- Asian rhinoplasty is the nose job procedure to enhance the typical Oriental nose.
- Dr Ng’s preferred method in Singapore is the Korean-style open rhinoplasty which improves tip projection, dorsal height, columellar length, nasal tip refinement and alar width.
- To fully appreciate rhinoplasty, it is essential to have a good understanding of the anatomy of the nose and the recommended aesthetic proportions. The following important basic information lay essential foundation to understand rhinoplasty.
RHINOPLASTY – IMPORTANT BASIC INFORMATION
- Anatomy of the Nose
- Aesthetic Proportions of the Nose
- Cosmetic and Functional Rhinoplasty
- How Rhinoplasty Changes the Whole Face
- Closed vs Open Rhinoplasty
- Minimally Invasive Technique vs Closed vs Open Rhinoplasty
- Patient with typical features of Oriental nose :
- Low and broad nose height / dorsum
- Broad and bulbous nose tip
- Fleshy and wide ala
- Dorsal hump on dorsum (nose bridge)
- Short columella
THE GOALS OF OPEN RHINOPLASTY DEPENDING ON PATIENT’S REQUEST INCLUDE :
- Lengthening of nose and improvement of nasal tip and columellar projection – using a cartilage graft from the nasal septum, ear or rib (if there is limited nasal septum available)
- Refinement and narrowing of nasal tip – by different techniques to suture the lower lateral cartilages (tiplasty)
- Raising the nasal dorsum and radix – by silicone implant insertion
- Correction of nasal hump – by rasping (filing) of nasal bone or humpectomy (excision of nasal hump)
- Narrowing of the bony side wall of the nose – by lateral osteotomy (cuts made in the nasal bone)
- Improvement of air passage – by insertion of spreader graft (small cartilage slips derived from the septum)
- Narrowing of the nasal ala – by alarplasty (removal of small portion of the ala)
Open rhinoplasty is the most versatile technique to address all the shortcomings of nasal aesthetics.
The followings are popular procedures that can be performed together with rhinoplasty :
- Upper blepharoplasty (Double eyelid surgey)
- Facelift – for younger and rejuvenated look for those with a lot of skin laxity
- Fat Grafting– to enhance facial features and lightening of nasolabial fold
- Breast augmentation – shared inframammary incision for breast augmentation and coastal (rib) cartilage harvesting
- Pre-operative marking
- General anaesthesia
- Conchal cartilage harvest :
- A cut is made at the back of the ear to harvest a small piece of ear cartilage. The scar is well hidden.
- The ear is then packed between 2 pieces of compressive dressing to prevent bleeding and blood clot accumulation (haematoma).
- Dr Ng uses the conchal cartilage as a cap cartilage over the nasal tip to improve projection and provide a natural contour.
- Rib cartilage harvest (if septal cartilage harvested is insufficient)
- A small cut is made over the region of the 5th – 6th rib cartilage. For female patients the scar is hidden under the breast fold.
- A small portion of the rib cartilage is removed – the bone is left intact.
- Only a slice of the centre portion of the rib is used for caudal extension graft or spreader graft.
- Open Rhinoplasty
- Small cut is made across the columellar (transcolumellar incision) and continue into the nostril called infracartilaginous incision. Further dissection is made to review internal architecture of the nose. The lower and upper lateral cartilages are dissected.
- Depending on the presenting problem of the nose a combination of the following steps are carried out:
- Rasping (filing) or cutting (humpectomy) of nasal hump
- Septal cartilage harvest
- A small rectangular piece of nasal septal cartilage is removed, leaving the remaining as a stable L-strut to support the nose.
- This is used as caudal extension graft and spreader grafts (see below)
- Nasal bone lateral osteotomy :
- If the bony nasal vault is broad, the lateral wall of the nasal bone is cut and shifted inwards to narrow a broad nasal vault
- Caudal extension graft placement.
- This graft lengthens the nose, elevates the nasal tip and improves columellar projection.
- It can be derived from the nasal septum or rib cartilage (if the former is insufficient).
- Tiplasty :
- Suturing of the lower lateral cartilages to narrow the tip, and improve projection and refinement.
- Spreader grafts placement :
- This is a pair of cartilage grafts that improves nasal obstruction. With longer grafts, they also improve the dorsum and control tip projection.
