Aesthetic plastic surgery of the east asian face (2016) PDF UnitedVRG

Title: Aesthetic plastic surger y of the East Asian face / [edited by] Hong Ryul Jin.. Mar yʼs Hospital Catholic Universit y of Korea Seoul, Republic of Korea Hokyung Choung, MD, PhD Ass

Hon g Ryu l Jin , MD, Ph D

Professor and Chair

Departm ent of Otorhinolaryngology–Head and Neck Surgery

Boram ae Medical Center

Seoul National Universit y College of Medicine

Seoul, Republic of Korea

956 illustrations

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Librar y of Congress Cataloging-in -Pu blication Data

Nam es: Jin, Hong Ryul, editor

Title: Aesthetic plastic surger y of the East Asian face / [edited by]

Hong Ryul Jin

Description: New York : Thiem e, [2016] | Includes bibliographical

references and index

Identifiers: LCCN 2015048817| ISBN 9781626231436 (hardcover :

alk paper) | ISBN 9781626231443 (eISBN)

Subjects: | MESH: Reconstructive Surgical Procedures | Cosm etic

Techniques | Surger y, Plastic m ethods | Face surgery | Asian

Continental Ancestr y Group

Classification: LCC RD119 | NLM WO 600 | DDC 617.9/52—dc23

LC record available at ht tp://lccn.loc.gov/2015048817

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Ackn ow ledgm en t s xii

Con t r ibu tors xiii

I Introduction

1 Th e Ch an gin g Face of Aesth et ic Facial Plast ic Su rger y am on g East Asian s 3

Keng Lu Tan and Hong Ryul Jin

II Rhinoplasty

2 Au gm en t at ion Rh in oplast y Usin g Silicon e Im plan t s 13

In-Sang Kim

3 Th e Use of Cost al Car t ilage for Dorsal Augm en t at ion an d Tip Graft in g 26

Victor Chung and Dean M Torium i

4 Nasal Tip Mod if cat ion in Asian s: Augm en t at ion an d Rot at ion Con t rol 47

Hong Ryul Jin and Jong Sook Yi

5 Hu m p Resect ion .60

Tae-Bin W on and Hong Ryul Jin

6 Cor rect ion of th e Deviated , Tw isted Nose 72

Hun-Jong Dhong

7 Cor rect ion of th e Sad d le Nose 87

Keng Lu Tan and Chae-Seo Rhee

8 Alar Base Mod if cat ion .99

Ian Loh Chi Yuan and Hong Ryul Jin

9 Aesth et ic Rh in oplast y for Sou th east Asian s 108

Eduardo C Yap

10 Cor rect ion of th e Sh or t , Con t racted Nose 122

Hong Ryul Jin

11 Man agem en t of Alloplast-Related Com p licat ion s 135

Eunsang Dhong

III Blepharoplasty

12 Dou ble-Eyelid Su rger y: Non in cision al Su t u re Tech n iqu es 151

Jin Joo Hong and Hae W on Yang

13 Dou ble-Eyelid Su rger y: In cision al Tech n iqu es 162

Jae W oo Jang

14 Agin g-Related Up p er Bleph arop last y 173

Hokyung Choung and Nam ju Kim

15 Ep ican th op last y an d Aesth et ic Lateral Can th oplast y 184

Yongho Shin

viii Content s

IV Facial Bone Surgery

19 Zygom a Red u ct ion .243

Sanghoon Park and Jihyuck Lee

20 Man d ible Red u ct ion .254

Sanghoon Park and Seungil Chung

21 Aesth et ic Or th ogn ath ic Su rger y 268

Seong Yik Han and Kar Su Tan

22 Gen ioplast y 286

Seong Yik Han and Kar Su Tan

V Facial Skin and Hair Rejuvenation

23 Man agem en t St rategies for th e Agin g Asian Face: Ph ilosoph y an d Evolu t ion .303

Sam uel M Lam

24 Facial Fat Graft in g 311

Kyoung-Jin (Saf ) Kang

25 En d oscop ic Foreh ead an d Brow Lift .324

Tee Sin Lee and Stephen S Park

26 Facial Reju ven at ion Usin g En ergy Devices 339

Un-Cheol Yeo

27 Hair Tran splan t at ion in East Asian s 349

Sungjoo (Tom m y) Hw ang

28 Aesth et ic Laser Hair Rem oval for th e Asian Face 364

W ooseok Koh

VI Minim ally Invasive Facial Plastic Surgery

29 Aesth et ic Facial Use of Bot u lin u m Toxin in East Asian s 377

Kyle Seo

30 Facial Con tou r in g Usin g Fillers 392

Jongseo Kim

31 Man agem en t of Facial Filler In ject ion Com p licat ion s 405

Hyoung Jin Moon and Jong Sook Yi

In d ex 415

There is no population in th e w orld th at has a higher

grow th of interest in aesthet ic surgery than the East Asian

population It is reported that one in five w om en in the

Republic of Korea have undergone aesthetic facial surger y

This dram atic increase is m ultifactorial and is in part

driven by local popular cult ure and m edia This trend has

been notable over recent years, w ith the advent of Korean

popular cult ure and the associated desire to look like the

fam ed K-pop stars The look is quite characteristic of Korean

aesthetics, w ith m any patients show ing their surgeon

photos of the sam e Asian m edia person alities This trend

has becom e so fashionable that it is no longer a stigm a to

undergo cosm et ic surger y in the Republic of Korea and

China In fact , it m ight now be considered a stat us sym bol

and reflect upw ard m obilit y in the eyes of m any This age

of the “selfie” and Facebook has m ade “looking good” even

m ore im portant to th is grow ing population These social

changes have dram at ically increased the dem and for Asian

cosm etic surger y, st im ulating a significant increase in the

num ber of surgeons perform ing th e surgery.

The aesthetics of the Asian face are constantly changing,

and surgical techniques m ust change to accom m odate

such changes Today, there is often the desire for a roun der

forehead, high er nasal dorsum , narrow er nasal tip, and a

less round, m ore angular m an dible and chin Many of these

characterist ics m ay indicate a desire for a m ore “Western”

look How ever, there are different degrees of change and this

m ust be recognized by the surgeon Hong Ryul Jin understands

the im portance of this variance from pat ient to patient This

requires the surgeon perform ing enough surgeries to have

acquired a num ber of techniques in their arm am entarium

In th is book, Dr Jin has com piled an outstanding collection

of chapters w rit ten by an expert group of surgeons The

book covers th e m ost updated techniques on contouring the

Asian face covering rhin oplast y, Asian eyelid surger y, facial

con touring, and aging-face surger y The book also covers

the rapidly changing field of nonsurgical treatm ents, such

as bot ulinum toxin, fillers, and lasers.

In the section on rhinoplast y, the authors discuss

the use of implants and autologous m aterials for Asian

augm entation rhinoplast y The difference in these techniques

is very significant and is reflected in these w ritings Use of

im plants continues to be the m ost com m only used m ethod

to augm ent the nose Nuances in the techniques are discussed

in great detail and are covered by several authors Com bined

alloplastic im plants into the nasal tip The use of costal cartilage for augm entation is discussed in detail, describing techniques used to stabilize the nasal tip and augm ent the nasal dorsum Also covered are the nuances of perform ing dorsal augm entation w ith costal cartilage and how to

m inim ize the likelihood of warping Popular techniques, such

as diced cartilage for dorsal augm entation and tip grafting, are covered as well.

The m any techniques available for m anaging the Asian eyelid are covered, including incisional and nonincisional sut ure techn iques, as w ell as conventional incisional techniques Precision m easurem ent and m arking, anesthetic inject ions, incision placem ent, m anagem ent of the fixation

m eth od, postoperative care, and m anaging com plications are all discussed Also covered is the m an agem en t of the epicanthal fold.

In the section on facial contouring, the chapters cover

m anagem ent of the Asian m alar region, m andible, perialar augm entation, chin augm entation, m asseter m uscle contouring, forehead contouring, and com plications Also covered are the nuances of facial contouring that provide the surgeon w ith m any options for creating a m ore aesthetically pleasing Asian face.

The section on n onsurgical m anagem ent covers the use of bot ulinum toxin for facial m uscle contouring, brow contouring, and rhytid m an agem en t This section also covers fat injections and contouring using autologous fat Laser resurfacing is discussed as w ell.

Dr Jin has been a strong academ ic figure in Korea for

m any years and has becom e w ell know n around the w orld

He has frequently lectured in the United States and all over Asia He is now considered an internat ional expert

on Asian rhinoplast y and Asian facial cosm etic surger y His international influence is reflected in the diversit y

of the authors contributing to his book, and he has done

a m asterful job editing this w ork Readers w ill find this book com prehensive in its content and detail of surgical descript ions and use of qualit y operative photography and illustrations This book is an essential reference for the surgeon interested in providing th e best outcom es in Asian aesthetic facial surger y.

Dean M Torium i, MD

Professor Division of Facial Plastic and Reconstructive Surgery

Forew ord

Hon g Ryu l Jin h as led t h e w ay in creat in g a u n iqu e book on

aest h et ic facial su rger y for t h e East Asian p at ien t Th ere

are m any u n iqu e var ian ces w it h p at ien t s from t h is region

of t h e w orld , an d t h ey h ave p u t toget h er a collect ion of

ch apters t h at cover all asp ect s of facial aest h et ic su rger y

as it p er t ain s to t h e Asian face Th e book h igh ligh t s t h e

m any n u an ces in facial aesth et ic su rger y in t h is grou p ,

an d any su rgeon w h o h as t h e occasion al Asian p at ien t

w ill be w ell ser ved to h ave t h is ed it ion in h is or h er

referen ce librar y.

