Rhinoplasty Korea

This lady has deviated silicone implant and associated short, contracted nose. It is a very common complication of silicone implant rhinoplasty. Revision rhinoplasty included silicone removal, replacing the silicone with rib cartilage, and lengthening the nose and tip. Only autogenous materials like rib cartilage can enable all these procedures. Filling the empty, excavated dorsum with carved rib cartilage requires a lot of efforts. Tedious carving to prevent warping, secure fixation of the graft to the widely dissected dorsum, making a smooth transition from forehead to nose, prevention of an operated look, etc. Lengthening the contracted skin needs wide undermining of skin, making a stable flatform to fix the lengthened tip cartilage and skin, and filling the deficient vestibular skin if present. Behind the 3 series of pre and postoperative photos below lie 4 hours of focused efforts of a rhinoplasty surgeon.   

Management of bulbous tip starts from analyzing what is contributing to the bulbous look of the nose. Contributing factors include large cartilage, thick fat tissue, thick dermis, and relativley flat nasal dorsum. Surgery of the bulbous tip includes reducing the large tip cartilage, removal of abundant subcutaneous fat, and reinforcing the tip with cartilage grafts. Simultaneous dorsal augmentation and tip elevation also help to relieve the bulbous look. Limitation in improving the bulbous tip comes from the thick dermis. Dermis is an essential component of the skin, so it must be preserved. In this case, retinoic acid such as Accutane or Roaccutane can be used cautiously to thin out the dermis. This should be used preoperatively to thin the thick dermis.

Tip surgery becomes more popular in Asian patients. To overcome low and bulbous tip, many surgeons use a lot of techniques to modify the tip. One of the most common tip elevation techniuqes is septal extension graft. In this technique, cartilage graft on the caudal septum is used to support the new tip position. The advantage of this technique, when properly used, is stable and enduring tip modification. Disadvantages are stiff tip and possible nasal obstruction due to twisted caudal septum. In Asian rhinoplasties, I often see an overly projected tip. Not only this pinocchio style nose gives unpleasant look, but also it causes too much tension and pain on the tip. Often it also causes nasal obstruction because the caudal septum twists due to skin pressure. Modest change harmonious with the elevated dorsum gives a natural look of the tip.

Narrowing the nose is needed in patients with wide dorsum for aesthetic improvement. Widening the dorsum is needed when the bony pyramid was pinched by previous osteotomy and the patient complains of nasal obstruction. Sometimes, widening the dorsum is necessary for aesthetic purpose, too. Narrowing and widening the dorsum all need osteotomy for bone management. Osteotomy is the most invasive technique among rhinoplasty techniques. It is totally different from breaking the nose unintentionally. It finely cuts the bone according to the surgeon's plan. Brusing and edema are unavoidable side effects of osteotomy, but they can be minimized with proper techniques. Cast is necessary for a week to reduce edema.

Deviate nose is often associated with chin deviation. If the nose is deviated to the opposite direction as the chin is deviated, centering the nose in the midline makes the face less asymmetric. On the other hand, when the nose is deviated to the same direction as the chin is deviated, correcting the nose can make the face more asymmetric. In this case, the chin needs to be centered after rhinoplasty. Correcting the deviated nose not only makes a straight, well-breathing nose but also can make the asymmetric face more harmonious.  

Septal deviation is associated with nasal obstruction, snoring, and deviated nose. Correction of septal deviation has a wide spectrum from simple excision of deviated portion to total septal reconstruction or replacement. High revision rate tells there are pitfalls to avoid. I analyzed 100 cases of revision septoplasty patients and published it in the journal. It shows the most common mistakes they make during the septoplasty is timid separation of bone and cartilage. It also shows caudal septal deviation is difficult to correct and septal batten graft is the solution. I hope that nose surgeons can get a little help from my article. read more

Preoperatively, her dorsum was slightly low, tip was underprojected, and alar-columellar relationship was not in harmony. Mild elevation of the dorsum using rib cartilage, tip and alar modification using septal extension graft and alar rim graft made her nose much more refined. I believe this small change of the nose can make her days brighter and happier!

