4 Asian Tip-Plasty Techniques: Surgical Approaches and Clinical Outcomes

Asian rhinoplasty, particularly nasal tip-plasty, continues to evolve as both patient demand and surgical sophistication grow. Aesthetic goals for Asian noses typically include increased projection, improved definition, and subtle elongation of nasal length. However, surgeons face anatomical challenges: thick nasal skin, excess subcutaneous tissue, and underdeveloped cartilaginous structures, particularly in the lower lateral cartilages and columella. These features often limit the efficacy of traditional suture techniques alone.

A recent systematic review and meta-analysis by Koento and Dewi (2023) offers a comparative look at the most effective techniques in Asian tip-plasty. Analyzing four non-randomized interventional studies, the review provides both objective nasal anthropometric data and insight into procedural design. Below, we break down each technique, outline its surgical flow, compare its outcomes, and provide guidance on selecting the right method for your patients.

1. Septal Extension Graft (SEG) with “Double Tower” Nasal Stent using Ear Cartilage

   
   

Source: Zhang, L., Wang, J. wen, Ding, J., Zhang, X., Wang, X. mei, Zhang, Z. zhao, & Yu, R. ze. (2022). A new technique for Asian nasal tip shaping: “twin tower” folding ear cartilage transplantation. Case Reports in Plastic Surgery and Hand Surgery, 9(1), 207–213. https://doi.org/10.1080/23320885.2022.2123807

This innovative technique, introduced by Zhang et al., is a structural approach designed to improve tip projection using a pair of vertically oriented cartilage pillars fashioned from folded conchal cartilage. These grafts are anchored directly to the caudal septum, forming a twin-tower configuration that mimics structural columns. A shield or cap graft is then sutured over the towers to refine the tip contour and columellar profile.

The surgical procedure begins with harvesting ear cartilage, folding two segments into double layers, and suturing them into compact pillars. These are affixed end-to-end to the existing septal cartilage to provide forward projection. A final shield graft is carefully carved and placed at the tip, smoothing the contour and enhancing definition.

Indications:

This technique proved effective in both primary and secondary rhinoplasty, especially for patients needing moderate projection without drastic nasal lengthening.

• Mild to moderate tip underprojection

• Patients with preserved caudal septum

• Cases needing tip definition without aggressive lengthening

Materials:

• Conchal cartilage (ear)

Surgical Steps:

1. Harvest conchal cartilage from the ear.

2. Create two cartilage towers by folding cartilage pieces and suturing each into a double-layer construct.

3. Anchor the twin towers vertically to the caudal septum to form a rigid extension graft.

4. Add a shield or cap graft over the twin towers to refine tip aesthetics and symmetry.

5. Secure with sutures and assess projection and rotation intraoperatively.

Postoperative results showed nasal length improvements from 40.6 mm to 45.9 mm, and nasolabial angle (NLA) improvements from 95.9° to 101.7°. The method is structurally sound, relatively simple to execute, and carries minimal donor site morbidity, although it may offer limited augmentation for severely short noses.

Advantage: The technique is simple and effective, utilizing autologous material. It offers rigid vertical support and causes minimal donor-site morbidity.

Disadvantages: It may provide limited projection for severely short noses, and tip bulk can be more pronounced in patients with thicker skin.

2. Sandwich Graft: SEG Technique with a Cartilage-Bone Complex Graft for Rigid Support

Source: Ahn TH, Zheng T, Kang HJ, Yoo BJ, Chung JH, Jeong JH. New Technique in Nasal Tip Plasty: Sandwich Technique Using Cartilage and Septal Bone Complex. Ear, Nose & Throat Journal. 2019;99(9):599-604. doi:10.1177/0145561319881570

For patients requiring stronger, long-lasting support—especially in revision cases or those with significant cartilage deficiency—the Sandwich Graft technique developed by Ahn et al. presents an ideal option. This method involves creating a composite graft using a central core of vomer and ethmoid bone, layered on either side with septal cartilage. The resulting "sandwich" is then shaped and sutured into a robust septal extension graft.

The graft is anchored to the caudal septum and serves as a powerful internal scaffold. To smooth the dorsal contour and mask any rigidity from the bony components, an alloplastic radix implant may be added. Intraoperatively, precise alignment of the sandwich graft is crucial, as is balancing the nasal profile through symmetric cartilage shaping.

