Can I achieve a more narrow and less bulbous nose with thick Asian skin? (photos)

Question

Hi, I am Chinese and I would like to ideally achieve the nose on the right (left picture of side profile and the frontal nose picture are the unedited nose). Is this possible? I am content with the overall structure of my nose but I would love to narrow it overall so that it is more fitting and smaller. Main goals: - Reduce slight hump (profile view) - Narrow nose (tip, alar base) - Add minor point to the tip Are these goals achievable without rib grafting for an ethnic nose like mine?

Goretti Ho Taghva, MD, FACS · Answer

Thank you for your question! You have a good nasal bridge height and what you need are small adjustments to get the result you desire — a small dorsal hump reduction and a tip-plasty to increase the tip projection and refine the nasal tip. For thick Asian skin, typically suturing the nasal cartilage is not enough to create substantial change and the use of ear/ septal cartilage is usually needed to change the tip projection.  Since your bridge does not need to be augmented, rib graft is not necessary.  Good luck!Goretti H. Taghva MD FACS

Edwin Kwon, MD, FACS · Answer

Having thick skin definitely makes achieving a finer tip more difficult but not impossible.  There are other factors other than thick skin that gives a full appearance to the nasal tip.  You may have to reduce some of the lower lateral cartilages to decrease the bulk as well as to try to thin out the skin.  The slight dorsal hump and be reduced and tip grafts may be necessary to achieve a narrower nasal tip.

