Aesthetic plastic surgery of the east asian face Phẫu thuật thẩm mỹ cho khuôn mặt ngưới châu á (sách tiếng anh)

Cuốn sách tiếng anh rất đầy đủ, chi tiết, hình ảnh minh hoạ rất đẹp mắt về phẫu thuật thẩm mỹ cho người châu á, các phẫu thuật nâng mũi, thu hẹp cánh mũi, tạo hình tháp mũi, các phẫu thuật cắt mí, nhấn mí, rất phù hợp cho các bạn đang học thẩm mỹ, xem hình cũng có thể hiểu được cách làm.

Hong Ryul Jin, MD, PhD

Professor and Chair

Department of Otorhinolaryngology–Head and Neck Surgery

Boramae Medical Center

Seoul National University College of Medicine

Seoul, Republic of Korea

956 illustrations

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Library of Congress Cataloging-in-Publication Data

Names: Jin, Hong Ryul, editor

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

Hong Ryul Jin

Description: New York : Thieme, [2016] | Includes bibliographical

references and index

Identifiers: LCCN 2015048817| ISBN 9781626231436 (hardcover :

alk paper) | ISBN 9781626231443 (eISBN)

Subjects: | MESH: Reconstructive Surgical Procedures | Cosmetic

Techniques | Surgery, Plastic methods | Face surgery | Asian

Continental Ancestry Group

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

LC record available at http://lccn.loc.gov/2015048817

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v

I Introduction

1 The Changing Face of Aesthetic Facial Plastic Surgery among East Asians 3

Keng Lu Tan and Hong Ryul Jin

II Rhinoplasty

2 Augmentation Rhinoplasty Using Silicone Implants 13

In-Sang Kim

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting 26

Victor Chung and Dean M Toriumi

4 Nasal Tip Modification in Asians: Augmentation and Rotation Control 47

Hong Ryul Jin and Jong Sook Yi

5 Hump Resection 60

Tae-Bin Won and Hong Ryul Jin

6 Correction of the Deviated, Twisted Nose 72

Hun-Jong Dhong

7 Correction of the Saddle Nose 87

Keng Lu Tan and Chae-Seo Rhee

8 Alar Base Modification 99

Ian Loh Chi Yuan and Hong Ryul Jin

9 Aesthetic Rhinoplasty for Southeast Asians 108

Eduardo C Yap

10 Correction of the Short, Contracted Nose 122

Hong Ryul Jin

11 Management of Alloplast-Related Complications 135

Eunsang Dhong

III Blepharoplasty

12 Double-Eyelid Surgery: Nonincisional Suture Techniques 151

Jin Joo Hong and Hae Won Yang

13 Double-Eyelid Surgery: Incisional Techniques 162

Jae Woo Jang

14 Aging-Related Upper Blepharoplasty 173

Hokyung Choung and Namju Kim

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty 184

Yongho Shin

16 Lower Blepharoplasty 196

Yoon-Duck Kim and Kyung In Woo

17 Correction of Ptosis 210

Woong Chul Choi and Juwan Park

18 Management of Double-Eyelid Surgery Complications 225

In-chang Cho and Aram Harijan

Sanghoon Park and Seungil Chung

21 Aesthetic Orthognathic Surgery 268

Seong Yik Han and Kar Su Tan

22 Genioplasty 286

Seong Yik Han and Kar Su Tan

V Facial Skin and Hair Rejuvenation

23 Management Strategies for the Aging Asian Face: Philosophy and Evolution 303

Samuel M Lam

24 Facial Fat Grafting 311

Kyoung-Jin (Safi) Kang

25 Endoscopic Forehead and Brow Lift 324

Tee Sin Lee and Stephen S Park

26 Facial Rejuvenation Using Energy Devices 339

Un-Cheol Yeo

27 Hair Transplantation in East Asians 349

Sungjoo (Tommy) Hwang

28 Aesthetic Laser Hair Removal for the Asian Face 364

Wooseok Koh

VI Minimally Invasive Facial Plastic Surgery

29 Aesthetic Facial Use of Botulinum Toxin in East Asians 377

Kyle Seo

30 Facial Contouring Using Fillers 392

Jongseo Kim

31 Management of Facial Filler Injection Complications 405

Hyoung Jin Moon and Jong Sook Yi

Index 415

There is no population in the world that has a higher

growth of interest in aesthetic surgery than the East Asian

population It is reported that one in five women in the

Republic of Korea have undergone aesthetic facial surgery

This dramatic increase is multifactorial and is in part

driven by local popular culture and media This trend has

been notable over recent years, with the advent of Korean

popular culture and the associated desire to look like the

famed K-pop stars The look is quite characteristic of Korean

aesthetics, with many patients showing their surgeon

photos of the same Asian media personalities This trend

has become so fashionable that it is no longer a stigma to

undergo cosmetic surgery in the Republic of Korea and

China In fact, it might now be considered a status symbol

and reflect upward mobility in the eyes of many This age

of the “selfie” and Facebook has made “looking good” even

more important to this growing population These social

changes have dramatically increased the demand for Asian

cosmetic surgery, stimulating a significant increase in the

number of surgeons performing the surgery

The aesthetics of the Asian face are constantly changing,

and surgical techniques must change to accommodate

such changes Today, there is often the desire for a rounder

forehead, higher nasal dorsum, narrower nasal tip, and a

less round, more angular mandible and chin Many of these

characteristics may indicate a desire for a more “Western”

look However, there are different degrees of change and this

must be recognized by the surgeon Hong Ryul Jin understands

the importance of this variance from patient to patient This

requires the surgeon performing enough surgeries to have

acquired a number of techniques in their armamentarium

In this book, Dr Jin has compiled an outstanding collection

of chapters written by an expert group of surgeons The

book covers the most updated techniques on contouring the

Asian face covering rhinoplasty, Asian eyelid surgery, facial

contouring, and aging-face surgery The book also covers

the rapidly changing field of nonsurgical treatments, such

as botulinum toxin, fillers, and lasers

In the section on rhinoplasty, the authors discuss

the use of implants and autologous materials for Asian

augmentation rhinoplasty The difference in these techniques

is very significant and is reflected in these writings Use of

implants continues to be the most commonly used method

to augment the nose Nuances in the techniques are discussed

in great detail and are covered by several authors Combined

techniques using alloplastic materials for dorsal augmentation

and ear cartilage for the nasal tip have become popular

to avoid some of the potential complications of extending

alloplastic implants into the nasal tip The use of costal cartilage for augmentation is discussed in detail, describing techniques used to stabilize the nasal tip and augment the nasal dorsum Also covered are the nuances of performing dorsal augmentation with costal cartilage and how to minimize the likelihood of warping Popular techniques, such

as diced cartilage for dorsal augmentation and tip grafting, are covered as well

The many techniques available for managing the Asian eyelid are covered, including incisional and nonincisional suture techniques, as well as conventional incisional techniques Precision measurement and marking, anesthetic injections, incision placement, management of the fixation method, postoperative care, and managing complications are all discussed Also covered is the management of the epicanthal fold

In the section on facial contouring, the chapters cover management of the Asian malar region, mandible, perialar augmentation, chin augmentation, masseter muscle contouring, forehead contouring, and complications Also covered are the nuances of facial contouring that provide the surgeon with many options for creating a more aesthetically pleasing Asian face

The section on nonsurgical management covers the use of botulinum toxin for facial muscle contouring, brow contouring, and rhytid management This section also covers fat injections and contouring using autologous fat Laser resurfacing is discussed as well

Dr Jin has been a strong academic figure in Korea for many years and has become well known around the world

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

on Asian rhinoplasty and Asian facial cosmetic surgery His international influence is reflected in the diversity

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

a masterful job editing this work Readers will find this book comprehensive in its content and detail of surgical descriptions and use of quality operative photography and illustrations This book is an essential reference for the surgeon interested in providing the best outcomes in Asian aesthetic facial surgery

Dean M Toriumi, MD

Professor Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology–Head and Neck Surgery

University of Illinois Chicago, Illinois

Foreword

Hong Ryul Jin has led the way in creating a unique book on

aesthetic facial surgery for the East Asian patient There

are many unique variances with patients from this region

of the world, and they have put together a collection of

chapters that cover all aspects of facial aesthetic surgery

as it pertains to the Asian face The book highlights the

many nuances in facial aesthetic surgery in this group,

and any surgeon who has the occasional Asian patient

will be well served to have this edition in his or her

reference library

A solid portion of this book is dedicated to the

techniques of Asian rhinoplasty It is not limited to strictly

alloplastic dorsal implants, but covers many subtleties that

are often required with Asian patients The third section

is dedicated to the periorbital rejuvenation 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 remaining sections touch on other procedures performed in facial aesthetic surgery, including facial bone contouring, minimally invasive and office based procedures, and hair rejuvenation

