Rhinoplasty in the Asian

Patient
Hong Ryul Jin, MD, PhDa,*, Tae-Bin Won, MD, PhDb

KEYWORDS
 Rhinoplasty  Nose  Asian  Nasal tip

KEY POINTS
 For successful Asian rhinoplasty, not only specific anatomic distinctions but also cultural nuances
and social framework surrounding the patient need to be considered.
 Nasal tip skin is typically thick and sebaceous, and the lower lateral cartilages and septum are para-
doxically small, weak, and deficient.
 The mainstream of dorsal augmentation is using alloplast, such as silicone or expanded polytetra-
fluoroethylene (e-PTFE); however, tip-plasty is safely performed with autogenous cartilage.
 Septal extension graft with added onlay tip graft is the workhorse for the tip.
 Alloplast-related complications are common causes of revision rhinoplasty. Proper selection of pa-
tients, judicious use of alloplast, and the ability to manage relevant complications are important at-
tributes in Asian rhinoplasty.

Video of an end-to-end style septal extension graft (SEG) used to modify the Asian nasal tip
accompanies this article at http://www.plasticsurgery.theclinics.com/

INTRODUCTION that distinguish the procedure from its white

Rhinoplasty is one of the most common facial
plastic surgeries performed in Asia. The primary
objective in an Asian rhinoplasty is fundamentally
the same as with all rhinoplasty patients. The goal
is to sculpture a natural-looking and appealing
Asian nose that goes well with the ethnic face.
An attractive white nose, although maybe beauti-
ful as a nose itself, does not harmonize with the
Asian face. Anatomic characteristics of the Asian
nose coupled with differences in aesthetic stan-
dards demand that they be approached in a
unique way. Numerous articles have been pub-
lished highlighting these different approaches
and techniques.1–4 These collectively stress that
counterpart.
This article highlights the characteristics and
techniques of different aspects of Asian rhino-
plasty. Procedures performed on the nasal
dorsum including dorsal augmentation and man-
agement of the nasal hump and procedures per-
formed on the nasal tip with emphasis on tip
augmentation are discussed. Finally, revision rhi-
noplasty in Asians is briefly addressed.
CHARACTERISTICS OF THE ASIAN NOSE AND
CLINICAL IMPLICATIONS
Although there are individual variations, most
Asian noses are characterized by thick skin with
plasticsurgery.theclinics.com

rhinoplasty among Asians includes peculiarities abundant subcutaneous fibrofatty tissue, a weak

a
Department of Otorhinolaryngology-Head and Neck Surgery, Boramae Medical Center, Seoul National Uni-
versity College of Medicine, 39 Boramae Road, Dongjak-gu, Seoul 156-707, Republic of Korea; b Department
of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul, Republic of Korea
* Corresponding author.
E-mail address: doctorjin@daum.net

Clin Plastic Surg 43 (2016) 265–279

http://dx.doi.org/10.1016/j.cps.2015.09.015
0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
266 Jin & Won

