The Perfect Asian Nasal Tip: A Step-by-Step Guide with Cartilage Grafts & Silicone Implants
The typical characteristics of the nose in Asians include a low bridge and a wide tip. The most commonly performed procedures in Asian rhinoplasty are dorsal augmentation using silicone implants and tip plasty using cartilage from the patient's own body. However, the use of synthetic materials can lead to infections and the displacement of silicone implants. Additionally, the use of autologous cartilage for nasal tip plasty can result in the formation of fibrous tissue or scarring, which can make revision rhinoplasty more challenging.
To address these issues, a study done by Dr. Hwang and Dr. Kang from South Korea employed a straightforward technique involving a combination of a silicone implant and cartilage from the conchal area. No previous studies have explored a systematic approach and detailed procedure for tip plasty using silicone implants, making it difficult to plan such an operation. Furthermore, they made modifications to the method of harvesting conchal cartilage.
Patient Segmentation
Their study included a total of 39 consecutive patients (35 women and 4 men) who underwent augmentation rhinoplasty. The procedures involved the use of silicone implants for dorsal augmentation and autologous cartilage for tip plasty. The patients were treated between January 2010 and November 2017. Their average age was 28.1 years, ranging from 16 to 64 years. The follow-up period lasted for an average of 16.6 months, ranging from 6 to 53 months.
Patients who received dorsal augmentation or nasal tip plasty using freeze-dried acellular allogenic cadaveric dermis or those who underwent only dorsal augmentation without nasal tip plasty, or only nasal tip plasty without dorsal augmentation, were excluded from the study. A single surgeon performed all of the rhinoplasty procedures. The medical records of the patients were retrospectively reviewed to gather information about their initial diagnosis, surgical techniques used, clinical follow-up, and any surgical complications. It is important to note that all of their patients provided written informed consent for the use of either conchal or septal cartilage during the procedures.
During the six-month follow-up evaluation, the patients were asked to rate their satisfaction with the surgery on a scale ranging from "very satisfactory" to "unsatisfactory." Additionally, the esthetic outcomes were assessed by two plastic surgeons who were not aware of the specific surgical techniques used, but were aware of the fact that the patients had undergone rhinoplasty. The surgeons evaluated the changes in the nose by comparing preoperative and postoperative photographs. They focused on assessing the improvements in dorsal augmentation, the downward rotation of the nasal tip, and enhanced tip projection. Based on their evaluation, the corrections were graded as "excellent," "good," "fair," or "no change."
Harvesting of Cartilage & Shaping the Silicone Implant
To obtain the cartilage for the procedure, the conchal area of the ear was used. This was done by making an incision behind the ear (post-auricular incision) while ensuring that the radix helicis (the root of the helix) was preserved as a cartilage bar. This particular technique is referred to as the "bridge" technique, which helps maintain the cartilage framework. Each cartilage graft was specifically designed to be positioned on the silicone tip.
The shield graft, which serves as a larger piece of cartilage, had a mean size of 12 × 7 mm. On the other hand, the onlay graft, which is a smaller piece of cartilage, had a mean size of 4 × 3 mm. After the cartilage was harvested, the donor site was closed primarily (without the need for additional tie-over dressing or external support). The rhinoplasty procedure was carried out using either the open or endonasal approach. The choice of approach depended on various factors, such as the surgeon's judgment, the patient's condition, and the complexity of the surgery.
For the silicone implant, it was carefully carved to achieve the desired volume and shape that would best suit the patient's needs. Before harvesting the cartilage, specific adjustments were made to the lower lateral cartilage. These adjustments included procedures like interdomal sutures, intradomal sutures, derotation sutures, or strut sutures, depending on the requirements of each case. Once the cartilage from the ear (auricular cartilage) was harvested, secondary modifications were performed. This involved trimming the cartilage in terms of height and width, and sometimes using hatching techniques for the shield and onlay graft. The trimmed cartilage was then sutured onto the upper surface of the silicone implant. This combination of the silicone implant and cartilage created a complex structure that was used during the procedure.
Edge Vs No-Edge Type
The complex, consisting of the silicone implant and cartilage, was classified into two types: the edge type and the no-edge type. In the edge type, the superior edge of the shield graft was positioned 1 or 2 mm above the silicone implant or onlay graft. On the other hand, in the no-edge type, the tip of the shield graft was at the same level as the silicone implant or onlay graft. The presence of an edge had advantages in cases where the patient had a broad or bulbous nasal tip, particularly in individuals with thicker skin. It helped in clearly defining the supra tip, the area above the nasal tip. To prevent the transparency of the cartilage through the skin, the angular contour of the superior edge of the shield graft was carefully trimmed.
The decision to create the "edge" or opt for the no-edge type was based on several factors. These factors included the patient's preference, the shape of the nasal tip, and the thickness of the soft tissues. The surgeon made the determination after considering these variables.