Herein is a collection of many authors with vast experience in facial aesthetic surgery in the Asian population It is comprehensive, eloquently written, and will serve as an invaluable resource for years to come Dr Jin is to be congratulated for a terrific book

Stephen S Park, MD Professor and Vice-Chairman Department of Otolaryngology Director, Division of Facial Plastic Surgery

University of Virginia Charlottesville, Virginia

Aesthetic facial plastic surgery has come under the spotlight

in East Asian countries in the past two decades Korea came

under the spotlight in this field recently and intrigued many

from all corners of the world to come, learn, and update

their techniques It is my hope that this knowledge can be

shared far and wide with the English speaking crowd, who

has been finding it difficult to access information that has

been passed on in various Asian languages

The chapters in this book describe most of what you

need to know about aesthetic plastic surgery on the face

The chapters were written by my renowned colleagues in

their respective specialties, detailing special techniques and

potential pitfalls These details do not come from overnight

enlightenment, but rather reflect experience and learning accumulated over decades of surgeries The content in this book is highly scientific and evidence based, which means

it has proven to be safe and efficient This book not only focuses on introducing techniques that are new, but teaches the basic concepts of how-to-do-it in a structured manner

to ensure that readers are able to clearly conceptualize the techniques and theories behind every maneuver

I sincerely hope and expect that this book will guide the new surgeons venturing into aesthetic plastic surgery of the Asian face, as well as provide valuable information to the others

Hong Ryul Jin

Acknowledgments

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

and I would like to express my most heartfelt gratitude to

all my colleagues who have contributed to it

I thank Thieme Publishers and its people for allowing me to

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

an ugly duckling into a swan Doctors who contributed their

valuable expertise to this book need special acknowledgment

for their patience in allowing and enduring my continuous requests I also wish to thank my fellows, Woo-Seong Na, Hahn Jin Jung, and Somasundran Mutusamy, for helping me to edit the manuscript Our excellent illustrator, Mrs Hyun-Hang Lee, who devoted her time and talents to this book, did a wonderful job in expressing the details in every drawing per the requests

of each contributor I give my sincere thanks to her

In-chang Cho, MD

Bio Plastic Surgery Clinic

Seoul, Republic of Korea

Woong Chul Choi, MD

Director of Myoung Oculoplastic Surgery

Clinical Attending Professor

Department of Ophthalmology

St Maryʼs Hospital

Catholic University of Korea

Seoul, Republic of Korea

Hokyung Choung, MD, PhD

Assistant Professor

Department of Ophthalmology

Boramae Medical Center

Seoul National University College of Medicine

Seoul, Republic of Korea

Seungil Chung, MD, PhD

Division of Facial Bone Surgery

Department of Plastic Surgery

ID Hospital

Seoul, Republic of Korea

Victor Chung, MD

Director

La Jolla Facial Plastic Surgery

San Diego, California

Eunsang Dhong, MD, PhD

Professor

Department of Plastic and Reconstructive Surgery

Guro Hospital, Korea University Medical Center

Seoul, Republic of Korea

Hun-Jong Dhong, MD, PhD

Professor

Department of Otorhinolaryngology–Head and

Neck Surgery

Samsung Medical Center

Seoul, Republic of Korea

Seong Yik Han, MD, DDS, PhD

Director

Facial Plastic Surgery

Simmian Maxillofacial Plastic Surgery Unit

Seoul, Republic of Korea

Aram Harijan, MD

Academic ConsultantWell Plastic Surgery ClinicSeoul, Republic of Korea

Jin Joo Hong, MD, PhD

Head

JJ Medical GroupSeoul, Republic of Korea

Sungjoo (Tommy) Hwang, MD, PhD

Konyang UniversitySeoul, Republic of Korea

Hong Ryul Jin, MD, PhD

Professor and ChairDepartment of Otorhinolaryngology–Head and Neck Surgery

Boramae Medical CenterSeoul National University College of MedicineSeoul, Republic of Korea

Kyoung-Jin (Safi) Kang, MD, PhD

Director Educational Center of KCCSSeoul Cosmetic Surgery ClinicBusan, Republic of Korea

In-Sang Kim, MD

Chief Executive Department of Facial Plastic SurgeryDoctor Be Aesthetic Clinic

Seoul, Republic of Korea

Jongseo Kim, MS

DirectorDepartment of Plastic SurgeryKim-Jongseo Plastic Surgery ClinicSeoul, Republic of Korea

xiv Contributors

Namju Kim, MD, PhD

Associate Professor

Department of Ophthalmology

Seoul National University Bundang Hospital

Seongnam-Si, Kyeonggi-Do, Republic of Korea

Samsung Medical Center

Sung Kyun Kwan University School of Medicine

Seoul, Republic of Korea

Wooseok Koh, MD

Director

Department of Dermatology

JMO Hair Removal Dermatology Clinic

Seoul, Republic of Korea

Samuel M Lam, MD, FACS

Division of Facial Bone Surgery

Department of Plastic Surgery

ID Hospital

Seoul, Republic of Korea

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

FAMS (ORL)

Deputy Director and Consultant

Facial Plastic and Reconstructive Surgery Service

Department of Otorhinolaryngology–Head and

Neck Surgery

Changi General Hospital

Clinical Lecturer

Yong Loo Lin School of Medicine

National University of Singapore

Singapore

Hyoung Jin Moon, MD

President

Dr Moon Aesthetic Surgery Clinic

Seoul, Republic of Korea

Juwan Park, MD, PhD

Associate ProfessorDepartment of OphthalmologyYeouido St Mary’s HospitalThe Catholic University of KoreaSeoul, Republic of Korea

Sanghoon Park, MD

ChairmanDepartment of Plastic Surgery

ID HospitalSeoul, Republic of Korea

Stephen S Park, MD

Professor and Vice-ChairDepartment of OtolaryngologyUniversity of Virginia

Charlottesville, Virginia

Chae-Seo Rhee, MD, PhD

ProfessorDepartment of Otorhinolaryngology–Head and Neck Surgery

Seoul National University College of MedicineSeoul National University Bundang HospitalSeongnam-Si, Kyeonggi-Do, Republic of Korea

Kyle Seo, MD, PhD

Clinical Associate ProfessorDepartment of Dermatology Seoul National University College of MedicineSeoul, Republic of Korea

Seoul, Republic of Korea

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

Medical DirectorThe Rhinoplasty Clinic ENT Facial PlasticsSingapore

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

Ear, Nose, and Throat, Head and Neck SurgeonFacial Plastic and Reconstructive SurgeonDepartment of OtorhinolaryngologyUniversity of Malaya

Kuala Lumpur, Malaysia

Dean M Toriumi, MD

Professor

Department of Otolaryngology–Head and Neck Surgery

University of Illinois at Chicago

Seoul National University Hospital

Seoul, Republic of Korea

Kyung In Woo, MD, PhD

Professor

Department of Ophthalmology

Sungkyunkwan University School of Medicine

Samsung Medical Center

Seoul, Republic of Korea

Hae Won Yang, MD

Jong Sook Yi, MD

Assistant ProfessorDepartment of Otorhinolarynology–Head and Neck Surgery

Bundang CHA Medical Center Seongnam-si, Republic of Korea

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

DirectorFacial Plastic and Reconstructive ServiceDepartment of Otorhinolaryngology–Head and Neck Surgery

