Rhinoplasty Korea

I had the joy to guest edit a special issue ' The key to costal cartilage in rhinoplasty' in journal 'Plastic and Aesthetic Research'. This special issue covers all issues of rib cartilage use in rhinoplasty; cutting edge techniques of harvesting and carving, application of rib cartilage in primary and revision rhinoplasty, practical points for proper preoperative and postoperative care, and diced cartilage and homologous cartilage applications. I invited world renowned rhinoplasty surgeons who are specialists in dealing with rib cartilage use. I hope rhinoplasty surgeons who wants to use rib cartilage in their practice will benefit from the wisdom of the experts.

This lady in below photos had nasal deviation, hump nose, and tip ptosis with breathing difficulty. Septum was corrected first, and this made the lower 2/3 of the nose straight. Hump was not resected but rasped with Piezotome and this did not breach the keystone area, which made spreader grafts unnecessary.Bilateral osteotomies with Piezotome made her bone straight. Together with septum correction and effective osteotomies, her nose became straight from the frontal view. Tip was modified with sutures and onlay graft only. No strut or septal extension graft was used and this made the tip soft even after considerable amount of rotation and projection increase. Radix was augmented with bruised cartilage. Overall, she could breath much better after surgery and her nose became more harmonious and feminine.

This patient had silicone implant on the dorsum and tip surgery with septal and conchal cartilage. As time passes, the tip and supratip area dropped and a step deformity of the dorsum developed. You can see the short silicone implant on the dorsum from the X-ray and the subsequent step deformity on the preoperative lateral view in the middle. Silicone was replaced with autologous cartilage and tip ptosis was corrected with cartilage support. It is sometimes difficult to expect how much the tip projection will decrease as time passes, but with proper technique using autologous tissue, the margin of error should be within 10%.

This gentleman had a few failed previous rhinoplasties and finally ended up with upturned tip with nose contraction. At surgery, there was no allplast inside but a long K-wire fixed to the anterior nasal spine supporting the tip was removed. All cartilage grafts removed, recarved, and used as septal extension graft and extended spreader grafts to fix it. Skin was widely undermined to mobilize to the elongated new dome. Conchal composite graft was used to fill the gap between elongated skin and the deficient mucosa on the right side. Even though this is an early postoperative photos, you can recongnize the elongated nose with pushed down nostril margin and columella. Even without using rib cartilage, short upturned nose can be fixed effectively.

https://www.realself.com/find/South-Korea/Seoul/Otolaryngologist/Hong-Ryul-Jin

The lady in below photos visited my clinic for rhinoplasty. She wanted to have more feminine nose instead of her muscline nose. She had a long nose with slight bump on the dorsum, overprojected, slightly bulbous and droopy tip, and slighly wide dorsum.  Surgery was focused on creating more feminine look: hump removal, narrowing the bony dorsum with osteotomies, tip volume reduction, decreasing tip projection, and slight cephalic rotation.  Photos taken 2 weeks after surgery (because she returnd back to her country after surgery) shows changes on the dorsum and the tip. Dorsum became slender with creation of smooth brow-tip aesthetic line. Tip was refined with volume reduction, slight underprojection, and cephalic rotation. Although the changes are not radical, her nose looks more feminine.

Removing nasal filler is often required due to diverse reasons. Acute side effects such as blindness, skin necrosis, infecton are representative reasons. Recurrent skin reaction, nodule or granulation formation, and pressure sense are other reasons for filler removal. Hyaluronic acid filler is easily removed with hyaluronidase injection. Non-resorbable fillers such as auqamid can be squeezed out after making a small incision on the skin, but sometimes it is difficult to completely remove all the fillers injected into the dermis. Trying to attempt all the fillers has the danger of damaging dermis. Sometimes open approach is required when simultanous rhinplasty after filler removal is required. At least a week prior to surgery, absorbable fillers are removed with hyaluronidase injection for accurate shape control in revision rhinoplasty. Fillers at the nasal tip can be removed at the time of open approach and you can often observe inflammation of the soft tissue around the tip. ...

This lady developed short nose after multiple previous rhinoplasties. By using folded temporalis fascia on the dorsum, conchal cartilage onlay graft on the tip, and conchal composite graft on the vestibule, a natural looking nose that has lengthened tip with mildly elevated dorsum. 

This gentleman had multiple rhinoplasties before. He has a Gore-Tex implant on the dorsum, pinched and upturned tip, narrow middle vault, and nasal obstruction. Surgery included replacing Gore-Tex with rib cartilage, septum and middle vault reconstruction, tip lengthening with new septal extension grafts, and medial and lateral reinforcement with cartilages. After surgery, his nose looks normal and he can breath much better. I used special technique called "grated cartilage paste" on the tip area. Grated rib cartilage was made as paste using patient's own blood and used as tip onlay graft. This gives volume not only on the tip but also on the lateral margins of the tip, which makes a more natural tip apprearance.

Management of bone in rhinoplasty includes bony hump resection, septal bone correction, and deviated nasal bone osteotomies. All these can be done efficiently with ultrasonic instrument. Advantages of ultrasoninc instrument over conventional method are less bleeding, less swelling, and greater control of fine bone adjustment. Patient can benefit a lot from this instrument, while doctors are more confient in bone managing techniques. I delcalre that I have no financial interest with the manufacturing company.

