State of the art in augmentation rhinoplasty: implant or graft?

Safety and Efficacy of Autologous Cartilage Graft in Augmentation Rhinoplasty

Augmentation rhinoplasty or commonly known as "nose jobs" is one of the most common plastic surgical procedures aimed to improve cosmetic appearance. This procedure is considerably safer, less time consuming with faster recovery and immediate cosmetic effect. This procedure needs of highly experienced and well-trained plastic surgeon. According to facial analysis you can select the type of rhinoplasty. Open discussion with the patient to select appropriate surgical technique and its possible risks with your plastic surgeon to ensure the highest level of safety and satisfaction. Autologous grafting materials are safe, efficient and also the first choice for rhinoplasty due to it can survive without a vascular supply, the resorption rate of cartilage is much lower than that of a bone graft. Autologous grafting materials are stable and resistant to infection and extrusion over time so, they are successfully used for dorsal augmentation. To perform successful augmentation rhinoplasty, surgeons should be highly experienced and well-trained and augmentation materials that are currently available and understand their risks, benefits and uses. Autologous cartilage graft regarded as the graft of choice in augmentation rhinoplasty because of their lower rate of infection, rejection, resorption, extrusion, donor site morbidity, easy reshaping.

Novel "Z" Technique to Overcome Warping of Costal Cartilage

BACKGROUND

Dorsal augmentation with costal cartilage is generally used for aesthetic rhinoplasty. However, the tendency of costal cartilage to warp may jeopardize the aesthetic outcome.

OBJECTIVES

The aim of this study was to describe a new "Z" technique to overcome the warping of costal cartilage after implantation and to evaluate the efficacy of this technique in vitro.

METHODS

A total of 31 pairs of porcine costal cartilage grafts (40 mm × 10 mm × 5 mm) were obtained and kept in Dulbecco's Modified Eagle Medium (Sigma-Aldrich, St. Louis, MO) to maintain cell viability. Paired grafts were obtained and randomly allocated for preparation by the accordion technique and the "Z" technique. Standardized photographs (obtained immediately after operation and at 4 weeks) were used for warping analysis. Biomechanical testing was performed to measure the graft's capacity to resist deformation by an external force.

RESULTS

Cell viability of the grafts at 4 weeks was comparably good in the accordion group and the Z group (61.88% ± 4.47% vs 67.48% ± 7.03%, P = 0.55). Warping angle was comparable between the 2 groups (P > 0.01). The capacity to resist external force was significantly better in the Z group; the force needed to cause deformation was 3.98 ± 1.04 N in the Z group vs 1.61 ± 0.47 N in the accordion group in lateral view (P < 0.0001), and 1.33 ± 0.41 N vs 0.96 ± 0.24 N, respectively, in frontal view (P = 0.0013).

CONCLUSIONS

The "Z" technique appears to be a simple and effective method to minimize the tendency of costal cartilage to warp after implantation.

Histology and Long-term Clinical Outcome of Crushed Cartilage with Double-layer Gelatin Sponge Membrane for Dorsum Refinement in Primary Rhinoplasty

This article demonstrates the ability to use autologous crushed cartilage grafts in rhinoplasty with rapid recovery and optimal nasal functionality without any tissue damage and allows its rapid rejuvenation. Eligible patients underwent primary rhinoplasty using autologous crushed cartilage graft followed by microscopy imaging of the grafted tissue after recovery. Tissue and cytological analysis using optical microscopy, transmission electronic microscopy (TEM), and scanning electronic microscopy (SEM) showed complete viability of chondrocytes, formation of new collagen fibers, neo-perichondrium, neo-angiogenesis, and exhibiting optimal aesthetic outcome. The surgical approach is easy to perform, feasible, and less time-consuming, with excellent tissue rejuvenation and rapid recovery.

Update on Rhinoplasty Research Trends: A Bibliometric Analysis

BACKGROUND

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures. The current study aimed to use bibliometric analysis to qualitatively and quantitatively evaluate rhinoplasty research and determine the research trends and hotspots in this field.