Changi General HospitalSingapore

Introduction

among East Asians

Keng Lu Tan and Hong Ryul Jin

■ Introduction

The recent surge in the number of people seeking aesthetic

facial surgery is a testament to the emphasis placed on one’s

looks as a way to gain considerable leverage in society The

new movement also involves the concept of eternal

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

younger can improve the competitiveness of a worker.1,2

This trend, which started in Western countries around the

end of the twentieth century, is fast becoming worldwide

As of this writing Asia is the most actively growing

economy in the world With more than half of the world’s

population residing on this continent, the impact of any

movement in Asia will be influential.3 With the population

getting more affluent and with the increasing affordability

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

many 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

who originate from Asia, in truth various ethnicities and

races with different facial morphologies reside in Asia

West and South Asia stretches to Turkey and India, where

Caucasoid people (i.e., Turks and Indians) are found In

Pearls

• Asians, particularly those in East Asia, have seen

rapid development in the field of aesthetic facial

plastic surgery, especially in the refinement of

Asian-specific techniques, over the past two decades

• The typical Asian belief in not altering the physical

appearance of one’s face, attributed to respect for

the elderly and one’s ancestors, has evolved with

globalization, resulting in a more neutralized Asian

culture, which is a cross between East and West

More Asians realize that to be at the leading edge of

society, an attractive appearance plays an important

role in determining success There has been a shift

in social acceptance of aesthetic surgery, and we see

more demand for it than ever before

• East Asian features of the face are discussed in detail

in the following chapters, with particular attention

to single-eyelid, small palpebral aperture, flat nasal

bridge and tip, malar prominence, broad mandible,

retruded premaxilla, and many other Asian-specific

aesthetic surgeries

• Common aesthetic surgeries of East Asians also include double-eyelid surgery, epicanthoplasty, rhinoplasty, facial bone contouring surgery, fat injection, and many other techniques discussed in this book

• Newer techniques, including the combination

of nonsurgical techniques in facial rejuvenation such as fillers and botulinum toxin, and laser hair removal and hair transplantation specific 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 with the latest technologies and the options available to achieve desired outcomes

• Most important, this book not only contains surgical techniques and pearls from surgeons who are experts in their respective fields of aesthetic facial plastic surgery, but also incorporates comments on pitfalls and complications, and how to overcome them, in detail

East Asia, where China, Korea, and Japan are located, ple possess East Asian features Although East Asians are grouped in the Mongoloid strain along with the Southeast Asians (Indonesians, Thai, Polynesians, etc.), the facial fea-tures among the Mongoloids are still quite distinct from each other.3 Fig 1.1 depicts the average of different beauti-

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

Due to Asia’s long-standing trade routes connecting East and West, modern Asian cities are often comprised

of multiple ethnic groups, reflecting the modern trends of interracial marriages and globalization There is a rapidly transforming effect of globalization on facial features as well, although at this time we still see rather characteristic Oriental features among East Asians

Aesthetic facial surgery in East Asia has expanded and developed at an exponential rate in the past two decades Such rapid progress has enabled us to develop surgical techniques suitable for Asians and to accumulate a con-

siderable amount of experience (Fig 1.2) The new skill

sets and experience have been translated into technical advancement and better surgical outcomes Those experi-ences and advances in aesthetic facial surgery more suited

I Introduction

4

Fig 1.1 Attractive composite faces of different 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 Attractive composite faces of different races Aesthetic Plast Surg 2010;34:800–801.)

Hair removal ortransplantation

RhinoplastyBotox 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 specific modifications for Asians

tures, such as double eyelids and tall, well-defined noses Fair skin is seen as the marker of class One ancient saying

in Japanese, Korean, and Chinese societies goes, “A white complexion overrides three appearance flaws,”6 emphasiz-ing the long-standing importance of light-colored skin in multiple countries across Asia This was reinforced during the Western colonization period, when the Europeans were present in Asia and enjoyed high social status In “The His-tory of White People,” Neil Painter even argued that Cau-casians produce “the most beautiful race of men” and that Chinese eyes are an “offence to beauty.”7 The ideal beauty

of Caucasians was once the well-accepted definition of beauty in Asia

Recently, Asian countries have become stronger and more influential economically Scholars have started to debate about “Eurocentric” beauty and the phenomenon

in Asia where it has become the norm to alter one’s facial appearance using plastic surgery to be more Westernized With growing confidence within Asian society, however, Asians have started to embrace their ethnic features The fusion of certain desirable Western features with Asian features is now seen as the ideal form of beauty in Asia The key concept now is to blend attractive features rather than having a certain defined template, 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, personality, and the person as a whole Enhancement rather than alteration of the facial features has become the new trend

Statistics show that up to 58% of women in Korea have plastic surgery by the age of 50.1,8 The percentage is grow-ing in their male counterparts too The desire to obtain aesthetic plastic surgery is often driven by the psychoso-cial aspiration of the patient Rapid development in this field is largely driven by the need to appear more attrac-tive in order to be better accepted in a society that places

a lot of emphasis on beauty and pleasant appearance Looking more beautiful becomes an investment to achieve higher socioeconomic status and to ensure one will find a wealthy romantic partner Thus a new culture or trend has emerged, unstoppable by past cultural beliefs and taboos, and strongly driven by novel concept of beauty, wealth, and

a good life As this concept has grown, the subjects seeking cosmetic enhancement have become younger and younger

As Korean dramas and movies have become more popular throughout Asia, so has the influence of the Korean defini-tion of beauty spread all across Asia This phenomenon of

“Han Ryu” (the Korean trend) was popular among viewers

of all ages With attractive actors and actresses portrayed

as heroes and heroines, many fantasized becoming like one

of them, which could be achieved by altering their looks.This trend became a strong driving force in the devel-opment of aesthetic surgery in Asia, enabling surgeons to grow and achieve a new level of understanding of aesthetic surgeries However, it is up to the conscience of individual practitioners to guard the sanctity of this field, preventing

for Asians are becoming more and more popular, especially

among the more affluent Asians living in the Western

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

than now to have our knowledge and experience gathered

and shared to stimulate more development in this field

Many years have passed since the introduction of

specific techniques for Asian aesthetic surgery Much has

evolved over the years, and the current focus seems to be

on refining the techniques to address the stigma faced by

Asian patients Although we still find a handful of patients

coming to the surgeon wanting to look like a particular

pub-lic figure, many are steering away from that trend Patients

these days often request a natural-looking face and wish

to enhance their current appearance while retaining their

facial characteristics, and they especially want to prevent

their plastic surgeries from being noticed by others While

embracing their existing facial characteristics, patients

pre-fer not to look the same as others who desire the ideal

com-position of a beautiful face, albeit all similar looking This

has resulted in surgeons reinventing themselves and

mov-ing into the next level of aesthetic facial surgery, combinmov-ing

less invasive procedures with surgery whenever possible

The art of combining nonsurgical and surgical techniques

to create a beautiful face will no longer be based on a gut

feeling but will be objectively described in this book

■ The Change in Cultural

Beliefs and the Modernization

of Asian Thinking

The Asian desire for a pleasant face is heavily influenced by

facial physiognomy in the past The combinations of

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

illustrated with pictures of faces that dictated the future of

a person, down to the position of moles on the face and

body.5 There was a realization of the need for an

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

into the aesthetic surgical field Individuals with

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

life and a good job, and those with unpleasant-looking

features were often associated with socially less

respect-able jobs or even criminality The latter types of faces were

deemed inauspicious and still very much influence how

a person is judged in modern society Despite this, there

was little development in this field Few wanted to change

their looks surgically, partly due to the unrefined state of

surgical skills at that time and the strong influence of

Con-fucianism all over Asia, which emphasized the sanctity 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 more

influence in Asian society via Western media, the

defini-tion of beauty became associated with white Caucasian

fea-I fea-Introduction

6

5 The narrow and relatively small palpebral aperture results in small eyes This has resulted in many techniques invented and modified over the past decade to increase the palpebral aperture by lateral canthoplasty Proper consideration of the anatomy involved in lateral and medial epicanthoplasty should be given before the surgery is done to prevent later complications such as lower eyelid ectropion

6 A flat nasal bridge and a poorly defined cartilaginous structure of the nose results in poor projection of the nose

7 There is a smaller nasal pyramid with shorter nasal bone length in Asians compared with other ethnicities A study done by Naser and Boroujeni concluded that the nasal bone length studied in the skulls of Koreans was smaller than in American Indians, Anatolians, Iranians, and African Americans.9The soft and small nasal septum encountered sometimes poses difficulty to the surgeon needing

a cartilage graft from the nasal septum Due to this, the use of homologous and autologous rib cartilage grafts has become popular when synthetic implants 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 with abundant sebaceous glands This makes maneuvering the nasal tip substantially more technically demanding

9 Asians possess different skin properties compared with other racial groups Asians are known to have

a thinner stratum corneum, the smallest in terms of pore size and pore numbers, and the highest water and lipid content in the stratum corneum compared with other peoples Their skin is also known

