Augmentation rhinoplasty using synthetic implants has been a common procedure in Asia for decades. However, unwanted complications occurred unexpectedly, which include early infection, chronic episodic infection, capsular contracture, extrusion, implant malposition, seroma, long-term calcification of the capsule, etc. These complications not only affect aesthetics but also functional outcomes, as they destroy the beautifully built internal framework and soft tissue envelope. Therefore we should try to augment the nasal dorsum with autogenous tissue, avoiding synthetic materials.
Herein, I describe my strategy and prefer techniques for nasal dorsal augmentation, using costal cartilage, regarding soft tissue envelope, degree of augmentation and dissected pocket. Patients with thin to moderate thickness skin and soft tissue envelope(SSE) that need minimal dorsal augmentation, if precise subperiosteal pocket can be made, fine diced cartilage with visible extended spreader grafts is preferred. Patients with thin to moderate SSE that need minimal augmentation, but precise pocket could not be made, diced cartilage wrapped with fascia is preferred. Patients with thin to moderate SSE that need significant augmentation, carved costal cartilage with or without soft tissue augmentation is preferred. Patients with thick SSE, soft tissue thinning and/or scoring follow by carved costal cartilage dorsal onlay graft is usually performed. Patients with scarred SSE, scar removal follow by carved costal cartilage dorsal onlay graft combined with soft tissue graft is usually performed, Patients with very thin SSE, such as impending implant extrusion, inflamed SSE, thin SSE after permanent injectable foreign body removal, dermal graft or dermal fat graft is preferred.
In conclusion, to achieve long-term beautiful nasal dorsum in Asian rhinoplasty, the surgeon should avoid synthetic material, replace like with like tissue, make a precise preoperative planning, understand 3D shape with relationship to the SSE, understand nature of cartilage and its characteristics, and most importantly, understand and respect the patients’ SSE.

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