Aesth Plast Surg (2008) 32:632637 DOI 10.

1007/s00266-008-9114-1

REVIEW

Aesthetic Rhinoplasty of the Asian Nasal Tip: A Brief Review

Guang-Yu Mao Song-Lin Yang Jiang-Hong Zheng Qing-Yang Liu

Published online: 24 January 2008 Springer Science+Business Media, LLC 2008

Abstract Tip surgery, the most important part of the rhinoplasty procedure, has entered a new era in the past few decades. Various treatment protocols have been attempted. To date, however, opinions on the management of the Asian tip have not been solidied. To generalize and provide appropriate guidelines for the treatment of typical Asian tips, an English literature search from 1977 to March 2007 was conducted. Finally, a total of 26 papers were selected for review. The full text of each paper was read carefully, and data were extracted. Then all extracted information was imported into Microsoft Excel. Nine articles treating 11 groups of patients described the suitable techniques for Asian nasal tips, with 81.8% of the groups advocating that the protocol include a grafting technique, 64% reporting use of the grafting technique alone, and 9% applying cartilage reduction and a suturing technique. Of the 11 (18%) groups, 2 attempted more than one technique. Because of the Asian nasal tips innate qualities, success with nasal tip plasty for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most. Keywords Asian Grafting Nasal tip plasty Rhinoplasty Suturing

often have failed to satisfy the high expectations of patients. Therefore, many procedures have been developed to improve the appearance of the nasal projection and nasal tip. Nasal tip surgery was rst introduced at the end of the 19th century by John O. Roe. At that time, aggressive techniques involving alar cartilage resection were used. Recently, more conservative techniques have become increasingly recognized including suture techniques, tip grafting, and subcutaneous tissue resection. However, the characteristics of the Asian nasal tip including the bulbous appearance, ared nostrils, and restriction of the nasal tip attributable to an underdeveloped medial crus of the alar cartilage and a short columella have made such procedures difcult. Metaanalyses are becoming an increasingly accepted means for achieving evidence-based conclusions, helping surgeons to make rational decisions in choosing methods. The lack of adequate trials and publications comparing the efcacy of varied methods for performing Asian nasal tip plasty spurred us to perform an analysis of the literature on this subject. In this evidence-based review, the current literature was examined to determine whether any signicant scientic evidence existed to support a standard method for the Asian nasal tip.

Currently, rhinoplasty is one of the most popular aesthetic surgical procedures, particularly in China and South Korea. However, the results of simple augmentation rhinoplasty
G.-Y. Mao S.-L. Yang (&) J.-H. Zheng Q.-Y. Liu Department of Plastic Surgery, Shanghai No.6 Peoples Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China e-mail: yangsonglin@hotmail.com

Materials and Methods Search Criteria A relevant literature search was performed by using Medline (through Pubmed, from 1977 to March 2007). The search strings and the number of hits are given in Table 1. The search was performed with limiting factors of

123

Aesth Plast Surg (2008) 32:632637 Table 1 Search strings and number of hits Search strings Nasal tip and Asian Nasal tip and Oriental Cartilage reduction and nasal tip Cartilage cutting and nasal tip Suturing and nasal tip Cartilage graft and nasal tip Medline 30 28 41 6 30 131

633

restriction of the nasal tip. With the development of the management for the Asian nose since the year 2000, plastic surgeons have paid more attention to the classication of the Asian nose/nasal tip. In this review, all classications were based on the internal anatomic structures (skin and alar cartilages) or on their external reections. According to the detailed distinctness, the different treatment programs listed in Table 2, were used.

human and English language. Additional articles identied from these references that contained relevant supporting information then were included.

Management Indication After screening of the abstracts, 9 articles describing treatment for 11 groups of patients were selected for techniques suitable for Asian nasal tips. The detailed data are listed in Table 3. Most clinical studies advocated a multiple choice for the Asian tip. Of the 11 groups, 9 (81.8%) included a grafting technique with the protocol, 7 (64%) reported the use of grafting techniques only, and 1 (9%) respectively underwent cartilage reduction and suturing techniques. Two (18%) of the 11 groups attempted more than one technique (Fig. 1).

