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Nasal Tip Augmentation for Asians

Dong Hak Jung

Tip Projection

Autologous cartilage grafts are used for the nasal tip

Columellar Strut

A columellar strut is placed between the medial crura through an external


approach (Figure 24-1 , A). Even without direct contact with the anterior nasal
spine, the strut strengthens tip support and adds significant projection when
used together with a shieldor cap graft. The collumellar strut does not span the
entire length of the columella in a tent pole fashion; rather , it is positioned in the
midportion of columella to preserve mobility. Although septal cartilage is
preferred, auricular or costal cartilage may be used. Before suture fixation,
temporary fixation with a 26 gauge needle helps maintain precise alignment (see
Figure 24-1, B). If simetry is not achieved, tilting or deviation of the columella
may occur (Figure 24-2).

Transdomal Suture
Transdomal suture fixation is made a horizontal mattress fashion using #5.0
polydiaoxane suture (PDS suture). The suture begins in the center, and the knot is
tied between the dome. The suture loop is positioned slightly cephalic to the
center of the dome to enhance the tip defining points (TDPs). It is crucial to
maintain the symmetry (Figures 24-3 and 24-4)

Figure 24.1
A, Placement of columellar strut. B, Intraoperative view

Figure 24-2
Asymmetric strut fixation cause a columellar deviation

Shield graft
A shield shaped septal cartilage graft with a-8 to 12 mm upper edge defines the
TDPs (Figure 24-5). On frontal view, TDPs are generally less than 10 mm apart.
These are the reflections of light at the junction between the domes (Figure 24-
6). The edges of the cartilage are tapered to provide a smooth surface contour. A
longer graft not only add projection but can also lengthen the nose. A shorter
graft tends to fall back cephalically, giving rotation in addition to projection
(Figure 24-7). When the graft projects more than 1 to 3 mm or the graft material
is weak, a buttress graft is added for posterior reinforcement. The surgeon must
keep in mind that the flat nature of the graft may lead to the loss of natural
infratip lobular contour.

Figure 24-3
A, Transdormal suture. B and C, Intraoperative views.

Figure 24-3 contd


D to G, Intraoperative views, H and J, Preoperative views. I and K, Postoperative
views.

Figure 24-4
A, An alternative method to the transdomal suture is to suture each dome
individually and the tie the two domes together. B, Preoperative view. C,
Postoperative view.

Figure 24-5
Shield graft A, The graft is 8 to 12 mm wide and projects 1 to 3 mmabove the
existing domes. B, The graft is fixed with four to six interrupted 6-0 PDS sutures.

Figure 24-6
Preoperative views (A) and postoperative view (B) after placement of sheld
grafts.

Figure 24-7
A, Long shield graft augmenting the nasal tip. B, A short graft can roll back and
create a cephalic rotation. C, A long graft with posterior reinforcement adds a
lightening effect to the nose.

Figure 24-8
A, Cap graft. B, Intraoperative view.

Cap Graft (Onlay Graft)


The cap graft is a simple method to enhance the TDPs. The 8 to 12 mm wide
grafts are stacked in layers. Fixation is done with two to four interrupted 6-0 PDS
sutures. It is better to place a columellar strut when a cap graft is planned
(Figures 24-8 and 24-9).

Plumping Graft
The use of plumping graft at the feet of the columella adds projection and
improves the nasolabial angle (Figure 24-10). This graft is more effective when
used in combination with other techniques.

Figure 24-9
Preoperative view (A) and postoperative view (B) after placement of cap grafts.

Figure 24-10
A and B, Plumping graft. Preoperative view (C) and postoperative view (D)
showing improvement of the nasolabial angle.

Tip Deprojection
Unlike in Caucasian patients, lowering the tip is rarely indicated in Asians. In the
case of boxy or bulbous noses, overzealous narrowing of the nasal tip may result
in an overly projected tip (i.e., Pinocchio nose). In such cases the tip should first
be deprojected before a radical narrowing is performed (Figures 24-11 and 24-
12).
Resection may be done at the medial crura alone or at both the medial and lateral
crura. Reapproximation is done in an end to end or overlapping fashion. Wedge
resection of the membranous septum may be added. Although it is somewhat less
effective, alar base resection can accomplish deprojection of the tip.

Figure 24-11
Tip deprojection by medial crural resection, overlap, and reapproximation
(dotted line).

Multiple graft
Nasal tip surgery using a single graft may not be effective for the Asian nose
because of the unfavorable combination of thick skin and weak cartilages. Tip
rhinoplasty in Asians often requires a sturdier graft to support and thrust the
heavy skin envelope. The author often uses multiple grafting techniques through
an external approach for more precise application of the grafts.

Figure 24-12
A and B, Intraoperative views. Preoperative view (C) and postoperative view (D)
demonstrate that the nasal tip has been narrowed but its height has been
maintained.

Figure 24-13
A, The LLCs are reinforced with auricular cartilage before other tip maneuvers
are made. B and C, Preoperative views. D and E, Postoperative views.

Strengthtening the Lower Lateral Cartilage


Auricular cartilage grafts are used to strengthen the lower lateral cartilage
support (Figure 24-13).

Multilayered Shield Grafts


A columellar strut should also be used in addition to multi layered shield grafts
(Figure 24-14)

Multilayered Cap Grafts


The choice of the shield graft versus cap graft is based on the grafts ability to
give better TDPs and the availability and type of cartilage (Figure 24-15)
Cap and Shield Grafts
The use of cap and shield grafts requires the placement of a columellar strut
(Figure 24-16).

Shield Graft Support


The overly projecting shield graft may bend posteriorly. Posterior support is
necessary to achieve reliable tip projection (Figure 24-17).

Costal Cartilage Shield and Cap Graft


The costal cartilage should and cap graft provides strong support (Figure 24-18).

Figure 24-14
A, Demonstration of the shield grafts layers. B and C, Preoperative views. D and
E, Postoperative views.

Postoperative Care
Postoperatively, Thermoplast is applied on the nose. The sutures are removed on
the fifth postoperative day. Prophylactic antibiotics are given for 3 to 5 days.
Application of an icepack may reduce the amount of edema and ecchymosis.
Nasal packing is placed for about 6 hours after septal cartilage harvesting. If the
septal deviation was corrected, the packing is left in place for 24 hours. Follow up
visits are made at the fifth day; 1 week; 1,3, and 6 month; and annually.

Figure 24-15
A, Intraoperative placement of multilayered cap grafts. B, Intraoperative view. C
and D, Preoperative views. E and F, Postoperative views.

Figure 24-16
A, Shield graft in combination with cap graft. B, Intraoperative view. C and D,
Preoperative views. E and F, Postoperative views

Figure 24-17
A, Posterior support of the shield graft. B and C, Intraoperative views. D and E,
Preoperative views. F and G, Postoperative views.

Figure 24-18
Costal cartilage grafts. A and B, Intraoperative views. C and D, Preoperative
views. E and F, Postoperative views.

References
1. Johnson CM, Toriumi DM: Open structure rhinoplasty, Philadelphia, 1990,
Saunders.
2. Jung DH, Jang TY, Kim YM: Aesthetic nasal tip surgery, Korean J
Otolaryngol 39 (10): 685-693, 1996.
3. Yoon JS, Jung DH, Min YG: Rhinoplasty through the external approach,
Korean J Otolaryngol 40(8): 1091-1096, 1997.

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