A, Type A: an extended spreader graft and a caudal septal extension graft are sutured on different sides of the existing L strut. B, Type B: bilateral extended spreader grafts and batten grafts are sutured on both sides of the existing L strut. C, Type C: bilateral extended spreader and caudal extension grafts are sutured on both sides of the dorsal strut with one caudal extension graft sandwiched between them. D, Type D: total septal reconstruction.
For cases with severe scarring and fibrosis of the skin soft-tissue envelope, in which the lower lateral cartilage cannot reach the new reconstructed caudal septum, we dissect the lateral crus of the lower lateral cartilage from the underlying vestibular skin and incise its anterior part to create a medially based cartilage flap, which is later rotated medially to cover the extended spreader graft (arrow).
Nasal length is the length from the nasion to the pronasale. Nasal tip projection (NTP) is the distance between the pronasale and the alar line. Both nasal length and NTP were expressed as multiples of a reference length, namely, the distance between the pupil and the anguli oris (the dotted line). The nasofrontal angle (NFA) is the angle between the proximal nasal bridge contour and the anterior surface of the forehead below the glabella. The nasolabial angle (NLA) is the angle between the surfaces of the columella and the upper-lip skin. The columella-lobular angle (CLA) is the angle between the surfaces of columella and the infratip lobule.
Photographs taken 10 days (A), 1 month (B), and 6 months (C) after operation. This 59-year-old woman had previously undergone 4 rhinoplasties. She had received dorsal augmentation with silicone in her previous rhinoplasty. This time she underwent postoperative short nose correction, which included the type C septal reconstruction method with homologous costal cartilage, dorsal augmentation with homologous costal cartilage and expanded polytetrafluoroethylene, tip shield graft, and lateral crural onlay graft with composite conchal cartilage graft. Impaired wound healing was noted postoperatively. A subnasale flap was used to reconstruct the skin defect at the transcolumellar incision site.
Preoperative (top row) and postoperative (bottom row) photographs of a 48-year-old woman who presented with postoperative short nose deformity. She received dorsal augmentation with homologous fascia and expanded polytetrafluoroethylene in her previous rhinoplasty. This time she underwent postoperative short nose correction, which included the type C septal reconstruction method with autologous costal cartilage and dorsal augmentation with autologous costal cartilage and expanded polytetrafluoroethylene. She had an excellent aesthetic outcome at the last follow-up visit (20 months postoperatively).
eTable 1. Surgical Techniques and Types of Grafts Used in Tip, Lateral Compartment, and Dorsal Augmentation
eFigure 1. Preoperative and Postoperative Clinical Images
Lan MY, Jang YJ. Revision Rhinoplasty for Short Noses in the Asian Population. JAMA Facial Plast Surg. 2015;17(5):325-332. doi:10.1001/jamafacial.2015.0645
Short nose, especially postoperative short nose in Asian patients, remains a challenging problem for plastic surgeons.
To determine the outcomes of revision rhinoplasty of postoperative short noses in Asian patients.
Design, Setting, and Participants
We performed a retrospective medical record review of 41 Asian patients with postoperative short nose who underwent revision rhinoplasty in a tertiary care referral center in South Korea from October 1, 2006, through August 31, 2014.
Main Outcomes and Measures
Patient demographic, surgical technique, graft use, anthropometric measurement, complication, and aesthetic outcome assessment data were retrieved.
The 41 enrolled patients were a mean (SD) of 36.5 (12.6) years old. There were 16 men and 25 women. The most commonly used dorsal graft in the previous rhinoplasty was silicone, followed by fascia with or without cartilage. Various surgical techniques were applied, including septal reconstruction, cartilage flap technique, tip surgery, lateral compartment correction, and dorsal augmentation. Autologous costal cartilage was the most commonly used septal reconstruction material. Eleven patients (27%) developed postoperative complications, including infection, nostril asymmetry, and pollybeak deformity. Revision rhinoplasty yielded statistically significant improvements in nasal length (increase of 12.0%, P < .001), nasal tip projection (increase of 13.4%, P < .001), nasofrontal angle (decrease of 2.39°, P = .04), nasolabial angle (decrease of 7.62°, P < .001), and columella-lobular angle (increase of 3.25°, P < .001). More than 90% (37) of the patients were judged to have good or excellent aesthetic results.
Conclusions and Relevance
Correction of postoperative short nose in Asian patients requires complicated surgery that usually involves more than one kind of surgical technique. Complications are not uncommon, and patients should be informed of this before surgery.
