COSMETIC Individualized Asian Rhinoplasty: A Systematic Approach to Facial Balance Zhanqiang Li, Jacob G. Unger, Jason Roostaeian, Fadi Constantine, Rod J. Rohrich,
M.D. M.D. M.D. M.D. M.D.
Beijing, People’s Republic of China; and Dallas, Texas
Background: Asian rhinoplasty, and rhinoplasty performed in other ethnic groups, remains a challenging operation for plastic surgeons. Precise clinical analysis and systematic planning preoperatively are widely accepted as the keys to success. Although a variety of analytical techniques have been published for other ethnic groups, a systematic approach for Asian rhinoplasty remains underrepresented in the current literature. Methods: A systematic approach and a stepwise technique were developed concomitantly with concepts in facial balance and proper preoperative evaluation for Asian patients. A retrospective review of 110 cases in 4 years was performed to evaluate the effectiveness of this approach. Results: Follow-up ranged from 6 to 48 months. Satisfactory results were achieved in 86 percent of cases. Typical cases were also reviewed. Conclusions: The systematic approach in Asian rhinoplasty presents a way to link appropriate analysis with specific techniques aimed at the subtleties of Asian rhinoplasty. This leads toward the individual’s aesthetic goals. In the authors’ experience, this approach allows for predictable and optimized results for this challenging procedure. (Plast. Reconstr. Surg. 134: 24e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
E
thnic rhinoplasty can be a surgical challenge because of the significant anatomical variability between groups and variability within each ethnicity.1 As widely accepted principles leading to success, precise clinical analysis and systematic planning preoperatively are emphasized frequently in publications. Some authors have developed systems of analysis that may be useful in a multitude of ethnic groups. Byrd and Hobar,2 on the basis of a large rhinoplasty experience and study of aesthetically pleasing faces, developed a system of dimensional analysis to determine optimal dimensional changes for Caucasian rhinoplasty and genioplasty patients. They stated that this system was intended not to replace surgical artistic judgment but to enhance the surgeon’s ability to deliver consistent, optimal results. Daniel3 identified three distinct types of deformities in Hispanic rhinoplasty and presented From the Plastic Surgery Hospital, Peking Union Medical College; and the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication June 20, 2013; accepted October 7, 2013. The first two authors are co–first authors with equal contribution to the content. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000294
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different approaches as solutions. The senior author (R.J.R.)4 discussed a pragmatic, systematic analysis of the African American nose and the techniques commonly used. He also emphasized the importance of keeping the nasofacial ethnic balance in Middle Eastern rhinoplasty.5 Asian rhinoplasty presents unique challenges to plastic surgeons. Platyrrhine nasal characteristics are common, with low dorsum, weak lower lateral cartilages, columellar retraction, and thick sebaceous skin often present. A number of studies focus on the technical concerns ranging from the materials used to the surgical details.6–9 Some other authors discern the aesthetic differences between Asians and Caucasians to find suitable solutions to these unique problems.10,11 However, it is well known that Asian aesthetic goals should be tailored to the ethnicity and culture of the individual patient. Gruber et al.12 reported some characteristics of Asian Americans, which are incorporated from various Asian nationalities and classified them into three categories for different treatments. Shirakabe et al. published their Disclosure: Dr. Rohrich receives instrument royalties from Micrins Instruments and book royalties from Quality Medical Publishing. The other authors have no financial interests to disclose.
www.PRSJournal.com
Volume 134, Number 1 • Individualized Asian Rhinoplasty 30-year experience on rhinoplasty, which proposed a systematic approach to divide the Japanese nose into four categories to achieve aesthetic goals.13 Although each of these articles has provided significant data with regard to Asian rhinoplasty, a complete systematic approach to analysis and operative treatment for Asian rhinoplasty has not been presented in the literature until now. Typically, Asian patients seek augmentation of existing structures rather than reductive procedures, especially with regard to dorsal augmentation and tip projection.7 Although still controversial, both autografts and alloplasts are now used quite commonly in Asian augmentation rhinoplasty in the Eastern Hemisphere.13–16 For obvious reasons, when implants are used in the nose, no tension is allowed on the nasal tip. In other words, there will be little or no change of the tip projection and/or rotation. In this situation, facial balance is mostly maintained. Thus, the importance of alloplastic implants in augmentation rhinoplasty has often been ignored. In addition, some patients will refuse the proposal of a combined genioplasty, which prevents an ideal result from coming into reality. With the spread of Dallas rhinoplasty techniques, more and more autologous cartilages are introduced into Asian rhinoplasty. Use of costal cartilage, in particular, has been shown to be a reliable technique.17 When executed properly, costal grafts can increase tip projection more safely and produce dramatic postoperative changes, with excellent long-term results. However, with the ability to create markedly increased nasal tip projection and dorsal augmentation, new challenges emerge with regard to facial balance, especially the nose-chin harmony. This further indicates the need for adequate preoperative planning and assessment to ensure a harmonious result after what can often be drastic changes to the nasal proportions. The senior author (R.J.R) had drafted a systematic approach for Asian rhinoplasty. This approach, based on the individual evaluations and aesthetic principles specific to Asian ideals, was applied in the first author’s (L.Z.Q.) clinic work later in China, with minimal revisions. Five simple steps are also developed to perform physical examinations in the consultation and planning phase, which are useful in intraoperative evaluation as well. This article presents the first author’s greater than 4-year experience with this approach that has developed along with concepts important in Asian facial balance and proper preoperative evaluation.
