Application of Cartilaginous Flap in the Bulbous and Saddle Nose

Abstract

Many oriental patients, both males and females, desire higher nasal bridges, sharper nasal tips, and narrower nostril widths because they perceive that this makes the nose, and hence the face, more refined. For decades, the simplest way to achieve this has been to insert a silastic implant into the nose. This is a 20to 30-min procedure, and for many patients, the result can be quite pleasing and aesthetic. Unfortunately, a high proportion of patients experience complications such as infection, extrusion, warping or deviation of the implant, and the development of shiny, thinned out, overlying skin that looks unnatural. More often, they experience a less than satisfactory aesthetic result because of wrong placement or choice of the implant, or even wrong assessment of the patient because not all oriental noses can be adequately treated by simple implant insertion alone. For thick bulbous tipped noses, for example, simple implant placement can produce a trilobed appearance of the tip, which is made up of the implant tip and the displaced domes of the alar cartilages (more correctly called the tip cartilages [1] or lower lateral cartilages [LLCs]) that lie on either side of the implant tip. The cranial one-half to twothirds of the LLC therefore need to be resected in addition to debulking of the fibrofatty areolar tissue overlying the cartilages and from the interdomal area to produce a smoothly contoured and sharper tip. Overzealous defatting, however, thins out the skin of the tip. Combined with attempts to insert implants, which often are too large for the nasal envelope (in a mistaken attempt to lengthen the nose and make the tip sharper), this is a recipe for tip erosion and extrusion. Silastic implants should never be inserted under undue tension! Similarly, I believe that aggressive thinning of the nasal skin should not be performed. To ‘‘thin’’ out the tip, most surgeons thin the undersurface of the raised skin flap, then excise and discard the fibrofatty areolar tissue over the tip and between the LLCs. This latter tissue is in fact a useful source of interpositional tissue between implant and skin. It also can be used to mold the tip. This article by Lin and colleagues presents a simple technique for reducing the risk of nasal implant erosion and extrusion. By wrapping the tip of Fig. 1. Implant tip extrusion.