Background  Bulbous nasal tips and lower dorsa are common facial features in Chinese people, and surgery to reshape these is frequently requested. The use of silicone implants in rhinoplasty has been widely used in China for many years, but is not suitable for patients seeking Caucasian tip shapes. The creation of an excessively high tip supported only by a silicone implant inevitably leads to implant extrusion. Although many rhinoplasty techniques have been used in Caucasian patients, there is currently no suitable method for Chinese patients, whose anatomy differs from that of Caucasians. The present study was aimed to investigate the clinical outcome of a novel method of rhinoplasty in Chinese people.
Methods  Eighty patients underwent rhinoplasty using our method between 2002 and 2006. We classified the patients into three types, according to the distance between tip defining points, and used different techniques accordingly. Furthermore, an innovative cartilage carving method and a tip fibro-fatty tissue flap were designed and combined with traditional techniques, such as insertion of silicone implant, cartilage grafts, suture techniques and cephalic trimming to reshape the nasal contours. The followup period was 10–60 months (average, 21 months).
Results  Remarkable modifications in nasal contours were achieved. No complications developed in any of the 80 patients. Seventy-eight patients were satisfied with the results. The outcomes remained unchanged over time.
Conclusion  Our method is effective and suitable for the treatment of Chinese patients with lower dorsa and bulbous nasal tips.

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Increasing numbers of Chinese people are seeking some kind of cosmetic surgery. Rhinoplasty has become popular in China so it is important for plastic surgeons to be skilled in this area. Lower dorsa and bulbous nasal tips are common reasons for seeking aesthetic rhinoplasty in Chinese patients.^1-5 Simple silicone implant insertion is the most frequently used technique for augmentative rhinoplasty. However, this technique can only produce an altered nasal dorsum and tip modifications cannot always be adequately corrected. Several techniques for nasal tip plasty have been reported in Caucasians, including nasal tip grafts, suture techniques and cephalic trimming,^6-8 but there is still no suitable method for dealing with Chinese patients, whose anatomy differs from that of Caucasians.

Subjects
Eighty patients (9 male and 71 female) underwent rhinoplasty between May 2002 and July 2006. The mean age was 26 years (range, 21–36 years). Sixty-one patients were primary cases and 19 patients were secondary cases, who had previously undergone silicone implant insertion but were dissatisfied with the resulting tip contour. All the patients were of Chinese ethnic origin. According to the distance between the tip defining points, we classified the 80 patients into three types: type 1 (12 patients, >6 mm and ≤8 mm); type 2 (36 patients, >8 mm and ≤10 mm); type 3 (32 patients, >10 mm). We further classified the three types into six subtypes according to the thickness of the soft tissue covering the domes and selected different techniques to treat them (Table 1). All surgery was performed by Dr. MA Ji-guang in the Plastic Surgery Hospital of Chinese Peking Union Medical College, Chinese Academy of Medical Sciences. patients were followed up for 10–60 months (average, 21 months).

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Table 1. Surgical techniques and nasal type

Surgical techniques
Local anaesthesia was achieved by infiltration of 0.5% lidocaine mixed with 1:200 000 epinephrine. All patients underwent bilateral infracartilaginous incisions and type 2 and 3 patients underwent transcolumellar incisions. Blunt dissection was continued just above the alar cartilages and below the nasal dorsal fascia. The cephalic segments of the lower alar cartilage were trimmed and at least 5 mm of intact rim strip was preserved. The lateral crura were then freed to move upwards, if there were no other resisting forces and the musculus depressor septi nasi was also usually resected to achieve a retrousse nasal tip, in place of a ptotic tip.⁹ Interdomal and transdomal suturing techniques were then adopted to reshape the alar cartilages, using 5-0 monofilament nylon sutures. An L shaped silicone implant was inserted after carving. The columellae of the implant were carved into a thin, slim shape to produce a smooth transition zone and a natural looking outcome.

To harvest an elliptical piece of conchal cartilage about 20-mm long and 10-mm wide, we firstly scored the convex side at a point 2/5 of the way along its length, to allow the superior part to bend to the concave side, as a tip graft. We then scored the inferior part and reversed the two transparent parts back to the concave side as a columellar strut (Figure 1). Lastly, we placed the graft above the silicone implant with the concave side down and sutured them together using 6-0 monofilament sutures, to prevent displacement (Figure 2).

