Autologous (One’s own tissue) Rhinoplasty

The nose is an extremely pivotal component of the face. The nose projects the most outwardly relative to the rest of the face, and is essentially responsible for creating the overall facial profile. In Asian patients specifically, the nose is vital to the overall aesthetics of the face for several reasons. Eastern Asian and Korean faces are generally wider in comparison to the lateral length of the eyes. The nasal bridge is also relatively shallow, making the face appear wider than it already is. And lastly, an underdeveloped middle portion of the face creates flatness, which is only further emphasized by a protruding mouth. A shapelier nose is able to remedy this overall unbalance of the facial structure, bringing evenness, and therefore beauty, to the entire face.

Korean Asian rhinoplasty, commonly known as a “nose job,” involves the restructuring of the nose, particularly between the nasal tip and bridge. The procedures generally enlarge the nose first, in an effort to balance the width of the face, and complement the distance between the eyes while lengthening the comparatively short Asian nose. The more detailed and technically complicated procedures add definition and shape to the nasal tip, which is the most crucial part of the nose. Korean rhinoplasty is often performed not only to produce an aesthetically pleasing nose, but also to improve the nose functionality.

Typically, it is recommended that Asian patients get a nose that is defined but not too sharp at the tip. This helps to the natural ethnic appearance. In Asian patients, the size and shape of the nasal tip – along with its relation to the nasal bridge – comprises the definition of a beautiful nose. Thus, it is crucial for patients to understand all of the options available before choosing to undergo the operation. Rhinoplasty surgery is so influential among Asian patients that it has become the second most common form of plastic surgery performed next to double eyelid surgery.

There are three factors to consider when performing rhinoplasty.
1.Aesthetics – The ideal nose For both men and women, there are general standards for the dimensions of a nose that will add to the overall aesthetic of a person’s face. In both men and women, the inter-alar distance (i.e., the distance between the outer edge of one nostril to the other) should be 1/5th of the size of the face and equal to the distance between the inner corners of the eye. Additionally, the nasal length should be 1/3rd the facial length while the nasal tip’s height should be 1/3rd the nasal length. Aside from the general standards, there are separate standards for men and women when it comes to an aesthetically pleasing nose. For men, a sharper and straighter nasal tip give a more masculine look. Thus, a masculine nose has a straight tip at a 95-105 degree angle; a nasal bridge that has a very straight edge or a very slight hump; and a columella (area below the tip of the nose and located directly between the nostrils) that is only slightly viewable from a profile view. For women, a slightly softer and upward tilted nasal tip is considered feminine. Thus, a feminine nose has a natural curve at the lower forehead (below the brows), a straight nasal bridge, and a slightly upward tilted tip at a 105-110 degree angle. The purpose of Asian aesthetic surgery is not to replicate the look of any other ethnicity on Asian patients; the purpose is to enhance the features that patients already have. In other words, what appears suitable to one patient may not be as suitable to another. It is extremely important to consider the relative facial attributes in order to achieve the “ideal” nose for each patient.

2.Biomechanics – Unique aspects of Asian rhinoplasty is that it is essentially an augmentation rhinoplasty. The process of augmentation involves a release of retraining ligaments of the patient’s cartilages and then supporting the released cartilage in the desired position. Because there is a limit to how much one’s own cartilages can move to the desired position, the nose is further augmented with cartilage grafts taken from the rib or ear cartilages. However, once expansion and augmentation have occurred, the nose is subjected to counter-acting, opposite, downward force from the nasal skin envelope. This counter force occurs not only intraoperatively but constantly after surgery. Therefore, the plastic surgeon must have detailed understanding of biomechanics and the principle of tension. If tension is significant, then the shape of the nose, especially the tip will descend. And if the tip is held up too rigidly like at tent pole, then the downward pressure from the nasal skin envelope will cause thinning of the nasal tip skin. Therefore, augmentation rhinoplasty is a fine balance between expansive force vs. contracting force.