A solid portion of th is book is dedicated to the

techniques of Asian rhinoplast y It is not lim ited to strictly

alloplastic dorsal im plants, but covers m any subtleties th at

are often required w ith Asian patients The third section

is dedicated to the periorbital rejuvenat ion of the Asian

patient, including ptosis and the double eyelid procedure

There are intricacies to this procedure that distinguish

a good from a great result, and this book captures them well The rem aining section s touch on other procedures perform ed in facial aesthetic surgery, including facial bone contouring, m inim ally invasive and office based procedures, and hair rejuvenation

Herein is a collection of m any authors w ith vast experience in facial aesthetic surgery in the Asian population It is com prehensive, eloquently w rit ten, and

w ill ser ve as an invaluable resource for years to com e Dr Jin is to be congrat ulated for a terrific book.

Stephen S Park , MD Professor and Vice-Chairm an Departm ent of Otolaryngology Director, Division of Facial Plastic Surgery

Universit y of Virginia Charlottesville, Virginia

Aesthetic facial plastic surger y has com e un der the spotlight

in East Asian countries in the past t w o decades Korea cam e

under the spotlight in this field recently and intrigued m any

from all corners of the w orld to com e, learn, and update

their techniques It is m y hope that this know ledge can be

shared far and w ide w ith the English speaking crow d, w ho

has been finding it difficult to access inform ation that has

been passed on in various Asian languages.

The chapters in this book describe m ost of w hat you

need to know about aesthetic plastic surgery on the face

The chapters w ere w rit ten by m y renow ned colleagues in

their respective specialties, detailing special techniques and

potential pitfalls These details do not com e from overnight

enlightenm ent, but rather reflect experience and learning accum ulated over decades of surgeries The content in this book is highly scientific and evidence based, w hich m eans

it has proven to be safe and efficient Th is book not only focuses on introducing techniques that are new, but teaches the basic concepts of how -to-do-it in a struct ured m anner

to ensure th at readers are able to clearly conceptualize the techniques and theories behind every m aneuver.

I sincerely hope and expect that this book w ill guide the new surgeons venturing into aesthetic plastic surgery of the Asian face, as well as provide valuable inform ation to the others.

Hong Ryul Jin

Acknow ledgments

It w as not an easy journey for the publication of this book,

and I w ould like to express m y m ost heartfelt gratitude to

all m y colleagues w ho have cont ributed to it

I thank Thiem e Publishers and its people for allow ing m e to

publish this Due to their great work, this book changed from

an ugly duckling into a swan Doctors w ho contributed their

valuable expertise to this book need special acknowledgm ent

for their patience in allow ing and enduring my continuous requests I also w ish to thank my fellows, Woo-Seong Na, Hahn Jin Jung, and Som asundran Mutusamy, for helping m e to edit the m anuscript Our excellent illustrator, Mrs Hyun-Hang Lee,

w ho devoted her tim e and talents to this book, did a wonderful job in expressing the details in every draw ing per the requests

of each contributor I give my sincere thanks to her.

In-chang Cho, MD

Bio Plastic Surger y Clinic

Seoul, Republic of Korea

Woong Chul Choi, MD

Director of Myoung Oculoplastic Surgery

Clinical At tending Professor

Departm ent of Ophthalm ology

St Mar yʼs Hospital

Catholic Universit y of Korea

Seoul, Republic of Korea

Hokyung Choung, MD, PhD

Assistant Professor

Departm ent of Ophthalm ology

Boram ae Medical Center

Seoul National Universit y College of Medicine

Seoul, Republic of Korea

Seungil Chung, MD, PhD

Division of Facial Bone Surger y

Departm ent of Plastic Surgery

ID Hospital

Seoul, Republic of Korea

Victor Chung, MD

Director

La Jolla Facial Plastic Surger y

San Diego, California

Eunsang Dhong, MD, PhD

Professor

Departm ent of Plastic and Reconstructive Surgery

Guro Hospital, Korea Universit y Medical Center

Seoul, Republic of Korea

Hun-Jong Dhong, MD, PhD

Professor

Departm ent of Otorhin olaryngology–Head and

Neck Surger y

Sam sung Medical Center

Seoul, Republic of Korea

Seong Yik Han, MD, DDS, PhD

Director

Aram Harijan, MD

Academ ic Consultant Well Plastic Surger y Clinic Seoul, Republic of Korea

Jin Joo Hong, MD, PhD

Head

JJ Medical Group Seoul, Republic of Korea

Sung joo (Tom m y) Hw ang, MD, PhD

Konyang Universit y Seoul, Republic of Korea

Hong Ryul Jin, MD, PhD

Professor and Chair Depart m ent of Otorhin olaryngology–Head and Neck Surger y

Boram ae Medical Center Seoul National Universit y College of Medicine Seoul, Republic of Korea

Kyoung-Jin (Safi) Kang, MD, PhD

Director Educational Center of KCCS Seoul Cosm etic Surger y Clinic Busan, Republic of Korea

In-Sang Kim , MD

Chief Executive Depart m ent of Facial Plastic Surger y Doctor Be Aesthetic Clinic

Seoul, Republic of Korea

Jongseo Kim , MS

Director Depart m ent of Plastic Surgery

xiv Contributors

Nam ju Kim , MD, PhD

Associate Professor

Departm ent of Oph thalm ology

Seoul Nation al Universit y Bundang Hospital

Seongnam -Si, Kyeonggi-Do, Republic of Korea

Yoon-Duck Kim , MD, PhD

Director

Oculoplastic and Orbital Surger y Division

Professor

Departm ent of Oph thalm ology

Sam sung Medical Cen ter

Sung Kyun Kw an Universit y School of Medicine

Seoul, Republic of Korea

Wooseok Koh, MD

Director

Departm ent of Derm atology

JMO Hair Rem oval Derm atology Clinic

Seoul, Republic of Korea

Sam uel M Lam , MD, FACS

Division of Facial Bone Surgery

Departm ent of Plastic Surgery

ID Hospital

Seoul, Republic of Korea

Tee Sin Lee, MBBS (S’pore), MRCS (Edin), MMed (ORL),

FAMS (ORL)

Deput y Director and Consultant

Facial Plast ic and Reconstructive Surger y Service

Departm ent of Otorhinolar yngology–Head and

Neck Surgery Changi General Hospital

Clin ical Lect urer

Yong Loo Lin School of Medicine

National Universit y of Singapore

Singapore

Hyoung Jin Moon, MD

President

Dr Moon Aesthetic Surger y Clinic

Seoul, Republic of Korea

Juw an Park, MD, PhD

Associate Professor Departm ent of Oph thalm ology Yeouido St Mar y’s Hospital The Cath olic Universit y of Korea Seoul, Republic of Korea

Sanghoon Park, MD

Chairm an Departm ent of Plastic Surger y

ID Hospital Seoul, Republic of Korea

Stephen S Park, MD

Professor an d Vice-Chair Departm ent of Otolar yngology Universit y of Virginia

Charlot tesville, Virginia

Chae-Seo Rhee, MD, PhD

Professor Departm ent of Otorhinolar yngology–Head and Neck Surgery

Seoul Nation al Universit y College of Medicine Seoul Nation al Universit y Bundang Hospital Seongnam -Si, Kyeonggi-Do, Republic of Korea

Kyle Seo, MD, PhD

Clinical Associate Professor Departm ent of Derm atology Seoul Nation al Universit y College of Medicine Seoul, Republic of Korea

Seoul, Republic of Korea

Kar Su Tan, MBBS (S’pore), MRCS (Edin), MMed (ORL), FAMS (ORL)

Medical Director The Rhinoplast y Clin ic ENT Facial Plast ics Singapore

Keng Lu Tan, MD, MRCS, MS (ORLHNS)

Ear, Nose, and Throat, Head and Neck Surgeon Facial Plast ic and Reconstructive Surgeon

Departm ent of Otorhinolar yngology

Dean M Torium i, MD

Professor

Departm ent of Otolar yngology–Head and Neck Surger y

Universit y of Illin ois at Chicago

Seoul Nat ional Universit y Hospital

Seoul, Republic of Korea

Kyung In Woo, MD, PhD

Professor

Departm ent of Ophthalm ology

Sungkyunkw an Universit y School of Medicine

Sam sung Medical Center

Seoul, Republic of Korea

Hae Won Yang, MD

Jong Sook Yi, MD

Assistant Professor Departm ent of Otorhinolar yn ology–Head an d Neck Surger y

Bundang CHA Medical Center Seongn am -si, Republic of Korea

Ian Loh Chi Yuan, MBBS, MRCS, MMED, FAMS

Director Facial Plastic and Reconstructive Ser vice Departm ent of Otorhinolar yngology–Head and Neck Surger y

Changi General Hospital Singapore

Introduction

Keng Lu Tan and Hong Ryul Jin

The recent surge in the num ber of people seeking aesthetic

facial surgery is a testam ent to the em phasis placed on one’s

looks as a way to gain considerable leverage in societ y The

new m ovem ent also involves the concept of eternal

youth-fulness; being young is considered attractive, and looking

younger can im prove the com petitiveness of a worker.1,2

This trend, w hich started in Western countries around the

end of the t wentieth century, is fast becom ing worldw ide

As of this w riting Asia is the m ost actively grow ing

econom y in the world With m ore than half of the world’s

population residing on this continent, the im pact of any

m ovem ent in Asia w ill be in uential.3 With the population

getting m ore a uent and w ith the increasing a ordabilit y

of a higher standard of living, the past 10 years have seen

m any Asians seeking aesthetic procedures to enhance their

facial features or to attenuate the aging process Although

the broad term Asians is generally used to denote people

w ho originate from Asia, in truth various ethnicities and

Pearls

• Asians, particularly those in East Asia, have seen

rapid developm ent in the eld of aesthetic facial

plastic surgery, especially in the re nem ent of

Asian -speci c techniques, over the past t wo decades

• The t ypical Asian belief in not altering the physical

appearance of one’s face, at tributed to respect for

the elderly and one’s ancestors, has evolved w ith

globalization, resulting in a m ore neutralized Asian

culture, w hich is a cross bet w een East and West

More Asians realize that to be at the leading edge of

societ y, an attractive appearance plays an im portant

role in determ ining success There has been a shift

in social acceptance of aesthetic surgery, and we see

m ore dem and for it than ever before

• East Asian features of the face are discussed in detail

in the follow ing chapters, w ith particular at tention

to single-eyelid, sm all palpebral aperture, at nasal

bridge and tip, m alar prom inence, broad m andible,

retruded prem axilla, and m any other Asian -speci c

aesthetic surgeries

• Com m on aesthetic surgeries of East Asians also include double-eyelid surgery, epicanthoplast y, rhinoplast y, facial bone contouring surgery, fat injection, and m any other techniques discussed in this book