PATIENTS AND METHODS One hundred ten consecutive Chinese patients were included in the first author’s rhinoplasty series from June of 2008 to June of 2012 (Table 1). A retrospective review of the approach was performed and the effectiveness was evaluated. Systematic Approach Figure 1 demonstrates the examination techniques in steps. Planning and operative procedures are presented in the algorithm shown in Figure 2. Step 1: Nasal Tip When performing physical examination, let the patient sit face-to-face with the physician and adjust the chair height to eye level. Use hands or instrumentation (e.g., two single bulbous-tip hooks) to adjust the columellar-labial angle first. Use the thumb and middle finger to pinch the upper part of the columella, pulling or pushing the columellar base to adjust the philtrum to the natural vertical facial plane. The index finger can push the cephalic area of tip-defining points to assist the action. Of note, if the physician wants to see the front face view when the tip projection is increased, hooks should be used. The tip projection and rotation are then set to a final position based on aesthetic principles. The surgeon can observe the morphology of the nose from the front and side by adjusting head position or letting the patient turn on the stool. Step 2: Chin Position Keep the nasal tip position and use the spare hand to pinch the chin. Adjust the chin to the “tip-(upper) lip-chin” plane. Step 3: Radix Position Release the chin and turn to the radix. If the radix is lower than the horizon line through the pupils when the patient is looking straight Table 1. Demographic Characteristics of the First Author’s Rhinoplasty Series Characteristic Age 15–25 years 25–35 years 35–45 years >45 years Sex Female Male Rhinoplasty type Primary Secondary Combined procedures Combined genioplasty Others (e.g., blepharoplasty)
No. 37 63 8 2 97 13 75 35 46 46
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Plastic and Reconstructive Surgery • July 2014
Fig. 1. Examination technique.
forward and/or the radix is underprojecting, use the thumb and index finger to pinch the soft tissue at the ideal radix position. Step 4: Dorsum Alignment If the dorsum is lower than the line through the pinched radix and the new tip point, use three fingers on one side of the dorsum to push the skin slightly until the new “dorsum” is projecting to the appropriate height from the lateral view. Step 5: Alar Base Release the radix, keep the distance between the thumb and index finger equal to the intercanthal distance, and slide down slowly from the radix to the alar base. This will help identify a wide alar base and/or alar flaring, deformities of the nasal dorsum such as broad nasal bone, and deviations from the front view. Follow-Up and Evaluation Follow-up ranged from 6 months to 4 years (mean, 24 months). Patients had standard facial
26e
series photographs before surgery and at each follow-up. At the 6-month postoperative visit, contrast photographs were shown to the patients. A 0- to 10-point scale was then used to score the result by both the patient and the surgeon. When a divergence of scores occurred, a revision operation would commonly be performed and the result rescored at the next 6-month postoperative visit. If the patient refused the revision proposal and turned to other surgeons, the case score would be 0.
RESULTS The evaluation score results are listed in Table 2.
CASE REPORTS Case 1 A 23-year-old woman wanted a natural change at the first consultation. The facial analysis showed that her philtrum was
Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 2. Systematic approach for Asian rhinoplasty. NHP, natural horizon plane.
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Plastic and Reconstructive Surgery • July 2014 Table 2. Evaluation Score Results Score 8–10 5–7 2–4 0–1
Description Very satisfied with aesthetic appearance Improved result and limited satisfaction Little change, complaints remain, and need revision Failed surgery
No. of Cases (%) 95 (86) 10 (9) 2 (2) 3 (3)
recessed from the natural facial vertical plane. The tip needed a 0.5-cm projection increase and derotation. When these changes were demonstrated with physical examination in the preoperative assessment, the chin was noted to be severely retrognathic. Therefore, a costal cartilage augmentation rhinoplasty and a silicone implant genioplasty were planned. Photographs obtained 3 years postoperatively are shown (Fig. 3).