Indication:

• Moderate to severe underprojection

• Revision cases with septal deficiency

• High-demand patients requiring strong dorsal support

Materials:

• Vomer and ethmoid bone

• Double-layered septal cartilage

• Alloplastic radix implant (optional)

  
  

Surgical Steps:

1. Harvest vomer, ethmoid plate, and septal cartilage.

2. Construct a sandwich graft with the bone core and cartilage layers on both sides.

3. Shape and suture the graft for dorsal alignment.

4. Anchor to the caudal septum as a robust SEG.

5. Overlay an alloplastic radix graft for dorsal contouring (if needed).

6. Fine-tune tip projection using interdomal sutures or cap grafts.

Postoperative outcomes in this group were impressive. The nasal length increased by nearly 10%, and the NLA improved by 13°, reaching a more desirable upward rotation. The tip projection showed significant elevation as well. Despite these gains, surgeons should be mindful of the technique’s complexity and the potential for bone resorption or visible irregularities if improperly shaped.

Advantages: It provides strong mechanical support and long-lasting projection, making it ideal for revision rhinoplasty.

Disadvantages: The procedure is technically complex and carries a risk of graft warping or bone resorption. It also requires precise shaping to avoid visible irregularities.

3. Folded Ear Cartilage Grafts and Pagoda Shape Tip On-lay

Source: Mo Young Woong et al. A new technique in Asian nasal tip plasty: Non-incisional double-layered conchal cartilage graft. Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 74, Issue 6, 1316 - 1323

Mo et al. proposed a technique combining an extended spreader graft, columellar strut graft, and a pagoda-shaped onlay graft at the nasal tip. The approach begins with conchal cartilage harvested and folded into a double layer, which is then shaped into a pagoda-style onlay. This configuration is designed to reinforce the nasal dorsum, prevent cephalic rotation, and offer a natural projection.

A columellar strut graft is inserted between the medial crura, reinforcing the M-arch framework and stabilizing the nasal base. The pagoda onlay is then secured over the dome area, creating a structured but harmonious nasal tip profile. This technique is especially useful in patients with broad or flat nasal tips, and those with soft tip cartilage that lacks natural definition.

Indication:

• Short noses with weak tip cartilage

• Patients with broad or flat tips

• Those needing subtle dorsal augmentation

Materials:

• Folded conchal cartilage

Surgical Steps:

1. Harvest conchal cartilage and fold it into a double-layered structure.

2. Fashion an extended spreader graft to stabilize the dorsum.

3. Add a columellar strut graft to support medial crura and enhance tip stability.

4. Create a pagoda-shaped onlay graft for tip definition.

5. Suture components together and align under direct visualization.

While the structural strength may not rival bone-based composites, this technique strikes a favorable balance between support and natural appearance. Postoperative metrics confirmed improvements in both nasal length and tip projection ratio, with the NLA increasing by approximately 4°. It is particularly suitable for patients who require mild to moderate correction with strong definition and minimal invasiveness.

Advantages: It offers balanced projection and definition while preserving the natural curvature of the nose. This technique is ideal for subtle reshaping with strong tip control.

Disadvantages: It may not be sufficient for revision cases or severe tip deformities and is limited by the size of the ear cartilage.

4. M-Shaped Alar Cartilage with SEG: Ideal for Short Nose Correction

Source: Zhang, C., Wang, G., Zhen, Y. et al. M-Shaped Auricular Cartilage Grafts for Correcting Short Nose Deformity in Asians: A Retrospective Study. Aesth Plast Surg 48, 1926–1934 (2024). https://doi.org/10.1007/s00266-023-03619-1

An et al. introduced a technique designed specifically for patients with a short or retracted nose—a common aesthetic concern in Asian rhinoplasty. Their method combines a traditional SEG with an M-shaped conchal cartilage graft positioned along the alar cartilages. The "M" configuration provides lateral expansion and support, complementing the vertical projection offered by the SEG.

After harvesting and shaping the conchal cartilage, the M-shaped graft is sutured along the lower lateral cartilages, bolstering the sidewalls and tip dome. The SEG is anchored caudally, forming a vertical spine that lifts the tip and elongates the nasal length. Together, these components provide a scaffold that balances strength and flexibility.

