Can I remove cartilage implants from an Asian rhinoplasty?

Question

Almost 2 years ago I got a asian rhinoplasty in which the bridge was made taller using DCF and the tip made longer/taller with rib. I am unhappy with the way the stiff implants feel, and genuinely miss the look of my old nose. I was wondering if removing all of the implants was an option? Or, will my nose lose structure without the grafts and run into problems? I know that I need to talk to a dr eventually about the details, but I just want to know if this can be done at all in the first place.

Edwin Kwon, MD, FACS · Answer

You can definitely remove all the cartilage that you had during your primary rhinoplasty.  However, you may need to repurpose some of the cartilage to maintain structure in your new nose.  Often times, just removing all the grafts, implants, DC-F, etc doesn't automatically mean that your nose will return back to the way it was before surgery.  Some of the native support in the nose is lost during a rhinoplasty procedure and need to be restored.  Often times if you are okay with less projection, you can use thinner/softer support cartilages as they do not need to be as strong to maintain the shape.  Even with some supporting cartilage grafts, your nose can still be soft and not have that stiff feeling.

William Lao, MD · Answer

What you are describing of course can be done. but like you said it yourself, how it can be done need a long discussion with your doctor so he or she can come up with a surgical plan that fits your desired look.

Charles S. Lee, MD, FACS · Answer

The stiffness and bridge height issues are some of the drawbacks to an overdone rib rhinoplasty. You can remove or reduce the stiffness and height by reducing or removing the prior cartilage grafts. The original surgeon would be best to do this, but other surgeons familiar with rib rhinoplasty can usually address your concerns.

Jonathan Kulbersh, MD · Answer

Thank you for your question. However, without at least a photo or two, it is very difficult to make any type of treatment recommendation. While cartilage implants can be removed, it is important for the surgeon to assess what will be left behind to determine whether the nasal structure will still have sufficient support. I strongly encourage you to schedule a consultation with a board-certified plastic surgeon with expertise in Asian rhinoplasty. Revision procedures are typically more complicated than the original surgery and require a great deal of expertise and experience to handle properly.

Alejandro Nogueira, MD · Answer

Asian rhinopasties are of extreme difficulty, few surgeons master them, and the majority of cases end with poor, suboptimal or simply bad results; I strongly recommend you seek revision with a professional experienced in all kind of ethnic noses (especially Asian and African noses) and revision rhinoplasties.
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.

Manish H. Shah, MD, FACS · Answer

Hello,Thanks for your question. Yes, you can remove graft material to soften the nose. DCF graft can be removed fairly easily, as can tip grafting material. However, the grafts must have been placed to improve structure. Removing them does risk losing some structural support. Whether this causes problems or not depends on the amount of scar tissue left behind with your first surgery. This scar can actually be quite supportive which could be good thing. Without seeing and feeling your nose, there isn't much more that I can tell you. I do recommend that you consult with a specialist in revision Ethnic rhinoplasty to be able to get the best results possible. If you have further questions, I consult with revision rhinoplasty patients outside the Denver region via Skype/FaceTime.Good luck,Dr. Shah

Ronald J. Edelson, MD · Answer

I have removed cartilage grafts from nose on several patients.  Technically it is not difficult to do.  The big question is what will be there when the grafts are removed.  I have found any surprises in my practice found this procedure but it is something you need to bear in mind.

Toby Mayer, MD · Answer

Removal of Diced cartilage grafts. These can be removed or reduced depending on your goals. An examination is needed to give an informed answer. See an experienced revision rhinoplasty surgeon for this.

Michael Elam, MD (retired) · Answer

Dear June_2019, I would suggest that you request a copy of your original operative report and then seek consultations with some experts regarding having the grafts removed. The grafts should be easily removed however it is important to see the entire operative report to determine if these have any structural concerns. I have removed many grafts during revision rhinoplasty procedures. I believe it is so important that patients have imaging performed prior to their procedure so that they can see their proposed results and this would reduce these requests. Best regards, Michael V. Elam, M.D.

Can I remove cartilage implants from an Asian rhinoplasty?

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