cartilaginous framework, short nasal bones, un-

derdeveloped anterior nasal spine, and small
quadrilateral septal cartilage. The associated cuta-
neous findings include a wide and underprojected
dorsum; a low radix and nasion; a nasal tip that is
bulbous, lacking definition, underprojected, and
either ptotic or overrotated (short nose); with a
short columella and an alar base that is wide and
flaring. These features are summarized in Table 1
and depicted in Fig. 1.
Clinical implications of these characteristics are
as follows:
 Thick skin can better tolerate alloplastic or
autogenous material than thin skin. It camou-
flages grafts in a more natural fashion. How-
ever, it also obscures minor changes
performed on the cartilaginous framework.
 Tip definition is harder to achieve in Asian
noses. Delicate and weak lower lateral carti-
lages together with thin, weak septal cartilag-
inous support generally require reinforcement
to obtain a desirable tip shape. Cephalic
resection or pure cartilage reshaping sutures
often do not work; instead, struts, grafts,
and battens are needed to effectively modify
the shape of the tip.
 The lack of septal cartilage frequently places
the surgeon in a challenging situation because
in most cases there is a need for significant
amount of cartilage. Consequently, one of
the primary sources of augmentation material
in Asia remains alloplastic implants.
 The shorter nasal bone width with flatter nasal
pyramid makes osteotomy more difficult
because the path tends to follow the thicker
part of the ascending process of maxilla.5 In
patients requiring large dorsal hump reduc-
tions, there is a higher chance for middle vault
collapse because of short nasal bone width
Table 1
Characteristic features of the Asian nose
Location Characteristics
Radix Low and inferior
Dorsum Underprojected,
short nasal bones
Tip Underprojected, poor definition
Lower lateral Weak, small, and pliable
cartilage
Ala Thick, flared, short columella
Skin Thick with abundant
subcutaneous fibrofatty tissue
Septum Thinner, smaller
Fig. 1. The anatomy of a typical Asian nose. Note the
weak cartilages, short nasal bones, and thick skin.
and length resulting in an inverted “V” defor-
mity.2 Because of the wide nasal valve angle
and thick skin envelope, nasal obstruction
caused by the internal nasal valve problems
is rare in Asians.6
MANAGEMENT OF THE NASAL DORSUM
Dorsal Augmentation
Most Asian patients request greater dorsal height
together with increase in tip projection. Prerequi-
sites for a successful augmentation rhinoplasty
include a thorough evaluation of the patient’s anat-
omy, knowledge of the ideal shape and size of the
nose within the context of cultural harmony, execu-
tion of proper surgical technique, and most impor-
tantly appropriate choice of augmentation material.
Determining the level and height of the nasion
The key in preoperative planning is determining
the level and height of the nasion, which is the
starting point of the nose. The difference in the
starting point among different races has been
extensively debated in the literature.7 Traditionally,
the supratarsal crease has been considered as the
ideal starting point for whites, and the midpupillary
line for Asians. However, there is a trend for
contemporary Asian patients to seek a higher
starting point. The authors consider the starting
point in Asians to be somewhere in between the
supratarsal crease and midpupillary line depend-
ing on individual preferences. The height of the na-
sion is usually determined by the nasofrontal
angle. The ideal nasofrontal angle in Asians is
around 135 for males and 140 for females.
Choice of augmentation material
The most important practical issue in dorsal
augmentation is the choice of augmentation mate-
rial. The amount of augmentation needed, skin
thickness, and patient’s age, wishes, and available
 Rhinoplasty in the Asian Patient 267

cartilaginous structures are a few of the factors to
consider.8–10 In addition, the surgeon should be
aware of the advantages and disadvantages of
each grafting material (Table 2). Dorsal augmenta-
tion with autologous cartilage is not dealt with in
this article. However, readers are advised that
the authors prefer using autologous cartilage
whenever possible.
Dorsal augmentation using alloplastic implant
Although the preferred implant material in rhino-
plasty is autologous cartilage, most Asian noses
require substantial augmentation, which on occa-
sion is beyond the amounts available from autolo-
gous cartilage. This realistic limitation has
popularized the use of alloplastic implants in
many Asian countries. The mainstay of practice
is using alloplastic implant for the dorsum and
autogenous grafting material for the tip. It is also
the authors’ personal opinion to restrict the use
of alloplastic implants if needed in the nasal
dorsum and use autologous materials for nasal
tip to reduce the risk of extrusion or infection of
the implant. When alloplastic implants are

Table 2
Advantages and disadvantages of commonly used graft materials in Asian rhinoplasty

