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!