• New er techniques, including the com bination

of nonsurgical techniques in facial rejuvenation such as llers and botulinum toxin, and laser hair rem oval and hair transplantation speci c to East Asian characteristics, are discussed in detail The pros and cons of nonsurgical techniques such as laser and ultrasound for facial rejuvenation are also thoroughly described to keep readers updated w ith the latest technologies and the options available to achieve desired outcom es

• Most im portant, this book not only contains surgical techniques and pearls from surgeons w ho are

experts in their respective elds of aesthetic facial plastic surgery, but also incorporates com m ents on pitfalls and com plications, and how to overcom e them , in detail

East Asia, w here China, Korea, and Japan are located, ple possess East Asian features Although East Asians are grouped in the Mongoloid strain along w ith the Southeast Asians (Indonesians, Thai, Polynesians, etc.), the facial fea-

peo-t ures am ong peo-the Mongoloids are speo-till quipeo-te dispeo-tincpeo-t from each other.3 Fig 1.1 depicts the average of di erent beauti-

ful Asian faces as described by Rhee.4 Indians, Chinese, and Japanese are all considered Asians; however, their facial features can be quite di erent

Due to Asia’s long-standing trade routes connecting East and West, m odern Asian cities are often com prised

of m ultiple ethnic groups, re ecting the m odern trends of interracial m arriages and globalization There is a rapidly transform ing e ect of globalization on facial features as

w ell, although at this tim e w e still see rather characteristic Oriental features am ong East Asians

Aesthetic facial surgery in East Asia has expanded and developed at an exponential rate in the past t w o decades

Such rapid progress has enabled us to develop surgical techniques suitable for Asians and to accum ulate a con -

siderable am ount of experience (Fig 1.2) The new skill

I Introduction

4

Fig 1.1 Attractive composite faces of di erent races Attractive famous female entertainers’ faces were morphed by sequentially mixing

photographs at the mean values to generate the composite faces (Used with permission from Rhee et al At tractive composite faces of

di erent races Aesthetic Plast Surg 2010;34:800–801.)

Hair removal ortransplantation

Fat injection Blepharoplast y

Rhinoplast yBotox and fillers

Facial bonecontouring

Fig 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians These various techniques will

be addressed throughout this textbook, with speci c modi cations for Asians

Fair skin is seen as the m arker of class One ancient saying

in Japanese, Korean, and Chinese societies goes, “A w hite com plexion overrides three appearance aw s,”6 em phasiz-ing the long-standing im portance of light-colored skin in

m ultiple countries across Asia This was reinforced during the Western colonization period, w hen the Europeans were present in Asia and enjoyed high social status In “The His-tory of W hite People,” Neil Painter even argued that Cau-casians produce “the m ost beautiful race of m en” and that Chinese eyes are an “o ence to beaut y.”7 The ideal beaut y

of Caucasians was once the well-accepted de nition of beaut y in Asia

Recently, Asian countries have becom e stronger and

m ore in uential econom ically Scholars have started to debate about “Eurocentric” beaut y and the phenom enon

in Asia w here it has becom e the norm to alter one’s facial appearance using plastic surgery to be m ore Westernized

With grow ing con dence w ithin Asian societ y, however, Asians have started to em brace their ethnic features The fusion of certain desirable Western features w ith Asian features is now seen as the ideal form of beaut y in Asia

The key concept now is to blend at tractive features rather than having a certain de ned tem plate, a concept that has been heavily criticized and is rapidly falling out of favor

The good-looking features are, of course, those that suit a person’s facial structure, personalit y, and the person as a

w hole Enhancem ent rather than alteration of the facial features has becom e the new trend

Statistics show that up to 58% of wom en in Korea have plastic surgery by the age of 50.1,8 The percentage is grow -ing in their m ale counterparts too The desire to obtain aesthetic plastic surgery is often driven by the psychoso-cial aspiration of the patient Rapid developm ent in this eld is largely driven by the need to appear m ore attrac-tive in order to be better accepted in a societ y that places

a lot of em phasis on beaut y and pleasant appearance

Looking m ore beautiful becom es an investm ent to achieve higher socioeconom ic status and to ensure one w ill nd a

w ealthy rom antic partner Thus a new cult ure or trend has

em erged, unstoppable by past cultural beliefs and taboos, and strongly driven by novel concept of beaut y, wealth, and

a good life As this concept has grow n, the subjects seeking cosm etic enhancem ent have becom e younger and younger

As Korean dram as and m ovies have becom e m ore popular throughout Asia, so has the in uence of the Korean de ni-tion of beaut y spread all across Asia This phenom enon of

“Han Ryu” (the Korean trend) w as popular am ong viewers

of all ages With attractive actors and actresses portrayed

as heroes and heroines, m any fantasized becom ing like one

of them , w hich could be achieved by altering their looks

This trend becam e a strong driving force in the opm ent of aesthetic surgery in Asia, enabling surgeons to grow and achieve a new level of understanding of aesthetic

devel-am ong the m ore a uent Asians living in the Western

coun-tries Authors of this book believe there is no better tim e

than now to have our know ledge and experience gathered

and shared to stim ulate m ore developm ent in this eld

Many years have passed since the introduction of

speci c techniques for Asian aesthetic surgery Much has

evolved over the years, and the current focus seem s to be

on re ning the techniques to address the stigm a faced by

Asian patients Although we still nd a handful of patients

com ing to the surgeon w anting to look like a particular

pub-lic gure, m any are steering away from that trend Patients

these days often request a natural-looking face and w ish

to enhance their current appearance w hile retaining their

facial characteristics, and they especially want to prevent

their plastic surgeries from being noticed by others W hile

em bracing their existing facial characteristics, patients

prefer not to look the sam e as others w ho desire the ideal com

-position of a beautiful face, albeit all sim ilar looking This

has resulted in surgeons reinventing them selves and m

ov-ing into the next level of aesthetic facial surgery, com binov-ing

less invasive procedures w ith surgery w henever possible

The art of com bining nonsurgical and surgical techniques

to create a beautiful face w ill no longer be based on a gut

feeling but w ill be objectively described in this book

Beliefs and the Modernization

of Asian Thinking

The Asian desire for a pleasant face is heavily in uenced by

facial physiognom y in the past The com binations of

pleas-ant-looking features described in the ancient books were

illustrated w ith pictures of faces that dictated the future of

a person, dow n to the position of m oles on the face and

body.5 There w as a realization of the need for an

aestheti-cally pleasing face, but few other than Shusrata ventured

into the aesthetic surgical eld Individuals w ith

pleasant-looking faces were m ore likely to be judged to have a good

life and a good job, and those w ith unpleasant-looking

features were often associated w ith socially less

respect-able jobs or even crim inalit y The lat ter t ypes of faces were

deem ed inauspicious and still very m uch in uence how

a person is judged in m odern societ y Despite this, there

w as little developm ent in this eld Few wanted to change

their looks surgically, partly due to the unre ned state of

surgical skills at that tim e and the strong in uence of Con

-fucianism all over Asia, w hich em phasized the sanctit y of

the physical body as a sacred gift from our parents Altering

one’s physical appearance was considered disrespectful to

one’s ancestors.1

As globalization and Westernization exerted m ore

I Introduction

6

5 The narrow and relatively sm all palpebral aperture results in sm all eyes This has resulted in m any techniques invented and m odi ed over the past decade to increase the palpebral aperture by lateral canthoplast y Proper consideration of the anatom y involved in lateral and m edial epicanthoplast y should be given before the surgery is done to prevent later com plications such as lower eyelid ectropion

6 A at nasal bridge and a poorly de ned cartilaginous structure of the nose results in poor projection of the nose

7 There is a sm aller nasal pyram id w ith shorter nasal bone length in Asians com pared w ith other ethnicities A study done by Naser and Boroujeni concluded that the nasal bone length studied in the skulls of Koreans w as sm aller than in Am erican Indians, Anatolians, Iranians, and African Am ericans.9The soft and sm all nasal septum encountered

som etim es poses di cult y to the surgeon needing

a cartilage graft from the nasal septum Due to this, the use of hom ologous and autologous rib cartilage grafts has becom e popular w hen synthetic im plants are not suitable or not preferred by patients Patients should be adequately counseled, as the likelihood of needing a rib graft is higher in Asian patients

8 The nasal skin is thick w ith abundant sebaceous glands This m akes m aneuvering the nasal tip substantially m ore technically dem anding

9 Asians possess di erent skin properties com pared

w ith other racial groups Asians are know n to have

a thinner stratum corneum , the sm allest in term s of pore size and pore num bers, and the highest w ater and lipid content in the stratum corneum com pared

w ith other peoples Their skin is also know n

to have the weakest chem ical barrier All these characteristics signify that topical drug penetration

is the best in Asian skin and that the form ation

of w rinkles is less in Asians Such anatom ical

di erences in the epiderm al layer of the Asian skin

m ake m anagem ent of scars and skin lesions di erent

in the Asian population

10 Asians have a high m alar prom inence due to a prom inent zygom atic body or arch

11 The broad m andibular angle is associated w ith

m asseter hypertrophy

12 Asians’ hair is thick and coarse, is round in shape, and grow s faster Asians also have a higher prevalence of curly hair, but thick and straight hair is predom inant

am ong East Asians These anatom ic di erences in Asian hair com pared w ith Caucasian hair require hair transplant equipm ent and procedures that are

di erent from those that are conventionally used

To successfully address the above issues, one should understand the unique anatom ic presentation of the Asian

the double-edged sw ord of harm to our patients and to the

practice of aesthetic surgery, by prescribing only

appro-priate and scienti cally sound procedures to patients and

providing the best surgical practices tested by tim e and

experience

Their Implications

Most East Asians share the phenotypic features represented

by the Mongoloid pro le It is currently the m ost w idely

dis-tributed physical type, constituting over a third of the hum an

species Therefore, it is not surprising to nd that m any living

throughout Asia share the sam e facial features Mongoloid

features are typically represented by epicanthal folds and

neoteny While som e of the features, such as the single eyelid

and m axillary retrusion, are not com m on am ong

Western-ers, they are w idely encountered in Asians, w ith

double-eyelid surgery being the m ost popular plastic surgery sought

(Fig 1.3) High cheekbones, a broad m andibular angle, and

a low nasal pro le are features in Asians that are not highly

favored, and are often associated w ith aggression or m

anli-ness Generally, a well-projected nose is preferred

A low nasal bridge is not lim ited to Mongoloids The Malay people found in m ost of Southeast Asia across

the Philippines, Malaysia, Thailand, and Indonesia often

request changes to address a low nasal bridge and w ide

aring ala (Fig 1.4).