Level of Evidence
In white patients, postoperative short nose usually results from overresection of the dorsal, septal, or lobular components of the nose in the initial surgery. This overresection weakens the cartilaginous support and is followed by the contracture of the overlying soft tissue and scar formation.1- 4 However, the pathogenesis of postoperative short noses in Asian patients is often the result of capsular contracture that is caused by the use of alloplastic dorsal augmentation implants, such as silicone, in the primary rhinoplasty, and the short nose deformity is then further aggravated by the injured weak cartilaginous framework and the thick skin soft-tissue envelope (SSTE).4- 6
Many studies have addressed the technical aspects of short nose correction, and some of these studies1- 18 reported good results. However, most studies4,7- 12 consisted of both primary and secondary short nose cases, which may not be appropriate because the underlying causes of primary and secondary short nose differ. Furthermore, there is little indication in the literature of the difficulties faced in correcting this complex deformity.
In this article, we describe our experiences with treating postoperative short nose in Asian patients. Of particular interest were the types of dorsal implants that were used in the previous surgery. In addition, the various surgical techniques used in the revision rhinoplasties were examined. We also introduced our novel surgical technique, namely, the cartilage flap technique. The complications were identified, and the aesthetic results were measured by performing anthropometric measurements and an aesthetic outcome assessment.
The study group consisted of patients who underwent revision rhinoplasty for short nose deformity at Asan Medical Center from October 1, 2006, through August 31, 2014. The study was approved by the Asan Medical Center Institutional Review Board, and written informed consent was obtained from all patients. The patient demographic, previous surgical history, graft use, surgical technique, anthropometric measurement, complication, and aesthetic outcome assessment data were collected and analyzed.
All rhinoplasties were performed by the one of us (Y.J.J.). All patients were under general anesthesia and underwent an open rhinoplasty technique with a transcolumellar inverted V-shaped incision along with bilateral marginal incisions. The method of septal extension was determined intraoperatively based on the shape and strength of the patients’ septal cartilage, as well as the thickness and length of the cartilage for grafting. Antibiotics were used prophylactically in all cases.
The central compartment was initially evaluated after the skin and bilateral septal mucoperichondrial flaps were elevated. Homologous cartilage or autologous cartilage served as nasal lengthening grafts. In cases with a strong remaining septal framework, an extended spreader graft or a caudal septal extension graft was placed. In cases with a weak internal cartilage framework that required septal reconstruction, 4 different methods, designated as types A, B, C, and D, were used. In the type A method, one extended spreader graft and one caudal septal extension graft were sutured on different sides of the existing L strut (Figure 1A). The type A method was used when the remaining dorsal L strut was curved and relatively thick grafting cartilage was available. One extended spreader graft was placed at the concave aspect of the dorsal L strut. In the type B method, bilateral extended spreader grafts and batten grafts were sutured on both sides of the existing L strut (Figure 1B). The type B method was used when the remaining dorsal L strut was very thin and we had relatively thin cartilage strips for grafting purposes. In the type C method, bilateral extended spreader grafts were sutured on both sides of the dorsal strut with one caudal extension graft sandwiched between them (Figure 1C).19 This method was used in conditions similar to those in which the type B method was used. However, we preferred this technique over type B because it allowed easier lengthening of the caudal septum and had less risk of creating too much thick caudal septum. In cases combined with severe deviated nasal septum, total septal reconstruction (the type D method) was used (Figure 1D).20 This method was used when there was virtually no septal cartilage left or a severely weakened rudimentary L strut was found. A new cartilage L strut was fashioned extracorporeally using costal cartilage and was inserted into the mucoperichondrial pocket in a way of lengthening the nose.
Several techniques were used in lateral compartment correction, including composite conchal cartilage graft, lateral crural strut graft, and lateral crural onlay graft. In cases with a concave dorsum, dorsal augmentation was performed by using autologous cartilage, homologous cartilage or fascia, or alloplastic materials, such as expanded polytetrafluoroethylene (Gore-Tex) or porous high-density polyethylene (Medpore). In cases with a cephalic-rotated nasal tip, the nasal tip was derotated by using several nasal tip procedures, including multilayer tip grafting,21 shield grafting with or without backstop graft, onlay grafting, and columellar strut.
For cases with severe scarring and fibrosis of the SSTE, in which the lower lateral cartilage cannot reach the new reconstructed caudal septum, a cartilage flap technique is applied. We dissect the lateral crus of the lower lateral cartilage from the underlying vestibular skin and incise its anterior part to create a medially based cartilage flap, which is later rotated medially to cover the extended spreader graft (Figure 2). In patients who have alar retraction after undergoing this technique, an additional lateral crural onlay graft is placed at the cartilage-devoid area of the middle to lateral crus.