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

is the best in Asian skin and that the formation

of wrinkles is less in Asians Such anatomical differences in the epidermal layer of the Asian skin make management of scars and skin lesions different

in the Asian population

10 Asians have a high malar prominence due to a prominent zygomatic body or arch

11 The broad mandibular angle is associated with masseter hypertrophy

12 Asians’ hair is thick and coarse, is round in shape, and grows faster Asians also have a higher prevalence of curly hair, but thick and straight hair is predominant among East Asians These anatomic differences in Asian hair compared with Caucasian hair require hair transplant equipment and procedures that are different from those that are conventionally used

To successfully address the above issues, one should understand the unique anatomic presentation of the Asian face to properly modify and make refined adjustments to the generic techniques presented in earlier textbooks

the double-edged sword of harm to our patients and to the

practice of aesthetic surgery, by prescribing only

appro-priate and scientifically sound procedures to patients and

providing the best surgical practices tested by time and

experience

■ Anatomic Differences and

Their Implications

Most East Asians share the phenotypic features represented

by the Mongoloid profile It is currently the most widely

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

species Therefore, it is not surprising to find that many living

throughout Asia share the same facial features Mongoloid

features are typically represented by epicanthal folds and

neoteny While some of the features, such as the single eyelid

and maxillary retrusion, are not common among

Western-ers, they are widely encountered in Asians, with

double-eyelid surgery being the most popular plastic surgery sought

(Fig 1.3) High cheekbones, a broad mandibular angle, and

a low nasal profile are features in Asians that are not highly

favored, and are often associated with aggression or

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

A low nasal bridge is not limited to Mongoloids The

Malay people found in most of Southeast Asia across

the Philippines, Malaysia, Thailand, and Indonesia often

request changes to address a low nasal bridge and wide

flaring ala (Fig 1.4).

Because the anatomy of the eyelids, nose, and facial

bones in Asians differs significantly from that of Caucasians,

a unique management strategy is required to successfully

improve the aesthetic outcome The management strategy

should be aimed at handling anatomic issues specific to the

Asian face such as the following:

1 The pretarsal skin of the upper eyelid is not attached

to the levator palpebrae muscle, leading to a poorly

defined superior palpebral fold The construction of a

double eyelid that suits the morphology of an Asian

face is different from practice involving Caucasians

2 Excessive fat is distributed between the orbicularis

oculi muscle and the levator muscle with relatively

thick palpebral skin and orbicularis oculi muscles

3 Orbits are smaller with a more protruding orbital

margin compared with Westerners Therefore,

recreating the features of Caucasian eyelids has

proven unsuitable Aesthetic eye surgery should be

refined and subtle rather than dramatic, or it can

give rise to a thick, deep upper eyelid, which is not

suitable for smaller orbits

4 The nasal sclera triangle is rounded due to the

prominent medial epicanthal fold A variety of

techniques (and their pros and cons) to eliminate

the obtunded angle will be described in detail in the

chapter on epicanthoplasty

Fig 1.3 Typical East Asian woman who had rhinoplasty with blepharoplasty (a–c) Typical East Asian face, illustrating the wide

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

individual after rhinoplasty and blepharoplasty 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 refinement in surgical techniques is also seen in rhinoplasty surgeries, with more versatile use of alloplas-tic materials such as Gore-Tex (W.L Gore & Associates Inc., Flagstaff, Arizona) and homologous cartilage in reconstruc-tion of the nose Nasal augmentation is rarely a need for the Western patient In contrast, almost every East Asian patient requests nasal dorsal augmentation In the past two decades, we have seen the popularity of silicone implants fall and the subsequent increased acceptance of Gore-Tex

as a more versatile implant material Although the use of silicone implants is declining due to the higher complica-tion rate and rigid appearance of the nasal dorsum, we see a current trend of surgeons carving silicone implants more judiciously, getting rid of the L-strut and combining use of the implant with other soft tissue to produce a softer and natural look and reducing the rate of implant extru-sion This allows the surgeon to continue using the silicone implant, which does have some advantages compared with other choices of implants On the other hand, continuous trials using autologous costal cartilage for dorsal augmen-tation have shown much improvement over the years with improved reliability and consistency We have seen a shift recently toward the increased popularity of autologous grafts compared with synthetic grafts due to the superior-ity of the autologous graft in resisting infection and pre-venting long-term complications.10,11

Recently, tip surgery in addition to dorsal tion has become a standard procedure undertaken dur-ing rhinoplasty The tip has to be properly supported and rotated after dorsal augmentation to produce a natural, pleasant-looking nose This is largely achieved by using

augmenta-■ Modification and Refinement

of Surgical Techniques

To enhance existing Asian facial characteristics, refinement of

the techniques is often required Such refinement is well

illus-trated by the various techniques of epicanthoplasty to address

a slightly different curve of the medial epicanthus, suturing

techniques to make eyes with ptotic or puffy upper eyelids

appear larger and more relaxed, and lateral canthopexy to

achieve a more attractive and lively appearance of the eyes

The conventional methods of epicanthoplasty, such as

Y-V, V-W, and W plasty, were noted to give rise to unsightly

scars As surgeons in Asia accumulated more experience,

many new techniques were developed, such as the

pal-pebral margin incision method (Chen, medial

epicantho-plasty), with others commonly combining blepharoplasty

with medial epicanthoplasty by extending the incision,

resulting in an obscured scar With the increasing number

of lateral canthoplasties done to widen the palpebral

aper-ture of the Asian eye, complications such as hypertrophic

scars and scar contracture causing the palpebral fissure to

become narrow again are possible The procedure may also

result in asymmetrical results due to unpredictable scar

formation In cases where the lateral canthal ligament is

cut to achieve maximal opening of the palpebral aperture,

lower eyelid ectropion and sagging may occur in the future

as the soft tissue and muscular support is weakened

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

be done only after sufficient risk and benefit assessment

Fig 1.4 (a–c) The face of a typical 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 type of face

would prove too drastic and destructive It also plays an important role as an adjunct to many cosmetic procedures Fat grafting techniques have progressed from the use of crude fat lobules to microfat grafts, giving rise to improved longevity in the recipient site The use of fat grafts is also very popular to improve the contour of facial topography, proving to be very versatile in creating whatever topogra-phy is desired With their expertise in this field, the authors

of this book are able to share many of their valuable ences in refining and perfecting the use of this technique to improve surgical outcomes

experi-Hair restoration has also become a popular procedure done for aesthetic purposes in Asia in recent years It is not only popular for males experiencing androgenic hair loss but also for females who wish to reshape the face and to soften the outline of the face by altering the hair-line More females are seeking hair transplant procedures

to extend the hairline at the temporal region, thus ing the muscularity of the face, or to change the face to a more favorable “oval” shape Hair transplantation is quite different in Asians This is due to their thicker and coarser hair structure, a broader base for the follicles, and a higher incidence of keloid-forming scars compared with Cau-casians Therefore, follicular unit extraction and use of a micropunch designed to minimize scarring and maximize hair follicle extraction have become more 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 must be precise and the base has to be broad enough so that the germinal unit of the hair will not be damaged As curly hair is more common in Asians than in Caucasians, the direction of the implantation has to be considered so as not to have unnatural hair growing in different directions These and many other pearls related to hair restoration in the Asian population will be presented in the correspond-ing chapters

reduc-We will also deal with facial hair removal using laser for aesthetic purposes The width of the forehead forms the shape of the face in the superior third The forehead

is also the location of the “chakra” where the third eye

or sixth sense resides as per Sanskrit scriptures A row forehead puts too much emphasis on the middle and lower parts of the face and is often associated with lack

nar-of radiance A balanced forehead can be created with manent removal of the appropriate amount of hair with least problem of dyspigmentation in Asians, who gener-ally have darker skin tone Nd:YAG laser has proven to be

per-a good choice for hper-air reduction in Asiper-ans, compper-ared with conventional diode laser, and was found to be superior in hair reduction.12 Many studies are still being conducted

on laser hair removal regarding the paradoxical effect of fine hair growth postremoval An exciting journey lies ahead, with more details revealed in the chapter on laser hair removal