METHODS

Publications on rhinoplasty research were extracted from the web of science core collection database. VOSviewer1.6.18 was used to analyze the co-authorship, co-occurrence, the citations of countries, institutions, authors, and hotspot keywords, and the journals in which the studies were published.

RESULTS

On April 8, 2022, 11,130 records of rhinoplasty research published between 1945 and 2021 were collected. Most of the retrieved studies were original research articles (n = 8309, 74.65%), and 1950 (17.52%) papers were available in an open-access format. The annual publication output increased annually. Research groups in the USA were the main contributors and had a strong academic reputation in this field. University of California System was the institution with the greatest contribution (4.17%, with 464 publications). Plastic and Reconstructive Surgery (1248 publications, 11.21%) published the most research in this field and was also the most frequently co-cited journal (33,894 citations, total link strength [TLS]: 722,672). R. J. Rohrich (140 publications) was the most prolific author and the most frequently co-cited author (2562 citations, TLS: 56,624). The following rhinoplasty research hotspots were identified: cleft rhinoplasty, nasal reconstruction, nasal tip, revision rhinoplasty, septorhinoplasty, nasal prosthesis, hyaluronic acid, and preservation rhinoplasty.

CONCLUSION

Our results provide a general overview of the major directions in rhinoplasty research. Preservation rhinoplasty, rib graft, nonsurgical rhinoplasty, hyaluronic acid, FACE-Q, fillers, and three-dimensional technology may be future research hotspots.

LEVEL OF EVIDENCE V

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 .

Rhinoplasty Considerations in the Ethnic Patient: The East-Asian Patients

To achieve an esthetically satisfying surgical outcome in rhinoplasty of East Asians, it is most important to emphasize the augmentation of the flattened nose. However, correction of the accompanying nasal deviation or hump reduction together with appropriate tip work is essential for a successful outcome following rhinoplasty. Additionally, the surgeon must be aware of cosmetic deformities following silicone rhinoplasty and should be capable of appropriate nasal reconstruction in patients with silicone implant-related problems.

Current Practices in Dorsal Augmentation Rhinoplasty

BACKGROUND

Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages.

METHODS

Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided.

RESULTS

Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient and surgeon understand their associated risks.

CONCLUSION

To perform successful dorsal augmentation, surgeons should be familiar with the wide variety of operative approaches and augmentation materials that are currently available and understand their risks, benefits, and uses.

Effectiveness of cross-linked human acellular dermal matrix in primary and revision augmentation rhinoplasty

BACKGROUND

Among the materials used for dorsal augmentation rhinoplasty (DAR), cross-linked human acellular dermal matrix (ADM) has been claimed for its low risk of infection and extrusion. The aim of this study was to compare the effectiveness of ADM in subjects undergoing primary versus revision dorsal augmentation rhinoplasties.

METHODS

Using a retrospective cohort study design, the investigators enrolled a cohort set of DAR patients operated by a single surgeon during a 65-month interval. The predictor variable was the treatment group (primary or revision DAR). The main outcome variables were postoperative changes with regard to the degree of augmentation (ratio of the dorsal height [DH] and radix height [RH] to the nasal length) and patients' and surgeons' satisfaction with the aesthetic and functional results. Other study variables were grouped into the following categories: demographic, surgical, and pathological. Descriptive, uni-, and bivariate statistics were computed using P ≤ 0.05 as a cutoff value.

RESULTS

The study cohort comprised 145 subjects (75.2% with primary DAR; 39.3% females) with a mean age of 30.7 ± 9.4 years (range, 19-58). DAR was linked to the significant changes in DH and RH in both the treatment groups. Comparison of the two groups revealed that there was no significant difference in DH and RH between both the groups. Surgeons' and patients' satisfaction rates were comparable between the two surgery groups, neither of which experienced serious complications. Microscopic findings of the removed ADM showed abundant collagen tissue with newly formed vessels without signs of foreign body reaction.

CONCLUSION

Despite significant differences in patient characteristics (age; number of osteotomy, tip plasty, and hump reduction surgeries), the results of this study suggest that ADM can be used in both primary and revision DAR, with minimal complications.