Because the anatom y of the eyelids, nose, and facial bones in Asians di ers signi cantly from that of Caucasians,

a unique m anagem ent strategy is required to successfully

im prove the aesthetic outcom e The m anagem ent strategy

should be aim ed at handling anatom ic issues speci c to the

Asian face such as the follow ing:

1 The pretarsal skin of the upper eyelid is not at tached

to the levator palpebrae m uscle, leading to a poorly

de ned superior palpebral fold The construction of a double eyelid that suits the m orphology of an Asian face is di erent from practice involving Caucasians

2 Excessive fat is distributed bet w een the orbicularis

oculi m uscle and the levator m uscle w ith relatively thick palpebral skin and orbicularis oculi m uscles

3 Orbits are sm aller w ith a m ore protruding orbital

m argin com pared w ith Westerners Therefore, recreating the features of Caucasian eyelids has proven unsuitable Aesthetic eye surgery should be

re ned and subtle rather than dram atic, or it can give rise to a thick, deep upper eyelid, w hich is not suitable for sm aller orbits

4 The nasal sclera triangle is rounded due to the

prom inent m edial epicanthal fold A variet y of techniques (and their pros and cons) to elim inate the obtunded angle w ill be described in detail in the

Fig 1.3 Typical East Asian woman who had rhinoplast y with blepharoplast y (a–c) Typical East Asian face, illustrating the wide

mandibu-lar angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip (d–f) The same

individual after rhinoplast y and blepharoplast y Her appearance greatly enhanced, the individual seems more approachable and attractive,

with softening of the unfavorable wide angle of the mandible

I Introduction

8

Such re nem ent in surgical techniques is also seen in rhinoplast y surgeries, w ith m ore versatile use of alloplas-tic m aterials such as Gore-Tex (W.L Gore & Associates Inc., Flagsta , Arizona) and hom ologous cartilage in reconstruc-tion of the nose Nasal augm entation is rarely a need for the Western patient In contrast, alm ost every East Asian patient requests nasal dorsal augm entation In the past t wo decades, we have seen the popularit y of silicone im plants fall and the subsequent increased acceptance of Gore-Tex

as a m ore versatile im plant m aterial Although the use of silicone im plants is declining due to the higher com plica-tion rate and rigid appearance of the nasal dorsum , we see a current trend of surgeons carving silicone im plants

m ore judiciously, get ting rid of the L-strut and com bining use of the im plant w ith other soft tissue to produce a softer and natural look and reducing the rate of im plant extru-sion This allow s the surgeon to continue using the silicone

im plant, w hich does have som e advantages com pared w ith other choices of im plants On the other hand, continuous trials using autologous costal cartilage for dorsal augm en-tation have show n m uch im provem ent over the years w ith

im proved reliabilit y and consistency We have seen a shift recently toward the increased popularit y of autologous grafts com pared w ith synthetic grafts due to the superior-

it y of the autologous graft in resisting infection and venting long-term com plications.10,11

pre-Recen tly, t ip su rger y in ad dit ion to d orsal augm en t

a-t ion h as becom e a sa-t an dard p rocedu re u n d er a-t aken d u ing rh in op last y Th e t ip h as to be p rop erly su p p or ted an d rot ated after d orsal augm en t at ion to p rod u ce a n at u ral,

r-p leasan t-looking n ose Th is is largely ach ieved by u sing

of Surgical Techniques

To enhance existing Asian facial characteristics, re nem ent of

the techniques is often required Such re nem ent is well

illus-trated by the various techniques of epicanthoplasty to address

a slightly di erent curve of the m edial epicanthus, suturing

techniques to m ake eyes w ith ptotic or pu y upper eyelids

appear larger and m ore relaxed, and lateral canthopexy to

achieve a m ore attractive and lively appearance of the eyes

The conventional m ethods of epicanthoplast y, such as Y-V, V-W, and W plast y, w ere noted to give rise to unsightly

scars As surgeons in Asia accum ulated m ore experience,

m any new techniques were developed, such as the

pal-pebral m argin incision m ethod (Chen, m edial

epicantho-plast y), w ith others com m only com bining blepharoepicantho-plast y

w ith m edial epicanthoplast y by extending the incision,

resulting in an obscured scar With the increasing num ber

of lateral canthoplasties done to w iden the palpebral

aper-ture of the Asian eye, com plications such as hypertrophic

scars and scar contracture causing the palpebral ssure to

becom e narrow again are possible The procedure m ay also

result in asym m etrical results due to unpredictable scar

form ation In cases w here the lateral canthal ligam ent is

cut to achieve m axim al opening of the palpebral aperture,

lower eyelid ectropion and sagging m ay occur in the future

as the soft tissue and m uscular support is w eakened

There-fore, such surgeries are never to be taken lightly and should

be done only after su cient risk and bene t assessm ent

Fig 1.4 (a–c) The face of a t ypical Southeast Asian woman, with natural double eyelid crease, wide nasal alar, broad nasal bridge and

bulbous nose with a voluminous lip These are some of the features associated with the Southeast Asian t ype of face

im portant role as an adjunct to m any cosm etic procedures

Fat grafting techniques have progressed from the use of crude fat lobules to m icrofat grafts, giving rise to im proved longevit y in the recipient site The use of fat grafts is also very popular to im prove the contour of facial topography, proving to be very versatile in creating w hatever topogra-phy is desired With their expertise in this eld, the authors

of this book are able to share m any of their valuable ences in re ning and perfecting the use of this technique to

experi-im prove surgical outcom es

Hair restoration has also becom e a popular procedure done for aesthetic purposes in Asia in recent years It is not only popular for m ales experiencing androgenic hair loss but also for fem ales w ho w ish to reshape the face and to soften the outline of the face by altering the hair-line More fem ales are seeking hair transplant procedures

to extend the hairline at the tem poral region, thus ing the m uscularit y of the face, or to change the face to a

reduc-m ore favorable “oval” shape Hair transplantation is quite

di erent in Asians This is due to their thicker and coarser hair structure, a broader base for the follicles, and a higher incidence of keloid-form ing scars com pared w ith Cau-casians Therefore, follicular unit extraction and use of a

m icropunch designed to m inim ize scarring and m axim ize hair follicle extraction have becom e m ore popular than the conventional single-strip harvesting technique Due to the thicker and coarser hair found in Asians, during follicular unit extraction the direction and depth of the scorings

m ust be precise and the base has to be broad enough so that the germ inal unit of the hair w ill not be dam aged As curly hair is m ore com m on in Asians than in Caucasians, the direction of the im plantation has to be considered so as not to have unnatural hair grow ing in di erent directions

These and m any other pearls related to hair restoration in the Asian population w ill be presented in the correspond-ing chapters

We w ill also d eal w ith facial h air rem oval u sing laser for aesth et ic p u rp oses Th e w id th of th e foreh ead form s

th e sh ap e of th e face in th e su p erior th ird Th e foreh ead

is also th e locat ion of th e “ch akra” w h ere th e th ird eye

or sixth sen se resid es as p er San skrit script u res A n row foreh ead p u t s too m u ch em p h asis on th e m id dle an d low er p ar t s of th e face an d is often associated w ith lack

ar-of radian ce A balan ced foreh ead can be created w ith p

er-m an en t reer-m oval of th e ap p rop riate aer-m ou n t of h air w ith least p roblem of dysp igm en t at ion in Asian s, w h o gen er-ally h ave darker skin ton e Nd :YAG laser h as p roven to be

a good ch oice for h air redu ct ion in Asian s, com p ared w ith conven t ion al d iod e laser, an d w as fou n d to be su p erior in

h air redu ct ion 12 Many st u d ies are st ill being con du cted

on laser h air rem oval regard ing th e p aradoxical e ect of

n e h air grow th p ost rem oval An excit ing jou rn ey lies

ah ead, w ith m ore d et ails revealed in th e ch apter on laser

exten sion graft an d th e u se of m u lt ip le layers of au

tologou s m aterial su ch as m u scle fascia an d car t ilage cou

-p led w ith som e su t u re tech n iqu es are th e m ost -p o-p u lar

opt ion s em p loyed n ow Both p at ien t s an d su rgeon s h ave

sh ied aw ay from syn th et ic m aterial for t ip w ork du e to

t h e h igh ext ru sion rate an d th e su bsequ en t disast rou s

sequ elae of an in fect ion Au tologou s m aterial is t im e

tested an d sh ow n to h ave th e least com p licat ion s an d

best resu lt s so far Th e overaggressive t ip w ork associated

w ith overam bit iou s m an euvers is h igh ly advised again st ,

as too m u ch of a good th ing in any circu m st an ces w ill on ly

resu lt in th e op p osite of th e d esired e ect Overp

rojec-t ion an d rorojec-t arojec-t ion of rojec-th e rojec-t ip is associarojec-ted w irojec-th a d eform ed