Types of Graft Materials Advantages Disadvantages

Autogenous grafts
Septal cartilage
Conchal cartilage
Rib cartilage
Calvarial bone
Temporalis fascia
Homologous grafts
Irradiated rib
Alloderm
Synthetic allografts
Expanded
polytetrafluoroethylene
(Gore-Tex)
Porous high-density
polyethylene
Silicone (solid form)
(Adapted from Jin HR, Won TB. Recent advances in Asian rhinoplasty. Auris Nasus Larynx 2011;38(2):157–64.)
Stable (lower absorption rates)
Reliable long-term results
Rare donor site morbidity
Resistant to infection
Ideal for various grafts
Stable (low absorption rates)
Resistant to infection
Suitable for tip grafts, alar
reconstruction
Larger quantities
Ideal for dorsal augmentation,
septal support grafts
Larger quantities
Useful for grafting of the upper
one-third of the nose
Larger quantities
Suitable for camouflage grafts
Larger quantities
Relatively biocompatible
Low infection and extrusion rates
Larger quantities
Relatively biocompatible
Compensation for irregularities
Suitable for covering graft edges
Relatively biocompatible
Soft/sculptable
Useful for dorsal augmentation
Relatively biocompatible
Sculptable
Useful for spreader grafts,
columellar strut
Ease of use
Sculptable
Easily removed in revision
Suitable for dorsal augmentation
Relatively small amount in Asians
Often limited in revision surgery
Requiring separate donor site
Has curvature and pliability
Risk of pneumothorax
Donor site scar and pain
Warping tendency
Risk of dural or brain injury
Higher rate of absorption
Requiring separate donor site
Potential disease transmission
Higher rate of absorption
Warping tendency
Potential disease transmission
Higher rate of absorption
Possible infection and rejection
Not suitable for structural support
Possible infection and rejection
Difficult to remove
Too rigid
Possible infection and rejection
Capsule formation
No tissue ingrowth
268 Jin & Won
considered, the benefits and risks should be ex-
plained to the patient before the surgery.
There is a wide array of alloplastic materials
available for rhinoplastic use. These include sili-
cone, expanded polytetrafluoroethylene (e-PTFE),
and high-density porous polyethylene implant
(Fig. 2). Thus far, which material is best remains a
controversial issue.
Procedural approach
Before local infiltration, the cephalic limit of the
implant or graft pocket is marked. Next, the pocket
where the implant will sit is outlined. The prefabri-
cated silicone or e-PTFE implants can be shaped
with a 15-blade preoperatively and then sterilized
for insertion, or can be shaped intraoperatively.
In cases of isolated dorsal augmentation, an inter-
cartilaginous incision is made and extended into a
partial transfixion incision along the upper caudal
end of the septal cartilage. When tip surgery is
combined, an infracartilaginous incision with
extension into the medial crus is used. The supra-
perichondrial plane over the upper lateral cartilage
is dissected, exposing the nasal pyramid. The
periosteum is incised and elevated to the marked
new nasion level. It is important to make a pocket
where the implant can fit snugly. The nasal implant
is inserted into the pocket and adjusted as neces-
sary (Fig. 3, Video 1).
Avoiding complications using alloplastic
implants
Alloplastic implants used to augment the dorsum
are associated with several complications. The
most common ones include deviation of the
implant, infection, extrusion, mobility of the implant,
and visibility of the implant.
To avoid deviation or migration (cephalic or
caudal) of the implant, it is important to raise a
symmetric pocket for implant insertion. For begin-
ners, bilateral intercartilaginous or infracartilagi-
nous incisions and dissection is recommended to
Fig. 2. The two most commonly used alloplastic implants for augmentation rhinoplasty in Asians are I-shaped
silicone implant (A) and expanded e-PTFE implant as a sheet form (B).
prevent unilateral deviation of the implant. It is usu-
ally helpful to make the pocket a little bigger than
the implant so that the implant can snugly fit into
the pocket and minimize the chances of displace-
ment. Creation of an oversized pocket can result in
shifting or displacement of the implant. It is also
important to mark the starting point of the nose
in the radix area and refrain from overdissection
beyond this point because it can cause unwanted
cephalic migration especially with silicone im-
plants (Fig. 4). It is necessary to fix the implant in
the desired location by suturing it to the surround-
ing tissue in an open approach. Making a few small
holes on the implant helps to prevent caudal
migration by fibrous ingrowth into the holes
(Fig. 5).
To avoid infection, cautious handing of the
implant and strict adherence to intraoperative
aseptic techniques and postoperative care is
essential. We usually prepare the nose with cotton
balls soaked in betadine solution, and irrigate the
nose frequently with antibiotic solution. The
implant is handled aseptically with new gloves
and inserted after soaking them in antibiotic solu-
tion. Postoperative broad-spectrum antibiotics
are given for 2 weeks.
Insertion in the proper subperiosteal plane is
important to avoid mobility of the implant,
decrease visibility, and reduce the chance of infec-
tion because the periosteum can act as a natural
barrier. The chance of extrusion is greatly
enhanced if the resulting tension on the nose is
increased and when the implant is located on the
more mobile portion of the nose, such as the nasal
tip. Therefore excessive augmentation and using
implants that extend to the nasal tip should be
avoided.
Management of the Dorsal Hump
Nasal hump surgery is frequently regarded as a
“reduction” surgery in most Western rhinoplasty
 Rhinoplasty in the Asian Patient 269

