A New Classification of Pollybeak Deformity and Its Treatment in Asian Rhinoplasty

BACKGROUND

Supratip deformity, also known as pollybeak deformity, is a common complication of primary and secondary rhinoplasty, characterized by fullness in the supratip region. The correction of pollybeak deformity is a challenging procedure, and its management requires a thorough understanding of the pathogenic mechanism of pollybeak deformity.

OBJECTIVES

This study aimed to evaluate the effectiveness of surgical methods for correcting pollybeak deformity in Asian rhinoplasty.

METHODS

A retrospective chart review was conducted for 53 patients who underwent pollybeak correction between 2021 and 2022. A modified classification system for pollybeak deformity, the Supratip Fullness Rating Scale (SFRS), was developed to evaluate supratip fullness. The aesthetic outcomes of the patients were assessed by surgeons using the visual analog scale (VAS), and patient was self-assessed using the Rhinoplasty Outcome Evaluation (ROE) scale.

RESULTS

The study demonstrated that our surgical method resulted in satisfactory outcomes, with a mean SFRS score change from 2.34[0.65] to 0.23[0.42], a decrease in VAS score from 7.47[1.73] to 1.79[1.67] and a high satisfaction rate of 77.36%, calculated by ROE score. No complications were reported.

CONCLUSION

Our surgical method for correcting pollybeak deformity in Asian rhinoplasty can result in satisfactory outcomes, particularly in terms of aesthetic appearance, without any side effects. The use of the modified classification system (SFRS) can provide an objective evaluation of supratip fullness, thereby aiding in the management of this challenging complication.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Non-Caucasian Rhinoplasty

Today non-Caucasian patients comprise an important group of patients seeking rhinoplasty. The term non-Caucasian is used interchangeably to speak about patients of ethnic origin. It becomes important to understand the interplay of culture, race, and ethnicity when evaluating patients and defining what their aesthetic ideals are and what will be needed for surgery. An integrated approach and management of the non-Caucasian patient is presented in which medical and surgical options are explored. The final goal when treating non-Caucasian patients should be trying to help patients achieve their aesthetic ideal in the best possible fashion.

Cosmetic Augmentation Rhinoplasty for East Asians

Symmetric pocket formation and meticulous implant carving are the most critical parts of nasal dorsal augmentation using implants. Innovative three-dimensional printed nasal implants can exactly fit the nasal dorsal contour, decreasing the chance of deviation and malpositioning. Vertically oriented folded dermal graft technique can avoid the high resorption rate of conventional dermofat grafts. Multilayered costal cartilage graft technique for dorsal augmentation can minimize warping and difficulty in the graft carving. Derotation graft allows supple and movable nasal tip while enabling enough tip lengthening, even if the septal extension graft is the most commonly performed procedure for short nose correction.

Special Consideration in Rhinoplasty for Deformed Nose of East Asians

Typical Asian deformed nose has many different types: concave nasal dorsum, low nasal dorsum, wide nasal dorsum, deviated nose, convex nasal dorsum, saddle nose, short-nose deformity, and deformities involving irreversible damage of skin/soft tissue envelop are the most representative ones. The key concept in Asian rhinoplasty is augmentation in all different forms of nasal deformities. Augmentation of the nose consists of framework, tip, and dorsal augmentation. Septal extension grafting and tip grafting are 2 maneuvers with profound importance in augmentation of lower two-thirds of the Asian nose. Dorsal augmentation is central concept in beautifying all different types of deformed noses, even the hump nose.

Multilayered Costal Cartilage Graft for Nasal Dorsal Augmentation

BACKGROUND

Nasal dorsal augmentation is one of the most commonly performed rhinoplasty procedures in Asia. We describe our experience with multilayered costal cartilage grafting (MCG) for dorsal augmentation in Asian patients. We aimed to evaluate the aesthetic outcomes and complications of MCG in comparison with those of one-block concentric carving costal cartilage graft (OCG) using objective and subjective assessment criteria.

METHODS

Eighty-two consecutive patients who underwent dorsal augmentation with OCG (n = 39) or MCG (n = 43) by a single surgeon between November 2010 and September 2018 with > 12 months of follow-up were included in this retrospective cohort study. The aesthetic outcomes, which were determined by both anthropometric analysis and consensus decision, were compared. Patients' satisfaction and postoperative complications were also analyzed.

RESULTS

Dorsal height ratios and radix height ratios increased significantly by 14.0% and 19.4%, respectively, after the OCG technique (p < 0.001) and by 13.5% and 19.0%, respectively, after the MCG technique (p < 0.001). Anthropometric comparison revealed that OCG did not show any significant differences in dorsal height ratio (p = 0.707) and radix height ratio (p = 0.856) postoperatively when compared with MCG. However, the warping rate was higher in the OCG (15.4%) than in the MCG (4.7%) group, although not significantly. There were no differences in overall patient satisfaction between the two groups.