the open approach Tip rotation achieved with a septal

extension graft and the use of multiple layers of

autolo-gous material such as muscle fascia and cartilage

cou-pled with some suture techniques are the most popular

options employed now Both patients and surgeons have

shied away from synthetic material for tip work due to

the high extrusion rate and the subsequent disastrous

sequelae of an infection Autologous material is time

tested and shown to have the least complications and

best results so far The overaggressive tip work associated

with overambitious maneuvers is highly advised against,

as too much of a good thing in any circumstances will only

result in the opposite of the desired effect

Overprojec-tion and rotaOverprojec-tion of the tip is associated with a deformed

tip in the long run as a certain degree of resorption of

the cartilage graft used and scarring of soft tissue will

cause instability of the tip constructed Therefore, from

our experience, judicious adjustment of the dorsum with

a matching tip should be the limit to such augmentation

procedures, although it may be very inviting

intraopera-tively to achieve a maximum effect

Understanding the specific anatomic differences

in Asians has enabled us to combine the use of various

adjunctive surgeries and procedures with rhinoplasty to

produce a more favorable outcome than is possible with

just rhinoplasty alone Some of these procedures include

paranasal implant, chin implant, nasal alar resection, and

columella-lengthening flaps to address issues like

maxil-lary retrusion, retrognathia, wide nasal ala, and short

col-umella, respectively, which are common problems found

in Asians Asian surgeons have also perfected their skills

in malar reduction, which is a more common procedure

in the East compared with the West Previous experience

has resulted in some cases of facial sagging, facial

asym-metry, and downward movement of the malar point The

reduction of the angle of the mandible is also a common

aesthetic surgery in Asia as opposed to the West, as a

softer look and a “V-shaped” face are strongly favored

in Asia Asian surgeons have substantially more

expe-rience when it comes to this kind of skeletal reduction

work Other skeletal alteration surgeries that are

popu-lar in Asia include orthognathic surgery such as

bimax-illary advancement/reduction or mandibular reduction/

advancement, which can be solely for cosmetic purposes

These surgeries were originally intended to correct

con-genital deformities related to functional problems such

as malocclusion As the appearance of a protruding

man-dible or retruding maxilla is unattractive, patients these

days are willing to undergo surgeries even without

func-tional problems, and even when the risk of associated

complications outweighs the benefit

The growing popularity of fat grafting has improved

patient satisfaction tremendously Fat grafting produces a

long-lasting effect in facial rejuvenation This is especially

true in the younger patients in whom a surgical face lift

I Introduction

10

■ Conclusion

New trends, concepts, and techniques are rapidly appearing

in Asia for aesthetic facial plastic surgery This trend not be ignored and will become our strength as experience grows Many of the new techniques should be reviewed judiciously and meticulously and used carefully Therefore, this new book is opening up a whole new chapter in aes-thetic facial surgery for East Asians

4 Rhee SC, Lee SH Attractive composite faces of different races Aesthetic Plast Surg 2010;34(6):800–801

5 Tempark T, Shwayder T Chinese fortune-telling based on face and body mole positions: a hidden agenda regarding mole removal Arch Dermatol 2012;148(6):772–773

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

7 Zhang L Eurocentric Beauty Ideals as a Form of Structural Violence: Origins and Effects on East Asian Women, in Vio-lence and Suffering in the Contemporary World (Spring 2013) 4–11

8 90% of Korean women would have plastic surgery, poll shows Chosun Ilbo 2009 (October 26): 11

9 Asieh ZN, Mariyya PB CBCT evaluation of bony nasal mic dimensions in Iranian population: a comparative study with ethnic groups International Scholarly Research No-tices 2014:1–5

pyra-10 Jin HR, Won TB Nasal tip augmentation 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 rhinoplasty Plast Reconstr Surg 2012;130(6):1338–1348

12 Wanitphakdeedecha R, Thanomkitti K, Sethabutra P, punth S, Manuskiatti W A split axilla comparison study

Eim-of axillary hair removal with low fluence high repetition rate 810 nm diode laser vs high fluence low repetition rate 1064 nm Nd:YAG laser J Eur Acad Dermatol Venereol 2012;26(9):1133–1136

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

A Blindness caused by cosmetic filler injection: a review

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

■ Procedural Techniques

Facial cosmetic procedures can no longer rely on surgery

alone Many practitioners can no longer afford to shun the

use of laser, intense pulsed light (IPL), and many other

non-surgical techniques to achieve better outcomes Although

many of these techniques do not provide long-term effects

as good as surgical intervention, they often complement

the surgical outcome or delay surgical intervention

appro-priately Examples are the use of thread lifting for younger

patients where a surgical face lift is too drastic and

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

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

resurfacing various types of scars and reconstructed flaps,

and filler injection for specific facial contour

augmenta-tion in limited areas Various types of filler injecaugmenta-tion,

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

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

becoming more and more accessible to patients as they are

noninvasive, are technically easier to apply, and provide

a reasonable outcome for a nonsurgical procedure At the

time this book is being prepared, hyaluronic acid remains

the most widely used filler due to its longevity and its safety

profile compared with the other types of fillers It is

impor-tant, however, that the reader be able to discern the

ben-efit of the filler injection and verify that it outweighs the

risks of its usage, which include, in the worst-case scenario,

blindness due to embolism of the retinal vessels.13 Although

not as severe as blindness, other complications, such as skin

necrosis of the injected area, should not be overlooked as

reconstruction of the affected area can be very troublesome

if it involves a large area requiring complex reconstructive

techniques The first sign of the grievous complications just

mentioned (pain in the patient postinjection) should not

be simply disregarded, and prompt usage of hyaluronidase

with or without hyperbaric oxygen is called for

Nonsurgical facial rejuvenation is often overlooked by

many surgeons due to its relatively brief history However,

with the growing number of clients preferring nonsurgical

intervention to surgical intervention and its definite role in

complementing surgical outcomes, nonsurgical

interven-tion has survived and is rapidly being reinvented and

diver-sified in providing solutions to facial rejuvenation Although

these techniques need to be further proven with more

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

nonsur-gical techniques available in the market because ultimately

patients who need surgery may be those who have

expe-rienced complications from these nonsurgical techniques

In certain circumstances, these nonsurgical techniques can

also be effectively combined with the use of surgical

tech-niques to achieve better results

Rhinoplasty

In-Sang Kim

■ Introduction

The noses of East Asian people are different in many

aspects from Caucasian noses Augmentation rhinoplasty

is one of the most common aesthetic procedures in Asian

countries because of the relatively flat and wide Asian nose

However, augmentation rhinoplasty should be

conserva-tive, preserving the ethnicity to make the nose appear very

natural and harmonious with other facial units In Asian

countries, augmentation rhinoplasty is not a major

recon-structive operation It is regarded as one of the

uncompli-cated common cosmetic procedures It is often regarded as

a trendy operation, and the aesthetic standard of patients

is generally high People want short recovery times and a

quick return to the job, although major augmentation is

frequently required

In this situation, a practical and cost-effective option

for a surgeon is rhinoplasty using an alloplastic implant

Pearls

• For East Asian noses, major augmentation is

frequently required for the nasal dorsum and the tip

• The silicone implant is widely used in Asian

countries because it is easy to use, limitless in

volume, cost-effective, and superior to the auto- or

homograft from the aesthetic viewpoint

• There are two sources of problems related to the

alloplastic implant One is the problems inherent

in the material itself, which can be minimized The

other is problems from technical or judgmental

errors, which are more common and must be

avoided

• Infection is a serious problem though uncommon

Thorough sanitization of the operation field,

including the nasal vestibule and anterior nasal

cavity, is important Care should be taken not to tear

the mucosal barrier using atraumatic techniques

Operation time should be reduced to decrease

the chance of infection The implant must be

immersed in antiseptic solution before and after any

manipulation

• Designing an implant must be individualized The

surgeon should have in mind the desired shape of

the nose Individual anatomic characteristics must

be considered such as the nasofrontal angle, dorsal

contour, and tip projection

• Proper selection of a tip technique is important

According to the tip technique, the design of an implant varies The implant should be connected to the augmented tip smoothly and seamlessly

• Do not try to augment the tip with the implant

Unlike the relatively immobile dorsum, the tip

is highly mobile Therefore, only autologous cartilage must be used for the tip, with appropriate techniques to prevent extrusion and skin problems

An implant placed on the tip is aesthetically unpleasing because it always leads to a rotated tip with an unnaturally thick infratip lobule

• With the use of only autologous cartilage for the tip, skin problems are prevented and more natural outcomes are ensured

• Stacking of multiple layers of onlay grafts is commonly required for sufficient tip projection

in Asians The wing graft should be used in combination with the stacked onlay graft to prevent noticeability of the onlay graft and pinching deformity

• Complication rates of alloplastic implants are medically acceptable Complications are more frequently the result of the surgeon’s technical and judgmental errors, rather than the fault of inherent characteristics of the material itself

Amounts of autologous materials except for costal cartilage are limited for the usual large-volume augmentation How-ever, with the use of costal cartilage, economic and psycho-logical burdens are heavy for patients Other disadvantages include postoperative scarring on the chest, rigidity of the tip, prolonged operation time, and a long recovery period