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Figure 1. Three views of a nose. A: Frontal view. B: Profile view. C: Base view. 1: L shaped silicone implant. 2: Cartilage graft. 3: Cephalic trimming of the lateral crura, 4: Lower lateral cartilage. 5: Interdomal suture.

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Figure 2. Conchal cartilage carving. A: Anterior view. B: Profile view.

For thick skinned patients of types 2 and 3, we designed a tip fibro-fatty tissue flap, instead of the fibro-fatty tissue resection. We marked the preoperative tip range and the desired postoperative tip range. We then dissected the redundant fibro-fatty tissue outside the postoperative tip range and formed a fibro-fatty tissue flap. During this process, skin thickness was preserved. Lastly, we sutured the fibro-fatty tissue to the centre and fixed it to the cartilage graft using 6-0 absorbable sutures (Figure 3).

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Figure 3. A. 1: Tip area. 2: Fibro-fatty tissue flap. 3: Tip defining points. B. 1: The preoperative tip range. 2: The postoperative tip range. 3: Tip fibro-fatty tissue flap. 4: Lower lateral cartilage .

Assessment method
Evaluation was based on comparisons between the results and the preoperative designs and severe complications. We designed a questionnaire to assess each patient's perception of five different aspects of the procedure, with each aspect worth 20 points (total, 100 points). The five aspects were: tip width, tip projection, dorsal contour, naso-frontal angle and columellar lobular angle. We classified the results into four categories according to the scores obtained: (1) excellent: scores for each aspect were ≥17; (2) good: scores for each aspect were ≥14; (3) fair: scores for each aspect were ≥12; (4) poor: scores for one or more aspects were <12. To make the evaluation less subjective, questionnaires were completed by the patients and by the same senior doctor in our department. Mean aspect scores were evaluated and comparisons between pre- and post-operative clinical photographs were used. Evaluations of postoperative results were made at least 2 months postoperatively to avoid the effects of swelling on the results.

No patients were left with abnormal appearances and the scars from the transcolumellar incisions were inconspicuous. No postoperative complications, such as infections, foreign body reactions, extrusions, resorption or displacement were noted. Seventy-eight patients (97.5%) were satisfied with their outcomes (Table 2). Two type 2 patients were dissatisfied: the dorsal height was slightly too high in one case, while the bulbous tip was under corrected in the other case. They underwent corrective operations and were satisfied with their results. Possibly, because of swelling or psychological factors, about 30% of the satisfied patients initially complained of an over projected tip or over high dorsum in the early postoperative period, but all these patients were accustomed to and satisfied with their new nasal shapes 1 month postoperatively.

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Table 2. Postoperative evaluation (n)

Case reports
Case 1
A 29-year-old female with a thin skinned type 2 tip, presented with a low, bulbous nasal tip and a low dorsum. She underwent silicone implant insertion and tip plasty. The nasal shape was improved 11 months postoperatively (Figure 4).

Case 2
A 23-year-old female with a thick skinned type 3 tip, underwent augmentative rhinoplasty with silicone implant insertion at another hospital. She was dissatisfied with her fatty tip and dorsal height and wanted a higher dorsum and a narrower tip. Photographs showed an improved contour 20 months postoperatively (Figure 5).

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Figure 4. Frontal and profile views of case 1. Preoperative views (4A–4C). Eleven months postoperative views (4D–4F). Note the differences in dorsal height and tip contour. Figure 5. Frontal and profile views of case 2. Preoperative views (5A–5C). Twenty months postoperative views (5D–5F). Note the differences in dorsal height and tip contour.

DISCUSSION

Several factors might explain why the nasal tip of Asian people is more bulbous and has less projection than that of Caucasians. (1) There is more fibro-fatty tissue between the paired domes of the lower lateral cartilages and the distance between both tip defining points is therefore greater than in Caucasians.¹⁰ Sun et al¹¹ suggested that an unrecognized extensive fat pad might interfere with tip narrowing and refinement. It might therefore be the cause of persistent post rhinoplasty supratip fullness and excessive tip width. (2) There is no attachment between the medial crus of the lateral cartilages and the caudal septum.¹⁰ (3) Compared with Caucasians, the alar cartilages in Asian are less developed, but are not significantly smaller.^2,12,13 In our opinion, the wider distance between both tip defining points in Asian is the most important reason for the ethnic differences. Numerous articles have reported on the anatomy of the nasal cartilages.^14-16 Rohrich and Adams¹² suggested that the normal distance between both tip defining points was about 5–6 mm, with a distance of more than 6 mm being considered as a bulbous tip and that different degrees of tip width required different surgical techniques.^17-21 We classified 80 patients into three types, according to the different distances between both tip defining points. In addition, thick tip skin is widely considered to be a limiting factor for surgical tip refinement.^12,15 We used more surgical techniques in the patients with thick skinned nasal tips than in those with thin skinned nasal tips, who were otherwise of the same type; for example, the distance between both tip defining points of type 1 patients was small and silicone implant insertion alone was adequate in patients with thin skinned tips, but in patients with thick skinned tips, conchal cartilage grafts were also used.