Crushed Cartilage and Autologous Fat for Dorsal Nasal Refinement

BACKGROUND

Dorsal contour irregularities remain a potential undesirable sequela of rhinoplasty. Use of dorsal onlay grafts can camouflage such irregularities. In this article, a novel technique for dorsal onlay grafting utilizing crushed cartilage mixed with autologous fat is described. This study aims to assess long-term graft retention and aesthetic outcomes with this technique.

METHODS

Patients with >18-month follow-up who underwent primary open rhinoplasty with the described technique were reviewed. Three-dimensional photographs taken at multiple timepoints were overlaid with volumetric subtraction used to quantify graft retention. The Rhinoplasty module of the FACE-Q was completed by each patient, and the Rhinoplasty Assessment Scale Photographic (RASP) was completed by surgeon reviewers. Pre- and postoperative changes in dorsal height as well as RASP scores were compared with paired t-tests. Changes in BMI, dorsal volume, and dorsal height were compared with linear regression. P values <0.05 were considered significant.

RESULTS

Fourteen patients were included, mean age 32. Mean intermediate and final follow-up was 17.8 months and 28.9 months, respectively. There were no statistically significant dorsal height change (mean = 0.0 mm, p = 0.91) and minimal dorsal volume change (mean = 0.02 cm³, range:  0.08 to 0.13). Patients reported a high degree of satisfaction with facial/nasal appearance and psychological/social functioning. There was a statistically significant improvement in RASP scores (p < 0.001) postoperatively.

CONCLUSION

Crushed septal cartilage mixed with autologous fat is an effective option for dorsal nasal onlay in rhinoplasty and is associated with excellent graft retention, patient satisfaction, and nasal aesthetics.

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.

Late-Onset Inflammation in Asian Rhinoplasty Using Alloplastic Implants

BACKGROUND

Late-onset inflammation is a rare complication that may occur several months to years after undergoing an uneventful rhinoplasty using alloplastic implants and an uneventful postoperative course. Studies to determine the pathophysiological mechanisms of late-onset inflammation related to implants used in rhinoplasty are limited. The purpose of the study was to analyze differences between non-healthy capsules (NHC) with late-onset inflammation and healthy capsules (HC) without inflammation as controls to determine the possible cause of the inflammation.

METHODS

Between April 2009 and May 2018, 39 patients who underwent rhinoplasty with alloplastic implants underwent histological studies. Twenty-one patients in the NHC group showed late-onset inflammation, while 18 patients in the HC group did not display late-onset inflammation. Capsules around the alloplastic implants were harvested, and histological studies using hematoxylin and eosin, Masson's trichrome, colloidal iron, and CD31 staining were performed and compared between the NHC and HC groups.

RESULTS

In hematoxylin and eosin and Masson's trichrome staining, edematous granulation tissues, inflammatory cellular contents, and a disorganized collagen layer were increased in the NHC group compared to the HC group. The colloidal iron staining revealed mucin deposition in the NHC group. CD31-positive cells were observed lining the capsule in both groups; however, the lining cells were damaged in the NHC group.

CONCLUSION

Granulation tissues, inflammatory reaction, collagen degeneration, mucin deposition, and endothelial lining cell damage were greater in the NHC group compared to the HC group. Damaged capsules may play a crucial role in late-onset inflammation.

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 .

Radiologic Findings of Complicated Alloplastic Implants in the Nasal Dorsum

Objectives

When performing cosmetic rhinoplasty with alloplastic materials, complications such as implant visualization, inflammation, dislocation, and extrusion should be thoroughly evaluated. Although computed tomography (CT) can provide useful information about the implant status and its interaction with the skin soft tissue envelope (SSTE), the radiologic findings of these interactions have rarely been reported.

Methods

We retrospectively reviewed the data of 80 patients who underwent facial bone CT or ostiomeatal unit CT at Asan Medical Center between July 2008 and January 2020 for the evaluation of dorsal implants with complications. We reviewed the implantation period, implant dislocation, implant curling or deformation, radiodensity (in Hounsfield units), and nasal bone changes including bone erosion or hyperostosis.