Case 2 A 30-year-old woman had a silicone augmentation rhinoplasty 1 year before presenting for secondary rhinoplasty. A tip erosion was seen because of great tension from the implant. Through systematic preoperative assessment, it became obvious that the philtrum and nasal tip needed to be repositioned. A genioplasty was further indicated from the preoperative examination. The surgical plan included a costal cartilage fixed strut, bilateral extended-spreader grafts, implant removal, dorsum onlay graft, and silicone implant genioplasty. Photographs obtained 6 months postoperatively are shown (Fig. 4).
DISCUSSION The definition of “Asian” may be arguable in this article. Strictly defined, it can be replaced by terms such as Mongoloid, Chinese, Han, and others. We simplified the classification of our patients because we feel these concepts are applicable to the general population commonly referred to as Asian and is analogous to other published articles on this ethnic group. However, the purpose of this article is to create a systematic yet individualized approach to preoperative evaluation of Asian patients and help achieve many common goals of this subset of rhinoplasty patients. This concept was not created to deliver an “aesthetic model” to the public. We support the viewpoint that the aesthetic goals of each rhinoplasty should be customized for the individual patient.8 What is emphasized here is paying attention to the importance of the facial balance, and how to keep this balance through a reproducible and systematic way in Asian rhinoplasty patients. Computer-assisted planning in rhinoplasty has been recommended by several experts.18 However, this group has not found this to be very effective in Chinese patients, particularly those
28e
in need of marked tip and/or dorsal augmentation. The computer was unable to accurately assess the changes to the surrounding structures of the soft-tissue envelope with the large forces placed on the nasal construct when a large augmentation was to be performed. Thus, the computerized images were unable to create a reproducible model of what the postoperative result would be. A stepwise systematic approach was therefore developed to assist with accurate preoperative planning. Several advantages are found with this approach. It is simple and noninvasive and can easily be adapted by surgeons and accepted by patients. Physicians can fully evaluate the facial balance and nose simultaneously with the steps outlined in this article. It is especially important to indicate the postoperative tension on the tip and chin and to help determine what steps will need to be taken to keep proper facial harmony. Therefore, the surgeon is able to create the complete presurgical plan in a short time by means of a reproducible and reliable technique. For example, if in the physical examination steps a 5-mm tip projection increase and a columellar base augmentation are found to be necessary, one can determine that costal cartilage should be used as the fixed strut. If the patient refuses and only desires that septal cartilage be used as tip grafts, the aforementioned maneuvers can be repeated to show a result with a lower tip projection. Furthermore, the patient and surgeon may see the effect that these forces will have on the surrounding soft tissue and the chin in real time. This allows the surgeon and patient to visualize the expected facial harmony while balancing it with the patient’s requests and desires to achieve the most satisfaction. The philtrum has been chosen as the initial point to begin the systematic approach. Aesthetically, by adjusting the philtrum to the natural facial vertical plane, one constructs a constant, objective, and visible reference plane for the nose and chin. This creates a basis for achieving facial harmony. Then, the focus is moved to the tip projection and rotation. The new tip location is the key point of the procedure. This identification will define all other parameters of the “new nose,” such as height and length and the relationship between the nose and surrounding structures (i.e., chin). Importantly, the surgeon can observe the expected changes to the patient’s face in real time. The next step is observing the harmony between the nose and the chin. Dimensional analysis between the nose and chin has been
Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 3. Case 1. Preoperative (left) and postoperative (right) views.
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Plastic and Reconstructive Surgery • July 2014
Fig. 4. Case 2. Preoperative (left) and 6-month postoperative (right) views.