Fig. 3. Preoperative (A, C) and postoperative photographs (B, D) of a patient who had dorsal augmentation with
I-shaped silicone implant. Tip augmentation was done with columellar strut and onlay grafts using septal carti-
lage through an endonasal approach.
270 Jin & Won
Fig. 4. Cephalic migration of a silicone implant resulted
in a flat nasofrontal angle.
textbooks and is also referred as “reduction rhino-
plasty.” The common goal of treating a dorsal
hump is to obtain a natural contour of the nasal
dorsum through adequate dorsal reduction while
dealing with the issues of an open roof. Although
there are Asian patients who have large humps,
most Asian dorsums differs from their Western
counterpart in that the size of the nasal hump is
limited, and is frequently associated with a low ra-
dix and underprojection or underrotation of the
Fig. 5. Small holes on the implant were made with
skin biopsy puncher. Fibrous tissue ingrowth into
these holes prevents migration of the implant.
nasal tip. Naturally, correcting a nasal hump in
Asians has distinct differences in concept and
technique. A small hump and additional need for
radix augmentation of the dorsum and the tip often
minimize the amount of hump removal or some-
times obviate resection itself. Therefore “profilo-
plasty” instead of “reduction rhinoplasty” might
be a more suitable word when dealing with Asian
dorsal humps.
Many techniques have been introduced
including en bloc resection, component resection,
and Skoog dorsal resection.11–14 In the classic
“composite en-bloc” resection of the hump, com-
ponents of the hump (bone, dorsal septum, and
both upper lateral cartilages) are removed all
together (en bloc) leaving an open roof. The use
of bilateral spreader grafts after removal of sub-
stantial amount of hump cannot be stressed
enough. Supporting and reinforcing the rhinion
(keystone) with spreader grafts to prevent an in-
verted V deformity is specially important in Asians
who have short nasal bones.15
For the relatively small dorsal hump, simple bony
rasping with minor trimming of the dorsal septal
cartilage is usually sufficient to achieve the desired
dorsal height or obtain the platform for further dor-
sal augmentation. Using a small straight osteotome
instead of the larger Rubin osteotome followed by
incremental rasping with a small or powered rasp
under direct visualization is helpful. Bony humpec-
tomy reveals the overlapping cartilaginous vault un-
derneath and precise reduction of the cartilaginous
vault can follow. The author uses the term “conser-
vative” humpectomy, and it is used in most small or
isolated dorsal humps in Asian patients. Subse-
quent dorsal augmentation with onlay grafts ce-
phalic and/or caudal to the hump in combination
with tip surgery contributes to the successful use
of conservative hump removal (Fig. 6).
Although the overlapping upper lateral cartilage
is visible underneath the nasal bones in the rhinion,
there is rarely an open roof deformity obviating
lateral osteotomies. Another reason that lateral os-
teotomy is not frequently performed is because
further radix and dorsal augmentation camouflage
the wide nasal base. Small amount of resection of
the cartilaginous hump decreases the need for
spreader grafts and rarely violates the nasal
mucosa, which can reduce the risk of infection
when using alloplastic implants for dorsal
augmentation.
The final touch of Asian hump rhinoplasty is
dorsal augmentation. Dorsal augmentation is per-
formed to achieve the desired height of the dorsum
and camouflage any remaining irregularities. This
can be in the form of radix augmentation or radix
and dorsal augmentation (Fig. 7). The latter has
 Rhinoplasty in the Asian Patient 271