In addition, the use of costal cartilage is not free of plications Problems of warping and resorption are well known Infection is rare but is possible Therefore, costal cartilage is reserved as a last resort by many surgeons

com-On the other hand, alloplastic implants are ready to use, easy to carve, varied in size, and superior to autolo-gous materials from an aesthetic viewpoint Also, they are not subject to resorption or warping Among the most com-monly used alloplastic materials are silicone, expanded polytetrafluoroethylene (Gore-Tex), and porous high-den-sity polyethylene (Medpor, Stryker, Kalamazoo, Michigan)

Silicone is the most frequently used material in Asian countries It is nonporous, in contrast to the other two

II Rhinoplasty

14

Professional recommendations should be given to the patient after a thorough analysis of the face The relation-ship of the nasal dorsum, tip, philtrum, lips, and mentum with the vertical facial axis should be investigated In ana-lyzing the face, any facial asymmetry must be noted and revealed to the patient before the surgery, because the augmentation rhinoplasty may worsen or accentuate a pre-existing facial asymmetry When the vertical facial axis is skewed or deflected, the augmented nose cannot

be absolutely vertical and straight In patients with cant facial asymmetry, it is better to augment the nose in a different vertical axis from the anatomic dorsum In these patients, nasal bones on the two sides are frequently asym-metric in terms of the width and the slope When the bony asymmetry is significant, the bottom of the implant is bet-ter carved asymmetrically accordingly

signifi-Facial asymmetry commonly accompanies ric nasal alae Pre-existing alar asymmetry makes the nose look deviated even after augmentation to the correct axis Asymmetric alar resection in these patients may not cor-rect the problem satisfactorily Alar asymmetry relating to facial asymmetry is difficult to correct because of its multi-dimensional nature

asymmet-A systemic examination of the nose is performed from

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

with the nasal root is important for a successful dorsal mentation The Asian forehead is relatively flat and less pro-truding Generally, Caucasians are more dolichocephalic

aug-materials, with no tissue ingrowth or vascularization

seen after implantation Because of its nonporous nature,

it is nonadhesive to surrounding tissue and enclosed in a

fibrous capsule Also, it is free from deformation, easy to

sterilize, and easy to remove when necessary It is relatively

cheap and available in a range of softness values

Expanded polytetrafluoroethylene (ePTFE) is

com-posed of nodules of Teflon interconnected by fibrils of

polytetrafluoroethylene and has a microporous

architec-ture, with pore sizes ranging from 10 to 30 mm Its

poros-ity makes it easily malleable and susceptible to long-term

compression, resulting in volume decrease or deformation

of the implant Its hydrophobic and porous nature makes

the sterilization process using an antiseptic or antibiotic

solution difficult Relatively high cost is another

disadvan-tage For the revision cases, sometimes it is very difficult

to remove the previous ePTFE implant, especially when the

implant is thin, and the duration of implantation is long

When the surrounding soft tissue is removed together

with the implant, the resulting soft tissue irregularity is

extremely difficult to repair

Porous polyethylene (Medpor) consists of a continuous

system of interconnecting pores of size 125 to 250 mm The

vascular and fibrous ingrowth leads to integration and

sta-bilization of the implant The tensile strength of the

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

its stiff nature, it should be used with utmost caution in

mobile areas such as the membranous septum or tip

Synthetic implants in rhinoplasty have been a topic of

great controversy In particular, silicone, which is the single

most commonly used implant material in Asian countries,

is a point of worldwide contention.1 Asian noses are

consid-ered more receptive to alloplastic implants because of their

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

skin cannot resist long-term thinning, extrusion,

inflam-mation, and infection Therefore, proper techniques using

an adequately designed implant must be executed

When an experienced surgeon uses proper techniques,

the complication rate for alloplastic implants is

surpris-ingly low and in a medically acceptable range Recent

stud-ies about the complication rates of alloplastic implants for

augmentation rhinoplasty show that they are much lower

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

changes are due to improvements in implant design,

con-servative surgical techniques, surgeons having more

expe-rience, and the use of softer silicone

■ Patient Evaluation

The shape and profile of the nose requested by the patient,

and their feasibility or desirability are discussed in this

section Advantages and disadvantages of using alloplastic

implants and possible alternatives to alloplastic materials

are also discussed

Fig 2.1 Key areas that should be considered for successful

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

pro-with the patient, because it is unrealistic to try to make the sides of the alae completely symmetric In patients with underdevelopment of the maxilla or premaxilla, paranasal

or premaxillary augmentation may be considered as lary procedures of the augmentation rhinoplasty

ancil-However, it should be taken into consideration that acute nasolabial angle is not uncommon in Asians Some Asian noses are beautiful enough even with the acute naso-labial angle, and in some patients acute nasolabial angle is not a concern at all

Patients with protruding lips can benefit from the bination of rhinoplasty, maxillary augmentation, and chin augmentation This combination of surgeries will dramati-cally enhance the facial profile in selected patients

com-■ Surgical Techniques Skin Marking

Skin marking for the augmentation must be done in the sitting position Marking a vertical line for the dorsal aug-mentation is important, because frequently the glabella, nasal dorsum, and nasal tip are off the same vertical axis,

and Asians are more brachiocephalic Brow ridges in Asians

are also not as prominent as in Caucasians As a result,

the nasofrontal angle in Asians is like a gentle and

grace-ful curve rather than an angle Augmentation rhinoplasty

in Asians must preserve this gentle curvaceous transition

from the forehead to the nasal dorsum And the augmented

nose must harmonize with the relatively flat forehead

Therefore, excessive augmentation of the radix area should

be avoided in patients with a flat forehead The proximal

end of the implant should be carefully tapered to

accom-modate to this area and not be visible or palpable Despite

the retruded forehead, if the patient wants a substantial

amount of dorsal augmentation, combined forehead

aug-mentation should be considered Forehead

augmenta-tion surgery is rarely performed in the West; however, it

is a common surgery in Asian countries, using alloplastic

implants or microfat injection

In patients with excessive skin and soft tissue crowding

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

considered That is because augmentation rhinoplasty may

make this area look heavier and thicker and may worsen

the masculine look in these patients, leading to

unsatisfac-tory outcomes Aged patients tend to have brow ptosis and

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

combined brow lift surgery should be considered in aged

patients and augmentation of the radix area should be

minimized, focusing more on tip augmentation However,

even in young patients having a short distance from

gla-bellar area to nasion, dorsal augmentation may further

shorten the distance, making the nasal root area unnatural

and flattened Therefore, a combined brow lift surgery may

be considered in these young patients also The endoscopic

brow lift is the best option for young patients considering

the effect on the medial brow and minimizing

postopera-tive scarring

The glabellar and nasal root region shows a wide range

of variation even in Asians Therefore, the proximal implant

should be carved carefully according to individual anatomy

to fit in this area Preoperative X-ray may be helpful for

visualization of the bone and soft tissue anatomy of this

area (Fig 2.2) Examination by manual palpation of this

area before or during the operation is also very important

Careful dorsal examination precedes the design of an

implant The nasal bone is examined for its length, width,

and asymmetry Manual palpation along the dorsum is

helpful in revealing soft tissue thickness, presence of hump,

or dorsal irregularity

Skin thickness of nasal tips is quite variable in Asians

For the thin-skinned patients, visibility of grafts or the

implant might be problematic On the other hand, for the

thick-skinned patients with bulbous tips, it is very difficult

to obtain a fine definition of the tip

Wide alae are common in Asians For the enhanced

outcome of dorsal augmentation, alar resection may be

required in some patients If alar asymmetry and

asymmet-ric maxillary development are present, they are discussed

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

bone and soft tissue anatomy of the nose

II Rhinoplasty

16

is required Any blood or secretion in the oral and geal cavity is sucked out repeatedly using a suction catheter through the oral airway during the operation To reduce the secretion, intravenous injection of glycopyrrolate before the surgery is recommended Oxygen supplementation through the oral airway also can be helpful

pharyn-Preparation of the Implant

Before local anesthetic injection, an implant is prepared

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

whether it is suitable for the desired height and desired nasal profile, whether it is well fitted for the nasofrontal angle, and the dorsal configuration Then initial carving is performed using a no 15 surgical blade before the surgery