The traditional classification method⁶ is based on the width of the dome arch and the intercrural angle of divergence. Using this method, the lower lateral cartilages need to be completely exposed during surgery to evaluate the degree of malformation. Although this method is more precise, it is therefore unsuitable for preoperative classification. Our classification method is based on the distance between both tip defining points, which can be measured easily and provides a means of preoperatively evaluating the degree of difference. The skin thickness can also be evaluated by inspection and palpation. Our classification method is therefore useful in aiding surgeons to choose the appropriate surgical techniques, so allowing them to explain the details of the procedure to patients preoperatively.

Cartilage tip grafts have become more popular in recent years. This grafting technique can increase the height of a low tip and the length of a short tip, increase the strength for support as a columellar strut and decrease the risk of extrusion by protecting the silicone implant. Among the various shapes of cartilage tip grafts, the shield-like graft²² and layer cartilage graft⁶ are the most popular. The shield-like graft provides a good intercrural strut for support, but the resulting tip contour is less natural looking and the height may not be adequate in some cases. The layer graft creates a more projecting and natural looking tip, but it cannot provide an intercrural strut for support. Our particular cartilage carving method has two merits. Firstly, after insertion of a silicone implant, it can further improve tip projection and decrease the risk of extrusion. Secondly, this method combines the merits of shield-like and layer cartilage grafts: the inferior part of the graft is similar to the shield like graft and the superior part is similar to the layer graft.

The types of cartilage that can be used for grafting include lower lateral cartilage, conchal cartilage, septal cartilage and rib cartilage.²² We prefer conchal cartilage for three reasons. Firstly, it has an appropriate degree of rigidity that is stronger than that of the lower lateral cartilage, but is less likely than septal cartilage to show an edge, over the long term. Secondly, its convex shape is convenient for reconstructing a natural looking nasal tip. Thirdly, the harvesting can be performed under local anaesthesia and no conspicuous scars or ear deformities are left by harvesting.

A bulbous nasal tip is mainly caused by divergent medial crura, a wide dome arch or both.⁶ We selectively adopted interdomal, or interdomal combined with transdomal suturing to narrow the tip, according to the degree of modification requested. Interdomal suturing reduces the flare of the lateral crura and decreases the distance between both tip defining points. Transdomal suturing decreases the width of the dome arch and gets a small amount of projection from each side dome. When this is done bilaterally, the divergence of both domes is increased and a long suture should therefore be left on each side and tied together, to narrow the distance between the tip defining points until the desired distance is achieved. After this, an interdomal suture is also necessary to achieve a stable nasal tip shape.

Although the alar cartilages in Asians do not develop as well as in Caucasians, type 1 and 2 patients do not require cephalic trimming, while in type 3 patients, whose cartilages are relatively better developed, moderate resection of cephalic portions can be allowed. Cephalic trimming not only reduces the tip fullness but also decreases the distance between the tip defining points. However, at least 5 mm of intact rim strip should be preserved to prevent alar collapse.

We did not resect the redundant fibro-fatty tissue at the tip, as in the usual method;¹¹ we formed a fibro-fatty tissue flap, sutured it to the centre area and fixed it to the graft. We found that this technique narrowed and heightened the tip at the same time, so indirectly reducing the required amount of cartilage. This technique also prevented any unnatural appearance of the graft.

Our method provides a suitable technique for the augmentation of low dorsa and reshaping of bulbous nasal tips in Chinese patients. This new method overcomes the limitations of older methods, while utilizing their merits, in order to obtain nasal contours requested by the patient. Furthermore, our classification method for preoperative evaluation provides a useful guide for choosing the appropriate surgical techniques. After 10–60 month follow-up, most patients were satisfied with their results. Compared with previous techniques, our method has the advantages of simpler manipulation, better outcomes, and fewer complications.

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