Results

Of the 80 patients, 67 (83.8%) had silicone implants and 13 (16.2%) had Gore-Tex implants. The radiologic findings of the silicone implants were as follows: maintenance of the implant shape (80.6%), radiolucency (similar density to that of fat tissue) halo (83.6%), and homogeneous attenuation (82.1%). Peri-implant calcification was often found in silicone implants with >20-year implantation periods. The findings of Gore-Tex were as follows: curling or deformation (84.6%), heterogeneous attenuation (84.6%), and consistent peri-implant calcification over time.

Conclusion

Silicone and Gore-Tex implants have distinctive radiologic features. These findings of alloplastic materials help us to understand how implants behave in the nasal dorsum and how they affect the SSTE.

Will Tissue-Engineering Strategies Bring New Hope for the Reconstruction of Nasal Septal Cartilage?

The nasal septal cartilage plays an important role in the growth of midface and as a vertical strut preventing the collapse of the nasal bones. The repair of nasal cartilage defects remains a major challenge in reconstructive surgery. The tissue engineering strategy in the development of tissue has opened a new perspective to generate functional tissue for transplantation. Given the poor regenerative properties of cartilage and a limited amount of autologous cartilage availability, intense interest has evoked for tissue engineering approaches for cartilage development to provide better outcomes for patients who require nasal septal reconstruction. Despite numerous attempts to substitute the shapely hyaline cartilage in the nasal cartilages, many significant challenges remained unanswered. The aim of this research was to carry out a critical review of the literature on research work carried out on the development of septal cartilage using a tissue engineering approach, concerning different cell sources, scaffolds and growth factors, as well as its clinical pathway and trials have already been carried out.

A Simple Combination Approach for Costal Cartilage Augmentation Rhinoplasty

Autologous costal cartilage graft is optimal for augmentation rhinoplasty but with complications including markedly visible graft margins and dorsal contour irregularities. Therefore, the authors introduced the diced costal cartilage graft to smoothen the margins of bilateral spreader graft for nasal dorsum augmentation. A total of 6 patients were recruited for this augmentation rhinoplasty. The pre- and postoperative photographs were taken for improvement evaluation. During a mean follow-up of 15 months, none of the patients developed major complications that may require removal or revision of the costal cartilage grafts. Five patients (80%) were very satisfied with the aesthetic outcome. This simple algorithm facilitates the substantial augmentation and removes the visibility of dorsal graft in the costal cartilage rhinoplasty for the East Asian population.

Use of an Augmentation Spreader Graft for Management of Nasofacial Angle in Patients With Pseudo-Hump

BACKGROUND

Correction of the hump nose entails more than just simple elimination of the dorsal hump. Recent trend is toward conservative reduction of the hump and appropriate adjustment of the radix height. East Asians often present with pseudo-hump due to underprojected radix or tip, which accentuates the height of the hump. This study introduces our method of pseudo-hump correction and achieving a balanced nasal profile with minimal reduction of the hump and augmentation of the dorsum and tip with a modified augmentation spreader graft.

METHODS

A retrospective review was conducted of 97 consecutive cases of Korean patients undergoing hump reduction with simultaneous augmentation of the radix with resected hump fragments and augmentation of the nasal dorsum with augmentation spreader graft. No implants were used in any of the patients. Anthropometric analysis was performed, and patient satisfaction was evaluated at postoperative 1 year.

RESULTS

Postoperatively, hump was eliminated, and the dorsum and tip were successfully elevated using only autologous septal cartilage. The radix was augmented without surface irregularity or graft visibility. Nasal dorsum, tip, and radix projection increased significantly after surgery. Subjective evaluation revealed a high level of satisfaction in 84%.

CONCLUSIONS

Our multipurpose bilateral augmentation spreader graft positioned above the septal plane was effective in dorsal and tip augmentation without the need for alloplastic material. Conservative hump reduction combined with augmentation of the relatively deficient areas of the nose produces a balanced nasal profile.

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.

