Should I do osteotomy or cartilage grafting/implant to slim and narrow the bridge? (Photos)

Question

Main concerns for Asian rhinoplasty: slim and narrow the bridge, tip plasty and alarplasty. I am worried osteotomy may result in my nose being crooked postsurgery. With cartilage grafting/implant on the bridge, I am worried that my profile might be too bulky or overprojected. I am happy with how my profile looks and would prefer not adding an higher bridge, does it look like I need to heighten my bridge? How can I best achieve a slim and narrow nose bridge? Osteotomy/cartilage grafting or is there another method?

Alejandro Nogueira, MD · Answer

Your dorsum is not the typical Asian flat one, it is very low and sunken at the radix, moderately low at the middle vault and of a normal height at the supratip; you need a perfectly matching dorsal raise graft which is thick at the radix and very thin and sharp at its lower end, so that the final assembly is a straight and canonical profile.
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

David Kahng, MD · Answer

hi,
Asian nose is very different than a Caucasian nose.  the structures are very different.  your nose based on your picture is very typical of an Asian nose with a low starting point and low bridge with no support at the tip.  you will need  to augment the bridge(silicone, rib, etc) and you will need support for your tip and also to reshape your tip. an osteotomy is usually not done and for you I would not recommend it.  a sharp narrow smaller tip will not give balance to your Asian face....although that look can be done.  Asian rhinoplasty is done usually as an open rhinoplasty.  hope this helps.

dr david kahng

Jeffrey T. Steitz, MD · Answer

Narrowing the bridge in Asian rhinoplasty is mostly related to elevating the bridge (dorsum) to provide a narrower view on the front.  Other techniques can also be used to narrow the bridge but in patients with thick skin (which is common in Asian women and men), much of the narrowing effect is created with raising the bridge with cartilage grafting or implants.  I prefer to use cartilage grafting personally since implants can be unpredictable and have various infection/extrusion rates but many surgeons use them frequently
The photo you show would be very difficult to achieve with your nose as the patient in the photos most likely has significantly thinner skin which allows the nose to look narrower without substantially raising the bridge height.  
An in person evaluation with a facial plastic surgeon comfortable with Asian rhinoplasty may be most helpful to you.  Preoperative computer imaging where the surgeon can morph your photos might help you understand what they may be capable of in your scenario.  Good luck!

Robert E. Zaworski, MD (retired) · Answer

Since you are happy with your profile, I would not recommend adding any type of graft to the bridge.  Osteotomy is the procedure used to narrow the nose.  Consult with a board certified surgeon who is highly experienced in Asian Rhinoplasty.

Should I do osteotomy or cartilage grafting/implant to slim and narrow the bridge? (Photos)

Answers (5)

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