CONCLUSIONS

Dorsal augmentation with MCG produces similar aesthetic outcomes but a lower warping rate than that with OCG. The MCG technique may minimize graft warping and thus might be an effective alternative for nasal dorsal augmentation, particularly in Asian rhinoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Closed Rhinoplasty with a Mushroom-Shaped Costal Cartilage Graft in East Asian Patients

BACKGROUND

The most challenging part of rhinoplasty is nasal tip management. For East Asian patients with a bulbous under projected nasal tip with thick skin, autologous cartilage is considered the gold-standard graft material to provide strong support to the nasal tip and effectively increase tip projection. The present study aimed to evaluate the outcomes of closed rhinoplasty with a mushroom-shaped costal cartilage graft in East Asian patients.

METHODS

From February 2018 to May 2019, 52 patients underwent rhinoplasty with a mushroom-shaped costal cartilage graft in our institution. Rhinoplasty was performed through a bilateral endonasal incision. Postoperatively, all patients were photographed and asked to complete a satisfaction survey online or by telephone.

RESULTS

The mean follow-up period was 15.8 months (range 12-21 months). Twenty-four of 52 patients agreed to participate in this study. Postoperatively, the mean nasofrontal angle was 137.7 ± 3.7°, mean nasolabial angle was 94.1 ± 6.2°, mean nasal tip angle was 79.4 ± 5.2°, and mean columellar/lobular angle was 44.7 ± 2.4°. The mean tip projection/nasal length index was 0.53 ± 0.07, and the mean columellar/lobular length index was 1.21 ± 0.22. There were no prolonged functional complications. Most patients (23/24; 95.8%) were satisfied with the aesthetic results.

CONCLUSION

The present results suggest that the mushroom-shaped costal cartilage graft in closed rhinoplasty is a good choice for the correction of a bulbous under projected nasal tip.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Use of Nasal Implants and Dorsal Modification When Treating the East Asian Nose

Dorsal augmentation and tip surgery are essential procedures for East Asians seeking rhinoplasty, because they generally have thicker skin and poorly developed nasal dorsum and tip. For dorsal augmentation, many Asian surgeons prefer using alloplastic material, like silicone, Gore-Tex, and filler injection, for cost-effectiveness, easy handling, and short operation times. Compared with autologous implant materials, the use of synthetic implant is suggested to be associated with many complications, such as infection, extrusion, and deviation. However, even with the use of the autologous material, problems such as reabsorption after grafting, donor site complications can take place.

Tip Grafting for the Asian Nose

Tip surgery during rhinoplasty is particularly difficult in Asians. Tip grafting is the best approach. Conchal cartilage with perichondrium and costal cartilage are powerful grafting materials. The most important grafting techniques are tip-onlay grafting, shield grafting, and multilayer tip grafting. Tip-onlay grafts are useful for dorsal convexity. Shield grafts require sufficient support to prevent bending. Multilayer tip grafts (usually 2 layers) are versatile. Asians vary in cartilage configuration, skin thickness, and aesthetic desires: tip-grafting strategies must be tailored to meet the aesthetic goals of individuals. Tip-grafting complications (eg, visible graft contour and infection) are not uncommon and should be considered.

Hump Nose Correction in Asians

Nasal hump surgery is frequently regarded as a reduction surgery in most Western rhinoplasty textbooks and referred to as reduction rhinoplasty. Most Asian hump noses have a small hump frequently associated with a low nasal dorsum and underprojection of the nasal tip. Correcting a hump nose in Asians has distinct differences in concept and technique. A small hump and additional need for augmentation of the dorsum and the tip often minimizes the amount of hump removal or obviates resection itself. Characteristics of the Asian hump nose with emphasis on surgical techniques commonly used to obtain reliable results are presented.

Augmentation Rhinoplasty Using Silicone Implants

Augmentation rhinoplasty is one of the most common aesthetic procedures in Asian countries with silicone implant being the most widely used material for augmentation rhinoplasty. Despite potential advantages, use of alloplastic materials in rhinoplasty is often discouraged in Western countries because of concern for possible risk of infection and extrusion of the implant. The collective experience of long-term favorable outcomes in Asia makes the silicone augmentation rhinoplasty a common procedure. Complication rates for silicone implants vary significantly, depending on surgeon experience, surgical technique, and implant design. Silicone implants can be safely used for nasal dorsal augmentation if precautions are taken.

