. and if they are. 8) requires more caution in the technique because the eyes may look even more closed after surgery. if the epicanthal fold disappears after the rhinoplasty. >35 mm. considering the possibility of silicone implant contamination. Maximal augmentation of the nasal root can cause a slight improvement. if the distance between the eyes decreases after rhinoplasty. But augmentation alone cannot decrease the intercanthal distance [1]. or both first for the swelling of skin [3]. More than 50% of Taiwanese have a single or hidden eyelid. balanced rhinoplasty is recommended (Figs. 4 The illustration of modified Y-V advancement epicanthoplasty fold. A medial epicanthal fold is found in 45% of males and 62% of females [6]. the augmentation rhinoplasty should be performed before double-eyelid blepharoplasty and medial epicanthoplasty. The typical Asian nose is characterized by a relatively deficient bony structure and a natural saddling of the dorsum. which appears too unnatural on an Asian face. which has been unnoticeable in all patients. removal of the epicanthal fold often leads to undesirable scarring. According to our experience.

-C. Right: Postoperative 5year view W. The relatively low rate of infections seen in our patients has been attributed to characteristically thick skin. who used only autologous grafts. 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. Right: Postoperative 9year view staged operations. contraction. Implant shifting or misalignment can occur from creation of too large a pocket. 6 A 12-year-old boy with a cleft lip. poor surgical technique and overaggressive augmentation with hardened versions of silicone implant have led to the problems of higher infection rates. Fig. an area of substantial mechanical stress. Left: Preoperative view. 5 A 20-year-old woman with a wide intercanthal distance. The use of silicone implants has a long legacy of safety among Orientals [9]. functions as a buffer to reduce the risk of 123 . The second stage will be performed after the proper interval about 1 month later. However.640 Fig. To augment the nose fully and minimize the risk of extrusion. We believe that autologous material at the nasal tip. [2]. Left: Preoperative view. we suggest that either blepharoplasty or rhinoplasty be performed first. the onlay graft technique of contoured auricular cartilage placed at the nasal tip has been used successfully in our series. Augmentation rhinoplasty of the Asian nose may be effectively accomplished with either alloplastic or autogenic materials [9]. and even possible extrusion [7]. 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. Extrusions. Liao et al. constant midface movement. 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]. displacement. and repetitive microtrauma.

If the alar base appears disproportionate or inordinately wide before or at the end of balanced rhinoplasty. Korea 123 . Our balanced rhinoplasty heightens the satisfaction with surgery and the effect of cosmetic improvement. balanced outcome with minimal scar. Jung DH (2006) Relationship of rhinoplasty and blepharoplasty. Plast Reconstr Surg 87:54–59 3. 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. Left: Preoperative view. the alar base width should approximate that of the intercanthal distance. There is an inseparable link between the eyes and the nose in terms of aesthetic surgery. References 1. Alar reduction or modification of any type must be based on the relative anatomy and the aesthetic appearance to achieve a symmetric.200 cases. alar base reduction or modification should be considered in a conservative and symmetric manner. Endo T. Right: Postoperative 5year view 641 extrusion. A perfect result achieved in one operation is difficult.Balanced Rhinoplasty Fig. Much depends on the experience and skill of the surgeon. Ito Y (1991) Augmentation rhinoplasty: Observations on 1. Alar base surgery often is indicated for Asians. Lee KY (2002) Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids. In our series. Cho BC. the decision for alar base surgery was performed as the final step. In: Proceedings of the 43rd Shimmian Rhinoplasty Hands-On Course. Plast Reconstr Surg 110:293–300 2. Nakayama Y. 7 A 23-year-old woman with a normal intercanthal distance. Seoul. We believe our approach can achieve a graceful harmony between the nose and the remainder of the face for Asians. Classically. as compared with rhinoplasty or blepharoplasty performed alone.

Shirakabe Y. Kao YS. Right: Postoperative 5year view W. Lin CH. Suzuki Y.-C. et al (2005) Silicone augmentation rhinoplasty in an Oriental population. Left: Preoperative view. Shirakabe Y. Aesth Plast Surg 27:221–231 9. Fang RH (1998) Epicanthoplasty with modified Y-V advancement procedure. Shirakabe T. Lai YL. Plast Reconstr Surg 102:1835–1841 5. et al (2005) Celebrity arcade suture blepharoplasty for double eyelid. Kishimoto T (1985) The classification of complications after augmentation rhinoplasty. Weng CJ. Liao et al. Tham C.642 Fig. 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 105:1872–1880 6. 4. Liao WC. Aesth Plast Surg 9:185–192 8. Aesth Plast Surg 29:540–545 7. Tung TC. Lam SM (2003) A systematic approach to rhinoplasty of the Japanese nose: A thirty-year experience. Ann Plast Surg 54:1–5 123 . Lee Y. 8 A 38-year-old woman with a narrow intercanthal distance. Lin CH.