Fig. 6. Conservative humpectomy with radix and tip augmentation. (A, C) Preoperatively photographs show a
mild hump, low radix, and slightly underprojected tip. (B, D) One-year postoperative photographs show smooth
dorsal profile, elevated radix, and more harmonious tip shape.
272 Jin & Won
Fig. 7. Radix and dorsal augmentation after hump removal. (A) Radix augmentation with soft tissue. (B) Radix
and dorsal augmentation with perichondrium. (C) Dorsal augmentation with e-PTFE.
the advantage of a smooth and gapless transition
in the thin-skinned rhinion area. Careful palpation
with wet gloves is important for detecting irregular-
ities after humpectomy. When performing radix
augmentation, we try to avoid using solid cartilage
grafts because they are prone to be visible. We
prefer soft tissue grafting material, such as fascia
(autologous or homologous) or e-PTFE. When
more augmentation is needed, crushed cartilage
is inserted below the soft tissue graft.
When the desired dorsal height exceeds the
height of the hump there is a choice of leaving it
alone or augmentation performed on top of it.
The author prefers to perform hump reduction to
smoothen the dorsum before augmentation. The
amount of resection in this situation depends on
the material used for dorsal augmentation. When
silicone is used, the undersurface of the implant
corresponding to the rhinion area can be carved
away thereby camouflaging small residual convex-
ity. For other grafting materials, such as cartilage,
e-PTFE, and homologous fascia, complete hum-
pectomy is performed to reduce the chance of
an irregular dorsum and/or residual convexity.
MANAGEMENT OF THE NASAL TIP
Projection, rotation, and volume are the three most
important factors to consider in tip rhinoplasty in
Asian patients. The projection of the nasal tip
must be in harmony with the augmented dorsum.
Furthermore, a gentle round shape is preferable
to a well-defined, angulated tip.
The main goal of tip rhinoplasty in the Asian pa-
tient is to obtain better projection, rotation, defini-
tion, aesthetically pleasing width, and minimal flare
at the nostrils while maintaining symmetry. One
important point that should be kept in mind is
that many Asian patients request an increase in
tip projection while maintaining or even decreasing
tip rotation. The amount of projection and rotation
differ according to personal preference, age, sex,
occupation, and overall facial features. In general,
because the dorsum of Asians is low most un-
dergo augmentation; therefore, the amount of tip
projection should be balanced accordingly. Nasal
tip width should always be evaluated in the context
of other facial anatomy and not as an isolated
feature. If the face is relatively wide, a narrow tip
can appear conspicuous and operated.
Tip Augmentation (Controlling Projection and
Rotation)
Augmenting the Asian nasal tip is more chal-
lenging because the fragile cartilage has to be
stabilized to a degree that it can withstand the
gravitational and contractile forces of the thick
 Rhinoplasty in the Asian Patient 273

skin soft tissue envelope (SSTE). Therefore, com-
mon tip surgery techniques, such as cartilage re-
shaping sutures or cephalic resection, often yield
inconsistent and incomplete results.16 Instead,
tip projection and rotation are more effectively
modified using structural grafts. The choice of
maneuvers to augment the nasal tip depends
on two factors: degree of tip support and amount
of projection needed to achieve the final
outcome.3
For the typical Asian patient with weak tip sup-
port, augmentation is usually accomplished in
two steps. The first step is stabilization of the nasal
tip. This step is the most important and key step in
Asian tip rhinoplasty. The objective is to establish a
firm foundation on which further grafting can be
performed. Stabilization of the nasal tip is achieved
either by a columellar strut or a septal extension
graft (SEG). Of the two, the SEG is by far the
more powerful tool that can be used reliably in
patients who have very weak tip support and/or
need substantial increase in tip projection. It can
alter projection and control rotation simultaneously.
The second step is fine sculpturing of the nasal tip.
This is done by combining sutures and a variety of
grafts to obtain the desired outcome (Fig. 8).
The septal extension graft
We emphasize the SEG because we believe that it
is a workhorse for tip rhinoplasty in the Asian nose.
Not only does it provide a firm foundation on which
the lower lateral cartilages can be repositioned,
but it can control tip projection, rotation, and nasal
length simultaneously. By varying its shape and
location, it is efficiently used to augment, rotate/
counterrotate, lengthen the nose, and/or correct
the nasolabial angle.4
There are different ways of executing the SEG
and it depends on the underlying deformity,
desired outcome, surgeon’s preference, strength