Alejandro Nogueira, MD · Answer

But is this a quite common feature in Asian rhinoplasties and does 
not pose a contraindication to surgery; however makes necessary using 
structural grafts of strong resistance to beat the sking and expand it 
to the new contour.
These Asian (Philippine, Malaysian, Thai, Chinese, Korean, etc) 
ethnic noses may present different genetical issues the patients might 
wish to modify, among which worth mentioning sometimes thin (Thai, 
Chinese, Korean) and sometimes thick (Philippine, Malaysian) skin but 
always a severe cutaneous shortfall, low dorsum, broad dorsum, flat 
dorsum, broad nose, short nose, short septum, short tip, eventually 
bulbous tip (not a constant feature), poorly defined tip, sometimes real
 alar flare (others is a virtual or fake alar flare caused by the lack 
of tip support), poorly supported tip, overrotated tip, alar rim 
retraction, etc.
Its treatment is based on the principles of structure rhinoplasty 
although upgraded and extended to a higher and larger level of 
complexity and technical options, with massive cartilage supply from 
nasal septum, ears concha and very often from rib cartilages, to restore
 the enormous lack of support, the weakness and the underdevelopment of 
the nasal skeleton.
Your case allows understanding the majority of anatomical features 
and technical requirements of such ethnic rhinoplasties, keeping in mind
 that great part of their features are common to other ethnicities like 
the African, Afroamerican, Afrocaribbean, etc; the underlying skeletal 
peculiarities cause the characteristic shape in this ethnicity noses and
 are the reasons behind their very high surgical difficulty, which 
explains why there are very few surgeons really trained, capacitated and
 skilled in such ethnic rhinoplasties and why most surgeons are tempted 
to employ simpler but disappointing, when not failed or even 
problematic, resolution methods.
Three key aspects feature Asian noses; the barely existent dorsum and
 the truncated nasal pyramid, from which half or more is missing; the 
totally collapsed nasal tip which lacks any kind of support due to 
totally incompetent filmy alar cartilages, tip which is also 
disproportionately augmented by a huge fibrofatty pad; and sometimes the
 large nostrils and excessively protruding alar flare.
The first stage after the open approach dissection of the nose is 
defatting the massive pad which typically makes these noses bulbous and 
large; this adipose mass is not only located above and in between the 
alar cartilage domes, like in any other ethnicity, but also extends 
between the medial cruras of the columella and spreads over the lateral 
cruras, the supratip dorsum and the sides of the lower nasal wall; a 
very meticulous defatting is a must, a very delicate maneuver that must 
be carried out with great care not to damage the cartilaginous 
structures and the overlying skin.
Another common finding is how weak, filmy and thin are the alar 
cartilages in this ethnicity, they play almost no structural role, if 
any, in the tip and alae shape, being the whole tip unsupported, 
collapsed and its shape made out of the fibrofatty mass and the skin 
itself; additionally the tip has no definition is too short and its 
cartilages lack sufficient length to comply with the required 
lengthening of the tip and the nose; for all these reasons the lateral 
cruras are frequently discarded and replaced by new ones made out of the
 cartilage grafts.
The tip and the columella also needed full replacement, therefore an 
en bloc tip and columella extended graft can be sculpted out from the 
rib or other source cartilage grafting.
Also septocolumellar or dorsocolumellar replacement graft augmented 
with one extension to build the tip and another extension to lengthen 
the columellar support down to the nasal septum; this structure achieves
 longitudinal and lateral blockage with stability by pressure forces 
between the radix, the dorsum, the septum and the interlocking between 
the dorsal and tip columella parts, with lateral assistance at the tip 
by means of the side pods formed by the new lateral cruras; no suturing 
is required to achieve stability of this dorsocolumellar structure.
In the end, the whole dorsum, tip, columella, medial cruras and 
lateral cruras are reinforced, supplemented or literally replaced by 
handmade brand new anatomical elements allowing the expansion of the 
skin cover.
It is remarkable how the septum is also massively short in these 
ethnicities; this makes the septum insufficient as donor of grafting in 
most cases and technically forces to some kind of septal lengthening and
 nose lengthening maneuvers; this is sometimes accomplished by the 
septocolumellar or dorsocolumellar structure which bridges over the 
missing gap of septum, thus in such a case there is no need for direct 
septal lengthening grafting.
Several methods allow rebuilding a massively missing nasal dorsum, 
either by congenital causes like ethnicity or by acquired traumatisms or
 iatrogenic dorsal over resections during previous rhinoplasties.
The alloplastic or synthetic prosthesis, made from Gore Tex, Medpor, 
Silastic, silicone, polyurethane, etc., is a tempting option since it is
 as easy as an out of the box solution, the surgeon only has to open the
 sterile sealed package and insert into the nose, only in few cases a 
slight shaving may be necessary to adapt the prosthetic dorsum to the 
patient's nose; however this is the worst of all the available technical
 solutions, to begin with it is unfeasible achieving an optimal fitting 
on the dorsum, the prosthesis is noticeable through the skin, they look 
pretty fake and unnatural, the rate of complications like infections, 
displacement or extrusion are terribly high, they are prone to 
dislocate, develop capsular contracture, extrude or become secondarily 
infected during their lifetime, which actually is not indefinite and 
