Asian Rhinoplasty: Understanding Autologous Cartilages - Roles, Advantages and Disadvantges

Fuelled by the increasing demand for higher nasal bridge and sharper nose tip, Asian rhinoplasty procedures have since become one of the most commonly performed cosmetic and aesthetic procedures around the world. As with any procedure, ethnicity plays an important role in rhinoplasty, with Asian rhinoplasty being starkly different from that of Caucasian rhinoplasty - regardless in terms of outcome, techniques or expectations.

The general anatomical differences in Asians and Caucasians suggest that Asian nasal bones, as well as the upper and lower lateral cartilages are comparatively less developed than their Western counter-parts; therefore, in Asian rhinoplasty, it largely necessitates the use of an implant.

As Asian rhinoplasty often requires the use of implant, one of the most commonly used implant in rhinoplasty are alloplastic implants made of silicone or Gore-Tex. Although the shaping of alloplastic implants is rather easy and removal is also simple; one of the disadvantages of a nasal alloplastic implant is the risk of fibrous capsular formation, which may lead to capsular contracture.

To overcome these disadvantages, cartilages are harvested from donor sites and used to create or lengthen tip projection in Asian rhinoplasty.

General Anatomy of Asian Nose

Asians generally have an anatomically thick fibrous fatty layer including underdeveloped superficial musculoaponeurotic system (SMAS) along with a thick fibrous tissue layer; hence, it is common for Asians to develop a bulbous nose tip - a reason for most Asians seeking augmentation for a higher nose bridge and sharper tip.

Image credits: Dr. Donald B. Yoo via https://www.donyoomd.com/services-asian-rhinoplasty.php

Similarly, Asians have relatively small nostrils, which could prove to be challenging for a surgeon to perform closed rhinoplasty, as it restricts possible maneuvers for support and tip definition. Therefore, most literatures suggest employing the open rhinoplasty approach because it facilitates better control of the nasal SMAS.

In addition, a highly developed Pitanguy ligament often inhibits tip projection in Asians, and the nasal SMAS with highly developed fibrous tissues may also cause postoperative contracture. This has led to some studies suggesting to harvest the Pitanguy ligament and the nasal SMAS during the skeletonization of the nasal cartilage and bone - with the harvested nasal SMAS inserted on top of the cartilage graft when deciding the final height of the nasal tip to determine the height of the nasal tip, as well as prevent potential cartilage graft visibility under the skin.

The understanding of a patient’s nasal anatomical characteristics is crucially important in rhinoplasty, as it determines the selection of the appropriate implant together with the suitable donor cartilage to attain a safe and aesthetically pleasing nose.

This same principle applies to secondary/revision cases; as the fibro-fatty layer of SMAS along with the capsular contracture must be removed or released to gain a sufficient soft tissue volume to provide stability to the overall framework.

Alloplastic Implants in Rhinoplasty

Alloplastic implants are most commonly used in augmenting the nasal bridge, and can be made of silicon or Gore-Tex. They have the advantage when it comes to bridge augmentation as these implants can help to reduce the cost of the procedure as well as surgical time. Another advantage of alloplastic implants is that they may be custom carved to address volume concerns as well as be custom shaped to fit the nasal bridge.

Image credits: Masterpiece Hospital (Thailand) via https://www.masterpiecehospital.com/en/rhinoplasty/nose-silicone-implant-with-ear-cartilage/

While alloplastic implants are useful and has some advantages in rhinoplasty procedures, they are not without disadvantages. Some of the complications of using alloplastic implants in rhinoplasty include unnatural or obvious operated appearance, deviation, foreign body reaction and compromised skin and soft tissue envelope (SSTE).

In fact, infection with alloplastic implants can occur immediately or years after surgery; although aggressive antibiotic therapy can be undertaken, the chances of implant salvage are low, especially in cases where expanded polytetrafluoroethylene (e-PTFE) has been used.

Furthermore, there is no consensus on the timing of the definitive revision rhinoplasty after implant removal. Although it can provide a more sterile environment, the delay in surgery can result in contracture of the overlying SSTE; not to mention the added frustration of the patient. These complications have thus, led to a shift in paradigm where more patients and practitioners favour the use of autologous cartilage from the different donor sites for rhinoplasty procedures.

Types of Autologous Cartilages for Rhinoplasty

In recent years, studies have yet again proved that autologous cartilages are extremely useful in rhinoplasty procedures - significantly eliminating risks of rejection by the body. Some of the most commonly harvested cartilages are the auricular cartilage, septal cartilage, and rib cartilage.

Image credits: Nasal Tip Plasty Using a Batten Graft with Ear Cartilage in East Asians (Lim et al. 2016) via

https://www.researchgate.net/publication/305270373_Nasal_Tip_Plasty_Using_a_Batten_Graft_with_Ear_Cartilage_in_East_Asians

Auricular Cartilage: The auricular cartilage is often harvested from the ear by making an incision behind the ear. The harvesting of auricular cartilage does not change the shape of the ear, and can hide any post-operative scar well - making it a good substitute when nasal septal cartilage is unavailable.