The following anthropometric measurements were calculated from preoperative and postoperative lateral view photographs by using the Image J tool (National Institutes of Health; http://rsb.info.nih.gov/ij/download.html): nasal length, nasal tip projection (NTP), nasofrontal angle (NFA), nasolabial angle (NLA), and columella-lobular angle (CLA) (Figure 3). Nasal length is calculated as the length between the nasion and the pronasale. The nasion position was set at the level of the supratarsal fold of the upper eyelid.22 The postoperative nasion position was approximately the same as the preoperative one because dorsal augmentation was performed in previous rhinoplasty in nearly all the cases in our study. The NTP is the distance between the pronasale and the alar line. A reference length defined as a distance between the pupil and the anguli oris was also measured.4 We took care to orient the camera exactly perpendicular to the subject while taking lateral profile views. To do that, the camera was moved slightly from side to side until the eyebrows were lined up during the framing.23 We also helped the patient to assume a relaxed face with no smile while taking photographs.23 To adjust for the variability caused by the size, object distance, and magnification of each photograph, the nasal length and NTP were expressed as multiples of this reference length.4,6 The NFA is the angle between the proximal nasal bridge contour and the anterior surface of the forehead below the glabella. The NLA is the angle between the surfaces of the columella and the upper-lip skin. The CLA is the angle between the surfaces of the columella and the infratip lobule.22
Four otolaryngologists who were not involved in any of the operations compared the preoperative and postoperative photographs of all patients. The postoperative outcomes of short nose correction were assessed on the basis of the latest photographs of the frontal, lateral, and basal view taken at the last follow-up. For each view, the outcomes were scored as excellent (score of 4), good (score of 3), fair (score of 2), or poor (score of 1). The total score of each patient (the sum of all 3 scores) was calculated for further analysis.
The numerical data are presented as means (SDs), whereas the categorical variables are expressed as numbers (percentages). The paired t test was used to compare preoperative and postoperative anthropometric measurements. The χ2 test or Fisher exact test was used for categorical variables. All statistical analyses were performed with SPSS statistical software, version 17.0 (SPSS Inc). All P values were 2-sided, with the level of significance set at <.05.
A total of 41 patients were enrolled in this study. The mean (SD) age of the patients was 36.5 (12.6) years (range, 21-62 years), 16 were men, and 25 were women. All patients were undergoing revision rhinoplasty. The patients had undergone a mean of 1.8 previous rhinoplasties. The mean duration of follow-up was 14.6 months (range, 5-34 months). Many kinds of materials served as dorsal grafts in the previous rhinoplasty, including silicone, expanded polytetrafluoroethylene, fascia, costal cartilage, and fascia with crushed or costal cartilage (Table 1).
With regard to the septal reconstruction grafts, autologous costal cartilage served as the graft in 22 cases, homologous costal cartilage in 6 cases, septal cartilage in 1 case, and conchal cartilages in 1 case. In septal reconstruction, the types A through D methods were used in 9, 1, 20, and 3 cases, respectively (Table 1). Various techniques were used for nasal tip surgery, including multilayer tip grafts, shield grafts, onlay grafts, and columellar strut. With regard to the lateral compartment grafts, lateral crural strut graft or lateral crural onlay graft alone or both together or either graft combined with composite conchal cartilage graft were used. In terms of dorsal augmentation material, homologous costal cartilage or autologous costal cartilage was mostly used, followed by expanded polytetrafluoroethylene and fascia (eTable 1 in the Supplement).
The most common complication was postoperative infection, followed by impaired healing of the transcolumellar incision that resulted in scar or wound disruption (Figure 4), nostril asymmetry, pollybeak deformity, dorsal irregularity, and costal cartilage warping (Table 2). In all 5 cases with postoperative wound problems (infection or impaired healing of the transcolumellar incision), silicone had been used as the dorsal augmentation graft in the previous surgery (P = .05). Revision surgery was performed in 6 patients with complications. Two patients underwent secondary tip surgery (endonasal tip grafting) to further lengthen the nose. In 1 patient, a deflected costal cartilage dorsal implant was removed and replaced with expanded polytetrafluoroethylene. In 1 patient, a subnasale flap was used to reconstruct the skin defect at the transcolumellar incision site. Revision surgery to correct persisting nostril notching was conducted in 2 patients.