Inclusion and Exclusion Criteria After excluding identical papers, we selected peerreviewed articles that met the following criteria: Articles about other elds except for the aesthetic nasal tip plasty were excluded. Literature that focused on the treatment of aesthetic nasal tip plasty was selected regardless of the number of patients. Additional articles identied from the references that contained relevant supporting information then were included.

Discussion Nasal tip procedures have undergone a signicant change in the past few years. Previous techniques resected or vertically divided the alar cartilage, resulting in altered structural integrity and stability. In contrast, the new philosophy of tip surgery focuses on preserving and reorienting the nasal tip structures, thus maintaining their integrity instead of destroying it. It is speculated that for Asian noses, sufcient tip projection cannot be attained by either the domal suture technique or onlay grafting alone because of weak alar cartilage, thick skin, and abundant subcutaneous tissue. Therefore, clinicians need to be familiar with suturing and grafting techniques and to combine them properly.

After all the abstracts had been read, 19 papers about the treatment were selected for review. The full text of each paper was read carefully, and data extraction was performed. Finally, all extracted information was imported into Microsoft Excel.

Data Extraction The techniques described in the articles were divided into three types: suturing, grafting, and cartilage reduction. The respective number of patients treated using each technique was calculated. Cases with no complications were considered as demonstrating a good result whether the patient was satised with the outcome or not. Any treatment that lengthened the columella (e.g., columellar strut use) was considered as a type of grafting.

Grafting and Implanting Many Asian plastic surgeons believe that an alloplastic implant [1], especially a silicone graft, is the correct material for three reasons. First, for most Asians, harvesting of autologous cartilage or bone may be difcult to accept for traditional or religious reasons. Second, for the Asian nose, a moderate amount of augmentation is indicated for preservation of the racial type. Finally, although many Western supporters of biologic nasal augmentation argue that silicone is a foreign body that is not incorporated into the patients

Results Classication According to common knowledge, the typical Asian nose is characterized by its bulbous appearance, ared nostrils, and

123

634 Table 2 Classication of Asian nose/tip Author Description Treatment

Aesth Plast Surg (2008) 32:632637

Aung et al. [3] 2000 A. A very prominent alar lobule forming a full and rounded nasal tip No mention B. A less prominent alar lobule forming a more dened nasal tip C. The least prominent alar lobule forming a relatively straight slope from the tip to the base Shirakabe et al. [25] 2003 A. An unprojected dorsum and tip B. Prominent dorsum and diminutive tip C. Adequate dorsum height and diminutive tip D. Prominent dorsum and adequate projected tip Ahn [1] 2006 A. Thin skin and strong cartilages B. Thick skin and strong cartilages C. Thick skin and weak cartilages Dorsum augmentation with or without tip augmentation Tip augmentation and dorsum reduction Tip augmentation only Dorsum reduction only Interdomal suturing/columellar strut/shield graft Cartilage onlay grafts/alloplastic implants B + A/premaxillary grafts

Table 3 Publications on the management of the Asian nasal tip Author Tip morphology Technique Suturing Shin & Lee [24] 1994 Deva et al. [7] 1998 McKinney [20] 2000 Lam & Kim [16] 2003 Shirakabe et al. [25] 2003 Flat nasal tip No mention Bulbous nose No mention Diminutive tip Cartilage reduction Resection of the cephalic or middle portion of the lateral crura Grafting Columella lengthening Silicon implant Bird Silicon implant Conchal cartilage + Silicon Lee et al. [18] 2004 Deviated nose Broad nose Flat nose Lin et al. [19] 2006 Hodgkinson [13] 2007 Jang et al. [14] 2007 Bulbous nose Saddle tip Flat tip No mention + + Lateral crura ap Silastic tip implant Conchal graft Bone graft Onlay graft Onlay graft Alar cartilage resection Columella strut Septal cartilage graft + Defatting -

tissue, and thus will become infected or extruded, this may not be completely true because the nasal soft tissue of Asians is thicker and less extensible than that of Caucasians. However, not all Asian noses can be treated adequately using simple implant insertion alone. Wu [27] thinks that for thick bulbous tipped noses, a simple implant placement can produce a trilobed appearance of the tip, which is made up of the implant tip and the displaced domes of the alar cartilages or lower lateral cartilages that lie on either side of the implant tip. In his opinion, the smallest, sharpest tips can be attained only with autogenous materials. Wu prefers

to use a silastic implant only for the dorsum, terminating the implant in the supratip region. The tip of the nose then is given more projection by resecting the upper two-thirds of the lower lateral cartilages and using these as supporting grafts for the columella and tip. The availability of increasingly varied alloplastic materials has evolved in response to techniques for nasal augmentation. The best implant for nasal augmentation, however, remains controversial. Three factors must be considered: biocompatibility, the patients selection, and long-term results.

