Rhinoplasty in Asian countries mainly refers to rhinoplasty, which increases the amount of soft tissue through implants and raises the dorsum of the nose. It is one of the most common plastic surgery procedures in Asia, and nowadays rhinoplasty is also performed along with tip shaping to make the nose more refined. In order to match the natural beauty, the purpose of rhinoplasty should be to make the features more three-dimensional and dynamic while also matching the characteristics of Asian faces. Dr. Hong from Korea summarized his years of clinical experience and conducted a review of rhinoplasty for Asians, including the differences between rhinoplasty, hump nose correction, tip reshaping, and restorative rhinoplasty. The findings were published in clinics in plastic sugery in January 2016. Asian nose characteristics The Asian nose has nasal morphology problems such as thick skin, rich subcutaneous tissue, soft and weak cartilage framework, short nasal bones, underdeveloped anterior nasal spine, small septal cartilage, wide and underdeveloped nasal dorsum, low nasal root, spherical nasal tip, lack of tip point and prominence, sagging, or twisting, short nasal column, and wide and flared nasal base. The following characteristics make the surgical operation different: 1. Thick skin can tolerate greater tension after implantation of the prosthesis, and the natural transition with the surrounding skin, but it also leads to imperceptible subtle changes in the nasal cartilage; 2. Because the large wing cartilage and nasal septum cartilage are weak and fragile, simple excision and inter-cartilage sutures do not work, and it is necessary to strengthen cartilage support and implantation of the prosthesis to obtain a satisfactory nasal tip point; 3. Nasal septum cartilage is often used as the material for autologous transplantation, the cartilage is small and the amount of bone is insufficient so that the material has to be replaced separately; 4, the nasal bone is short and wide making it difficult to operate the osteotomy in the nasal entry path, and the osteotomy may lead to nasal fracture collapse. Rhinoplasty The location and height of the nasal root design have ethnic differences. Westerners generally have their nasal root at the level of the upper lid crease, while Asians are at the level of the pupillary line. If the nasal root is required to be moved up, it should also be designed between the upper lid crease and the pupillary line. The height of the nasal root is determined by the size of the nasofrontal angle, with the ideal angle for Asians being 135° (men) and 140° (women). The choice of material for rhinoplasty is the most important aspect of the procedure; the amount of material, dorsal nasal skin thickness, and preoperative cartilage structure are all factors to be considered. Although researchers prefer to use autologous cartilage grafts, given the larger volume of prosthetic material for Asian rhinoplasty, autologous cartilage cannot be accommodated and a dorsal artificial prosthesis – tip autologous prosthesis surgical protocol is usually used. Artificial prosthesis materials (Figure 1) can be classified by material as silicone, tumescent (polytetrafluoroethylene) and Medpor (high-density polyethylene), and it is controversial which is the best. Surgical operation: The cartilage beneath the caudal part of the nasal septum is separated through an incision or, in the case of combined rhinoplasty, the cartilage beneath the medial foot of the nasal cartilage is separated, and then the cartilage membrane and nasal periosteum on the lateral nasal cartilage are separated to the designed position of the nasal root to form a cavity for incorporation of the prosthesis. The size of the cavity should be just suitable for the embedding of the prosthesis, and the nasal shape should be observed after implantation of the prosthesis and further adjusted. Complications and means of prevention: Artificial prosthesis implantation leads to complications, the most common of which are deviation of the prosthesis, infection, bulging, movement, and visible in the skin. The key to prosthesis movement lies in the size of the cavity, with just the right size embedded to reduce the chance of displacement. Small holes are cut in the prosthesis to facilitate suturing to the surrounding tissue and to facilitate the growth of scar fibers into the small holes to hold the prosthesis in place. To prevent infection, the nasal cavity and prosthesis need to be treated with prophylactic antibiotics before surgery. Implantation of the prosthesis under the periosteum prevents displacement of the prosthesis, reduces the visibility of the skin, and reduces the chance of infection. The prosthesis tends to bulge from the tip of the nose. Avoid excessive use of rhinoplasty or the use of artificial prosthesis at the tip of the nose. Treatment of humped nose A common procedure for correction of humped nose is nasal osteotomy, which involves amputation of the overhanging nasal bones to change the open dorsal structure of the nose and restore the dorsum to its normal shape. Compared with Westerners, Asian humped noses have a lower dorsum with a lower nasal root and a smaller, less prominent nasal tip twist. The Asian humped nose is generally less deformed and has problems with the nasal root and tip, so osteotomy should be avoided and rhinoplasty is more appropriate. The nasal bones, nasal dorsal septum and lateral cartilage are removed and extended prostheses are inserted bilaterally in the nasal dorsum to support the nasal suture points to avoid inverted V deformity. For a relatively mild hump nose, a simple narrowing of the dorsal septum cartilage with a bone file can achieve the desired dorsal nasal result. Nasal osteotomy combined with nasal root and dorsal rhinoplasty can adjust the height of the nasal dorsum and disguise the irregular shape of the osteotomy to create a natural transition zone in patients with thin skin. If the designed nasal dorsal height is higher than the height of the hump deformity, it is possible to perform rhinoplasty without dealing with the deformity or directly on it, combined with tip rhinoplasty, which is relatively safe and effective, but the author recommends first hump amputation until the nasal dorsum is smooth and then perform rhinoplasty. Tip rhinoplasty The purpose of tip rhinoplasty is to improve nasal tip prominence, nasal tip pointing, nasal tip point, nasal width and nostril size, and to achieve bilateral symmetry. Generally speaking, most Asians with low nasal dorsum will undergo rhinoplasty, paying attention to the degree of nasal tip protrusion in harmony with the nasal dorsal height. 