Fig. 8. Asian tip rhinoplasty using septal extension graft (clockwise rotation). Tip support is restored by applying
a septal extension graft and repositioning the lower lateral cartilages. Fine sculpting is done with additional
onlay tip grafts. (From Won TB, Jin HR. Nuances with the Asian tip. Facial Plast Surg 2012;28(2):187–93.)
274 Jin & Won
of the cartilage, integrity of the caudal septum,
and the amount of available grafting material.17–19
It can be placed on the anterior nasal spine, inte-
grated to an extended columellar strut, overlap-
ped to the caudal septum (unilaterally or
bilaterally), or secured in an end-to-end fashion
to the caudal septum. It can also be sculpted in
different shapes and sizes, depending on the
desired changes of the tip. The septal cartilage
is the preferred grafting material but in depleted
cases the costal cartilage can be used as an alter-
native source.
Procedural approach
Usually the SEG is performed unilaterally overlap-
ping the caudal septum by at least 5 mm or more
(see Video 1). Care is taken to bevel or thin this
portion of the graft overlapping the septal cartilage
because nasal obstruction can occur postopera-
tively from increased thickness in this area. If the
caudal septum is deviated, it is important to
straighten it first so that the extended portion of
the graft lies in the midline. Occasionally, the
SEG is used as a batten to straighten the deviated
caudal septum and augment the tip projection
simultaneously. The caudal septum to which the
SEG is fixed must be stable and strong enough
to withstand the pressure exerted by the thick
overlying SSTE characteristic of the Asian nose
and predictably maintain projection. Deviation of
the SEG can lead to the deviation of the nasal tip
especially if the caudal septal support is weak. In
cases where the caudal septum is weak, the
SEG can be also secured to the anterior nasal
spine, batten grafts, and/or extended spreader
grafts (Fig. 9).
Once the SEG is securely positioned in the
midline, the lower lateral cartilages are reposi-
tioned by suturing it to the SEG. In cases where
Fig. 9. When the caudal septum is weak, batten grafts
with septal cartilage or bone can further stabilize the
septal extension graft.
substantial augmentation is needed or when
lengthening of the nose is involved, it is important
to release the lower lateral cartilages as much as
possible to reduce the tension exerted on the
SEG–caudal septum complex and minimize
distortion of the lower lateral cartilages. This is
achieved by thorough dissection of the lower
lateral cartilages laterally to the pyriform aperture
and cephalically releasing the scroll area adjacent
to the upper lateral cartilages.
When the SEG is applied, the nasal tip tends to
become stiff and even though it softens with time,
it can be a source of postoperative complaint. We
consider this added stiffness an acceptable trade-
off for achieving desirable tip projection and
patients should be warned of this change preoper-
atively if a SEG is considered.
Managing the Bulbous Asian Tip (Decreasing
Volume and Increasing Definition)
Bulbous nose is a term used to describe the
shape of the nasal tip where it resembles a ball.
The common features of a bulbous tip include
rounded shape, broad or absent tip defining
point, poor definition, and increased sense of vol-
ume. Although the final shape of the nose is
similar, the causative factor that gives rise to
this peculiar shape of the tip is not uniform. Thick
SSTE and the character of the alar cartilages,
namely the size, shape, strength, and orientation,
are the principal causative factors. The contribu-
tion of each varies within individual patients.
Because of this diversity, there have been limited
attempts to try to classify the bulbous nose.20
Techniques to manage a bulbous nose are tar-
geted to correct the underlying causative fac-
tors.21 Procedures targeted to the alar cartilage
include reorientation and volume reduction of
alar cartilages. Diverse suture techniques and/or
grafts are used for the reorientation, and excision
techniques are used for the volume reduction.
Managing the thick skin is challenging and has
limitations. Soft tissue trimming is the most
commonly performed procedure (Fig. 10). We
usually limit our soft tissue trimming to the deep
fatty layer, taking care not to include the superfi-
cial musculoaponeurotic system layer because
this can lead to excessive scar contracture and
adhesions that can cause noticeable irregular-
ities. The limitations of tissue excision are over-
come or supplemented by expanding the skin
envelope.
Because most Asian noses need dorsal and tip
augmentation, a tip may appear less bulbous and
more balanced without any modification if the
dorsum and tip are augmented. An algorithm
 275