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Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 5. Unbalanced result after one factor was accentuated without appropriate discussion of overall facial harmony.
widely accepted among Caucasian rhinoplasty surgeons and patients, although it has not been as popular with their Asian counterparts. There are some explanations for this phenomenon. First, most of the alloplastic augmentation rhinoplasty that has historically been performed has little effect on tip position. This means the original balance would be little changed, if at all. Second, not all patients can visualize the imbalance that will occur after large tip position changes, therefore causing them to choose not to address chin position preoperatively. Our systematic approach indicating future changes to the shape of the nose and face helps patients to have a better understanding of the future imbalance between the nose and chin should one occur. Thus, they can be better informed to make the appropriate decision. Figure 5 shows an example where improper preoperative education and planning resulted in a patient refusing the author’s genioplasty proposal and insisting on undergoing only rhinoplasty. One month after surgery, she had to undergo the planned genioplasty to achieve the final satisfactory result. Step 3 establishes the new radix point. We hereby strongly recommend the principle on Asian radix point setting proposed by Toriumi and Pero.7 It should not be higher than the line through the pupils when the patient is in primary gaze. In addition, we suggest the radix projection should lie in the anterior half of the distance between the natural facial vertical planes through the glabella and cornea to keep a natural nasofrontal angle and sufficient projection. The dorsum line is a simple connection between the radix and nasal tip points.
Augmentation or reduction is planned to achieve this line. One- to 2-mm variations are allowed to achieve a slight curvature on the side view. The width of the dorsum and alar base is evaluated lastly. When performing steps 2 through 5, the position of the nasal tip and the columellar base should be maintained. Because of the triangular pyramid structure of the nose, changes of the columellar height will influence the nasal base width and even the dorsum width. This approach also represents the first author’s operating sequence of the nose. After incision and full dissection as in the classic open approach, the nasal base is stabilized and the columellar base is augmented first.19,20 Then, the tip projection and rotation are fixed through reliable techniques such as columellar strut grafts and septal extension grafts. The skin envelope is redraped, making sure of the extent of the genioplasty (if needed) and determining the appropriate radix and dorsum adjustment. The alar base resection is the last step after the columellar incision is closed.
CONCLUSIONS Aesthetic rhinoplasty remains a challenging operation because of its complexity and importance to facial appearance. Precise and reproducible facial analysis by means of a systematic approach to both evaluation and operative techniques along with individual and ethnically tailored aesthetic goals are the keys to success. This holds true in particular in Asian rhinoplasty. This systematic approach to Asian rhinoplasty presents a way of linking precise analysis and reliable techniques, which lead to the individual’s aesthetic
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Plastic and Reconstructive Surgery • July 2014 goals both in rhinoplasty and in overall facial harmony. Further research will need to be performed to expound on and refine this Asian rhinoplasty algorithm to improve on our ability to obtain consistent and better results in the future. Rod J. Rohrich, M.D. UT Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, Texas 75390-9132 [email protected]
PATIENT CONSENT
Patients provided written consent for the use of their images. REFERENCES 1. Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37:353–370. 2. Byrd HS, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr Surg. 1993;91:642–654; discussion 655. 3. Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican American nose. Plast Reconstr Surg. 2003;112:244–256; discussion 257. 4. Rohrich RJ, Muzaffar AR. Rhinoplasty in the AfricanAmerican patient. Plast Reconstr Surg. 2003;111:1322–1339; discussion 1340–1341. 5. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343–1354. 6. Jin HR, Won TB. Recent advances in Asian rhinoplasty. Auris Nasus Larynx 2011;38:157–164.
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7. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37:335–352. 8. Lam SM. Asian rhinoplasty. Semin Plast Surg. 2009;23:215–222. 9. Bergeron L, Chen KT. Asian rhinoplasty techniques. Semin Plast Surg. 2009;23:16–21. 10. Sim RS, Smith JD, Chan AS. Comparison of the aesthetic facial proportions of southern Chinese and white women. Arch Facial Plast Surg. 2000;2:113–120. 11. Leong SC, White PS. A comparison of aesthetic proportions between the Oriental and Caucasian nose. Clin Otolaryngol Allied Sci. 2004;29:672–676. 12. Gruber R, Kuang A, Kahn D. Asian-American rhinoplasty. Aesthet Surg J. 2004;24:423–430. 13. Shirakabe Y, Suzuki Y, Lam SM. A systematic approach to rhinoplasty of the Japanese nose: A thirty-year experience. Aesthetic Plast Surg. 2003;27:221–231. 14. Ahn J, Honrado C, Horn C. Combined silicone and cartilage implants: Augmentation rhinoplasty in Asian patients. Arch Facial Plast Surg. 2004;6:120–123. 15. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg. 2005;54:1–5; discussion 6. 16. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: A systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538e–550e. 17. Park JH, Jin HR. Use of autologous costal cartilage in Asian rhinoplasty. Plast Reconstr Surg. 2012;130:1338–1348. 18. Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis: Quality Medical Publishing; 2007. 19. Toriumi DM. Structural approach to primary rhinoplasty. Aesthet Surg J. 2002;22:72–84. 20. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156–185.
