In this paper, the authors presented a series of Asian patients for revision rhinoplasty with the chief complaint of deviation of the nasal implant after augmentation Asian rhinoplasty with silastic implants or autologous materials.1 This is a very common presentation for revision Asian rhinoplasty, and the authors are to be congratulated for formulating a treatment approach incorporating the routine application of preoperative computed tomography (CT) evaluation and for providing their surgical approach based on what was found on the CT. CT is not a routine part of the preoperative work-up for many surgeons. The authors noted that assessment of the underlying bony asymmetry is difficult because the nasal implant is masking the underlying condition of the bony vault and recommended the routine application of preoperative CT scan. Most surgeons rely on meticulous clinical examination, which remains a crucial part of the evaluation. Diagnostic clues as to the cause of the posttreatment deviation of the nasal implant for assessment include palpation for deviations of the bony vault, feeling for excessive tension from the skin envelope on the implant, especially in the cephalo-caudal dimension (commonly an implant that is too long will result in deforming forces from the skin envelope that would deviate the implant) and intranasal assessment to evaluate for septal deviations. Usually, an exploratory element is present during the revision surgery. The implant is meticulous removed and the nasal cartilages and bone carefully evaluated then to confirm the final operative plan. The aim is to provide a straight dorsum and a stable well projected nasal tip on which a nasal implant may be employed to augment the bridge. CT is indeed helpful for a few reasons that the authors highlighted. Firstly, in communicating with the patients their existing (either congenital or surgically created) asymmetry and secondly, as noted by the authors, in providing more accuracy in the preoperative planning of the procedure. This is particularly helpful in cases where a specific cause of the deviation of the bony platform may be identified preoperatively, as in the CT scan shown in Figure 3A. This certainly takes away some of the uncertainty with the initial exploratory phase of the revision rhinoplasty. There is of course financial cost involved with the routine application of CT scans which are borne by the patients. The authors also noted that CT was important for assessing asymmetry in the glabella-radix and in 6 of their patients, this was diagnosed. I am not exactly sure what extent of asymmetry in the glabella-radix region would be appropriate for one to make this diagnosis. Figure 5A shows a very slight deviation whereas in Supplemental Figure 1A the deviation is even milder (if any). In terms of managing minor glabella-radix asymmetry, some preferential rasping would even out this degree of deviation. However, many Asian patients with a very low dorsum also have a hypoplastic glabella-radix and I think this group would potentially benefit from the so-called “chimeric implant” that the authors designed. The value of the preoperative CT scan perhaps would be in providing some guidance in prefabricating the glabella component of the implant, should the surgeon wish to augment the glabella. Adding a glabella component to the dorsal implant would give patients with hypoplastic glabella a better cosmetic result. However, this is technically challenging to perform with a potential for widening the glabella as seen in the frontal view of the patient presented in Figure 5. About the straightening and centralizing the dorsum of the nose, the focus of the discussion was on the osteotomies and grafts (extender spreader grafts on the concave side) for managing asymmetry in the osteocartilaginous upper two-thirds of the nose. An important aspect of straightening the Asian nose that the authors did not discuss (but probably applied in their cases) is the deviation of the anterior septum. As Cottle noted, “as the septum goes, so goes the nose”. In the 2 cases presented, particularly in Supplemental Figure 1, there was significant deviation of the anterior septum as seen on the CT scan. In those cases, in addition to the management of the bony vault and keystone deviation, straightening the anterior septum would be the key determinants of success of the procedure. While the authors did not specifically mention their management of the deviated anterior septum, this aspect of the surgery is crucial in providing a stable, straight base for the implant to sit securely on the midline. This may be achieved by maneuvers previously presented, including separating the dorsal septum from deforming forces from the upper lateral cartilages, centralizing the caudal septum on the anterior nasal spine, scoring the concave side, using spreader grafts to straighten the septum and asymmetric “clocking” sutures of the upper lateral cartilages.2–6 Having achieved a straighter upper two-thirds anatomy of the nose as best as one was able to, placement of the dorsal component of the nasal implant onto this foundation is equally important. Not mentioned in the article was the authors’ approach of asymmetrically shaping and carving for the implant, to compensate and allow the dorsal implant to sit more centrally on an asymmetric bony platform and to camouflage residual deviation that may be present. While the surgical techniques done (that of paramedian osteotomy on the concave side of the keystone area and extended spreader grafts as a wedge into the stabilize the lateralized nasal fragment on the concave side) were designed to straighten the bone, these may not be able to straighten the bone completely in the more deviated cases. In both clinical cases presented (Figure 1 and Supplemental Figure 5), despite these maneuvers, the authors have found it necessary to compensate for the residual asymmetry in the upper two-thirds of the nose by placing the implant in an off-centered manner. This has been my experience as well with the more difficult cases. Moving the nasal bone significantly to straighten and centralize the nasal bones is more difficult in the Asian noses compared to the Caucasian noses. This is because the nasal bones in Asian noses are much smaller in dimension and flatter in their configuration. Osteotomies often create fragments that were small and difficult to definitively moved by more than 2 or 3 mm. Accordingly, even after these maneuvers, it is often necessary to compensate for the residual asymmetry or to camouflage the residual asymmetry with placing the implant in a non-centralized location and to carve the implant in an eccentric manner (Figure 1E and Supplemental Figure 5E). Carving the implant in these situations would require preferential carving of the posterior implant groove on the deviated side to allow the implant to centralize and reduction of the dorsal height and prominence on the side the foundation is deviated towards and providing more augmentation on the contralateral side. These refinements in the carving are usually done intraoperatively as a final step before placing the implant. In conclusion, the authors are to be congratulated for stimulating us with this article and providing a more advanced and artistic solution to the common problem of post augmentation Asian rhinoplasty presenting with deviation of the nasal implant. Certainly, a CT evaluation is potentially helpful in the preoperative planning of more difficult cases. Disclosures The author declares no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Lee PC, Chang RH, Chang YL. Treatment of nasal deviation with underlying bony asymmetry secondary to augmentation rhinoplasty in Asian patients. Aesthet Surg J . 2018 Jan 11. doi: 10.1093/asjour/sjy006. [Epub ahead of print] 2. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg . 2003; 111( 7): 2449- 57; discussion 2458. Google Scholar CrossRef Search ADS PubMed 3. Kosins AM, Daniel RK, Nguyen DP. Rhinoplasty: the asymmetric crooked nose-an overview. Facial Plast Surg . 2016; 32( 4): 361- 373. Google Scholar CrossRef Search ADS PubMed 4. Ahmad J, Rohrich RJ. The crooked nose. Clin Plast Surg . 2016; 43( 1): 99- 113. Google Scholar CrossRef Search ADS PubMed 5. Wong CH, Daniel RK. Immediate functional and cosmetic open rhinoplasty following acute nasal fractures: our experience with Asian noses. Aesthet Surg J . 2013; 33( 4): 505- 515. Google Scholar CrossRef Search ADS PubMed 6. Wong CH, Daniel RK, Lee ST. Asian cleft rhinoplasty: the open structural approach. Aesthet Surg J . 2018; 38( 1): 28- 37. Google Scholar CrossRef Search ADS © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: email@example.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Aesthetic Surgery Journal – Oxford University Press
Published: May 21, 2018
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