Surgical Anatomy of the Asian Nose

Rhinoplasty for Asian noses is markedly different from that for white noses. As rhinoplasty becomes increasingly popular among Asian people, it is important that the rhinoplasty surgeons master relevant anatomy and become skilled in required techniques to serve this segment of population. In this article, distinct characteristics of Asian noses are briefly described. Noses in the Asia population exhibit broad phenotypic variations. There is no typical Asian nose. Therefore, the terms of Asian noses in this article are confined to noses of people from East Asian (eg, Korea, Japan, and China).

Outcome of Septorhinoplasty in Deviated Nose Deformity: One Year Cross-Sectional Study

To evaluate outcome of Septorhinoplasty in Deviated nose deformity using Nasal Obstruction Symptom Evaluation (NOSE) scale and Rhinoplasty outcome evaluation score (ROE). This observational study was conducted in the department of Otorhinolaryngology and Head and Neck Surgery of KLE University's Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital and Medical Research Center, Belagavi from January 2015 to December 2015. Forty patients were evaluated and comparisons were made for NOSE score preoperatively and postoperatively. Comparison of decrease in NOSE score with age distribution, sex distribution, type of septorhinoplasty, ROE score of patients and ROE score of surgeons were also made. ROE score of patients and ROE score of surgeons were correlated. Their statistical significance (p value) and Cohen's kappa (k) were calculated. Out of 40 patients, there were total of 16 Open Septorhinoplasty cases and 24 Close septorhinoplasty cases. NOSE score preoperatively and postoperatively showed statistically significant i.e., total score (p = 0.001). ROE score of patients and surgeons had poor correlation (k = 0.1; p = 0.2). Decrease in NOSE score postoperatively with ROE score of patients showed statistically significant (p = 0.01). There was no significance on comparison of decrease in NOSE score postoperatively with ROE score of surgeons (p = 0.09), age distribution (p = 0.1), sex distribution (p = 0.2) and septorhinoplasty (open/close) (p = 0.2). The outcome of septorhinoplasty has been validated with NOSE scale and ROE score and has been proven that there is improvement in nasal obstruction and quality of life after septorhinoplasty. The quality of life scoring is essential for patients subjected to septorhinoplasty for assessing success of the surgery.

Alloplastic Augmentation of the Asian Face: A Review of 215 Patients

BACKGROUND

Asian aesthetic surgery has become increasingly popular over the last decade, especially augmentation of characteristically flattened facial features. Alloplastic implants are an option for facial augmentation, however many avoid their use due to concerns for morbidity associated with their use.

OBJECTIVES

To validate our hypothesis that when used properly, alloplastic implants have a low complication profile and provides excellent aesthetic results.

METHODS

A retrospective review was performed of all Asian patients undergoing alloplastic facial augmentation between 2009 and 2013 by a single surgeon. Procedures included augmentation of the forehead, nasal dorsum, midface, and chin. Charts were reviewed for outcomes including infection, extrusion, malposition, and operative revision.

RESULTS

Two hundred and fifteen patients had 243 implants placed. Of 141 nasal augmentations, there were 2 infections (1.4%), 1 extrusion (0.7%), 7 malpositions (4.9%), and 16 revisions (11.3%), 5 for malposition, 2 for contour irregularity, and 9 for aesthetic change. Augmentation genioplasty was performed in 40 patients with 1 malposition (2.5%) and 6 revisions (15%), 4 for under-correction and 2 for aesthetic change. Thirty-one midface and 31 forehead augmentations were performed without complications. One patient (3.2%) had forehead implant removal for aesthetic change. Overall infection and extrusion rates were 0.8% and 0.4%, respectively.

CONCLUSIONS

By utilizing surgical techniques such as creation of a precise sub-periosteal pocket, placing the implant away from the incision site, and leaving well-vascularized soft tissue coverage under minimal tension, alloplastic implants can safely be used as a first-line option for Asian facial augmentation.