Analysis of the anthropometric measurements revealed that there were statistically significant differences between the preoperative and postoperative values in relation to nasal length (P < .001), NTP (P < .001), NFA (P = .04), NLA (P < .001), and CLA (P < .001) (Table 3). Compared with the preoperative measurements, the postoperative nasal lengths were a mean of 12.0% longer, and the postoperative NTPs were a mean of 13.4% longer. The NTP ratio, as measured by the Goode method,4 increased from 0.495 to 0.502, but this change did not achieve statistical significance. The mean total aesthetic outcome score at the last follow-up visit was 8.81 (range, 5.00-10.25). Only 4 of the 41 patients had an aesthetic outcome score of 6 or less. Therefore, the mean score of each view was 2.94 (8.81 divided by 3), which means the outcome was nearly good.
There are 3 primary features of short nose: (1) decreased distance from the nasion to the tip-defining point, (2) a low ratio of tip projection to nasal length, and (3) an obtuse NLA. Other features that are also sometimes found in short nose cases include concavity of the nasal dorsum, an overrotated tip, increased nostril display, and a low or deep radix.1- 3
Postoperative short nose in Asian patients is associated most commonly with prior silicone implantation,4- 6 which was also observed in the present study. It is believed that silicone implantation can result in the formation of a capsule around the implant in situ, thus resulting in short nose. Short nose may also arise as a sequela of progressive scar contracture after implant removal.4,5 Moreover, silicone implantation often has long-term effects in terms of injuring the nasal cartilaginous and bony framework and causing its resorption.4,5 The present study also found that all the patients who exhibited wound-healing problems after revision surgery had previously undergone silicone implantation. This finding may be because the SSTE of noses that have undergone silicone implantation exhibit substantial loss of normal elasticity, which makes it extremely difficult to redrape the surgically lengthened nasal skeleton. Another interesting finding of the present study was that the primary rhinoplasty in many of the cases involved dorsal augmentation using fascia with or without cartilage as the materials. It is known that, over time, fascia with or without cartilage on the nasal dorsum is resorbed and replaced by the host’s own fibrous tissue.24 This tissue reaction may also be a cause of contraction of the overlying SSTE. This finding further supports the notion that a key cause of postoperative short nose pathogenesis is fibrous tissue buildup under the SSTE.
Soft-tissue release relies on the stretchability of the SSTE and is always an important procedure when lengthening the nose.15 Contraction of the SSTE may cause the lengthened nose to lose its intraoperative length. Poor SSTE condition and possible scar problems mean that it is often more difficult to correct short nose in revision cases than in primary cases.15 This difficulty may partly explain why the increases in nasal length and NTP achieved by revision surgery in the present study were limited.
In terms of framework reconstruction, various surgical options have been proposed to increase the nasal length. Most focus on the middle and lower one-third of the nose.2 In cases of minimal nasal shortening, radix, tip, and columellar onlay grafts can increase nasal length.2,25- 27 To lengthen the nose in cases of moderate and severe nasal shortening, various autologous grafts can be used to generate a graft with the desired shape and length that can then be anchored to the existing nasal framework.1- 3,8,13,14,17,28 For septal reconstruction in the present study, 4 different surgical techniques were used (Figure 1). The type C method is derived from the tongue-and-groove technique outline by Guyuron and Varghai8 in which septal cartilage is harvested and shaped into 2 extended spreader grafts and 1 columellar strut. The columellar strut is then placed between the medial crura in continuity with the caudal septum, and all the grafts are sutured to the septum to elongate the nose.8 In the present study, approximately 50% of cases underwent type C septal reconstructions. However, in all but 2 of these cases, costal cartilages (not septal cartilage) served as grafts. The different cartilage graft use in our cohort related to the fact that most of our cases were in Asian patients with postoperative short nose. In these patients, the septal cartilages were weak and insufficient and not strong enough for septal reconstruction.
For septal reconstruction in a short nose, costal cartilage is the preferred choice of graft material for 2 reasons. First, it is stronger than septal or conchal cartilage and thus provides rigid support that resists the forces of scar contracture of the SSTE during the healing process. Second, unlike septal or conchal cartilage, it provides sufficient cartilage for not only septal reconstruction but also dorsal and tip augmentation. As indicated in Table 1, costal cartilage was the preferred material for septal construction in the present study. In 6 cases using homologous costal cartilage, we did not find obvious resorption of the homografts with subsequent loss of nasal length, and no infection was noted postoperatively. The reason for choosing homologous costal cartilage in these 6 patients was that they did not want to use autologous costal cartilage for their grafts because of morbidity related to costal cartilage harvesting. Some patients who underwent septal construction with autologous costal cartilage developed wound healing problems postoperatively. Therefore, patients should be informed of the possibility of postoperative wound infection or impaired wound healing if they are to undergo septal reconstruction with a costal cartilage graft.