A correctly designed implant is crucial for a successful outcome Any single implant must be customized accord-ing to individual anatomy The thickness of the implant is decided first Implants with 4 to 5 mm of thickness are most frequently chosen among the 2 to 10 mm thickness range However the thickness is not uniform and varies along the dorsum after carving according to the individual’s ana-tomic characteristics In general, when the nose is low in radix and the tip is well projected, the implant is carved proximally thick and distally thin On the contrary, when the nose is adequately high in radix and the tip is low, the implant is carved proximally thin and distally thick When

a hump is present, the implant is often carved thinner in

the rhinion area (Fig 2.5)

The implant’s shape, especially the distal portion, is also variable according to the preferred tip augmentation technique

The initially carved implant is immersed in antiseptic solution such as hypochlorous acid until its later use The

and augmentation rhinoplasty may accentuate the

devi-ated look of the nose

Therefore, the surgeon must set a vertical line for the

augmentation The line that looks the straightest is

care-fully chosen for the line of augmentation (Fig 2.3) When

the dorsum and tip are vertically misaligned, usually a

ver-tical line extended upward from the tip is more appropriate

for the line of augmentation, 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

marked, usually at the height of the ciliary margins In

gen-eral, when the patient wants a higher dorsum, the line may

be drawn at the height of the supratarsal crease When the

patient wants a more natural look, then the line is drawn

between the ciliary margin and the pupil However, it is

individualized according to the patient’s facial

character-istics This horizontal line also provides a landmark 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 Augmentation rhinoplasty using

allo-plastic implants is done under general anesthesia or

intra-venous anesthesia with sedation When it is done under

intravenous anesthesia, close monitoring 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.

for later closure and there is no risk of notching deformity The columellar flap is elevated in the conventional man-ner Elevation of the skin flap from the tip is on the supra-perichondrial plane for the thin-skinned patients as usual However, for the thick-skinned Asian patient, the defatting procedure is frequently required for debulking the thick soft tissue and for better definition of the tip For the defat-ting procedure, a layer of soft tissue is deliberately left on the cartilage surfaces elevating the skin flap (Fig 2.6).

Because the tip soft tissue is arranged in a layered fashion, it is not quite as difficult to raise the flap with an even thickness This technique is better for smooth and even removal of the soft tissue along the cartilage surfaces than defatting from the undersurface of the skin flap after supraperichondrial elevation There is thick soft tissue on the supratip area also, and it can be removed 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 important to accurately raise the periosteal flap from the nasal bone When the implant is not correctly placed in the subperiosteal space, the implant tends to be more mov-able and more visible To elevate the periosteum precisely,

it is better to use a sharp and narrow tip elevator, such as the Joseph elevator, at first When the subperiosteal space is correctly raised partially, then a wider elevator is inserted and the space is widened If a wide and blunt instrument is used from the start, the periosteum is easily torn

Close to the nasofrontal suture line, bleeding is likely

to ensue because of proximity 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 first when it is expected to

be necessary Conchal cartilage is harvested commonly

through a postauricular incision And it is harvested from

the cavum concha and cymba concha separately, leaving

the crus of helix as a bridge This valuable anatomic

land-mark of the auricle is best preserved for aesthetic purposes

and structural support, and to maintain 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 rhinoplasty, transcolumellar and marginal

incisions are marked first In Asian patients, occasionally

the caudal margins of the alar cartilages are not prominent

through the vestibular skin Therefore, marking for

mar-ginal incision is helpful for a precise and symmetric

inci-sion The marginal incision is placed 1 mm anterior to the

caudal margin of the alar cartilages, because this is better

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

Fig 2.6 Elevating the skin flap A thin layer of soft tissue on the

alar cartilage is deliberately left for the defatting procedure

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The soft tissue on the surface of the alar cartilages and

in the supratip area that was left deliberately during flap elevation for the defatting procedure is now removed Clear identification and delineation of the cartilage margins are

important at this stage for later procedures (Fig 2.8)

Mar-ginal incisions are extended laterally as needed, especially when the tension on the augmented tip is expected to be high The piriform ligaments may also be further released as necessary For more release of tension, the scroll area may

be dissected However, the dissection should be as vative as possible, because more dissection will cause more distortion, scar formation, and unpredictability

conser-Harvest of Septal Cartilage

Next the membranous septum is dissected and the caudal margin of the septum is identified The septal cartilage is harvested, leaving the L-strut In Asians, the septal cartilage

is frequently weak and small In those patients with a weak septum, more of the septal cartilage should be preserved than the conventional 1 cm width for the dorsal and cau-dal strut to maintain the structural stability Therefore, the amount of harvested septum is frequently very small Even when the harvested amount of septal cartilage is enough, the caudal septum is too weak and frail to provide long-term stable support for the septal extension graft In this regard, tip surgery using septal cartilage only has clear limitations in many Asian patients However, despite these drawbacks, the septal extension graft is still one of the most reliable tip techniques for Asians It provides tip projection and rotation/derotation itself, as well as providing strong

medial support for combined onlay grafts (Fig 2.9)

How-If this bleeding is not controlled correctly, hematoma can

arise postoperatively on the nasal root Hematoma is a

seri-ous complication, because if not adequately treated, it will

be accompanied by bacterial infection The position of the

implant may also be changed by a hematoma

Therefore, it is better not to dissect overly extensively

in the cephalic direction if it is not necessary Excessive

cephalic dissection may also lead to cephalic migration of

the implant

The subperiosteal pocket is widened laterally as needed

The space should be close to symmetric and adequately

wide for the implant to be snugly placed inside When the

subperiosteal pocket is too small, the implant may not be

placed properly and may later be displaced or deviated On

the other hand, an overly wide pocket is also a common

cause of early postoperative displacement of the implant

Defatting and Release of

Ligamentous Attachments

After the dissection along the dorsum is finished, the tip

surgery is initiated A successful dorsal augmentation

can-not be accomplished without a successful tip augmentation

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 estimated amount of tip projection, onlay grafts using septal or auricular cartilage are pre-pared Because the amount of septal cartilage is limited in Asians usually, auricular cartilage is generally used for this purpose

Stacking of multiple onlay grafts is frequently sary because the required amount of tip augmentation is commonly substantial in Asians.4 Stacking of two or three layers of auricular cartilage is usually required, although the number is variable The layered cartilages may be sutured together Three layers of auricular cartilage will be around 5 mm in thickness

neces-The graft should be cephalo-caudally long enough to be placed over the domes of the alar cartilages The margins

of the graft are meticulously trimmed to be devoid of any sharp edges

When the stacked onlay grafts are prepared, the same cephalo-caudal length as used for the graft is resected

from the distal implant (Fig 2.11) The removed part of

the implant is replaced by the onlay graft, which is sutured

to the cut end of the implant By suturing the graft to the implant, an unbroken, seamless transition from the dorsum

to the tip is ensured Tip mobility is mildly decreased but not restricted by suturing the graft to the implant How-ever, when the septal extension graft is used, decreased tip mobility is an inevitable trade-off The thickness of the distal end of the implant is adjusted to match the thickness

of the onlay graft The distal part of the implant may be beveled according to the inclination of the lateral crura of the alar cartilages

The stacked onlay graft is supported medially by the septal extension graft Without strong medial support, the

ever, excessive tension from overzealous tip augmentation

relying only on the septal extension graft will be a cause of

septal buckling, long-term resorption or weakening of the

caudal septum, and tip drooping Therefore, a minimal to

moderate amount of tension should be applied,

consider-ing the strength of the individual septal cartilage

After harvesting the septal cartilage, osteotomies are

performed if required Although the osteotomy is not a

contraindication for alloplastic dorsal augmentation, the

osteotomy should be as atraumatic as possible and

muco-sal tearing should be minimized to exclude the chance of

ascending bacterial infection

Insertion of the Implant

The prefabricated implant is now inserted in the dorsal

pocket (Fig 2.10) The excessive length outside the pocket

is trimmed The profile of the nose is closely examined and

compared with the planned shape The conformity of the

implant on the nasal dorsum is closely checked The

proxi-mal end should not be visible, readily palpable, or

mov-able The dorsum should be smooth and straight, or mildly

concave in women To obtain the desired shape and dorsal

smoothness, repeated carving and trials of the implant may

be necessary

The projection and rotation of the tip, which is

tem-porarily formed by the distal tip of the implant, is

care-fully examined The implant may be used as a dummy for

the tip surgery The surgeon can estimate the required

amount of projection by the thickness of the implant tip

And also the surgeon can estimate the desired amount of

rotation/derotation by moving the tip of the implant back

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cases of alar rim retraction, because it is securely fixed to the onlay graft to provide strong support against retraction, compared with the alar rim graft