Fig. 10. Soft tissue excision can be done in situ (left) or after subsuperficial musculoaponeurotic system dissection
(right). (From Won TB, Jin HR. Nuances with the Asian tip. Facial Plast Surg 2012;28(2):187–93.)

for the management of the bulbous nose in REVISION RHINOPLASTY IN ASIANS

Asians should include all these considerations
and the strategy needs to be personalized The main reasons for revision rhinoplasty in Asians
(Fig. 11). often involve alloplastic implant.22 Common indi-
cations for unsatisfactory primary rhinoplasty

Fig. 11. A simplified algorithm for the management of the bulbous nose in Asians. (From Won TB, Jin HR. Nuances
with the Asian tip. Facial Plast Surg 2012;28(2):187–93.)
276 Jin & Won
outcome are as follows: alloplast-related compli-
cations, such as deviation, extrusion, and infec-
tion; short, contracted nose after multiple
surgeries; dorsal deviation/irregularity; and tip
problems related with SEG.
Alloplast-Related Complication
Although alloplast-related complications are
endless, typical examples are deviation, extrusion,
infection, foreign body reactions, unnatural or
operated appearance, and compromised SSTE.
Proper selection of patients, adherence to opera-
tive techniques that help avoid common complica-
tions associated with alloplastic implants
(discussed previously), and the ability to manage
complications when they occur are important attri-
butes in Asian rhinoplasty.
Infections with alloplastic implants may
occur immediately or even years after surgery
(Fig. 12).23–26 Although aggressive antibiotic
therapy is always initiated, the implant almost al-
ways needs to be removed, especially in cases of
e-PTFE.24,26 The major dilemma in cases of an
infected implant is the timing of the definitive
revision rhinoplasty after its removal. Currently,
the mainstay of treatment in most clinics in Asia
is a staged approach with removal of the allo-
plast and subsequent revision operation after
Fig. 12. Infection after e-PTFE augmentation of the
dorsum. Purulence is seen at the left sidewall near
the radix.
the inflammation has subsided. Although this
staged approach can provide a more sterile envi-
ronment for the subsequent revision surgery,
delaying surgery in a patient with nasal disfigure-
ment is a cause of frustration for the already un-
happy patient. Furthermore, contracture of the
overlying skin can occur, which is a greater chal-
lenge in correction.27 In a recent study, we have
shown that immediate reconstruction using
autologous cartilage after removal of an infected
alloplast is associated with a favorable outcome
with minimal chances of infection and
resoprtion.28
Short, Contracted Nose
A short, contracted nose is also a common
complication. It is a devastating complication
usually associated with repeated surgeries and
alloplastic material in dorsal and tip augmentation.
The pathogenesis is unknown but capsular
contraction around the implant, lower lateral
cartilage necrosis by long-term pressure from
implants, chronic inflammation, and scar contrac-
tion from multiple rhinoplasties are thought to be
possible etiologies. As the contraction progresses,
the soft nasal tip gets constricted and a so-called
snub nose develops (Fig. 13).
For correction, caudal rotation of the tip with
superior movement of the nasion is necessary.
Wide undermining of the contracted skin, readjust-
ing the lower lateral cartilage on the SEG, and
additional onlay tip grafts are key technical points
for caudal rotation of the tip. A firm structural sup-
port of the SEG using extended spreader grafts
and conchal composite graft in the vestibule are
needed to overcome the tension of stiff and inelas-
tic skin with deficient vestibular mucosa. Dorsal
onlay graft to fill the dorsal defect after removal
of the alloplast also helps to make the nose appear
longer (Fig. 14).
Dorsal Deviation and Irregularity
Common postoperative dorsal problems include
residual/iatrogenic deviations of the nasal dorsum,
dorsal irregularity or depression, and a visible
cartilaginous or alloplastic graft. Postoperative re-
sidual dorsal deviation is mostly caused by failure
to recognize or correct the pre-existing deviation.
Improper osteotomy with or without adequate
correction of septal deviation is the most common
cause. Deviation of the dorsal graft/implant and
warping of the costal cartilage graft can also cause
postoperative deviation. Complete realignment
or restoration measures of the bone and cartilagi-
nous structures is required to create more symme-
try. If residual deviation remains after all these
 277