1.Improve the degree of nasal tip protrusion and pointing The nasal tip shaping is commonly used to increase the support of the nasal tip, so that it can withstand gravity and skin soft tissue tension, and increase the degree of nasal tip protrusion, the prosthetic material can be taken from the nasal septum or rib cartilage. The septum tail must be stable and strong enough to withstand the downward pressure exerted by the skin and soft tissues, and the tip structure must first be stabilized by the nasal column support bar or septal extension prosthesis, which is the key to success or failure. The septal extension prosthesis provides strong support to reposition the nasal cartilage while increasing the degree of prominence and correcting the tip pointing and nasolabial angles. The nasal tip becomes stiffer after septal extension implantation, but will soften over time. This change should be communicated to the patient before surgery to avoid unnecessary disputes. Surgical operation: The septal extension prosthesis should overlap the caudal part of the nasal septum in the median axis or be fixed to the anterior nasal spine by a slatted prosthesis or extension graft (Figure 5). Then the nasal cartilage is sutured and fixed to the prosthesis, such as separation of the lateral and upper edges of the nasal cartilage can reduce the pulling force on the prosthesis downward. 2. Treatment of bulbous nose Bulbous nose is characterized by rounded tip, hypertrophy, lack of nasal tip point, and visual increase in volume, which are closely related to the thickness of skin and subcutaneous tissue, and the characteristics of nasal cartilage, i.e., size, shape, strength, and pointing. Surgical approach: The treatment of nasal cartilage includes different sutures and implantation of prosthesis to change the cartilage pointing, in addition to reducing the volume of nasal cartilage by excision. If the thickness of the skin and subcutaneous tissues is to be treated, the effect can be achieved by deep soft tissues such as fat clipping (Figure 6), but accidental injury to the muscular layer can lead to scar adhesions and contracture of the nasal skin. To deal with low nasal tip need to be combined with nasal dorsal nasal tip elevation to achieve better results, such as nasal tip protrusion need to be combined with lateral foot head excision. Rhinoplasty repair The reasons for carrying out secondary repair surgery are mainly related to artificial prosthesis related to have a greater relationship, such as displacement, bulging, infection and other problems, in addition there is also a short nose after surgery, nasal dorsal distortion, irregularity. 1.Infection of artificial prosthesis can appear immediately or several years later, and usually the prosthesis is taken out. Repair surgery is usually performed after the infection has healed, but during this period the patient’s nasal appearance is damaged and skin contracture may occur making repair surgery difficult, however, it is also suggested that the artificial prosthesis can be removed at the same time for autologous transplantation; 2, short nose is usually related to multiple surgeries and artificial prosthesis materials, such as the formation of cysts around the prosthesis, long-term pressure necrosis of nasal cartilage, chronic inflammation, scar contracture, etc., and progress over time The tip of the nose shrinks to form a skyward nose. By adjusting the nasal cartilage pointing, as well as the use of nasal tip external graft is the key to repair. In addition, extension prosthesis and nasal contour composite prosthesis can be implanted in the nasal vestibule to strengthen the septal extension prosthesis support and thus counteract the skin pressure; 3. nasal dorsal distortion may be related to preoperative deformity, displacement and deformation of the prosthesis, the bone and cartilage structure can be rearranged and combined, or the prosthesis can be covered and filled again to achieve symmetrical effect. The irregular side of the nasal dorsum is commonly seen after hump nose osteotomy, which can be avoided by soft tissue and prosthesis coverage; 4. With the widespread use of nasal septum extension prosthesis in nasal tip shaping, complications have increased, such as excessive nasal tip protrusion, pain, dullness of sensation, asymmetric nasal tip, nasal airway obstruction and other problems. Excessive nasal tip protrusion is mainly due to the use of excessive prosthesis use, which is also the cause of nasal tip tension and pain, and is treated by removing the prosthetic material and reconstructing the normal protrusion of the nasal tip. Displacement of the septal extension prosthesis should be re-fixed with the septal extension prosthesis in the midline position, as well as nasal cartilage reset. In summary, although the main principles and techniques of rhinoplasty abroad are the same as those in China, but due to the differences with anatomy and aesthetics, Asian rhinoplasty has its own characteristics, and improvements to the procedure are necessary so as to achieve a beautiful nose in line with our national characteristics.