We designed a cartilage flap technique for 8 patients with severe scarring and fibrosis of the SSTE. Thus, a medially based cartilage flap from the lower lateral cartilage was designed to cover the newly reconstructed caudal septum.29 This method is particularly suitable for Asian patients with thick tip skin and relatively well-developed lower lateral cartilage. Complications, such as excessive narrowing of the tip and tip asymmetry, may occur.29
Dorsal augmentation is an important procedure in short nose correction, especially in patients with concave dorsum. After addressing concave dorsum in short noses, nasal length usually appears improved.29 However, in revision cases, the limited ability to stretch the SSTE may impede sufficient augmentation. Therefore, depending on the condition of the SSTE, it is essential to select an appropriately sized dorsal augmentation graft and to follow this by tension-free closure of the transcolumellar incision because this will help to prevent possible complications, such as nasal tip skin necrosis.29 For patients who needed septal reconstruction and dorsal augmentation, autologous or homologous costal cartilages were used. For patients who needed only dorsal augmentation without septal reconstruction, expanded polytetrafluoroethylene, fascia, or crushed cartilage was used as dorsal augmentation graft. If the previous implant was silicone, we used fascia with or without cartilage as the dorsal implant. If the previous implant was fascia, expanded polytetrafluoroethylene was chosen as the dorsal implant. The reason for the use of costal cartilage and expanded polytetrafluoroethylene in 6 cases was because the harvested costal cartilage was not enough for dorsal augmentation in some cases, or we intended to reduce the costal cartilage implant visibility by covering with expanded polytetrafluoroethylene.
Because deprojection and overrotation of the nasal tip are common findings in short nose, tip surgery plays an important role in correcting this deformity.29 Approximately 60% (24) of the cases in the present study required tip surgery, and multilayer tip grafting was the most commonly used technique. This technique is a flexible approach because the surgeon can adjust the number of tip grafts according to the condition of the individual. This method has been proven to be effective for aesthetic tip refinement and nasal lengthening in the noses of Asians.21,30
Short nose is a complicated deformity that usually requires more than one kind of surgical technique. Solid septal foundation and adequate SSTE undermining are crucial for achieving aesthetic results. In the present study, various surgical techniques that ranged from septal reconstruction to tip surgery were applied in a tailored fashion according to the nasal profile of each patient. Aesthetic outcome assessment revealed that more than 90% of the cases had either good or excellent aesthetic results at the last follow-up visit (Figure 5 and eFigure 1 in the Supplement). This finding suggests that our methods were generally effective for correcting postoperative short nose. However, we did not have a patient satisfaction measurement, which is a limitation of this study.
Postoperative complication is not uncommon in revision rhinoplasty for short nose correction. In the present study, 11 patients developed postoperative complications. The most common complication was wound problems, including infection and impaired wound healing. Previous silicone implantation was found to be a marked risk factor for this complication. Of the patients with complications, 6 had to undergo revision surgery again. Therefore, it is important to inform the patients about such possible complications and to give them a realistic expectation of the outcomes before performing this kind of surgery.
Postoperative short nose deformities are mostly caused by silicone-related capsule contracture or fascia-related absorption, and various surgical techniques are usually required to achieve the desired aesthetic result. Possible complications are not infrequent, and patients should be informed about complications before surgery.
Accepted for Publication: April 25, 2015.
Corresponding Author: Yong Ju Jang, MD, PhD, Department of Otolaryngology, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-ro 43-gil, Songpagu, Seoul 138-736, South Korea (firstname.lastname@example.org).
Published Online: June 25, 2015. doi:10.1001/jamafacial.2015.0645.
Author Contributions: Drs Lan and Jang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Jang.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Lan.
Critical revision of the manuscript for important intellectual content: Jang.
Statistical analysis: Lan.
Administrative, technical, or material support: Jang.
Study supervision: Jang.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Ho Chan Kim, MD, and Joon Pyo Park, MD (Asan Medical Center, Seoul, South Korea), and Cheng Chieh Hsu, MD, and Ting Shuo Chang, MD (Taipei Veterans General Hospital, Taipei, Taiwan), who provided aesthetic outcome assessment. No financial compensation was provided for their contributions.