M.D. M.D. M.D. M.D. M.D.
Beijing, People’s Republic of China; and Dallas, Texas
Background: Asian rhinoplasty, and rhinoplasty performed in other ethnic groups, remains a challenging operation for plastic surgeons. Precise clinical analysis and systematic planning preoperatively are widely accepted as the keys to success. Although a variety of analytical techniques have been published for other ethnic groups, a systematic approach for Asian rhinoplasty remains underrepresented in the current literature. Methods: A systematic approach and a stepwise technique were developed concomitantly with concepts in facial balance and proper preoperative evaluation for Asian patients. A retrospective review of 110 cases in 4 years was performed to evaluate the effectiveness of this approach. Results: Follow-up ranged from 6 to 48 months. Satisfactory results were achieved in 86 percent of cases. Typical cases were also reviewed. Conclusions: The systematic approach in Asian rhinoplasty presents a way to link appropriate analysis with specific techniques aimed at the subtleties of Asian rhinoplasty. This leads toward the individual’s aesthetic goals. In the authors’ experience, this approach allows for predictable and optimized results for this challenging procedure. (Plast. Reconstr. Surg. 134: 24e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
E
thnic rhinoplasty can be a surgical challenge because of the significant anatomical variability between groups and variability within each ethnicity.1 As widely accepted principles leading to success, precise clinical analysis and systematic planning preoperatively are emphasized frequently in publications. Some authors have developed systems of analysis that may be useful in a multitude of ethnic groups. Byrd and Hobar,2 on the basis of a large rhinoplasty experience and study of aesthetically pleasing faces, developed a system of dimensional analysis to determine optimal dimensional changes for Caucasian rhinoplasty and genioplasty patients. They stated that this system was intended not to replace surgical artistic judgment but to enhance the surgeon’s ability to deliver consistent, optimal results. Daniel3 identified three distinct types of deformities in Hispanic rhinoplasty and presented From the Plastic Surgery Hospital, Peking Union Medical College; and the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication June 20, 2013; accepted October 7, 2013. The first two authors are co–first authors with equal contribution to the content. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000294
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different approaches as solutions. The senior author (R.J.R.)4 discussed a pragmatic, systematic analysis of the African American nose and the techniques commonly used. He also emphasized the importance of keeping the nasofacial ethnic balance in Middle Eastern rhinoplasty.5 Asian rhinoplasty presents unique challenges to plastic surgeons. Platyrrhine nasal characteristics are common, with low dorsum, weak lower lateral cartilages, columellar retraction, and thick sebaceous skin often present. A number of studies focus on the technical concerns ranging from the materials used to the surgical details.6–9 Some other authors discern the aesthetic differences between Asians and Caucasians to find suitable solutions to these unique problems.10,11 However, it is well known that Asian aesthetic goals should be tailored to the ethnicity and culture of the individual patient. Gruber et al.12 reported some characteristics of Asian Americans, which are incorporated from various Asian nationalities and classified them into three categories for different treatments. Shirakabe et al. published their Disclosure: Dr. Rohrich receives instrument royalties from Micrins Instruments and book royalties from Quality Medical Publishing. The other authors have no financial interests to disclose.
www.PRSJournal.com
Volume 134, Number 1 • Individualized Asian Rhinoplasty 30-year experience on rhinoplasty, which proposed a systematic approach to divide the Japanese nose into four categories to achieve aesthetic goals.13 Although each of these articles has provided significant data with regard to Asian rhinoplasty, a complete systematic approach to analysis and operative treatment for Asian rhinoplasty has not been presented in the literature until now. Typically, Asian patients seek augmentation of existing structures rather than reductive procedures, especially with regard to dorsal augmentation and tip projection.7 Although still controversial, both autografts and alloplasts are now used quite commonly in Asian augmentation rhinoplasty in the Eastern Hemisphere.13–16 For obvious reasons, when implants are used in the nose, no tension is allowed on the nasal tip. In other words, there will be little or no change of the tip projection and/or rotation. In this situation, facial balance is mostly maintained. Thus, the importance of alloplastic implants in augmentation rhinoplasty has often been ignored. In addition, some patients will refuse the proposal of a combined genioplasty, which prevents an ideal result from coming into reality. With the spread of Dallas rhinoplasty techniques, more and more autologous cartilages are introduced into Asian rhinoplasty. Use of costal cartilage, in particular, has been shown to be a reliable technique.17 When executed properly, costal grafts can increase tip projection more safely and produce dramatic postoperative changes, with excellent long-term results. However, with the ability to create markedly increased nasal tip projection and dorsal augmentation, new challenges emerge with regard to facial balance, especially the nose-chin harmony. This further indicates the need for adequate preoperative planning and assessment to ensure a harmonious result after what can often be drastic changes to the nasal proportions. The senior author (R.J.R) had drafted a systematic approach for Asian rhinoplasty. This approach, based on the individual evaluations and aesthetic principles specific to Asian ideals, was applied in the first author’s (L.Z.Q.) clinic work later in China, with minimal revisions. Five simple steps are also developed to perform physical examinations in the consultation and planning phase, which are useful in intraoperative evaluation as well. This article presents the first author’s greater than 4-year experience with this approach that has developed along with concepts important in Asian facial balance and proper preoperative evaluation.