- Nasal implant insertion :
- The implant raises the height of the dorsum and radix.
- This is inserted within the subperiosteal pocket in a space created just under the covering of the nasal bone (periosteum). Implant placed in this space tend not to displace.
- Alarplasty :
- Part of the nasal alar or nostril floor can be trimmed to narrow a widened nasal base.
- Dr Ng believes that using sufficient cartilage material to create adequate tip projection reduces the necessity for alarplasty. This can avoids scarring and unnatural nostril shape.
- Surgical duration: 4-6 hour
- Discharge plan:
- Most patients go home on the same day (day surgery)
- Few opt to rest overnight in the hospital or hotel.
- General anaesthesia
- Dr Ng performs rhinoplasty under general anaesthesia for optimal safety in Singapore. Most patients are fearful of general anaesthesia because they have a misconception that it is unsafe. In truth, most anaesthetist would agree that general anaesthesia is the safest way to ensure sufficient oxygen delivery to the lungs because there is a tubing (endotracheal tube) in the windpipe (trachea).
- During nose surgery, small amount of blood can flow into the lungs with serious consequence. This problem is avoided by the endotracheal tube in the windpipe (trachea) during general anaesthesia.
- General anaesthesia is essential if rib cartilage harvest is needed.
- However, some Singapore plastic surgeons may offer sedation during rhinoplasty due to lack of general anaesthesia facility.
POST OPERATIVE CARE
- Immediately after surgery :
- Both nostrils are packed with absorbent material to prevent bleeding – these are removed after 24-48 hours.
- Nasal splint (adhesive aluminium nose support) is worn over the nose for 1-2 weeks.
- Medications include topical and oral antibiotics and oral analgesics (pain relief).
- Rest head up 30 degree for optimal resolution of swelling.
- Avoid exertion and rest adequately
- Sutures over the columella are removed at 1 week.
- Refrain from wearing heavy spectacles which rest on the nasal dorsum for up to 2-3 months post-surgery
POST OPERATIVE RECOVERY
- Bruising normally resolves by 2 weeks
- Nasal obstruction due to swelling improves significantly within the first week.
- Swelling resolves rapidly within the first 1-2 months, and this is usually complete by 6 months. It is the normal to judge the final result of rhinoplasty at about 6 months.
- Most patient return to work within 1-2 weeks.
RISK AND COMPLICATION
- Bleeding : prevented by nasal packing, avoidance of exertion and maintaining head up position after surgery.
- Infection – sterile technique is maintained throughout operation to prevent this
- Nasal septum perforation – avoid sneezing, blowing of nose, or excessive cleaning
- Wound dehiscence – avoid excessive stretching of the wound and cleaning
- Asymmetry – wearing of nasal splint (support) in the early post-operative period is important to keep the implant central.
- Asian rhinoplasty in Singapore is considered as cosmetic surgery hence non-Medisave nor Insurance claimable
Can I avoid using rib cartilage during rhinoplasty ?
This is dependent on the amount cartilage that can be harvested from the nasal septum to be used as the caudal extension graft.
It is important to understand that the caudal extension graft needs to be straight and stable in order to lengthen the nose, elevate the nasal tip and improve columellar projection. In a small Oriental nose, the nasal septum may not be able to supply all the raw material to achieve this. Dr Ng prefers not to compromise the final result. Harvesting the rib cartilage becomes a necessity.
It is understandable that most patients prefer not to have an additional cut over the chest. The incision is no larger than a breast implant wound which is hidden below the breast fold.
Only a small piece of the rib cartilage is removed and the rest of the bony rib is left intact. In Dr Ng’s experience, more than 95% of his patients in Singapore and Korea tolerated this procedure very well.
Can I use a simple L-shaped nasal implant ? What is the risk ?
The L-shape implant was popular in Singapore in the past before the emerging popularity of open rhinoplasty. The L-shaped implant cannot narrow a broad nasal tip and it not able to improve columellar projection significantly. The tip of the implant tends to thin out the nasal tip skin after a few years, causing extrusion of the implant with scarring and infection. The implant is also not sutured to the inner structures of the nose. This predisposes to implant deviation and displacement.