123

Aesth Plast Surg (2008) 32:632637

635

Fig. 1 Distribution of patients undergoing different techniques

Generally, implants can be divided into biologic and alloplastic types. Biologic materials include cartilage, bone, and fascia [17]. Alloplastic materials comprise silicone, Supramid, Vicryl, Proplast, Mersilene, Medpore, polytetrauoroethylene, and ivory. Each has its advantages and disadvantages [1, 7]. Alloplastic implants are straight or curved sheets for augmentation of the dorsum, and sometimes for augmentation of the tip as well. They are readily available and easy to fashion and shape, but they may incur some serious complications (e.g., resorption, infection, extrusion, and foreign body reaction), which can be avoided with the application of autogenous implants. Nevertheless, autogenous implants also have some disadvantages such as insufcient supply, longer procedure time, high cost, and donor-site morbidity. nig [8] was the rst to use autogenous cartilaginous Ko grafts for humans. The earliest clinical application of septal

grafts in the nose was reported by Metzenbaum [8]. One of the two most commonly used techniques is the shieldshaped (sometimes triangular) graft proposed by Sheen and Sheen [23]. The rst technique places the shield graft in the lobule to accentuate the middle cruracolumella angle and to provide tip projection. The second technique positions the rectangular onlay graft over the domes, as proposed by Peck and Peck [22]. Some widely used biologic grafts are listed in Table 4, and a few donor sites are listed in Table 5. In addition, actual lengthening of the columella would increase nasal tip projection. The medial crura of the alar cartilages are the primary components of the columella and provide tip support. Footplates of the medial crus vary in size, shape, and angulation. To solve this problem, Oguz Cetinkale et al. [5] used cartilage grafts in both the tip and the labiocolumellar junction at the same time, whereas Shin and Lee [24] used V-Y advancement or an earlobe composite graft in the columella base to lengthen the columella.

Suturing Rhinoplasty in the 20th century places more emphasis on surgery of the nose for aesthetic reasons than ever before. The period ranging from 1930 to the early 1980s was

Table 4 Overview of tip grafts [5, 6, 910, 12, 15, 2123] Description Anchor graft Graft pocket (envelope) Application

Shaft is sutured to the caudal margin of the medial crura Improve tip support and/or project and collapse or deform the lateral crura Transverse components replacing the lateral crura or lying over their remnants and sutured to them Between the tip-dening points and the middle crura Rene, soften, and ll in clefts of the nasal tip in patients with thin skin to enhance tip projection minimally and occasionally to rene the infratip lobule area Maintain tip support and increase tip projection and aid in shaping the columella-lobular angle Increase tip projection and perhaps aid in lengthening the nose

Cap graft

Columella strut (oating/xedoating) Columellar strut (xed) Extended columella strut tip graft (extended shield graft) Onlay tip graft Shield graft (Sheen or infralobular graft) Subdomal graft

Between the medial crura through a small incision caudal to the feet of the medial crura Fixed to the nasal spine or premaxilla

In the precrural space or by placed caudal to or between Provide tip support, projection, denition, and the medial crura and sutured in place to the crura fullness caudal to the medial crura to aid in shaping the columella Placed horizontally over the alar domes Placed adjacent to the caudal edges of the anterior middle crura, extending into the tip Placed under the domes Minimally increase tip projection but mainly to camouage tip irregularities Increase tip projection, dene the tip, and improve contour of the infratip-lobule Correct dome asymmetry by controlling the horizontal and vertical orientation of the domes Correct the pinched nasal tip deformity

Umbrella graft

Transverse component placed in a small tight pocket or Increasing both tip projection and support sutured to the domes of the lateral crura

