Newport beach, Calif. – Rhinoplasty for Asian patients brings with it a variety of challenges, not the least of which is the lack of agreement among surgeons on how to achieve the best results, along with a paucity of good reports in the literature.
Nazih Haddad, M.D., who has extensive experience in treating Asian noses, explained his techniques for achieving consistent outcomes and happy patients.
A clear recognition of the challenges with the Asian nose is necessary, he advised, to develop a good surgical plan. “Asian skin is thicker and less elastic than Caucasian skin, making it less easy to remodel,” he said.
What’s more, the cartilage is softer and thinner compared with Caucasian noses, so it is somewhat less reliable. Attempts to sculpt the cartilage fail because “it does not take the shape you want due to its softness, in addition to warping and possible absorption,” said Dr. Haddad, aesthetic plastic surgeon in Newport Beach, Calif.
To further complicate matters, the bony framework, in general, is tiny. This means that the patient’s bone structure itself does not help the surgeon to reshape the nose.
Building the bridge
The Asian nose is often saddle-shaped: the bony structure is disproportionately small with a wide tip. If the patient wants a Caucasian nose, then the surgeon must build the upper and middle portion of the nose and reduce the lower part of the nose (the tip and alae). The latter techzique sometimes requires making an incision in the skin, and this can be challenging, warned Dr. Haddad, who is also a clinical associate professor of facial plastic surgery at the Uiversity of California, Irvine.
Asians, Dr.Haddad said, prefer to have a strong nasal profile. A quick and easy way to achieve this – at least as a first-line treatment – is by using Silastic implants. “I suggest using the larger rather than the smaller implants because I have found my patients prefer this look. They also want a more narrow ala.”
Dr. Haddad also uses implants to achieve the narrow alae. This he noted, can be somewhat controversial because conventional wisdom holds that implants have a high likelihood for eventual extrusion. “The incidence of extrusion is about 5 percent, but I believe the benefits far outweigh this risk. The good news is that the thickness of Asian skin better protects and hides the implant.”
Placing the implants is not a lengthy procedure, he said, and can be done under local anesthesia. This is important because the patient does not experience a great deal of downtime; often they can return to work right away because swelling is not a problem.
An average of 7 to 8 mL of buffered lidocaine with epinephrine is injected in the nasal dorsum, the tip, and the gingivallabial area. After 10 minutes, an incision is made in the gingival-labial area and, tith sharp and blunt dissection, is tunneled up the the columella. Then scissors and a periosteal elevator are used to undermine the skin of the nose and the periosteum to create a pocket for the implant.
Dr. Haddad used a preformed, L-shaped Silastic implant. “I like the preformed models because they require almost no carving. Many surgeons will carve the unformed Silastic at the time of surgery. This usually takes longer and the end results are not as pleasing as those achieved with preformed Silastic. I prefer Silastic over harder implants because the feel is better,” he explained.
Closing the wound
The wound is closed with chromic or polyglactin 910 (Vicryl) sutures. “if the implants is placed deep the the periosteum, then it is well secured,” he said. If necessary, Steristrips can be placed on top of the nose.
Projecting the tip of the nose will sometimes narrow the nasal alae. If this does not occur after he places the implant, then Dr. Haddad removes a wedge of skin at the junction between the nasal alae and the floor of the nose which he cuts from the inside or from the outside along the crease of the nostril.
Asian eyes also require special attention, and the patient dictates the outcome based not just on personal preference, but on cultural factors as well.