See below the table of explanations of graft-based silicone implants by group number and edge type. (From Hwang & Kang, 2019)
See below the figure below: In the edge type, the superior edge of the shield graft was located 1 or 2 mm above the silicone implant or onlay grafts. In the no-edge type, the shield graft tip was located at the same level of the silicone implant or onlay grafts. Each type is divided into three groups depending on the number of onlay grafts: Group I, no onlay graft; Group II, one onlay graft; and Group III, ≥2 onlay grafts.
The two types of complexes were further categorized into three groups based on the number of supporting onlay grafts. Group I consisted of the silicone implant complex without any onlay grafts. Group II included the silicone implant complex with one onlay graft. Group III comprised the silicone implant complex with two or more onlay grafts. The decision regarding the number of onlay grafts was made by the surgeon, taking into consideration the patient's preferences and the characteristics of their nose. Afterward, the silicone end was carefully carved.
The position of the shield graft tip can be adjusted by carving the end of the silicone implant in the cephalic direction. This allows for easy movement of the supra tip and supra tip location. In order to ensure stability of the silicone implant complex, cap grafts can be placed between the silicone implant and the cartilage graft. Once the complex is prepared, it is positioned on the dorsum of the nose. If any displacement is observed in key skin sutures, absorbable 6-0 sutures are occasionally used to fix the implant complex to the lower lateral cartilage. If there is a need to reduce a bulbous tip, some of the soft tissue at the bottom of the tip skin flap is carefully resected during the surgery. After confirming the final contour of the nose, the skin incision is closed. See below the figure below: The end of the silicone implant can be carved for angulating the shield and onlay grafts for cephalic movement of the supra tip.
See below the figure below: Cap grafts (green color) can be used between the grafts and the silicone implant for complex stability.
See below the table of number of cases by group number and edge type in 39 patients:
Case 1: Edge Type
A 37-year-old woman visited with concerns about her deviated nose and a low nasal tip. She had previously undergone dorsal augmentation using a silicone implant and a cartilage graft for the tip of her nose, approximately 10 years ago. However, there was an evident mismatch between the position of the silicone tip and the nasal tip area. During the preoperative examination, it was observed that she had thick nasal skin and soft tissue.
Surgical Steps
Endonasal approach rhinoplasty by the bilateral alar rim incision included the following:
A sub-SMAS pocket was dissected on the dorsum
The previously inserted silicone implant was removed.
The previously inserted cartilages were dissected and removed.
The conchal cartilage of the right ear was harvested.
It was trimmed into two pieces for a shield graft and an onlay graft.
The silicone implant was carved into the desired volume and shape.
A piece of the cartilage graft was sutured to the silicone implant with the edge, and a silicone implant with a shield complex was created.
The silicone implant complex was placed into the dissected pocket and fixed with absorbable 6–0 sutures on the lower lateral cartilage.
After confirming the final contour with key sutures, closure was performed.
At the 11-month postoperative follow-up, a corrected nasal dorsum and an increased projected tip were observed.
Case 2: No-Edge Type
A 16-year-old girl came in with concerns about her nasal appearance, which included a bulbous and underprojected nasal tip, asymmetric alar cartilage, a dorsal hump, and a low nasal dorsum. It's important to note that she had not undergone any previous operations. During the preoperative examination, it was observed that her septum was straight, allowing for unobstructed nasal airflow. Additionally, her nasal skin and soft tissue were thin.
Surgical Steps
Open rhinoplasty by the transcolumellar incision included the following:
A subsuperficial musculoaponeurotic system (sub-SMAS) pocket was then dissected on the dorsum.
Rasping of the bony part for correcting the dorsal hump was performed.
Interdomal fixation was performed.
The conchal cartilage of the right ear was harvested with the bridge technique.
The cartilage was trimmed into three pieces for a shield graft and two onlay grafts.
The silicone implant was carved into the desired volume and shape.
A no-edge, Group II silicone implant-cartilage complex was created by suturing one shield graft and one onlay graft to the distal end of the silicone implant.
The silicone implant complex was placed into the dissected pocket and fixed with absorbable 6–0 sutures on the lower lateral cartilage.
After confirming the final contour with a key suture, closure was performed.
At the 15-month postoperative follow-up, an increased tip projection, a symmetric nasal tip, and an augmented nasal dorsum were observed.
Common Complications
The use of alloplastic materials in rhinoplasty carries certain risks, including infection, displacement, translucency (being visible through the skin), and extrusion. On the other hand, autologous grafts, which utilize the patient's own tissues, are considered to be superior to alloplastic materials. However, using autologous grafts alone, such as dermofat tissue or rib cartilage, may not always achieve the desired aesthetic outcomes in rhinoplasty. Additionally, the presence of donor site scarring can be a concern in terms of aesthetics and patient satisfaction.