In a widely used technique for alloplastic augmentation

in Asia, the tip of the implant (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 implant in an attempt to decrease the risk of skin problems such as extrusion These techniques provide tip projection and rotation with relative ease, and produce fair outcomes in selected cases, especially in those with under-projected and under-rotated nasal tips However, these techniques have apparent disadvantages The resul-tant tip tends to be over-rotated and unnatural, because the projection and rotation increase without proportional elongation of the tip The infratip lobule becomes unnatu-rally thick with a decreased columellar-lobular ratio Fine tip modification is also difficult using these techniques, and the tip often looks sharp and pointed In addition, the piece

of cartilage on the distal implant is likely to become spicuous with time

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 with additional carving and grafting Combining the wing grafts, it is more naturally smooth in shape, and there are no visibility or conspicuity problems of onlay grafts over time

Variant Techniques

The aforementioned procedures can be done using the endonasal approach However, generally this makes it more difficult to manipulate the grafts and to control the tension

on the tip skin For more visualization and more release

effect of the graft will abate with the collapse of columella

and membranous septum, requiring more amounts of

car-tilage, and the columellar-lobular ratio will deteriorate

Insertion of the Unified Graft and

Implant Hybrid

The unified graft and implant hybrid is inserted into the

dorsal pocket, and the profile is closely examined again

The surgeon has to examine the nose carefully,

temporar-ily closing the incision by pulling down the columellar flap,

because the profile can be changed due to the tension on the

skin Repeated carving may be required at this stage also

When the desired shape of the nose is finally obtained,

the onlay graft is fixed to the alar cartilages with sutures

The final fine modification 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 final tip shape, so-called wing grafts are

applied bilaterally on the lateral sides of the onlay graft

(Fig 2.12) The wing graft is shaped to assimilate the

lat-eral crura of the alar cartilages, to correspond with the

dome newly created by the stacked onlay graft Auricular

cartilage is best suited to this purpose because of its

natu-ral curvature The purpose of the wing graft is to prevent

the collapse or pinching deformity on the lateral sides of

the onlay graft Without the wing grafts, the tip is centrally

prominent only near the onlay graft, and laterally tip

lob-ules are collapsed and pinched The wing graft provides a

smooth transition from the tip to the lobules, softens the

margins of the onlay graft, and acts as a structural support

against soft tissue collapse The wing 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 final procedure, meticulous suture closure is done Then irrigation with antibiotic and antiseptic solutions is performed using a syringe after the closure

Taping is done to decrease the edema and to decrease the mobility of the implant and grafts Then a thermo-plastic splint is applied on the dorsum The splinting is important to immobilize the implant and to prevent edema and hematoma on the radix area in the immediate post-operative period The splint should be applied along the pre-marked vertical line of the augmentation The splint is maintained for at least 7 days

■ Key Technical Points

1 Designing an implant is the first and most critical step Based on the desired shape and individual anatomy, the implant should be carved correctly

2 The subperiosteal pocket is created The pocket should be symmetric and appropriately wide for the implant to be snugly placed inside and not be excessively mobile

3 For the septal extension graft, excessive tension on the graft is undesirable, especially when the septal cartilage is frail It provides a stable platform for the onlay tip graft, which is used for further tip projection and definition, commonly required in Asian patients

of tension, a marginal incision is extended medially over

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

ligaments

When the height difference between the tip and the

anterior septal angle is significant and the inclination of

lateral crura is considerable, a variant technique can be

used (Fig 2.13) The substantial tip-to-septum height

dif-ference and lateral crural inclination are commonly created

by the strong tip projection with the septal extension graft;

however, a considerable tip-to-septum height difference is

present even prior to surgery in some patients In this

situ-ation, the distal implant is carved in a wedge shape with

appropriate thickness to fit in the cephalic divergence of

alar cartilages The implant may be sutured to the cephalic

margins of the alar cartilages

For some patients, only the low nasal bridge, not the

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

carved implant according to the individual dorsal anatomy

will suffice The implant is inserted through the marginal

or intercartilaginous incision Inadequately narrow, small,

or asymmetric dorsal pockets will predispose to extrusion

For the symmetry of the dorsal pocket, bilateral incision

and dissection are recommended The distal end of the

implant is tapered to be paper thin to smoothly continue

to the cephalic portion of the alar cartilages An implant

of excessive length, in a small or asymmetric pocket, may

extrude, especially when the distal implant is in direct

con-tact with the incision site In this regard, marginal incision

is more appropriate for the alloplastic implantation With

the marginal incision, additional tip grafting or other tip

manipulations are also possible

Fig 2.13 (a,b) When the gap is significant between the tip and the anterior septal angle, the implant may be carved in a wedge shape

and suture fixed to the cephalic margins of the alar cartilages

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Problems Caused by Inherent Physical Characteristics of Alloplastic Implants

Capsule Formation

In cases where complications such as contraction do not occur, the fibrous capsule prevents the implant from bond-ing with skin, prevents skin damage, and maintains the thickness of the skin and soft tissue to some degree On the other hand, the fibrous capsule has a side effect of making the area susceptible to infection by preventing antibiotics from effectively penetrating the area around the implant and by letting the silicone implant create dead space within the capsule as it moves inside

In certain situations, the capsule causes severe cations, most notably the contracted nose.6 Creation of an excessively thick and wide capsule and contraction is usu-ally caused by additional factors such as bacterial infection and excessive tissue damage

compli-Therefore, to avoid overproduction of capsules and its ensuing complications, the surgeon must take care to pre-vent inflammation or infection from occurring during or after surgery, while minimizing tissue damage and bleed-ing by surgery

Skin and Mucosal Damage

Stimulation of the skin, damage to skin and appendages, skin thinning, skin contraction, and telangiectasis are long-term complications The slight yet repetitive damage caused

by the solid implant can harm the mucous membrane and create recurring chronic inflammation, possibly by ascend-ing bacterial infection through small mucosal defects To minimize such physical damage from silicone implants, the implant should be of appropriate length and width, and it must be well fitted and immobile Additionally, using

a softer material for the implant can help reduce cal stimulation Suturing a layer of dermis or dermofat on the outer surface of the implant is helpful in thin-skinned patients or revision cases to decrease mechanical stimula-

physi-tion, and mobility and visibility of the implant (Fig 2.14).Calcification

When removing a long-seated implant, the surgeon may come across calcification of the implant A calcified implant forms a harder and rougher surface, increasing stimulation

to the overlying skin and letting the irregular surface show through the skin Calcification may worsen with time.7 Cal-cification also relates to mechanical stimulation and dam-age to surrounding tissue

4 The pre-carved implant is inserted in the pocket

and the dorsal profile is carefully checked Repeated

carving may be necessary Using the distal implant

as a dummy for the tip augmentation allows

the amount of tip projection and rotation to be

estimated

5 The onlay graft is prepared It is commonly

stacked in multiple layers for sufficient tip

projection The same length as the onlay graft is

excised from the distal implant The onlay graft is

sutured to the cut end of the implant

6 The wing graft is prepared mimicking the lateral

crus It is placed on both sides of the onlay graft to

prevent the pinching deformity of tip lobules, to

decrease the conspicuity of the onlay graft

7 Further fine 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

compressive dressing with a thermoplastic splint is

important to immobilize the implant and to prevent

edema and hematoma

■ Complications and

Their Management

Negative reactions toward alloplastic implants for

rhino-plasty were common in the Western part of the world This

may stem from experience with injectable materials such

as paraffin oil, liquid silicone, and early implants of

exces-sive size.5 Interestingly, recent research shows much lower

complication rates from silicone implants compared with

reports published in the 1960s and 1970s These changes

are thought to be due to improvements in implant design,

conservative surgical techniques, physicians having more

experience, and use of softer silicone Many physicians in

Asia perceive the complication rates of silicone implants

as acceptable, in part due to more experience with

rhi-noplasty using silicone implants compared with Western

physicians

Complications from silicone implants can be largely

grouped into two categories, those caused by inherent traits

of silicone itself and those resulting from the surgeon’s

technical or judgmental errors For a successful surgical

result, it is essential to minimize the inevitable problems

from inherent physical characteristics of the material and

to make efforts to reduce technical and judgment errors.5

Common complications, such as deviation, tip skin

problems, and infection, are more frequently related to

technical errors that are avoidable, and less frequently to

the physical characteristics of the material itself