will need replacement after a few years.
Fat transfer and dermal or fascial rolls are not suitable, they lack 
volume to rebuild such noses, their look is weird, it is impossible to 
shape the dorsum with precision and they are not consistent enough; 
apart from the former they are prone to complications, infection and 
resorption; they'll likely disappear in the postoperative or be short 
lasting.
Bone grafting is not recommended, the rates of resorption are very 
high and the look is not natural; the ideal material to rebuild massive 
dorsal shortfalls is cartilage grafting, being several the modalities.
Irradiated human or animal cartilage from a tissue bank is not a 
recommended option; firstly because it is not own patient's tissue, 
making no sense when there are excellent donors sites available of safer
 quality, however mainly because the rates of resorption, infection and 
dislocation with deformities are very high with irradiated cartilage, 
which in practical terms is a cartilage biologically destroyed by 
radiation.
Ear and septum cartilage harvested from the patient's tissues are 
excellent donors biologically but in the vast majority of cases not 
valid because the available amount is scarce or their shape might not be
 optimal; notwithstanding their use may be suitable in selected cases.
One popular option which deserves severe criticism is the so called 
Turkish Delight technique or better named as diced cartilage wrapped in 
fascia; it essentially consists in harvesting cartilage from the 
patient's donor sites, commonly the rib, and crush down to tiny bits, 
which means destroying the chondrocytes or cartilage cells and 
annihilating any biological viability; once this jelly mass is obtained 
the surgeon sticks the bits together by applying a synthetic fibrin 
glue, rolling them in temporalis fascia or both; this roll is inserted 
as neo dorsum, however the result is an avascular cylinder in which this
 mass of crushed tissue develops necrosis, resorption, eventually 
infection, irregularities, deformities, cystic phenomena, etc.; the 
results are between poor and disastrous in the mid and long term, the 
touch is fake like jelly and the dorsum experiences molding like it 
would be clay with palpation or bearing the glasses pads.
The ideal option to massively rebuild nasal dorsums is own patient's 
rib cartilage; in relative terms to the nose size it is an unlimited 
source of cartilage, it is biologically compatible and safe since it 
belongs to the patient, the likeliness o resorption, infection and 
displacement are terribly low, is firm and strong enough to expand the 
skin, is form stable, the touch and feel is natural, when it is well 
tailored the look is totally natural, it should be lifetime lasting and 
totally opposite to what many surgeons think it does not warp; the only 
caution to be taken is harvesting straight fragments of rib cartilage 
and not the curvy ones, and as additional caution peel off the cortex 
and use mainly the core or central shaft of the cartilage, since the 
cortex or outer layers have curvaceous streaks of cartilage making it 
prone to warp.
In the case you post here the rib cartilage not only is an excellent 
option to rebuild the dorsum but also may serve as donor for other 
grafts required, like the tip and columella replacement graft and the 
lateral cruras replacement grafts; the septum, otherwise very short, and
 the ears remained untouched.
Once the rib cartilage is freed and the donor site meticulously 
closed by means of layered sutures, the sculpting stage starts so that 
the necessary anatomical elements can be restored in this kind of noses.
With the personal design I follow in these cases, one single fragment
 of cartilage is shaped as dorsal rebuild graft with a hollow cylinder 
carved in at the undersurface of such dorsal graft; this cylinder has 
the purpose of providing stability by blockage obtained when the 
patient's natural dorsum would be inserted within; this dorsal graft has
 other very tricky and interesting geometrical features in its design, 
like the beveled upper end to match the contour of the nasal radix and 
the frontalis bone at the frontonasal sulcus, the slope gradient at its 
lower end to prevent a supratip prominence or polly beak deformity, the 
somehow imperfect broken contour at its sides in a very slightly 
rhomboid shape to mimic a natural bridge and avoid a plasticized nasal 
look, and the thin on top towards thick on bottom of dorsum gradient of 
dorsal raise in order to create a correct nasal profile; at its caudal 
end this dorsal graft is shaped featuring a cubic prong matching the tip
 and columella extended graft in order to achieve interlocking stability
 by perfect pressure effect.
Once the dorsocolumellar grafting structure is thoroughly tested and 
deemed as definitive in terms of aesthetic effect and mechanical 
stability, the final closure of the skin allows the assessment and 
planning of the nostril sills resection and the alar flare wedge 
reduction, is they are deemed indicated.
The smooth contour and the perfection of the tailoring of the dorsal 
block makes often unnecessary additional camouflage with temporalis 
fascia or specific blockage gestures to prevent its displacement, since 
the final assembly is a perfect puzzle matching under pressure between 
the frontalis bone, the original dorsum and the caudal septum.
Experience, fine skills and large amounts of creativity are of 
paramount importance in order to successfully approach these complex rib
 cartilage ethnic rhinoplasties.
See the link below to view a full series of images explaining the 
procedure with real intraoperative and before & after photos.
If you wish better grounded opinion well lit, focused and standard 
images have to be assessed: frontal, both lateral and both oblique 
views, from underneath too.
Feel free to request any additional information from me.