123

636

Aesth Plast Surg (2008) 32:632637

marked by two parallel developments. On the one hand, the increased use of cartilage excision techniques in aesthetic rhinoplasty often resulted in disruption of the nasal tip components, with inconsistent outcomes. Thus, sutures served to hold the disrupted tip components and then reposition them in place. On the other hand, a concurrent evolution was taking place in the eld of cleft nose surgery. The ensuing two decades leading to the 21st century were marked by a rapid transition from disruptive cartilagealtering techniques to procedures that made use of precision suture placement for reshaping of the nasal tip cartilages without serious disruption of the components. In this innovative eld, it is not surprising that many techniques have developed in tandem but with varying nomenclature. Invariably, this creates confusion for the novice and the experienced surgeon alike. It is of great importance to extend credit to the pioneers of tip rhinoplasty techniques. Surgical results are more predictable with increased reliance on sutures placed with precision and with an understanding of the dynamic that they induce when used singly or in combination. Currently, instead of excising and repositioning of the tip cartilages, the focus is

on lateral crus preservation and tip cartilage modication through precise suture placement and tension control (Table 6).

Assistant Technique To some extent, the characteristic of an Asian nasal tip is its bulbous nature. It is different from the tip of Western noses, which is characterized by a strong nasal cartilage. Five soft tissue layers overlying the osseocartilaginous framework are identied: the skin, the subcutaneous areolar plane, the vascular-bromuscular layer, the deep areolar plane, and the perichondrium/periosteum. The cartilaginous framework provides projection, support, and shape to the dorsum and tip of the nose. The skin of the nose is specialized, capable of retaining its shape even after dissection due to an arrangement of elastin bers in the upper dermis and the subcutaneous areolar plane that confers elasticity to the skin, especially in the region of the alar lobule, which is a skin and bromuscular sandwich [28]. To thin out the tip, most surgeons thin the

Table 5 Indications for donor cartilage related to the area to be reconstructed [2]

Donor site Septum Auricle

Advantages Easy harvest No separate donor-site morbidity Easy harvest Relatively abundant Curved nature ideal for certain purposes

Disadvantages May be decient Separate donor site Curved (less desirable for some purposes) Donor-site morbidity Warping possible

Rib

Large volume (abundant, even for signicant augmentation) Distant donor site (2-team approach possible) Reliable

Table 6 Evolution of suture placement in the nasal tip [4, 11, 26] Surgeon Joseph 1931 Goldman 1954 McIndoe and Rees 1959 McCollough and English 1985 Tardy and Cheng 1987 Daniel 1987 Kridel et al. 1989 Tebbetts 1989,1994 Gruber 1997 Guyuron 1998 Technique Orthopedic suture: columella septal suture (interdomal and medial crura anchor sutures) Lateral crura divided just lateral to domes, medial crura sutured together (medial crural, middle crura, and interdomal sutures) Cleft nose repair: alar cartilage repositioned with medial crural and lateral crural sutures (medial crura anchor and medial crural sutures) Double-dome unit: morselization of domes; horizontal mattress through both medial and lateral crura under domes (early transdomal and interdomal sutures) Transdomal suture: horizontal mattress through both domes with knot placed interdomally Domal creation sutures: an individual horizontal mattress suture placed across each dome Lateral crural steal technique Systematic nondestructive approach: specic sequence of suture placement; medial crura anchor suture, medial crura footplate suture, medial crura suture, lateral crura suture, tip rotation sutures Lateral crura convexity control suture Medial crura footplate suture renement