3.Biomaterial – The next concept to discuss is the material to be used for augmentation, especially the dorsum / bridge ofthe nose. Traditionally, silicone has been widely used but silicone can induce unwanted negative effects. These potential effects of the silicone or any foreign materials are a deviation, mobility of the graft, silhouette effect, thinning of the nasal skin, infection, extrusion, shortening and upward turn of the nose over time. And if the silicone implant is placed over decades, then the scar tissue that surrounds the implant becomes gritty and harder due to crystallization. Crystallization or hardening of the implant occurs because the silicone has a negative charge. And this negative charge attracts the positive charge of calcium in our blood stream. As the calcium deposits to the silicone over time, the bridge becomes gritty and loses the smoothness effect.

Therefore, the ideal material is one’s own tissue. Often, rib cartilage is recommended because of excess amount that is available and the versatility in its use. The 6th and / or 7th rib are often used. The incision is made just under the breast crease to hide the incision. Typically, rib cartilage harvesting has the potential complication for pneumothorax (entering into the lung space). However, our method leaves the posterior rib cartilage intact. Therefore, the chance of pneumothorax is significantly decreased. Our review of 1000 rib cartilage rhinoplasty cases performed had no incidences of pneumothorax. Furthermore, we have refined the technique of rib harvesting to the point where the procedure is done under local anesthesia.

Rib cartilage when used as a carved block of tissue, can lead to warping. Warping is deviation or curving of the cartilage and this can happen as part of the cartilage is resorbed (absorbed) by one’s body. The principle of autologous grafting is that all tissues are partially absorbed by one’s body. Even though cartilage has one of the lowest resorption rates, it still partially resorbs. So when carved rib cartilage is used as a tent pole to support the base of the nose for the nasal tip or the bridge, it can lead to nasal deviation over time. Therefore, the cartilage is diced into fine pieces that are less than 1mm. By breaking up the warping potential of the large cartilage piece, the negative consequence of warping is eliminated. And our method of dicing is so detailed and fine that warping material from the scalp / head is not required.

In patients where their dorsal skin is thin, then we would apply dermis from one’s back skin. This skin is contoured and shaped to augment the bridge in these selective patients. One significant advantage of the dermal graft is that it is extremely resistant to infection and also help combat infection in patients who have an active infection from silicone implants.

Short Nose Correction

We specialize in correction of short noses with a use of autologous tissue (one’s own tissue). As mentioned above, short nose correction involved combining the three aspects of Asian aesthetics, three- dimensional biomechanics, and effects of biomaterials. Dr. Kenneth Kim has studied with surgeons both in America and Korea regarding this particular field. He has published peer-reviewed journals regarding topics relating to short nose correction, nasal skin envelope, and tension affecting revision rhinoplasty.

Dr. Kim has also studied the effects of tension at the molecular level as a Howard Hughes Fellow. In addition, Dr. Kim spent a year studying biomechanics at Switzerland and UC Davis as an AO Fellow. Dr. Kim continues to collaborate with plastic surgeons in Korea to further improve the field of Asian rhinoplasty.

Revision rhinoplasty

As rhinoplasty has become the second most commonly performed cosmetic procedure among Asians, revision rhinoplasty has also become relatively common. Some of the common reasons for revision rhinoplasty is a correction of the short nose, inadequate tip projection, correction of deviated nose from silicone implant, and treatment of nasal infection. Patients who require revision rhinoplasty often have tight and thinned out nasal skin envelope. Therefore, the nasal skin envelope needs to be adequately expanded first. The prior implant or graft is removed and the internal cartilages are reconstructed if damaged. An autologous (one’s own) tissue is placed to augment the nose and reshape it. Our philosophy is that rhinoplasty should be done with one’s own tissue to eliminate any potential negative effects of foreign materials on the nose that can change the shape of the nose throughout one’s life.