Indication:

• Short or retracted noses

• Patients requiring vertical tip support

• Suitable for severe tip ptosis

Materials:

• Conchal cartilage

Surgical Steps:

1. Harvest M-shaped conchal cartilage.

2. Anchor the M-shaped graft bilaterally into the lower lateral cartilages.

3. Place SEG along the caudal septum to project the tip vertically.

4. Suture the grafts together with domal approximation.

5. Assess for nasal length and rotation adjustment.

The outcomes demonstrated excellent improvements: nasal length increased by over 3.5 mm, and tip projection improved significantly (14.8 mm to 16.2 mm), with long-term follow-ups up to 36 months confirming stability. This technique is highly effective for patients with columellar retraction or inadequate nasal length and is recommended for those seeking both structural elongation and refined contouring.

Advantages: It is effective for increasing both projection and nasal length, providing a strong internal framework. This technique is particularly useful in short-nose correction.

Disadvantages: There is a slight learning curve, and it may require additional radix augmentation.

Comparing the 4 Techniques: Outcomes, Strengths, and Use Cases

Each of the four techniques offers distinct advantages depending on patient anatomy and aesthetic goals. The “Double Tower” method is ideal for primary rhinoplasty with moderate tip needs and thick skin. It’s straightforward, reliable, and particularly helpful for adding vertical projection in patients with decent septal support.

The Sandwich Graft technique is more complex but offers unmatched strength, making it the preferred option for revision cases, severe underprojection, or patients with very soft cartilage. It offers robust and stable long-term results but requires meticulous handling of bone and cartilage materials.

The Pagoda Onlay technique stands out for its aesthetic balance. It’s well-suited for patients seeking definition without aggressive augmentation and excels in preserving nasal curvature and dome symmetry.

The M-Shaped graft with SEG is best for short or retracted noses, providing both structural elongation and aesthetic refinement.

Despite their variations, all techniques prioritize framework reinforcement—a critical consideration in Asian noses where weak cartilage often leads to tip droop or postoperative regression. By understanding nasal tip dynamics (tripod theory, M-arch structure), and combining the right grafts, surgeons can achieve lasting, natural-looking results.

The table below summarises the advantages and disadvantages of each techniques:

Technique	Best For	Projection	Complexity	Key Graft Material	Main Advantage	Limitations
Double Tower SEG	Mild-moderate underprojection	★★★★☆	Low	Ear cartilage	Simple, reliable support	Limited for very short noses
Sandwich Graft	Severe cases, revisions	★★★★★	High	Bone + cartilage	Excellent strength and durability	Technical complexity
Folded Ear Cartilage Grafts + Pagoda Tip	Broad tips, weak domes	★★★★☆	Medium	Ear cartilage	Balanced projection and definition	Less effective in severe ptosis
M-Shaped Graft + SEG	Short/retracted noses	★★★★★	Medium	Ear cartilage	Elongates and supports tip well	Needs careful design and placement

When to Use Which Technique?

Patient Profile	Recommended Technique
First-time rhinoplasty with moderate needs	"Double Tower" SEG
Revision rhinoplasty, septal deficiency	Sandwich Cartilage-Bone Graft
Thick skin, undefined tip, broad alae	Folded Ear Cartilage Grafts + Pagoda Tip
Retracted columella, short nose deformity	M-Shaped Graft + SEG
Need for long-term projection and definition	Sandwich or M-Shaped Graft

Conclusion

Modern Asian tip-plasty has moved beyond simple tip suturing to embrace structurally engineered graft-based solutions. Whether using folded conchal cartilage, composite bone-cartilage constructs, or multi-layered onlay designs, the goal remains the same: to refine, project, and stabilize the nasal tip in a way that aligns with the patient’s ethnic features and aesthetic desires.

Surgeons should assess each case individually, considering nasal length, skin thickness, cartilage strength, and the desired projection. The techniques highlighted in this review all demonstrate significant improvements in objective nasal anthropometry and hold promise for consistent, reproducible outcomes.

As always, mastering these techniques involves not just replicating steps, but deeply understanding the anatomical and mechanical principles that support successful nasal tip-plasty.

Reference:

1. Koento, T., & Dewi, D. J. (2023). The ideal technique for nasal tip surgery for Asians: Understanding the best technique and post-operative improvement: A systematic review/meta-analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery, 39, 142-151. https://doi.org/10.1016/j.jpra.2023.11.010

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