Therefore, silicone implants are widely utilized as alloplastic materials in Asian rhinoplasty. Silicone implants offer advantages such as being pliable, relatively nonreactive, easy to shape during surgery, and resistant to enzymatic degradation. These properties make silicone implants a popular choice for surgeons performing rhinoplasty procedures. The author do not recommend the polytetrafluoroethylene (PTFE)-and-cartilage tip complex because in our experience, PTFE does not support cartilage grafts, unlike silicone implants, and tip irregularities arise from the complex.
In Asian rhinoplasty, it is common to perform dorsal augmentation using silicone implants in conjunction with tip plasty using autologous cartilage grafts. This combination helps reduce the risk of silicone tip extrusion. While septal cartilage is often considered a suitable material for use in the same surgical field, it is sometimes perceived as too straight and rigid. On the other hand, ear cartilage has a natural curve and a softer texture, allowing for more precise control during surgery. It also provides a smoother and more natural curvature to the nasal tip, resulting in a desirable and natural-looking tip point. Typically, only a few pieces of conchal cartilage are sufficient to reconstruct the nasal tip using our method. Furthermore, the use of conchal cartilage has been reported to improve the patient's airway.
However, we avoid using conchal cartilage as a timber-like strut because it may lead to the formation of a deviated strut due to its inherent characteristics. Instead, when a strong and timber-like columellar strut made of cartilage is needed, we harvest septal cartilage. There is limited information available regarding the combination of a silicone implant with a diced cartilage complex for tip projection, as this technique aims to preserve the natural anthropometric shape of the nose without significant alterations. In rhinoplasty procedures, projecting the nasal tip using a silicone implant can potentially result in lateral collapse of the silicone tip area after surgery. However, in Asians, due to their thick soft tissue and the broad and low shape of their nasal tips, a silicone implant safely positioned at the center of the nasal tip area does not typically lead to lateral collapse in that region. Moreover, the silicone implant complex serves as a protective barrier, preventing adhesion between the nasal tip area and the grafted cartilages. This helps preserve the original nasal cartilage structures. Importantly, the complex can be easily removed in revision operations, making it a viable option to consider for revision rhinoplasty cases.
Suggested Techniques
The authors have developed a specific pattern for the silicone implant and cartilage graft complex. In terms of the concept of creating an edge, the shield graft is positioned 1-2 mm higher than the silicone implant or onlay graft. This technique is particularly useful in improving the appearance of the Asian bulbous or broad nasal tip by creating a distinct nasal supra tip. However, in cases where thick soft tissues pose a challenge in achieving a supra tip, the "edge" concept allows for easier positioning of the supra tip, even in noses with thick soft tissue. It is important to trim the end margin of the edge to avoid excessive stimulation and transparency through the tip skin. Depending on the patient's preferences, the thickness of their skin, and the desired aesthetic tip shape, the surgeon can choose whether to create a no-edge-type complex.
Both the edge and no-edge types of the silicone implant and cartilage graft complex may require additional supporting onlay grafts. In our study, we classified them into three groups: Group I, Group II, and Group III. Patients with stiff and thick soft tissues and an underprojected tip may benefit from strong and high tip-supporting onlay grafts, leading to better outcomes. Surgeons can choose to create a Group I, Group II, or Group III complex based on the patient's desired aesthetic and nasal tip shape.
It's important to note that achieving high projection or cephalic rotation of the tip carries the risk of decreased tip projection. To mitigate this risk, it is crucial to minimize dissection between the medial crura of the lower lateral cartilages and ensure that the inferior portion of the shield graft is properly fixed to the medial crura. These measures help maintain adequate tip projection and prevent undesirable changes in the tip position.
The angle of the end surface of both the silicone implants and shield grafts can be adjusted during the operation. Surgeons have the ability to manipulate this angle, which in turn affects the positions of the supra and infra tips. This procedure is important for relieving tension at the nasal tip point, which is the endpoint of the grafted cartilage. Even with the protection provided by autologous cartilage, there is still a risk of thinning or protrusion at the nasal tip point. To prevent the tip from pushing against the skin and to ensure appropriate tension, the surgeon must trim the end of the silicone implant as necessary. Another crucial aspect of creating the silicone implant and cartilage complex is the insertion of cap grafts. In some cases, additional support may be required to enhance the stability of the complex. Cap grafts placed between the grafts and silicone implants can provide added support and stability to the overall structure.
Their classification pattern and step-by-step procedure for Asian nasal tip plasty provide a reliable method with minimal morbidity associated with cartilage harvesting. It is easy to create a tip projection and esthetic nasal shape using this procedure. It produces an esthetically pleasing result in Asian patients undergoing dorsal augmentation and nasal tip plasty.
Reference
Classification Pattern and Step-by-step procedure for cartilage grafts with silicone implants for nasal tip plasty in Asians (2019)
Combined Silicone implant and cartilage grafts for augmentation rhinoplasty (2013)
The Asian Nose: Augmentation Rhinoplasty with L-shaped silicone implants (2002)
Nasal Tip Augmentations for Asians (2009)
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