PATIENTS AND METHODS One hundred ten consecutive Chinese patients were included in the first author’s rhinoplasty series from June of 2008 to June of 2012 (Table 1). A retrospective review of the approach was performed and the effectiveness was evaluated. Systematic Approach Figure 1 demonstrates the examination techniques in steps. Planning and operative procedures are presented in the algorithm shown in Figure 2. Step 1: Nasal Tip When performing physical examination, let the patient sit face-to-face with the physician and adjust the chair height to eye level. Use hands or instrumentation (e.g., two single bulbous-tip hooks) to adjust the columellar-labial angle first. Use the thumb and middle finger to pinch the upper part of the columella, pulling or pushing the columellar base to adjust the philtrum to the natural vertical facial plane. The index finger can push the cephalic area of tip-defining points to assist the action. Of note, if the physician wants to see the front face view when the tip projection is increased, hooks should be used. The tip projection and rotation are then set to a final position based on aesthetic principles. The surgeon can observe the morphology of the nose from the front and side by adjusting head position or letting the patient turn on the stool. Step 2: Chin Position Keep the nasal tip position and use the spare hand to pinch the chin. Adjust the chin to the “tip-(upper) lip-chin” plane. Step 3: Radix Position Release the chin and turn to the radix. If the radix is lower than the horizon line through the pupils when the patient is looking straight Table 1. Demographic Characteristics of the First Author’s Rhinoplasty Series Characteristic Age 15–25 years 25–35 years 35–45 years >45 years Sex Female Male Rhinoplasty type Primary Secondary Combined procedures Combined genioplasty Others (e.g., blepharoplasty)
No. 37 63 8 2 97 13 75 35 46 46
25e
Plastic and Reconstructive Surgery • July 2014
Fig. 1. Examination technique.
forward and/or the radix is underprojecting, use the thumb and index finger to pinch the soft tissue at the ideal radix position. Step 4: Dorsum Alignment If the dorsum is lower than the line through the pinched radix and the new tip point, use three fingers on one side of the dorsum to push the skin slightly until the new “dorsum” is projecting to the appropriate height from the lateral view. Step 5: Alar Base Release the radix, keep the distance between the thumb and index finger equal to the intercanthal distance, and slide down slowly from the radix to the alar base. This will help identify a wide alar base and/or alar flaring, deformities of the nasal dorsum such as broad nasal bone, and deviations from the front view. Follow-Up and Evaluation Follow-up ranged from 6 months to 4 years (mean, 24 months). Patients had standard facial
26e
series photographs before surgery and at each follow-up. At the 6-month postoperative visit, contrast photographs were shown to the patients. A 0- to 10-point scale was then used to score the result by both the patient and the surgeon. When a divergence of scores occurred, a revision operation would commonly be performed and the result rescored at the next 6-month postoperative visit. If the patient refused the revision proposal and turned to other surgeons, the case score would be 0.
RESULTS The evaluation score results are listed in Table 2.
CASE REPORTS Case 1 A 23-year-old woman wanted a natural change at the first consultation. The facial analysis showed that her philtrum was
Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 2. Systematic approach for Asian rhinoplasty. NHP, natural horizon plane.
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Plastic and Reconstructive Surgery • July 2014 Table 2. Evaluation Score Results Score 8–10 5–7 2–4 0–1
Description Very satisfied with aesthetic appearance Improved result and limited satisfaction Little change, complaints remain, and need revision Failed surgery
No. of Cases (%) 95 (86) 10 (9) 2 (2) 3 (3)
recessed from the natural facial vertical plane. The tip needed a 0.5-cm projection increase and derotation. When these changes were demonstrated with physical examination in the preoperative assessment, the chin was noted to be severely retrognathic. Therefore, a costal cartilage augmentation rhinoplasty and a silicone implant genioplasty were planned. Photographs obtained 3 years postoperatively are shown (Fig. 3).