Donald B. Yoo, MD, FACS · Answer

The best way to determine what specific changes will look good on your face, and what changes are surgically possible, is to do your research to find the top Asian rhinoplasty specialists and consult with several of them in person.  During your consultation, your photos can be computer-morphed to show how the changes to your nose will affect your appearance.  An Asian rhinoplasty specialist will have the experience to determine whether the morphed images are surgically attainable.   Also, while there are several approaches to building up your nose during Asian rhinoplasty, using tissue from your own body will give you the safest, longest-lasting, and attractive result.

Toby Mayer, MD · Answer

Asian rhinoplasty for the bulbous tip etc.will give you the corrections of the features you dislike. A tip graft will be need as your skin is thick.See several very experienced rhinoplasty surgeons who do natural noses.

Jonathan Kulbersh, MD · Answer

A nonsurgical rhinoplasty is wonderful technique to camouflage irregularities, dents, humps, and bumps of the nose, and it can be performed multiple times. Your nose could be improved with rhinoplasty, which would give permanent improvements in symmetry, shape and profile. You can bring photos of noses that you think would be flattering to your face and these can be discussed. When you meet with a facial plastic surgeon, he or she will consider your nose in balance with your other features and can over the cost of the procedure. I hope this helps.

Philip J. Miller, MD, FACS · Answer

These are the most common issues I hear patients discuss with me regarding their reasons for wanting to alter the appearance of their nose while still maintaining their ethnic identity:
Asian rhinoplasty patients discuss their dissatisfaction with the following: 
Flat nasal profileSlight nasal bridgeFlared nostrilsWide nasal tipPoor nasal tip strengthWhen selecting a rhinoplasty surgeon, it is of the utmost importance that you choose a surgeon who is board certified in facial plastic surgery. Board certification matters. Especially, when you are considering ethnic rhinoplasty. You want your face and nose in the hands of an experienced and qualified surgeon who can walk you through the procedure and cost. 
I am including a website link about Asian Rhinoplasty as well as video that discusses in detail the specifics of this procedure. I hope you find this information helpful. 
Sincerely,
Philip J. Miller, MD, FACS

Raja Mohan, MD · Answer

Asian rhinoplasty, also known as Asian nose surgery, is a cosmetic procedure that reshapes the nose to achieve a more balanced and harmonious appearance. It's different from traditional Caucasian rhinoplasty, which aims to make the nose smaller. Asian rhinoplasty typically involves: Lengthening and enlarging the nose to balance the width of the face Adding definition and shape to the nasal tip Enhancing the nose bridge, which is often less pronounced in Asian patients The goal is to achieve a natural-looking improvement that respects the patient's ethnic heritage and facial aesthetics. Some common reasons for Asian rhinoplasty include: Low nasal bridge and radix, Wide nostrils, and Lack of projection.

Joshua A. Halpern, MD, PA · Answer

I have performed a number of Rhinoplasties on Chinese noses. It appears from your pictures that you would be a candidate to reduce the hump on your nose and to narrow the nasal tip. There are different techniques that can be used. As a former art student from the LA. County museum of art, I prefer using advance suturing techniques to narrow and refine the nasal tip. To further enhance the nose sometimes I will also use cartilage graft placed into the nasal tip. You can narrow your alar rims but before performing this procedure one would like to look at how your alar rims line up with your eyes. One typically does not want to narrow the alar base if the width of the alar rims are smaller then the distance between the inner aspect of your eyes. I incorporate the FINNESSE technique which I invented. I typically do not pack the nose. Post operative bruising, pain and recovery are minimal when compared to traditional techniques. I hope you find this information useful. Please watch the enclosed video.

Victor Chung, MD · Answer

Asian rhinoplasty is different from other rhinoplasty as there is typically thick skin to address.Thick skin may be stretched to give a more narrow refined appearance, but the nose will be larger overall. I would discuss this with a rhinoplasty surgeon who understands this concept for a safe and happy result. Safety comes first.

Can I achieve a more narrow and less bulbous nose with thick Asian skin? (photos)

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