123

Aesth Plast Surg (2008) 32:632637

637 10. Gunter JP, Landecker A, Cochran CS (2006) Frequently used grafts in rhinoplasty: Nomenclature and analysis. Plast Reconstr Surg 118:14e29e 11. Guyuron B, Behmand RA (2003) Nasal tip sutures part II: The interplays. Plast Reconstr Surg 15:11301145 12. Han SK, Lee DG, Kim JB, Kim WK (2004) An anatomic study of nasal tip supporting structures. Ann Plast Surg 52:134139 13. Hodgkinson DJ (2007) The Eurasian nose: Aesthetic principles and techniques for augmentation of the Asian nose with autogenous grafting. Aesth Plast Surg 31:2831 14. Jang TY, Choi YS, Jung YG. Kim KT, Kim KS, Choi JS (2007) Effect of nasal tip surgery on Asian noses using the transdomal suture technique. Aesth Plast Surg 31:174178 15. Juri J, Juri C, Grilli DA, Zeaiter MC, Vazquez GD (1988) Correction of the secondary nasal tip and of alar and/or columellar collapse. Plast Reconstr Surg 160165 16. Lam SM, Kim YK (2003) Augmentation rhinoplasty of the Asian nose with the Bird silicone implant. Ann Plast Surg 51:249 256 17. Leaf N (1996) SMAS autografts for the nasal dorsum. Plast Reconstr Surg 97:12491252 18. Lee KC, Kwon YS, Park JM, Kim SK, Park SH, Kim JH (2004) Nasal tip plasty using various techniques in rhinoplasty. Aesth Plast Surg 28:445455 19. Lin J, Tan X, Chen X, Lin J, Shi S, Tian F, Shen J (2006) Another use of the alar cartilaginous ap. Aesth Plast Surg 30:560563 20. McKinney P (2000) Management of the bulbous nose. Plast Reconstr Surg 106:906917 21. McLure TC (1991) A modied Goldman nasal tip procedure for the drooping nasal tip. Plast Reconstr Surg 87:254260 22. Peck GC Jr, Michelson L, Segal J, Peck GC Sr (1998) An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconst Surg 102:21662168 23. Sheen JH (1993) Tip graft: A 20-year retrospective. Plast Reconstr Surg 91:4863 24. Shin KS, Lee CH (1994) Columella lengthening in nasal tip plasty of Orientals. Plast Reconstr Surg 94:446453 25. Shirakabe Y, Suzuki Y, Lam SM (2003) A systematic approach to rhinoplasty of the Japanese nose: A thirty-year experience. Aesth Plast Surg 27:221231 26. Tardy ME Jr, Cheng E (1987) Transdomal suture renement of the nasal tip. Facial Plast Surg 4:317 27. Wu W (2006) Application of cartilaginous ap in the bulbous and saddle nose. Aesth Plast Surg 30:564 28. Wu W (1992) The oriental nose: An anatomical basis for surgery. Ann Acad Med Singapore 21:176

undersurface of the raised skin ap, then excise and discard the brofatty areolar tissue over the tip and between the lower lateral cartilages. This latter tissue is in fact a useful source of interpositional tissue between implant and skin, which also can be used to mold the tip [27].

Conclusion In summary, because of the Asian nasal tips innate qualities, including weak cartilages and abundant subcutaneous tissue, success with nasal tip procedures for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most.

References
1. Ahn JM (2006) The current trend in augmentation rhinoplasty. Facial Plast Surg 22:6169 2. Araco A, Gravante G, Araco F, Castri F, Delogu D, Filingeri V, Casciani CU, Cervelli V (2006) Autologous cartilage graft rhinoplasties. Aesth Plast Surg 30:169174 3. Aung SC, Foo CL, Lee ST (2000) Three-dimensional laser scan assessment of the Oriental nose with a new classication of Oriental nasal types. Br J Plast Surg 53:109116 4. Behmand RA, Ghavami A, Guyuron B (2003) Nasal tip sutures part I: The evolution. Plast Reconstr Surg 112:11251129 5. Cetinkale O, Altintas O, Yakut H, Yucel A (2004) Labiocolumellar graft combined with tip graft in the management of inadequate tip projection. Aesth Plast Surg 27:454461 6. de Benito J, Fernandez Sanza I (1995) Rhinoplasty and the aesthetic of the smile. Aesth Plast Surg 9:7981 7. Deva AK, Merten S, Chang L (1998) Silicon in nasal augmentation rhinoplasty: A decade of clinical experience. Plast Reconstr Surg 102:12301237 an B, Ayhan M, Go rgu M, Deren O (2002) Umbrella graft 8. Erdog of columella tip: 20 years experience. Aesth Plast Surg 26:167 171 9. Gruber RP, Grover S (1999) The anatomic tip graft for nasal augmentation. Plast Reconstr Surg 103:17441753

123