Case 2 A 30-year-old woman had a silicone augmentation rhinoplasty 1 year before presenting for secondary rhinoplasty. A tip erosion was seen because of great tension from the implant. Through systematic preoperative assessment, it became obvious that the philtrum and nasal tip needed to be repositioned. A genioplasty was further indicated from the preoperative examination. The surgical plan included a costal cartilage fixed strut, bilateral extended-spreader grafts, implant removal, dorsum onlay graft, and silicone implant genioplasty. Photographs obtained 6 months postoperatively are shown (Fig. 4).
DISCUSSION The definition of “Asian” may be arguable in this article. Strictly defined, it can be replaced by terms such as Mongoloid, Chinese, Han, and others. We simplified the classification of our patients because we feel these concepts are applicable to the general population commonly referred to as Asian and is analogous to other published articles on this ethnic group. However, the purpose of this article is to create a systematic yet individualized approach to preoperative evaluation of Asian patients and help achieve many common goals of this subset of rhinoplasty patients. This concept was not created to deliver an “aesthetic model” to the public. We support the viewpoint that the aesthetic goals of each rhinoplasty should be customized for the individual patient.8 What is emphasized here is paying attention to the importance of the facial balance, and how to keep this balance through a reproducible and systematic way in Asian rhinoplasty patients. Computer-assisted planning in rhinoplasty has been recommended by several experts.18 However, this group has not found this to be very effective in Chinese patients, particularly those
28e
in need of marked tip and/or dorsal augmentation. The computer was unable to accurately assess the changes to the surrounding structures of the soft-tissue envelope with the large forces placed on the nasal construct when a large augmentation was to be performed. Thus, the computerized images were unable to create a reproducible model of what the postoperative result would be. A stepwise systematic approach was therefore developed to assist with accurate preoperative planning. Several advantages are found with this approach. It is simple and noninvasive and can easily be adapted by surgeons and accepted by patients. Physicians can fully evaluate the facial balance and nose simultaneously with the steps outlined in this article. It is especially important to indicate the postoperative tension on the tip and chin and to help determine what steps will need to be taken to keep proper facial harmony. Therefore, the surgeon is able to create the complete presurgical plan in a short time by means of a reproducible and reliable technique. For example, if in the physical examination steps a 5-mm tip projection increase and a columellar base augmentation are found to be necessary, one can determine that costal cartilage should be used as the fixed strut. If the patient refuses and only desires that septal cartilage be used as tip grafts, the aforementioned maneuvers can be repeated to show a result with a lower tip projection. Furthermore, the patient and surgeon may see the effect that these forces will have on the surrounding soft tissue and the chin in real time. This allows the surgeon and patient to visualize the expected facial harmony while balancing it with the patient’s requests and desires to achieve the most satisfaction. The philtrum has been chosen as the initial point to begin the systematic approach. Aesthetically, by adjusting the philtrum to the natural facial vertical plane, one constructs a constant, objective, and visible reference plane for the nose and chin. This creates a basis for achieving facial harmony. Then, the focus is moved to the tip projection and rotation. The new tip location is the key point of the procedure. This identification will define all other parameters of the “new nose,” such as height and length and the relationship between the nose and surrounding structures (i.e., chin). Importantly, the surgeon can observe the expected changes to the patient’s face in real time. The next step is observing the harmony between the nose and the chin. Dimensional analysis between the nose and chin has been
Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 3. Case 1. Preoperative (left) and postoperative (right) views.
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Plastic and Reconstructive Surgery • July 2014
Fig. 4. Case 2. Preoperative (left) and 6-month postoperative (right) views.
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Volume 134, Number 1 • Individualized Asian Rhinoplasty
Fig. 5. Unbalanced result after one factor was accentuated without appropriate discussion of overall facial harmony.