Homologous Tissue for Dorsal Augmentation

Homologous graft materials for dorsal augmentation are safe and biocompatible with a low risk of complications. Acellular dermal matrix (ADM) provides natural appearance of the nose and long-term structural integrity without extrusion, showing favorable augmentation results. Tutoplast-processed fascia lata (TPFL) is soft and easy to manipulate, providing a smooth postoperative contour of the nasal dorsum with low risk of infection or extrusion. ADM and TPFL carry low risk of major complications, such as infection, foreign body reaction, and graft extrusion. ADM and TPFL are suitable graft materials that deliver proper dorsal augmentation and patient satisfaction in primary and revision rhinoplasty.

Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians-Aesthetic Balance from Forehead to Chin, Part I

Asian rhinoplasty patients can be analyzed by the nose's component structures and their relationship to one another. A comprehensive understanding of the underlying anatomical structure including bone, cartilage, and soft tissue contributes to better preoperative planning. To achieve an optimal postoperative result, a thorough preoperative analysis utilizing standardized measurements is essential. Knowledge of the Asian nose facilitates the use of an algorithmic approach to Asian rhinoplasty that increases surgical predictability.

Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians-Aesthetic Balance from Forehead to Chin, Part II

Caucasians usually have reduction or correction rhinoplasty; however, Asian nasal surgery is mainly for augmentation rhinoplasty. Therefore, an Asian rhinoplasty should start with a precise understanding of ethnic anatomical differences. The authors summarize the anatomical characteristics of Asians to ensure the best results.

Simple Implant Augmentation Rhinoplasty

Augmentation rhinoplasty among Asian patients is often performed to improve the height of the nasal dorsum. As the use of autogenous tissues poses certain limitations, alloplastic materials are a viable alternative with a long history of use in Asia. The superiority of one implant prosthesis over another for augmentation rhinoplasty is a matter of debate, with each material representing varying strengths and weaknesses, indications for use, and precautions to consider in nasal implant placement. An implant prosthesis should be used on a case-by-case basis. Augmentation rhinoplasty requires the consideration of specific anatomical preoperative factors, including the external nose, nasal length, nasofrontal angle, humps, and facial proportions. It is equally important to consider several operative guidelines to appropriately shape implants to minimize the occurrence of adverse effects and postoperative complications. The most common postoperative complications include infection, nasal height change, movement of implant prosthesis, and silicone implant protrusion. In addition, the surgeon should consider the current standards of Asian beauty aesthetics to better understand the patient's desired outcome.

Asian Rhinoplasty: Correction of the Short Nose with a Septal Integration Graft

Correction of the short nose is the most challenging part in a rhinoplasty. It is even more difficult in Asians compared with Caucasians due to the thicker skin soft tissue envelope and weaker cartilaginous frameworks. Additionally, most of the Asian patients need augmentation of the nasal dorsum, and projection of the nasal tip at the same time of short nose surgery, which makes short nose correction more complex. Septal extension grafts can effectively and concomitantly correct a short nose. However, the amount of the septal cartilage is not sufficient as a source for the graft often; therefore, the authors devised a septal integration graft in which a septal cartilage graft was fixed to the caudal septum (columellar L-strut) in an end-to-end position to save an amount of the septal cartilage for correction of the short nose. A septal integration graft application resulted in lengthening of the short nose. In addition, the retracted columella and the acute columellar labial angle were improved aesthetically. Therefore, the authors suggest a septal integration graft, a modification of the septal extension graft, for correction of the short nose in an Asian rhinoplasty.

Asian Rhinoplasty: Preoperative Simulation and Planning Using Adobe Photoshop

A rhinoplasty in Asians differs from a rhinoplasty performed in patients of other ethnicities. Surgeons should understand the concept of Asian beauty, the nasal anatomy of Asians, and common problems encountered while operating on the Asian nose. With this understanding, surgeons can set appropriate goals, choose proper operative procedures, and provide an outcome that satisfies patients. In this article the authors define the concept of an Asian rhinoplasty-a paradigm shift from the traditional on-top augmentation rhinoplasty to a structurally integrated augmentation rhinoplasty-and provide a step-by-step procedure for the use of Adobe Photoshop as a preoperative program to simulate the expected surgical outcome for patients and to develop a preoperative plan for surgeons.

Rhinoplasty in the Asian nose

For Asian people with poorly developed dorsal height and tip height combined with thick skin, augmentation is the most common procedure in rhinoplasty. Nasal deformities are also prevalent. Frequent use of dorsal augmentation material and grafting procedures in Asian rhinoplasty results in a relatively high rate of revision surgery to correct complications. This article describes dorsal augmentation using alloplastic implant materials and several tip grafting procedures. Surgical techniques for the correction of a deviated nose and convex dorsum are also discussed, with emphasis on extracorporeal septoplasty as modified by the senior author. A technical guide is described to treat this condition.