Diced cartilage in fascia was used in silicone-related contracted nose patient. She had a silicone implant on the nose and the tip was up-rotated due to contracture. Her nose looked short and the tip was upturned. Silicone was removed from the dorsum and the deficient dorsum was filled with diced rib cartilage in temporalis fascia. Her tip was elongated using septal extension graft and tip grafts. After surgery, her dorsum looks natural and the tip was refined with optimal lengthening.

Bone cutting in rhinoplasty is an essential part for nasal bone modification. It is necessary to correct a deviated nose, to remove the hump, and to narrow/widen nasal bone. It is the most invasive surgical technique in rhinoplasty and causes edema and brusing of the nose. Most surgeons use osteotome for cutting the bone. It literally cuts the bone with physical strength like we cut apple with knife. The common problem of cutting the bone with conventional osteotome is difficulty in fine control of the cut. It is also blindly done under the skin relying on the tactile sense of the surgeon. New ultrasonic osteotome called Piezotome uses the ultrasonic power to cut the bone. It enables fine cutting of the bone with easy control and causes less bone loss. It is done under direct vision after wide skin elevation, which causes less edema and brusing on the contrary to the common belief that edema will increase with wide skin elevation. The use of this equipment is slowly increasing rec...

Dermis is one of the skin layers, which is in between the epidermis and subcutanous layer. It is the thickest part of the skin. The thinnest one is 0.6 mm in the upper eyelid and the thickest one is about 3 mm in the palm, sole, and back. For rhinoplaty purpose, dermis is harvested from the buttock, which has the thickest layer. After elliptical skin excision, epidermis and subcuatenous tissue are removed to obatin dermis (below photos). Dermis is commonly used to cover the tip grafts to prevent showing. It is also used to camouflage damaged skin after failed rhinoplasties. Some surgeons use it to augment the dorsum after silicone removal. Augmenting the dorsum with dermis has two potential disadvantages: one is infection and the other is resorption. Once the dermis graft is infected, there is a high possibility of comcomittant skin damage, so absolute sterile technique is important. Resorption of dermis is somewhat unpredictable. In severe revision cases that has decreased bloo...

Medpor is porous polyethylene which has many pores that tissue grows in. Thin sheet of Medpor is commonly used as septal extension graft, columellar strut, and splinting graft of the septum. Sometimes it is used as dorsal implant, too. Common problems of Medpor used for rhinoplasty are bad smell from the nasal cavity, hard and painful tip, extrusion of implant, and infection. Removal of implant is the only solution for these problems. As tissue grows into the pores, removal is sometimes difficult, but it can be safely removed in most cases. Important point is maintaining the septal support or tip support after removal. After removal, often the septum or tip cartilage is weak with loss of dorsal or tip height, needing support with autologous cartilages. Below is a case of Medpor removal. She complained of overly projected tip with stiffness and  pain. From the surgical photo, you can see the L-strut made with Medpor. After removal of Medopor, septum was reconstructed and tip an...

Recently an Australian patient had a revision surgery using rib cartilage. She posted a thorough review of her journey on the web. You may want to look at it, so here is the link. So impressive not because she said good things on me, but because I could feel her pain and incredible efforts during her journey of revision rhinoplasty. https://forum.purseblog.com/threads/my-revision-rhinoplasty-at-dr-jins-premium-nose-clinic-2018-pt-1.994030/

Nasal obstruction developing after rhinoplasty is increasing. Diverse etiologies are involved and evaluation is not always straightforward. Analyzing the anatomic etiology needs thorough physical examination, radiologic evaluation, and functional tests. There are a lot of armamenterium to improve the nasal airway, but a wise choice of these techniques is very important. In addition to the improvement of the airway, patient also requests aesthetic improvement. Achieving these two goals is often tricky and requires experience and skill.

Silicone is the most widely used alloplastic implant for dorsal augmentation. Gore-Tex, an expanded polytetrafuoroethylene, is also a commonly used material. Unlike silicone implant, Gore-Tex is soft and feels natural. It has micropores, so tissue grows inside and the implant is fixed to the tissue. While Gore-Tex has many advantages, its disadvantages are also distinct. Firstly, it can erode nasal bone a little when the implantation duration is long. Erosion causes pain and heaviness on the dorsum. It is common to see a 'rail road deformity' after longstanding Gore-Tex removal. 'railroad deformity of the dorsum after Gore-Tex removal' Second, it is more difficult to remove than silicone implant. Because tissue grows inside the micropores, it adheres to the tissue. If the implant is inserted deep to the radix, sometimes complete removal is extremely difficult. In this case, endoscopic observation of the nasofronta area helps to completely remove the silicone piec...

This short video clip shows how I harvest a 4 cm rib cartilage from a 1.7 cm incision. Initial 1.5 cm incision changed into 1.7 cm incision with stretching. No muscle is cut during the dissection and it minimized postoperative pain. Incision heals well with meticulous suture. There is no need for admission and the patient can go home on the day of surgery.

This short video clip shows how a rib cartilage is changed into a graft for dorsal augmentation. It usually takes about 10 minutes to finely carve the rib and this process is repeated for 2-3 times before it is finally seated on the dorsum. Artistic sense of carving, relaxed mind, concentration, and perseverance are needed for this work.