widely accepted among Caucasian rhinoplasty surgeons and patients, although it has not been as popular with their Asian counterparts. There are some explanations for this phenomenon. First, most of the alloplastic augmentation rhinoplasty that has historically been performed has little effect on tip position. This means the original balance would be little changed, if at all. Second, not all patients can visualize the imbalance that will occur after large tip position changes, therefore causing them to choose not to address chin position preoperatively. Our systematic approach indicating future changes to the shape of the nose and face helps patients to have a better understanding of the future imbalance between the nose and chin should one occur. Thus, they can be better informed to make the appropriate decision. Figure 5 shows an example where improper preoperative education and planning resulted in a patient refusing the author’s genioplasty proposal and insisting on undergoing only rhinoplasty. One month after surgery, she had to undergo the planned genioplasty to achieve the final satisfactory result. Step 3 establishes the new radix point. We hereby strongly recommend the principle on Asian radix point setting proposed by Toriumi and Pero.7 It should not be higher than the line through the pupils when the patient is in primary gaze. In addition, we suggest the radix projection should lie in the anterior half of the distance between the natural facial vertical planes through the glabella and cornea to keep a natural nasofrontal angle and sufficient projection. The dorsum line is a simple connection between the radix and nasal tip points.
Augmentation or reduction is planned to achieve this line. One- to 2-mm variations are allowed to achieve a slight curvature on the side view. The width of the dorsum and alar base is evaluated lastly. When performing steps 2 through 5, the position of the nasal tip and the columellar base should be maintained. Because of the triangular pyramid structure of the nose, changes of the columellar height will influence the nasal base width and even the dorsum width. This approach also represents the first author’s operating sequence of the nose. After incision and full dissection as in the classic open approach, the nasal base is stabilized and the columellar base is augmented first.19,20 Then, the tip projection and rotation are fixed through reliable techniques such as columellar strut grafts and septal extension grafts. The skin envelope is redraped, making sure of the extent of the genioplasty (if needed) and determining the appropriate radix and dorsum adjustment. The alar base resection is the last step after the columellar incision is closed.
CONCLUSIONS Aesthetic rhinoplasty remains a challenging operation because of its complexity and importance to facial appearance. Precise and reproducible facial analysis by means of a systematic approach to both evaluation and operative techniques along with individual and ethnically tailored aesthetic goals are the keys to success. This holds true in particular in Asian rhinoplasty. This systematic approach to Asian rhinoplasty presents a way of linking precise analysis and reliable techniques, which lead to the individual’s aesthetic
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Plastic and Reconstructive Surgery • July 2014 goals both in rhinoplasty and in overall facial harmony. Further research will need to be performed to expound on and refine this Asian rhinoplasty algorithm to improve on our ability to obtain consistent and better results in the future. Rod J. Rohrich, M.D. UT Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, Texas 75390-9132 [email protected]
PATIENT CONSENT
Patients provided written consent for the use of their images. REFERENCES 1. Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37:353–370. 2. Byrd HS, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr Surg. 1993;91:642–654; discussion 655. 3. Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican American nose. Plast Reconstr Surg. 2003;112:244–256; discussion 257. 4. Rohrich RJ, Muzaffar AR. Rhinoplasty in the AfricanAmerican patient. Plast Reconstr Surg. 2003;111:1322–1339; discussion 1340–1341. 5. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343–1354. 6. Jin HR, Won TB. Recent advances in Asian rhinoplasty. Auris Nasus Larynx 2011;38:157–164.
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7. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37:335–352. 8. Lam SM. Asian rhinoplasty. Semin Plast Surg. 2009;23:215–222. 9. Bergeron L, Chen KT. Asian rhinoplasty techniques. Semin Plast Surg. 2009;23:16–21. 10. Sim RS, Smith JD, Chan AS. Comparison of the aesthetic facial proportions of southern Chinese and white women. Arch Facial Plast Surg. 2000;2:113–120. 11. Leong SC, White PS. A comparison of aesthetic proportions between the Oriental and Caucasian nose. Clin Otolaryngol Allied Sci. 2004;29:672–676. 12. Gruber R, Kuang A, Kahn D. Asian-American rhinoplasty. Aesthet Surg J. 2004;24:423–430. 13. Shirakabe Y, Suzuki Y, Lam SM. A systematic approach to rhinoplasty of the Japanese nose: A thirty-year experience. Aesthetic Plast Surg. 2003;27:221–231. 14. Ahn J, Honrado C, Horn C. Combined silicone and cartilage implants: Augmentation rhinoplasty in Asian patients. Arch Facial Plast Surg. 2004;6:120–123. 15. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg. 2005;54:1–5; discussion 6. 16. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: A systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538e–550e. 17. Park JH, Jin HR. Use of autologous costal cartilage in Asian rhinoplasty. Plast Reconstr Surg. 2012;130:1338–1348. 18. Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis: Quality Medical Publishing; 2007. 19. Toriumi DM. Structural approach to primary rhinoplasty. Aesthet Surg J. 2002;22:72–84. 20. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156–185.