t ip in th e long r u n as a cer t ain d egree of resorpt ion of

t h e car t ilage graft u sed an d scarring of soft t issu e w ill

cau se in st abilit y of th e t ip con st ru cted Th erefore, from

ou r exp erien ce, ju d iciou s adju st m en t of th e d orsu m w ith

a m atch ing t ip sh ou ld be th e lim it to su ch augm en t at ion

p roced u res, alth ough it m ay be ver y invit ing in t raop

era-t ively era-to ach ieve a m a xim u m e ecera-t

Un derst an d ing th e sp eci c an atom ic di eren ces

in Asian s h as en abled u s to com bin e th e u se of variou s

adju n ct ive su rgeries an d p roced u res w ith rh in op last y to

p rod u ce a m ore favorable ou tcom e th an is p ossible w ith

ju st rh in op last y alon e Som e of th ese p rocedu res in clu de

p aran asal im p lan t , ch in im p lan t , n asal alar resect ion , an d

colu m ella-length en ing ap s to add ress issu es like m

axil-lar y ret ru sion , ret rogn ath ia, w id e n asal ala, an d sh or t

col-u m ella, resp ect ively, w h ich are com m on p roblem s focol-u n d

in Asian s Asian su rgeon s h ave also p erfected th eir skills

in m alar red u ct ion , w h ich is a m ore com m on p roced u re

in th e East com p ared w ith th e West Previou s exp erien ce

h as resu lted in som e cases of facial sagging, facial asym

-m et r y, an d d ow nw ard -m ove-m en t of th e -m alar p oin t Th e

red u ct ion of th e angle of th e m an dible is also a com m on

aesth et ic su rger y in Asia as op p osed to th e West , as a

softer look an d a “V-sh ap ed” face are st rongly favored

in Asia Asian su rgeon s h ave su bst an t ially m ore exp

e-rien ce w h en it com es to th is kin d of skelet al redu ct ion

w ork Oth er skelet al alterat ion su rgeries th at are p op u

-lar in Asia in clu d e or th ogn ath ic su rger y su ch as bim

ax-illar y advan cem en t/red u ct ion or m an dibu lar red u ct ion /

advan cem en t , w h ich can be solely for cosm et ic p u rp oses

Th ese su rgeries w ere origin ally in ten d ed to correct con

-gen it al d eform it ies related to fu n ct ion al p roblem s su ch

as m alocclu sion As th e ap p earan ce of a p rot r u d ing m an

-d ible or ret ru -ding m a xilla is u n at t ract ive, p at ien t s th ese

days are w illing to u n dergo su rgeries even w ith ou t fu n

c-t ion al p roblem s, an d even w h en c-th e risk of associac-ted

com p licat ion s ou t w eigh s th e ben e t

The grow ing popularit y of fat grafting has im proved

patient satisfaction trem endously Fat grafting produces a

long-lasting e ect in facial rejuvenation This is especially

I Introduction

10

New trends, concepts, and techniques are rapidly appearing

in Asia for aesthetic facial plastic surgery This trend can not be ignored and w ill becom e our strength as experience grow s Many of the new techniques should be reviewed judiciously and m eticulously and used carefully Therefore, this new book is opening up a w hole new chapter in aes-thetic facial surgery for East Asians

4 Rhee SC, Lee SH At tractive com posite faces of di erent races Aesthetic Plast Surg 2010;34(6):800–801

5 Tem park T, Shwayder T Chinese fortune-telling based on face and body m ole positions: a hidden agenda regarding m ole rem oval Arch Derm atol 2012;148(6):772–773

6 Wagatsum a H Color and race: the social perception of skin color in Japan Daedalus 96(2);1967:407–443

7 Zhang L Eurocentric Beaut y Ideals as a Form of Structural Violence: Origins and E ects on East Asian Wom en, in Vio-lence and Su ering in the Contem porary World (Spring 2013) 4–11

8 90% of Korean wom en would have plastic surger y, poll show s Chosun Ilbo 2009 (October 26): 11

9 Asieh ZN, Mariyya PB CBCT evaluation of bony nasal

pyra-m ic dipyra-m ensions in Iranian population: a copyra-m parative study

w ith ethnic groups International Scholarly Research tices 2014:1–5

No-10 Jin HR, Won TB Nasal tip augm entation in Asians ing autogenous cartilage Otolaryngol Head Neck Surg 2009;140(4):526–530

us-11 Park JH, Jin HR Use of autologous costal cartilage in Asian rhinoplast y Plast Reconstr Surg 2012;130(6):1338–1348

12 Wanitphakdeedecha R, Thanom kit ti K, Sethabutra P, Eim punth S, Manuskiatti W A split axilla com parison study

-of axillar y hair rem oval w ith low uence high repetition rate 810 nm diode laser vs high uence low repetition rate 1064 nm Nd:YAG laser J Eur Acad Derm atol Venereol 2012;26(9):1133–1136

13 Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers

A Blindness caused by cosm etic ller injection: a review

of cause and therapy Plast Reconstr Surg 2014;134(6): 1197–1201

Facial cosm etic procedures can no longer rely on surgery

alone Many practitioners can no longer a ord to shun the

use of laser, intense pulsed light (IPL), and m any other non

-surgical techniques to achieve bet ter outcom es Although

m any of these techniques do not provide long-term e ects

as good as surgical intervention, they often com plem ent

the surgical outcom e or delay surgical intervention

appro-priately Exam ples are the use of thread lifting for younger

patients w here a surgical face lift is too drastic and

unnatu-ral, laser or high -frequency focused ultrasound (HIFU) in

face lifting for m ild soft tissue sagging, laser and/or IPL in

resurfacing various t ypes of scars and reconstructed aps,

and ller injection for speci c facial contour augm

enta-tion in lim ited areas Various t ypes of ller injecenta-tion,

rang-ing from collagen, hyaluronic acid, and calcium hydroxyl

apatite to poly-L-lactic acid and platelet-rich plasm a, are

becom ing m ore and m ore accessible to patients as they are

noninvasive, are technically easier to apply, and provide

a reasonable outcom e for a nonsurgical procedure At the

tim e this book is being prepared, hyaluronic acid rem ains

the m ost w idely used ller due to its longevit y and its safet y

pro le com pared w ith the other t ypes of llers It is im

portant, however, that the reader be able to discern the ben

-e t of th-e ll-er inj-ection and v-erify that it out w-eighs th-e

risks of its usage, w hich include, in the w orst-case scenario,

blindness due to em bolism of the retinal vessels.13 Although

not as severe as blindness, other com plications, such as skin

necrosis of the injected area, should not be overlooked as

reconstruction of the a ected area can be very troublesom e

if it involves a large area requiring com plex reconstructive

techniques The rst sign of the grievous com plications just

m entioned (pain in the patient postinjection) should not

be sim ply disregarded, and prom pt usage of hyaluronidase

w ith or w ithout hyperbaric oxygen is called for

Nonsurgical facial rejuvenation is often overlooked by

m any surgeons due to its relatively brief history However,

w ith the grow ing num ber of clients preferring nonsurgical

intervention to surgical intervention and its de nite role in

com plem enting surgical outcom es, nonsurgical

interven-tion has survived and is rapidly being reinvented and

diver-si ed in providing solutions to facial rejuvenation Although

these techniques need to be further proven w ith m ore

stud-ies and research, surgeons should be aware of the

nonsur-gical techniques available in the m arket because ultim ately

patients w ho need surgery m ay be those w ho have

expe-rienced com plications from these nonsurgical techniques

In certain circum stances, these nonsurgical techniques can

also be e ectively com bined w ith the use of surgical

tech-niques to achieve better results

Rhinoplasty

■ Introduction

The noses of East Asian people are di erent in m any

aspects from Caucasian noses Augm entation rhinoplast y

is one of the m ost com m on aesthetic procedures in Asian

countries because of the relatively at and w ide Asian nose

However, augm entation rhinoplast y should be

conserva-tive, preserving the ethnicit y to m ake the nose appear very

natural and harm onious w ith other facial units In Asian

countries, augm entation rhinoplast y is not a m ajor recon

-structive operation It is regarded as one of the uncom

pli-cated com m on cosm etic procedures It is often regarded as

a trendy operation, and the aesthetic standard of patients

is generally high People w ant short recovery tim es and a

Pearls

• For East Asian noses, m ajor augm entation is

frequently required for the nasal dorsum and the tip

• The silicone im plant is w idely used in Asian

countries because it is easy to use, lim itless in

volum e, cost-e ective, and superior to the auto- or

hom ograft from the aesthetic view point

• There are t wo sources of problem s related to the

alloplastic im plant One is the problem s inherent

in the m aterial itself, w hich can be m inim ized The

other is problem s from technical or judgm ental

errors, w hich are m ore com m on and m ust be

avoided

• Infection is a serious problem though uncom m on

Thorough sanitization of the operation eld,

including the nasal vestibule and anterior nasal

cavit y, is im portant Care should be taken not to tear

the m ucosal barrier using atraum atic techniques

Operation tim e should be reduced to decrease

the chance of infection The im plant m ust be

im m ersed in antiseptic solution before and after any

m anipulation

• Designing an im plant m ust be individualized The

surgeon should have in m ind the desired shape of

the nose Individual anatom ic characteristics m ust

be considered such as the nasofrontal angle, dorsal

contour, and tip projection

• Proper selection of a tip technique is im portant

According to the tip technique, the design of an

im plant varies The im plant should be connected to the augm ented tip sm oothly and seam lessly

• Do not try to augm ent the tip w ith the im plant

Unlike the relatively im m obile dorsum , the tip

is highly m obile Therefore, only autologous cartilage m ust be used for the tip, w ith appropriate techniques to prevent extrusion and skin problem s

An im plant placed on the tip is aesthetically unpleasing because it alw ays leads to a rotated tip

w ith an unnaturally thick infratip lobule

• With the use of only autologous cartilage for the tip, skin problem s are prevented and m ore natural outcom es are ensured

• Stacking of m ultiple layers of onlay grafts is com m only required for su cient tip projection

in Asians The w ing graft should be used in com bination w ith the stacked onlay graft to prevent noticeabilit y of the onlay graft and pinching

deform it y

• Com plication rates of alloplastic im plants are

m edically acceptable Com plications are m ore frequently the result of the surgeon’s technical and judgm ental errors, rather than the fault of inherent characteristics of the m aterial itself