Auricular cartilage also has high elasticity and sufficient thickness, while retaining a natural curve. Auricular cartilage may also be cut in half, with their opposite sides sutured for use in areas that require a straight line.

In addition, due to its natural curve, the auricular cartilage is most suitable to be used for nasal tip projection. While its natural shape is suitable to be used to enhance nasal tip projection, it is important for the performing surgeon to carefully carve the cartilage, round the edges, and smoothen off any rough corners before finally covering up the new cartilage with healthy tissues so that the graft may be shaped and camouflaged without showing through the skin.

Image credits: Functional and Aesthetic Results After Augmentation Rhinoplasty (Blanco et al. 2011) via

https://www.elsevier.es/en-revista-acta-otorrinolaringologica-espanola-402-articulo-functional-aesthetic-results-after-augmentation-S2173573511000573

Nasal Septal Cartilage: Nasal septal cartilage is another common donor choice. The design is largely suitable for augmentation in Caucasians, due to the fact that Asians, in general, have underdeveloped nasal septum in both quality and quantity. Owing to this, nasal septal cartilage harvest including the vomer in Asian rhinoplasty may be insufficient in size for septal extension grafts and/or other uses. Furthermore, the thickness of the nasal septum in Asians may also be inadequate. Due to these factors, nasal septal cartilage is not usually considered as a first choice of donor cartilage in Asian rhinoplasty.

Image credits: Costal Cartilage Graft in Asian Rhinoplasty: Surgical Techniques (Rajbhandari, Kao et al. 2019)

via https://parjournal.net/article/view/3042

Rib Cartilage: Rib cartilage has the advantage of providing large volume, but may leave undesirable scars in donor site. Additionally, rib cartilage carries a higher risk of warping on top of additional operative time required. Thus, the use of rib cartilage should be reserved for reconstructive cases, such as short nose deformity secondary to contracture or a cleft lip and nose deformity.

Advantages of Autologous Cartilage in Rhinoplasty

The use of autologous cartilage for rhinoplasty has a number of benefits not only because the cartilage is harvested from the patient’s own natural tissue, which reduces the risks of infection, it is moldable with its edges being able to blend seamlessly with the patient’s own tissue, but also for the fact that it is capable of healing with the body to be incorporated with the rest of the nose for a more natural and longer lasting result.

Another advantage of using autologous cartilage for rhinoplasty procedure is that it largely reduces the chances of extrusion, as compared to the use alloplastic implants and rib cartilage can be harvested and used for changing the shape of the nose in complex cases without all the complications of alloplastic implants.

Autologous cartilages have also been proven to be great for rebuilding or strengthening the sides of the nose if there is collapse or weakness. They also can be used to rebuild nasal tip in cases where the natural tip cartilage are damaged or have been removed. Finally, the perichondrium that covers the auricular cartilage makes a great graft for the bridge of the nose.

Disadvantages of Autologous Cartilage in Rhinoplasty

As with alloplastic implants, there are also disadvantages to using autologous cartilage and when considering the use of autologous cartilage for rhinoplasty, the distance from donor to site of implant must be taken into account. This is, but a slight disadvantage, and can be overcome by harvesting the auricular cartilage; as the donor side is of close proximity to the nose. It is also an easier site to harvest from than rib cartilage. Recovery from auricular cartilage harvest is also shorter as compared to harvesting of rib cartilage and procedural risks minimal.

One other disadvantage of harvesting cartilage is the possibility of contour irregularity of the ear, but such cases are rare and with good surgical techniques, can be avoided.

Scarring is also another disadvantage of using autologous cartilage for rhinoplasty but in the case of harvesting auricular cartilage, post-operative scars are usually well concealed behind ears or within the creases.

Lastly, warping is another possible disadvantage to consider when suggesting the use of autologous cartilage for rhinoplasty procedures to patients as it can potentially cause marked indentations, asymmetries, and/or crooked section of the nose - but in skilled hands and when correctly placed, the risks are markedly reduced, concealing the graft perfectly with little to no risk for extrusion.

Autologous Cartilage in Rhinoplasty: A Safer and Better Approach

Autologous cartilages are cartilages harvested from and implanted into the same patient, making any disadvantages almost relatively negligible, and far outweighed by the advantages. In fact, studies have shown that the disadvantages of autologous cartilage in rhinoplasty can be easily overcome if the performing surgeon has an in-depth knowledge in the anatomy of the nose, respect the anatomical differences of the various ethnics, as well as understand the properties and characteristics of the different cartilage harvested from the respective donor sites.

Above all, it lies in the skills and techniques of the performing surgeon, therefore, it is imperative for one to not only be equipped with the latest and most advanced skills and techniques but most importantly, be able to determine and implement the right techniques to deliver best results.

Hope you have enjoyed the article! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4656163/

https://parjournal.net/article/view/3042

https://journals.lww.com/prsgo/Fulltext/2018/09000/Cartilage_Allografts_for_Aesthetic_Nose_Surgery__.6.aspx

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