Asian Rhinoplasty

Nose Augmentation

Nose augmentation is a type of rhinoplasty performed to correct a flat nose. The main objective of nose augmentation is to increase the height and length of the nasal bridge to create a nose that looks sharp and well-defined. Augmentation rhinoplasty may also produce minor enhancement to the nasal tip. Augmentation rhinoplasty can be performed as a standalone procedure or can be combined with other procedures such as tip-plasty. Augmentation rhinoplasty can be performed through a closed rhinoplasty approach or an open rhinoplasty approach. Traditionally, the closed rhinoplasty approach using an L-shaped implant is a common option. In recent years, the open rhinoplasty approach using an I-shaped implant to augment the nasal bridge combined with the use of cartilage graft for tip-plasty has become more popular. As in all rhinoplasty, augmentation rhinoplasty is a highly individualized procedure, each case should be managed individually based on the patient’s anatomy and the results that she/he desires. The important point in augmentation rhinoplasty is to achieve a harmonious balance between the nose and other facial features.

In nose augmentation, the materials used to augment the nasal bridge come from 2 main sources: implant or autologous tissues (tissues from the patient’s own body).

Common implant materials are:

1.    Silicone implant is the commonest material used in nasal augmentation. It is safe and simple to use. Silicone implants do not change in shape and provide long term stable support to the nose.

2.    Gore-Tex implant, which is made of PTFE (polytetrafluoroethylene), allows tissue in-growth, minimizes capsular formation, and gives a more natural look to the augmented nose. Gore-Tex is softer than silicone and thus is suitable for those with very thin nasal skin. However, because of its softness, Gore-Tex implants provide slightly less support to the shape of the nose compared to silicone.  

3.    Composite implant also known as chimera implant, consists of a core made of silicone that is covered by a thin layer of PTFE on its surface. The silicone core provides adequate rigidity to support the shape of the nose while the PTFE envelope ensures good tissue-ingrowth and blending to provide a natural look. Thus, composite implants combine the advantages of both silicone and Gore-Tex implants.

Autologous tissues that can be used to augment the nose bridge include rib cartilage, diced cartilage, fascial graft, and dermofat graft. Ear cartilage and septal cartilage are suitable for tip-plasty but are not suitable for augmentation of the nasal bridge in Asian because they are too thin and the volume is too small.

Theoretically, autologous tissues should be a better option for nose augmentation because the tissues are coming from the patient’s own body. In reality, however, the majority of the cases of nose augmentation in Asians use implants instead of autologous tissues. This is because there are several limitations and disadvantages of autologous tissues in augmentation of the nasal bridge. Rib cartilage is hard and the sharp margins of rib cartilage graft tend to be visible through the thin nasal skin. Rib cartilage grafts may also have issues with the shape and contour because they need to be hand-carved. Another potential problem is warping, in which the rib cartilage graft undergoes spontaneous bending and distortion. The results of diced cartilage, dermofat graft, and fascial graft may be unpredictable because of tissue absorption. The use of autologous tissues also involves an additional surgery to harvest the tissues, which patients may be reluctant to do especially those involving rib harvesting.

Preparation

1.    Inform the doctor of any pre-existing medical conditions and drug allergy. All medical conditions must be treated and stabilized before surgery.

2.    Stop smoking at least one week before surgery. Smoking is harmful to wound healing and increases the risks of other post-operation complications.  

3.    Stop the following one week before surgery:

a.    All supplements that contain vitamin E, ginseng, ginkgo, garlic, fish oil and other ingredients that increase bleeding during surgery. Other supplements, traditional medicine and herbs in which the ingredients are unknown have to be stopped as well.

b.    Medicine that increases bleeding during surgery such as aspirin, NSAIDs and warfarin. However, you may need to consult your physician who prescribed the medicine before you stop them. 

4.    On the day of surgery, wear simple and comfortable clothing and do not wear any makeup. Do not wear any jewelry and metal objects on the face and body.

5.    Don’t wear glasses on the day of surgery

Surgery

Duration:

Closed rhinoplasty: 1 hour.

Open rhinoplasty: 2-4 hours.

Anaesthesia: Local anaesthesia

Hospitalization: Not required.

Recovery*: Back to work in 3-7 days, light exercise after 2 weeks, heavy exercise after 3-4 weeks.

* The actual speed of recovery may vary from person to person.

Surgery Technique*:

1. Closed rhinoplasty: Small incisions are made inside both the nostrils. There are no external scars. Implant alone or implant plus cartilage graft is inserted through the nostril incisions.

2. Open rhinoplasty: In addition to incisions made inside both nostrils, an additional incision is made to the columella. The nasal skin is lifted and the nose is opened. This technique provides excellent exposure, enables various procedures to be performed including the insertion of the implant and other rhinoplasty procedures such as tip-plasty.

Post-operative Care**

1.    What to expect: Swelling usually peaks on the second to third day after surgery and will gradually subside thereafter. Post-operative pain is usually minimal.

2.    General care:

a.    Apply cold pack in the first 3 days. Elevate the head during sleep to reduce swelling.

b.    Avoid smoking for at least one month. Smoking increases the risk of wound complications.

c.     Good rest and adequate sleep are helpful for a speedy recovery.

d.    Avoid applying pressure on the nose. Sleep on the back and do not sleep on one side to avoid pressure on the nose.

e.    Do not pick to nostrils with finger. Instead use cotton tip to clean the nose.

f.     Be relaxed and calm. Contact the clinic if there are any queries.

3.    Medicine: Finish the oral antibiotics as prescribed. Take the painkiller when necessary.

4.    Wound care: Clean the wound with a clean cotton tip soaked with sterile water/saline. Apply antibiotic ointment. No wound dressings are required. Remove the plastered paper applied on the nose after 3 days.

5.    Physical activity: Avoid heavy physical activity and exercise for at least one month.

6.    Follow-up: Come back one week after surgery for suture removal and review. If an ear cartilage graft is taken, the compression dressing on the ear is to be removed after one week. Sutures within the nostrils are absorbable and removal is not required.

7.    Emergency: If there is heavy bleeding, rapid increase in swelling or severe pain, contact the clinic/doctor for advice immediately.

** The instructions in this list are only for general guidance and the list is not meant to be exhaustive. If you have any specific queries or concerns during the post-operative recovery, please contact the clinic for further advice.