Am ounts of autologous m aterials except for costal cartilage are lim ited for the usual large-volum e augm entation How -ever, w ith the use of costal cartilage, econom ic and psycho-logical burdens are heavy for patients Other disadvantages include postoperative scarring on the chest, rigidit y of the tip, prolonged operation tim e, and a long recovery period

In addition, the use of costal cartilage is not free of com plications Problem s of w arping and resorption are w ell know n Infection is rare but is possible Therefore, costal cartilage is reserved as a last resort by m any surgeons

-On the other hand, alloplastic im plants are ready to use, easy to carve, varied in size, and superior to autolo-gous m aterials from an aesthetic view point Also, they are not subject to resorption or w arping Am ong the m ost com -

m only used alloplastic m aterials are silicone, expanded

II Rhinoplast y

14

Professional recom m endations should be given to the patient after a thorough analysis of the face The relation -ship of the nasal dorsum , tip, philtrum , lips, and m entum

w ith the vertical facial axis should be investigated In lyzing the face, any facial asym m etry m ust be noted and revealed to the patient before the surgery, because the augm entation rhinoplast y m ay w orsen or accentuate a pre-existing facial asym m etry W hen the vertical facial axis is skewed or de ected, the augm ented nose cannot

anabe absolutely vertical and straight In patients w ith signi cant facial asym m etry, it is bet ter to augm ent the nose in a

-di erent vertical axis from the anatom ic dorsum In these patients, nasal bones on the t w o sides are frequently asym -

m etric in term s of the w idth and the slope W hen the bony asym m etry is signi cant, the bottom of the im plant is bet-ter carved asym m etrically accordingly

Facial asym m etry com m only accom panies asym m ric nasal alae Pre-existing alar asym m etry m akes the nose look deviated even after augm entation to the correct axis Asym m etric alar resection in these patients m ay not cor-rect the problem satisfactorily Alar asym m etry relating to facial asym m etry is di cult to correct because of its m ulti-dim ensional nature

et-A system ic exam ination of the nose is perform ed from

top to bottom (Fig 2.1) The relationship of the forehead

w ith the nasal root is im portant for a successful dorsal

aug-m entation The Asian forehead is relatively at and less truding Generally, Caucasians are m ore dolichocephalic

pro-m aterials, w ith no tissue ingrow th or vascularization

seen after im plantation Because of its nonporous nature,

it is nonadhesive to surrounding tissue and enclosed in a

brous capsule Also, it is free from deform ation, easy to

sterilize, and easy to rem ove w hen necessary It is relatively

cheap and available in a range of softness values

Expanded polytetra uoroethylene (ePTFE) is com posed of nodules of Te on interconnected by brils of

-polytetra uoroethylene and has a m icroporous

architec-t ure, w iarchitec-th pore sizes ranging from 10 architec-to 30 m m Iarchitec-ts

poros-it y m akes poros-it easily m alleable and susceptible to long-term

com pression, resulting in volum e decrease or deform ation

of the im plant Its hydrophobic and porous nature m akes

the sterilization process using an antiseptic or antibiotic

solution di cult Relatively high cost is another disadvan

-tage For the revision cases, som etim es it is very di cult

to rem ove the previous ePTFE im plant, especially w hen the

im plant is thin, and the duration of im plantation is long

W hen the surrounding soft tissue is rem oved together

w ith the im plant, the resulting soft tissue irregularit y is

extrem ely di cult to repair

Porous polyethylene (Medpor) consists of a continuous system of interconnecting pores of size 125 to 250 m m The

vascular and brous ingrow th leads to integration and

sta-bilization of the im plant The tensile strength of the m

ate-rial is very high, contrary to the case for ePTFE Because of

its sti nature, it should be used w ith utm ost caution in

m obile areas such as the m em branous septum or tip

Synthetic im plants in rhinoplast y have been a topic of great controversy In particular, silicone, w hich is the single

m ost com m only used im plant m aterial in Asian countries,

is a point of worldw ide contention.1 Asian noses are

consid-ered m ore receptive to alloplastic im plants because of their

thick skin.2 This is true to som e extent, but even thicker

skin cannot resist longterm thinning, extrusion, in am

-m ation, and infection Therefore, proper techniques using

an adequately designed im plant m ust be executed

W hen an experienced surgeon uses proper techniques, the com plication rate for alloplastic im plants is surpris-

ingly low and in a m edically acceptable range Recent

stud-ies about the com plication rates of alloplastic im plants for

augm entation rhinoplast y show that they are m uch lower

than those in studies from the 1960s and 1970s.3 These

changes are due to im provem ents in im plant design, con

-servative surgical techniques, surgeons having m ore

expe-rience, and the use of softer silicone

The shape and pro le of the nose requested by the patient,

and their feasibilit y or desirabilit y are discussed in this

section Advantages and disadvantages of using alloplastic

im plants and possible alternatives to alloplastic m aterials

are also discussed

Fig 2.1 Key areas that should be considered for successful

aug-mentation rhinoplast y: forehead slope, nasofrontal transition, jections of the nasal tip, premaxilla, and chin

pro-w ith the patient, because it is unrealistic to try to m ake the sides of the alae com pletely sym m etric In patients w ith underdevelopm ent of the m axilla or prem axilla, paranasal

or prem axillary augm entation m ay be considered as lary procedures of the augm entation rhinoplast y

ancil-However, it should be taken into consideration that acute nasolabial angle is not uncom m on in Asians Som e Asian noses are beautiful enough even w ith the acute naso-labial angle, and in som e patients acute nasolabial angle is not a concern at all

Patients w ith protruding lips can bene t from the com bination of rhinoplast y, m axillary augm entation, and chin augm entation This com bination of surgeries w ill dram ati-cally enhance the facial pro le in selected patients

Skin Marking

Skin m arking for the augm entation m ust be done in the sitting position Marking a vertical line for the dorsal aug-

are also not as prom inent as in Caucasians As a result,

the nasofrontal angle in Asians is like a gentle and

grace-ful curve rather than an angle Augm entation rhinoplast y

in Asians m ust preserve this gentle curvaceous transition

from the forehead to the nasal dorsum And the augm ented

nose m ust harm onize w ith the relatively at forehead

Therefore, excessive augm entation of the radix area should

be avoided in patients w ith a at forehead The proxim al

end of the im plant should be carefully tapered to accom

-m odate to this area and not be visible or palpable Despite

the retruded forehead, if the patient wants a substantial

am ount of dorsal augm entation, com bined forehead

aug-m entation should be considered Forehead augaug-m

enta-tion surgery is rarely perform ed in the West; however, it

is a com m on surgery in Asian countries, using alloplastic

im plants or m icrofat injection

In patients w ith excessive skin and soft tissue crow ding

in the glabellar and nasal root area, the brow lift should be

considered That is because augm entation rhinoplast y m ay

m ake this area look heavier and thicker and m ay w orsen

the m asculine look in these patients, leading to

unsatisfac-tory outcom es Aged patients tend to have brow ptosis and

a thick soft tissue load in the glabellar area Therefore, a

com bined brow lift surgery should be considered in aged

patients and augm entation of the radix area should be

m inim ized, focusing m ore on tip augm entation However,

even in young patients having a short distance from

gla-bellar area to nasion, dorsal augm entation m ay further

shorten the distance, m aking the nasal root area unnatural

and attened Therefore, a com bined brow lift surgery m ay

be considered in these young patients also The endoscopic

brow lift is the best option for young patients considering

the e ect on the m edial brow and m inim izing

postopera-tive scarring

The glabellar and nasal root region show s a w ide range

of variation even in Asians Therefore, the proxim al im plant

should be carved carefully according to individual anatom y

to t in this area Preoperative X-ray m ay be helpful for

visualization of the bone and soft tissue anatom y of this

area (Fig 2.2) Exam ination by m anual palpation of this

area before or during the operation is also very im portant

Careful dorsal exam ination precedes the design of an

im plant The nasal bone is exam ined for its length, w idth,

and asym m etry Manual palpation along the dorsum is

helpful in revealing soft tissue thickness, presence of hum p,

or dorsal irregularit y

Skin thickness of nasal tips is quite variable in Asians

For the thin-skinned patients, visibilit y of grafts or the

im plant m ight be problem atic On the other hand, for the

thick-skinned patients w ith bulbous tips, it is very di cult

to obtain a ne de nition of the tip

Wide alae are com m on in Asians For the enhanced

outcom e of dorsal augm entation, alar resection m ay be

Fig 2.2 A preoperative X-ray helps in planning by visualizing the

bone and soft tissue anatomy of the nose

II Rhinoplast y

16

is required Any blood or secretion in the oral and pharyn geal cavit y is sucked out repeatedly using a suction catheter through the oral airw ay during the operation To reduce the secretion, intravenous injection of glycopyrrolate before the surgery is recom m ended Oxygen supplem entation through the oral airway also can be helpful

-Preparation of the Implant

Before local anesthetic injection, an im plant is prepared

and tried on the dorsum (Fig 2.4) The surgeon m ust check

w hether it is suitable for the desired height and desired nasal pro le, w hether it is w ell tted for the nasofrontal angle, and the dorsal con guration Then initial carving is perform ed using a no 15 surgical blade before the surgery

A correctly designed im plant is crucial for a successful outcom e Any single im plant m ust be custom ized accord-ing to individual anatom y The thickness of the im plant is decided rst Im plants w ith 4 to 5 m m of thickness are m ost frequently chosen am ong the 2 to 10 m m thickness range However the thickness is not uniform and varies along the dorsum after carving according to the individual’s ana-tom ic characteristics In general, w hen the nose is low in radix and the tip is well projected, the im plant is carved proxim ally thick and distally thin On the contrary, w hen the nose is adequately high in radix and the tip is low, the

im plant is carved proxim ally thin and distally thick W hen

a hum p is present, the im plant is often carved thinner in

the rhinion area (Fig 2.5)