Fig. 13. (A, B) Severely short and contracted nose after multiple rhinoplasties.

Fig. 14. Preoperative (A, C, E) views of a short and contracted nose following augmentation rhinoplasty with porous
high-density polyethylene (G). One-year postoperative photographs (B, D, F) showing improved nasal shape.
278 Jin & Won
measures, camouflage grafts are applied to make
the nose look symmetric and straight.
A supratip depression or fullness after alloplastic
dorsal augmentation is not uncommon. Careful
design of the implant and fine adjustment with
soft tissue or cartilage onlay graft at the supratip
area may be necessary. Radix irregularity after
hump removal is more common when the radix is
augmented with cartilage rather than alloplast.
To avoid this, radix graft should be bruised and/
or placed with soft tissue coverage in a small
pocket. Mastoid periosteum provides a good ma-
terial to smoothly elevate the radix area.
Tip Problems Related with Septal Extension
Graft
Tip problems include underprojection (or loss of)
or overprojection, overrotated tip, visible or pro-
truding grafts, tip deviation/asymmetry, and pain
or severe pressure sensation. Recent increase of
SEG for tip surgery in Asian rhinoplasty has re-
sulted in many complications, such as overly
aggressive tip projection (Pinocchio nose), pain/
dullness, deviated/asymmetric tip, and nasal
obstruction caused by caudal septal deviation.
Overly aggressive tip projection using septal
bone or Medpor beyond tissue’s acceptance is
the main cause for continuous pain, tenderness,
and pressure sense of the tip. Careful history
Fig. 15. Sagittal computed tomography scan of a
patient complaining of nasal tip pain, tenderness,
and hardness. Dorsal silicone implant and suspicious
bone at the caudal septal area used as septal extension
graft are observed.
taking and detailed examination including
computed tomography scan often reveal exces-
sive projection of the tip by the septal bone or
Medpor as the possible cause (Fig. 15). Removing
the stiff materials and reconstructing proper pro-
jection with cartilage is the best solution.
Inadequate stabilization of the overlapping SEG
in the midline is the main reason for tip deviation,
nostril asymmetry, and deviation of the caudal
septum with nasal obstruction. Stable fixation of
the SEG in the midline and symmetric restoration
of the lower lateral cartilage on the new dome is
most important to prevent these complications.
This often requires securely suturing the graft to
the anterior nasal spine and positioning the end
into the midline in overlapping type of SEG. In
end-to-end-type SEG, it needs reinforcement
with the extended spreader graft.
SUMMARY
Although the main principles of various rhinoplasty
techniques apply equally to the Asian nose, some
modifications are inevitable caused by anatomic
and aesthetic differences. Understanding these
differences and mastering the techniques unique
to the Asian nose based on the general principles
of rhinoplasty lead to a successful outcome. These
differences can only be recognized with contin-
uous exposure to Asian rhinoplasty and sustained
efforts to compare the differences between the
two practices.
SUPPLEMENTARY DATA
Supplementary data related to this article are
found online at http://dx.doi.org/10.1016/j.cps.
2015.09.015.
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