LEVEL OF EVIDENCE

4 Therapeutic.

Preventing Elevated Radix Deformity in Asian Rhinoplasty with a Chimeric Dorsal-Glabellar Construct

BACKGROUND

Asian facial aesthetic surgery should enhance, but not change, natural features. Augmentation rhinoplasty is a hallmark of Asian cosmetic surgery. In the authors' experience, I-shaped implants can elevate and efface the radix, leading to an unnatural appearance (elevated radix deformity).

OBJECTIVES

The Chimeric technique was developed to control final radix position and preserve the nasal profile. We aim to demonstrate that the Chimeric technique promotes forward projection, not elevation, of the radix.

METHODS

Between 2013 and 2015, 49 patients underwent rhinoplasty with I-shaped implants. Nineteen patients had Chimeric dorsal-glabellar implants, 30 did not. Standardized photographs were obtained at every visit. Novel and established photogrammetric parameters were used to describe radix position and position change. A retrospective chart review provided additional procedural details and outcomes data.

RESULTS

Patients were followed for 10.8 months (range, 2-36 months). Nasal height increase (113% vs 107%) and bridge length increase (118% vs 105%) were significantly greater when the Chimeric technique was not performed (P < .0001). The nasofrontal angle increased 6° in both groups; there was no difference between groups. The vector of radix position change was 26.1° in the Chimeric group and 63.4° in the traditional group (P < .0001).

CONCLUSIONS

The Chimeric technique preserves the nasal profile with a favorable (horizontal) radix transposition vector. There was not a significant difference in final radix position when Chimeric rhinoplasty was performed because that is controlled by implant thickness and position. The technique did not blunt the radix significantly. LEVEL OF EVIDENCE 4: Therapeutic.

Engineered nasal cartilage by cell homing: a model for augmentative and reconstructive rhinoplasty

BACKGROUND

Current augmentative and reconstructive rhinoplasties use auto logous tissue grafts or synthetic bioinert materials to repair nasal trauma or attain an aesthetic shape. Autologous grafts are associated with donor-site trauma and morbidity. Synthetic materials are widely used but often yield an unnatural appearance and are prone to infection or dislocation. There is an acute clinical need for the generation of native tissues to serve as rhinoplasty grafts without the undesirable features that are associated with autologous grafts or current synthetic materials.

METHODS

Bioactive scaffolds were developed that not only recruited cells in the nasal dorsum in vivo, but also induced chondrogenesis of the recruited cells. Bilayered scaffolds were fabricated with alginate-containing gelatin microspheres encapsulating cytokines atop a porous poly(lactic-co-glycolic acid) base. Microspheres were fabricated to contain recombinant human transforming growth factor-β3 at doses of 200, 500, or 1000 ng, with phosphate-buffered saline-loaded microspheres used as a control. A rat model of augmentation rhinoplasty was created by implanting scaffolds atop the native nasal cartilage surface that was scored to induce cell migration. Tissue formation and chondrogenesis in the scaffolds were evaluated by image analysis and histologic staining with hematoxylin and eosin, toluidine blue, Verhoeff elastic-van Geison, and aggrecan immunohistochemistry.

RESULTS

Sustained release of increasing doses of transforming growth factor-β3 for up to the tested 10 weeks promoted orthotopic cartilage-like tissue formation in a dose-dependent manner.

CONCLUSIONS

These findings represent the first attempt to engineer cartilage tissue by cell homing for rhinoplasty, and could potentially serve as an alternative material for augmentative and reconstructive rhinoplasty.

Combined alloplastic implant and autologous dermis graft for nasal augmentation rhinoplasty in Asians

Alloplastic implants may be used in augmentation rhinoplasty but are associated with thinning of the skin over the implant as well as extrusion and translucency of the implant. To minimize these complications, this report describes a combined alloplastic implant and autologous dermal graft for dorsal and tip augmentation rhinoplasty. Of 37 Chinese patients, 35 (94.6 %) were satisfied with the outcome of this procedure during a follow-up period of up to 24 months, and no implant extrusions occurred. The preliminary findings indicate that a combined alloplastic implant and autologous dermis graft is appropriate for nasal augmentation, especially for patients with thin tip skin.

LEVEL OF EVIDENCE V

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 .

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.