The im plant’s shape, especially the distal portion, is also variable according to the preferred tip augm entation technique

The initially carved im plant is im m ersed in antiseptic solution such as hypochlorous acid until its later use The

and augm entation rhinoplast y m ay accentuate the

devi-ated look of the nose

Therefore, the surgeon m ust set a vertical line for the augm entation The line that looks the straightest is care-

fully chosen for the line of augm entation (Fig 2.3) W hen

the dorsum and tip are vertically m isaligned, usually a

ver-tical line extended upward from the tip is m ore appropriate

for the line of augm entation, rather than the line along the

dorsum , although this is not always the case

The nasal starting point is set and a horizontal line is

m arked, usually at the height of the ciliary m argins In gen

-eral, w hen the patient w ants a higher dorsum , the line m ay

be draw n at the height of the supratarsal crease W hen the

patient w ants a m ore natural look, then the line is draw n

bet ween the ciliary m argin and the pupil However, it is

individualized according to the patient’s facial

character-istics This horizontal line also provides a landm ark for the

cephalic extent of the subperiosteal dissection

Anesthesia and Positioning

The patient is put under anesthesia in a supine position

and draping is done Augm entation rhinoplast y using

allo-plastic im plants is done under general anesthesia or

intra-venous anesthesia w ith sedation W hen it is done under

intravenous anesthesia, close m onitoring of the respiration

is crucial Maintaining the oral airway during the surgery

Fig 2.3 Skin marking is done in a sitting position using a straight

wooden stick A vertical line is drawn The nasal starting point,

rhinion, and nasal tip are marked

Fig 2.4 The implant is tried on the dorsum for the initial carving.

The colum ellar ap is elevated in the conventional m an ner Elevation of the skin ap from the tip is on the supra-perichondrial plane for the thin -skinned patients as usual

-However, for the thick-skinned Asian patient, the defat ting procedure is frequently required for debulking the thick soft tissue and for bet ter de nition of the tip For the defat-ting procedure, a layer of soft tissue is deliberately left on

the cartilage surfaces elevating the skin ap (Fig 2.6).

Because the tip soft tissue is arranged in a layered fashion, it is not quite as di cult to raise the ap w ith an even thickness This technique is bet ter for sm ooth and even rem oval of the soft tissue along the cartilage surfaces than defatting from the undersurface of the skin ap after supraperichondrial elevation There is thick soft tissue on the supratip area also, and it can be rem oved or preserved depending on the situation On the cartilaginous dorsum , the plane is changed to the supraperichondrial plane

Creation of the Periosteal Pocket

As dissection proceeds on the nasal bone, the plane is

changed again to the subperiosteal plane (Fig 2.7) It is

very im portant to accurately raise the periosteal ap from the nasal bone W hen the im plant is not correctly placed in the subperiosteal space, the im plant tends to be m ore m ov-able and m ore visible To elevate the periosteum precisely,

it is better to use a sharp and narrow tip elevator, such as the Joseph elevator, at rst W hen the subperiosteal space is correctly raised partially, then a w ider elevator is inserted and the space is w idened If a w ide and blunt instrum ent is used from the start, the periosteum is easily torn

Close to the nasofrontal suture line, bleeding is likely

to ensue because of proxim it y of vessels to the suture line

hypochlorous acid is suitable for this purpose because it is

clear in nature and relatively less toxic, nonirritating, and

potent

Harvest of Ear Cartilage

After local anesthetic injections at the nose and the ear,

conchal cartilage is harvested rst w hen it is expected to

be necessary Conchal cartilage is harvested com m only

through a postauricular incision And it is harvested from

the cavum concha and cym ba concha separately, leaving

the crus of helix as a bridge This valuable anatom ic

land-m ark of the auricle is best preserved for aesthetic purposes

and structural support, and to m aintain the abundant

neu-rovascular supply of this area The harvested conchal

carti-lages are preserved in the antibiotic solution

Incision and Elevation of the Skin Flap

For an open rhinoplast y, transcolum ellar and m arginal

incisions are m arked rst In Asian patients, occasionally

the caudal m argins of the alar cartilages are not prom inent

through the vestibular skin Therefore, m arking for m

ar-ginal incision is helpful for a precise and sym m etric

inci-Fig 2.5 The initial carving is done using a no 15 surgical blade

The three most common shapes of implants are shown (top,

proxi-mally thin and distally thick; middle, proxiproxi-mally thick and distally

thin; bottom, anatomically carved) Implants are further custom

-ized during the surgery

II Rhinoplast y

18

The soft tissue on the surface of the alar cartilages and

in the supratip area that w as left deliberately during ap elevation for the defat ting procedure is now rem oved Clear identi cation and delineation of the cartilage m argins are

im portant at this stage for later procedures (Fig 2.8)

Mar-ginal incisions are extended laterally as needed, especially

w hen the tension on the augm ented tip is expected to be high The piriform ligam ents m ay also be further released as necessary For m ore release of tension, the scroll area m ay

be dissected However, the dissection should be as vative as possible, because m ore dissection w ill cause m ore distortion, scar form ation, and unpredictabilit y

conser-Harvest of Septal Cartilage

Next the m em branous septum is dissected and the caudal

m argin of the septum is identi ed The septal cartilage is harvested, leaving the L-strut In Asians, the septal cartilage

is frequently weak and sm all In those patients w ith a weak septum , m ore of the septal cartilage should be preserved than the conventional 1 cm w idth for the dorsal and cau-dal strut to m aintain the structural stabilit y Therefore, the

am ount of harvested sept um is frequently very sm all Even

w hen the harvested am ount of septal cartilage is enough, the caudal septum is too w eak and frail to provide long-term stable support for the septal extension graft In this regard, tip surgery using septal cartilage only has clear lim itations in m any Asian patients However, despite these draw backs, the septal extension graft is still one of the m ost reliable tip techniques for Asians It provides tip projection and rotation/derotation itself, as well as providing strong

m edial support for com bined onlay grafts (Fig 2.9) How

-If this bleeding is not controlled correctly, hem atom a can

arise postoperatively on the nasal root Hem atom a is a

seri-ous com plication, because if not adequately treated, it w ill

be accom panied by bacterial infection The position of the

im plant m ay also be changed by a hem atom a

Therefore, it is bet ter not to dissect overly extensively

in the cephalic direction if it is not necessary Excessive

cephalic dissection m ay also lead to cephalic m igration of

the im plant

The subperiosteal pocket is w idened laterally as needed

The space should be close to sym m etric and adequately

w ide for the im plant to be snugly placed inside W hen the

subperiosteal pocket is too sm all, the im plant m ay not be

placed properly and m ay later be displaced or deviated On

the other hand, an overly w ide pocket is also a com m on

cause of early postoperative displacem ent of the im plant

Defatting and Release of

Ligamentous Attachments

After the dissection along the dorsum is nished, the tip

surgery is initiated A successful dorsal augm entation can

-not be accom plished w ithout a successful tip augm entation

Fig 2.7 The dissection plane is supraperichondrial on the

carti-laginous dorsum and subperiosteal on the nasal bone

Fig 2.8 Cartilage margins are clearly delineated after the

defat-ting procedure

Preparation of the Stacked Onlay Graft

According to the estim ated am ount of tip projection, onlay grafts using septal or auricular cartilage are pre-pared Because the am ount of septal cartilage is lim ited in Asians usually, auricular cartilage is generally used for this purpose

Stacking of m ultiple onlay grafts is frequently sary because the required am ount of tip augm entation is com m only substantial in Asians.4 Stacking of t w o or three layers of auricular cartilage is usually required, although the num ber is variable The layered cartilages m ay be sutured together Three layers of auricular cartilage w ill be around 5 m m in thickness

neces-The graft should be cephalo-caudally long enough to be placed over the dom es of the alar cartilages The m argins

of the graft are m eticulously trim m ed to be devoid of any sharp edges

W hen the stacked onlay grafts are prepared, the sam e cephalo-caudal length as used for the graft is resected

from the distal im plant (Fig 2.11) The rem oved part of

the im plant is replaced by the onlay graft, w hich is sutured

to the cut end of the im plant By suturing the graft to the

im plant, an unbroken, seam less transition from the dorsum

to the tip is ensured Tip m obilit y is m ildly decreased but not restricted by suturing the graft to the im plant How -ever, w hen the septal extension graft is used, decreased tip m obilit y is an inevitable trade-o The thickness of the distal end of the im plant is adjusted to m atch the thickness

of the onlay graft The distal part of the im plant m ay be beveled according to the inclination of the lateral crura of the alar cartilages

ever, excessive tension from overzealous tip augm entation

relying only on the septal extension graft w ill be a cause of

septal buckling, long-term resorption or weakening of the

caudal septum , and tip drooping Therefore, a m inim al to

m oderate am ount of tension should be applied,

consider-ing the strength of the individual septal cartilage

After harvesting the septal cartilage, osteotom ies are

perform ed if required Although the osteotom y is not a

contraindication for alloplastic dorsal augm entation, the

osteotom y should be as atraum atic as possible and m

uco-sal tearing should be m inim ized to exclude the chance of

ascending bacterial infection

Insertion of the Implant

The prefabricated im plant is now inserted in the dorsal

pocket (Fig 2.10) The excessive length outside the pocket

is trim m ed The pro le of the nose is closely exam ined and

com pared w ith the planned shape The conform it y of the

im plant on the nasal dorsum is closely checked The

proxi-m al end should not be visible, readily palpable, or proxi-m

ov-able The dorsum should be sm ooth and straight, or m ildly

concave in wom en To obtain the desired shape and dorsal

sm oothness, repeated carving and trials of the im plant m ay

be necessary

Th e project ion an d rotat ion of th e t ip, w h ich is tem

-porarily form ed by th e dist al t ip of th e im p lan t , is

care-fu lly exam in ed Th e im plan t m ay be u sed as a du m m y for

th e t ip su rger y Th e su rgeon can est im ate th e requ ired

am ou n t of project ion by th e th ickn ess of th e im plan t t ip

An d also th e su rgeon can est im ate th e desired am ou n t of

rot at ion /derotat ion by m oving th e t ip of th e im plan t back

Fig 2.9 Septal extension grafting is done on the caudal septum

as an overlapping pattern

Fig 2.10 The prefabricated implant is inserted into the dorsal

pocket

II Rhinoplast y

20

cases of alar rim retraction, because it is securely xed to the onlay graft to provide strong support against retraction, com pared w ith the alar rim graft