In the filed of rhinoplasty, there are so many materials for graft purposes. I have my special technique to smoothen the dorsum and radix after cartilage graft. Mastoid periosteum is a relatively thick periosteum behind the ears. It affords soft covering on the irregular dorsum with slight volume. I use this graft especially for radix augmentation. It makes the forehead to nose transition smooth and natural. Harvesting scar is well camouflaged within the postauricular skin crease and there is no complication.

Hump nose is quite common in middle east and western countries. Asians do have hump nose. There are many types of hump nose in Asian, however, in general it is associated with low radix and underprojected tip. Correction of hump nose is not just a simple bump resection. It is a harmonization of dosrum by minimally resecting the hump while elevating the radix and tip. It is a kind of redistribution process. Raidx elevation needs special attention. Becuase the graft easily shows up at radix, it needs a soft tissue covering. Prevention of nasal obstruction after big hump resection is also important because the cartilage tends to roll into the nasal cavity and narrows the airway.  Nasal hump correction may look simple, but it has many pitfalls to avoid.

Instead of wrapping diced cartilage in temporalis fascia, I devised a template that can mold a silicone implant shaped cartilage graft. This graft is made from diced cartilage pieces that are bio-glued together into a template. This is a good substitute of diced cartilage in fascia and is effective when applied properly. It saves time for the surgeon and patient can avoid separate incision on the scalp. In the patient above, Gore-Tex implant was removed and dorsum was replaced with diced cartilage in glue made from conchal cartilage. You can see more natural looking dorsum after revision.

Dicec cartilage in fascia (DCF) is one of graft material used for dorsal augmentation. Cartilage diced into fine pieces is wrapped in temporalis fascia as a sausage shape and grafted on the dorsum for general dorsal augmentation or filling of defect area. Mostly, cartilage is grafted as a whole piece for the dorsum. However, when cartilage are curly or available in separate pieces like in conchal cartilage harvesting or when rib cartilage warping cannot be controlled, DCF is an alternative. It has merits such as avoiding rib cartilage warping, smooth dorsal margins in thin skinned patient, a little maleability in early postoperative period, and adaptible fitting of irregular dorsum. However, additional harvesting of temporalis fascia is necessary and possible junctional step offs at radix or supratip is possible if not careful.

No matter how beautiful the nose may look, it is really depressing and embarassing if the patient cannot breathe well. Unfortunaely, nasal obstruction after rhinoplas ty is pretty common. These unexpected functional problem needs a lot of attention for proper treament. Finding out an exact place of obstructon is most important for proper treatment. However, this is complicated due to altered shape, distorted anatomy, lack of surgery information, and scar formation. Common reasons for obstruction after rhinoplaty includes; 1) deviated septum (not corrected or newly developed) 2) internal valve stenosis after hump removal 3) collapsible lateral nasal wall due to weakened cartilage 4) narrowing of nostril due to thickend or deviated septal grafts 5) nostril stenosis due to scar 6) saddle nose with collpase of nasal cartilage 7) nasal cavity mucosal problem (stenosis, turbinate hypertrophy, mucosal loss...) Treatment follows complete analysis of the site and etiology of obstr...

In short nose, the dorsal length is shorter than normal, the tip is upturned, and the nostril show is exaggerated. It can be congenital or more commonly, it is caused by complications of previous rhinoplasty. Repeated silicone insertion, infection, and traumatic manipulation of the tissue build up scar tissue around the tip which contracts and pulls the tip upwards. While overresection of cartilage is a common casue of this phenomenon in Caucasian rhinoplasty, implant related scar contraction is common cause in Asian rhinoplasty. Correction needs a lot of work because the skin is contracted with decreased elasticity, the framework is damaged and weak, and often the inner mucosa is deficient. In severe cases, rib cartilage is a must material for grafting and wide skin undermining to move it downwards is necessary. Not infrequently, a staged operation is required. Deficiency inside the nose needs a composite graft from the ear. With all these efforts, the result is often not satisfact...