In a w idely used technique for alloplastic augm entation

in Asia, the tip of the im plant (straight or L-shaped) is placed

on top of the alar cartilages, and then a piece of autologous cartilage is laid on top of (onlay-like) or in front of (shield-like) the distal im plant in an attem pt to decrease the risk of skin problem s such as extrusion These techniques provide tip projection and rotation w ith relative ease, and produce fair outcom es in selected cases, especially in those w ith under-projected and under-rotated nasal tips How ever, these techniques have apparent disadvantages The resul-tant tip tends to be over-rotated and unnatural, because the projection and rotation increase w ithout proportional elongation of the tip The infratip lobule becom es unnatu-rally thick w ith a decreased colum ellar-lobular ratio Fine tip m odi cation is also di cult using these techniques, and the tip often looks sharp and pointed In addition, the piece

of cartilage on the distal im plant is likely to becom e spicuous w ith tim e

con-In contrast, for the previously described technique using the stacked onlay graft, it is easy to elongate the tip Fine tip shaping is possible w ith additional carving and grafting Com bining the w ing grafts, it is m ore naturally

sm ooth in shape, and there are no visibilit y or conspicuit y problem s of onlay grafts over tim e

Variant Techniques

The aforem entioned procedures can be done using the endonasal approach However, generally this m akes it m ore

di cult to m anipulate the grafts and to control the tension

on the tip skin For m ore visualization and m ore release

e ect of the graft w ill abate w ith the collapse of colum ella

and m em branous septum , requiring m ore am ounts of

car-tilage, and the colum ellar-lobular ratio w ill deteriorate

Insertion of the Uni ed Graft and

Implant Hybrid

The uni ed graft and im plant hybrid is inserted into the

dorsal pocket, and the pro le is closely exam ined again

The surgeon has to exam ine the nose carefully, tem

porar-ily closing the incision by pulling dow n the colum ellar ap,

because the pro le can be changed due to the tension on the

skin Repeated carving m ay be required at this stage also

W hen the desired shape of the nose is nally obtained, the onlay graft is xed to the alar cartilages w ith sutures

The nal ne m odi cation of the tip and tip lobules is

done by carving and additional grafting A shield graft in

front of the graft or additional onlay grafts can be added

as necessary

Placement of the Wing Grafts

After obtaining a nal tip shape, so-called w ing grafts are

applied bilaterally on the lateral sides of the onlay graft

(Fig 2.12) The w ing graft is shaped to assim ilate the

lat-eral crura of the alar cartilages, to correspond w ith the

dom e new ly created by the stacked onlay graft Auricular

cartilage is best suited to this purpose because of its nat

u-ral curvature The purpose of the w ing graft is to prevent

the collapse or pinching deform it y on the lateral sides of

the onlay graft Without the w ing grafts, the tip is centrally

prom inent only near the onlay graft, and laterally tip

lob-ules are collapsed and pinched The w ing graft provides a

sm ooth transition from the tip to the lobules, softens the

m argins of the onlay graft, and acts as a structural support

against soft tissue collapse The w ing graft is also helpful in

Fig 2.11 The same length of the silicone implant as the stacked

onlay cartilage tip graft is cut out from the caudal end

Fig 2.12 The wing grafts are applied on both sides of the onlay

graft

Closure and Splinting

For the nal procedure, m eticulous suture closure is done

Then irrigation w ith antibiotic and antiseptic solutions is perform ed using a syringe after the closure

Taping is done to decrease the edem a and to decrease the m obilit y of the im plant and grafts Then a therm o-plastic splint is applied on the dorsum The splinting is

im portant to im m obilize the im plant and to prevent edem a and hem atom a on the radix area in the im m ediate post-operative period The splint should be applied along the pre-m arked vertical line of the augm entation The splint is

m aintained for at least 7 days

1 Designing an im plant is the rst and m ost critical step Based on the desired shape and individual anatom y, the im plant should be carved correctly

2 The subperiosteal pocket is created The pocket should be sym m etric and appropriately w ide for the im plant to be snugly placed inside and not be excessively m obile

3 For the septal extension graft, excessive tension on the graft is undesirable, especially w hen the septal cartilage is frail It provides a stable platform for the onlay tip graft, w hich is used for further tip projection and de nition, com m only required in Asian patients

the footplate to the nasal sill, and laterally to the piriform

ligam ents

W hen the height di erence bet ween the tip and the

anterior septal angle is signi cant and the inclination of

lateral crura is considerable, a variant technique can be

used (Fig 2.13) The substantial tip -to-sept um height

dif-ference and lateral crural inclination are com m only created

by the strong tip projection w ith the septal extension graft;

however, a considerable tip -to-septum height di erence is

present even prior to surgery in som e patients In this

situ-ation, the distal im plant is carved in a wedge shape w ith

appropriate thickness to t in the cephalic divergence of

alar cartilages The im plant m ay be sutured to the cephalic

m argins of the alar cartilages

For som e patients, only the low nasal bridge, not the

tip, is the problem and their concern Then only a correctly

carved im plant according to the individual dorsal anatom y

w ill su ce The im plant is inserted through the m arginal

or intercartilaginous incision Inadequately narrow, sm all,

or asym m etric dorsal pockets w ill predispose to extrusion

For the sym m etry of the dorsal pocket, bilateral incision

and dissection are recom m ended The distal end of the

im plant is tapered to be paper thin to sm oothly continue

to the cephalic portion of the alar cartilages An im plant

of excessive length, in a sm all or asym m etric pocket, m ay

extrude, especially w hen the distal im plant is in direct con

-tact w ith the incision site In this regard, m arginal incision

is m ore appropriate for the alloplastic im plantation With

the m arginal incision, additional tip grafting or other tip

m anipulations are also possible

Fig 2.13 (a,b) When the gap is signi cant bet ween the tip and the anterior septal angle, the implant may be carved in a wedge shape

In certain situations, the capsule causes severe com cations, m ost notably the contracted nose.6 Creation of an excessively thick and w ide capsule and contraction is usu-ally caused by additional factors such as bacterial infection and excessive tissue dam age

pli-Therefore, to avoid overproduction of capsules and its ensuing com plications, the surgeon m ust take care to pre-vent in am m ation or infection from occurring during or after surgery, w hile m inim izing tissue dam age and bleed-ing by surgery

Skin and Mucosal Damage

Stim ulation of the skin, dam age to skin and appendages, skin thinning, skin contraction, and telangiectasis are long-term com plications The slight yet repetitive dam age caused

by the solid im plant can harm the m ucous m em brane and create recurring chronic in am m ation, possibly by ascend-ing bacterial infection through sm all m ucosal defects To

m inim ize such physical dam age from silicone im plants, the im plant should be of appropriate length and w idth, and it m ust be w ell tted and im m obile Additionally, using

a softer m aterial for the im plant can help reduce cal stim ulation Suturing a layer of derm is or derm ofat on the outer surface of the im plant is helpful in thin -skinned patients or revision cases to decrease m echanical stim ula-

physi-tion, and m obilit y and visibilit y of the im plant (Fig 2.14).

Calci cation

W hen rem oving a long-seated im plant, the surgeon m ay com e across calci cation of the im plant A calci ed im plant form s a harder and rougher surface, increasing stim ulation

to the overlying skin and letting the irregular surface show through the skin Calci cation m ay w orsen w ith tim e.7 Cal-

ci cation also relates to m echanical stim ulation and dam age to surrounding tissue

-4 The pre-carved im plant is inserted in the pocket and the dorsal pro le is carefully checked Repeated carving m ay be necessary Using the distal im plant

as a dum m y for the tip augm entation allow s the am ount of tip projection and rotation to be estim ated

5 Th e on lay graft is p rep ared It is com m on ly

st acked in m u lt ip le layers for su fficien t t ip

p roject ion Th e sam e len gt h as t h e on lay graft is excised from t h e d ist al im p lan t Th e on lay graft is

su t u red to t h e cu t en d of t h e im p lan t

6 The w ing graft is prepared m im icking the lateral crus It is placed on both sides of the onlay graft to prevent the pinching deform it y of tip lobules, to decrease the conspicuit y of the onlay graft

7 Further ne tip shaping is achieved by delicate carving and the use of additional onlay or shield grafts

8 Meticulous closure and irrigation using antibiotic and antiseptic solutions are done Use of a

com pressive dressing w ith a therm oplastic splint is

im portant to im m obilize the im plant and to prevent edem a and hem atom a

Their Management

Negative reactions toward alloplastic im plants for

rhino-plast y were com m on in the Western part of the w orld This

m ay stem from experience w ith injectable m aterials such

as para n oil, liquid silicone, and early im plants of

exces-sive size.5 Interestingly, recent research show s m uch lower

com plication rates from silicone im plants com pared w ith

reports published in the 1960s and 1970s These changes

are thought to be due to im provem ents in im plant design,

conservative surgical techniques, physicians having m ore

experience, and use of softer silicone Many physicians in

Asia perceive the com plication rates of silicone im plants

as acceptable, in part due to m ore experience w ith

rhi-noplast y using silicone im plants com pared w ith Western

physicians

Com plications from silicone im plants can be largely grouped into t w o categories, those caused by inherent traits

of silicone itself and those resulting from the surgeon’s

technical or judgm ental errors For a successful surgical

result, it is essential to m inim ize the inevitable problem s

from inherent physical characteristics of the m aterial and

to m ake e orts to reduce technical and judgm ent errors.5

Com m on com plications, such as deviation, tip skin problem s, and infection, are m ore frequently related to

technical errors that are avoidable, and less frequently to

the physical characteristics of the m aterial itself