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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 675-682

Invasive and noninvasive tip rhinoplasty in a group of Egyptian thick-skinned patients


Department of Plastic and Reconstructive Surgery, Menoufia University Hospital, Menoufia, Egypt

Date of Submission29-Sep-2019
Date of Decision13-Nov-2019
Date of Acceptance23-Nov-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Hanan A Dawoud
Shebin Elkoom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_301_19

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  Abstract 


Objective
The aim was to evaluate the indications, contraindications, and complications of surgical and filler nasal tip rhinoplasty among Egyptians.
Background
Egyptian nasal tip is predominantly characterized by the bulbous tip, thick skin, and weak cartilage with broad lateral crus. Preoperative analysis guides the selection of the suitable operative technique.
Patients and methods
This is a prospective cohort study that was done on 32 patients with nasal tip deformities in the period from December 2017 to September 2019 in Menoufia University Hospital, Egypt. Patients were divided into two groups: invasive (surgery) and noninvasive (filler). Patient data (age, sex, and comorbidities), nasal tip analysis (definition, skin thickness, projection, and rotation), operative techniques, postoperative complications, and follow-up data were recorded.
Results
Surgery group included 21 (65.6%) patients. All cases were operated under general anesthesia in the operating room. Most patients were females (71.4%), with a mean age of 28.05 years. Filler group included 11 (34.4%) patients. All cases were operated under local anesthesia in the outpatient clinic. All patients were females, with a mean age of 30.4 years. Doctor satisfaction was significant among the surgery group (P < 0.05).
Conclusion
The predominant anatomic nature of Egyptian nose (thick skin and weak saucer-shaped cartilage) made surgical techniques more suitable to correct nasal tip deformity and achieve satisfying permanent results.

Keywords: egyptian, filler, nose, surgery, thick skin


How to cite this article:
Keshk TF, Taalab AA, Fergany A, Ghoneim MM, Dawoud HA. Invasive and noninvasive tip rhinoplasty in a group of Egyptian thick-skinned patients. Menoufia Med J 2020;33:675-82

How to cite this URL:
Keshk TF, Taalab AA, Fergany A, Ghoneim MM, Dawoud HA. Invasive and noninvasive tip rhinoplasty in a group of Egyptian thick-skinned patients. Menoufia Med J [serial online] 2020 [cited 2020 Oct 19];33:675-82. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/675/287776




  Introduction Top


Rhinoplasty is one of the most performed cosmetic surgeries. The most popular indications for tip rhinoplasty among Egyptian patients are bulbous nasal tip, inappropriate tip projection, or rotations. The Egyptian nose has specific anatomical and morphological features of ethnic nature. Thick skin, weak cartilages, amorphous nasal structure, and bulbous tip are the unique characteristics of the Egyptian nose that should be appreciated in preoperative analysis, counseling, and choice of the operative techniques[1].

The lower lateral cartilages (LLC) of most Middle Eastern noses are weak and thin relative to thick skin and soft tissue envelope. Lateral crura are usually wide and thin, with no sex difference, whereas the middle and medial crura are insufficient[2].

The middle and lateral crura of LLC orientation and position should be interpreted preoperatively, as they affect nasal tip refinement. According to the severity and causes of the underlying nasal tip deformity, the different surgical techniques will be chosen regarding tip sutures and grafts[3].

Noninvasive nose reshaping have become popular. It includes Botox, threads, and filler [autologous fat and synthetic injectable such as hyaluronic acid (HA)]. They include simple procedures that are done in the outpatient clinic under local anesthesia with high patient satisfaction. Noninvasive rhinoplasty is less financially demanding with less downtime. HA can be injected in the interdomal area, columellar space, and over the nasal spine to manipulate tip definition support and projection correspondingly[4].

The patients who generally tend to show good results are those with mild hump nose, mild nasal deviation, high nasal tip with a flat radix, slight imbalance from surgery, and so forth. Those with severe hump nose, sever nasal deviation, cephalic tip rotation, and the bulbous tip will not achieve good results from filler alone[5].

The aim of this study was to evaluate the indications, advantages, disadvantages, and complications of invasive and noninvasive techniques used to create a refined, aesthetically pleasing nasal tip in Egyptians. The appropriated technique will be chosen based on the degree of nasal tip deformities, the needed modifications, and patient's desires.

Preoperative nasal analysis and the degree of nasal deformity is a necessary step to choose suitable surgical or nonsurgical techniques.


  Patients and Methods Top


This is a prospective cohort study that was conducted in Menoufia University Hospitals, Egypt, between December 2017 and March 2019, after the approval of Menoufia Ethical Committee on the study proposal. Thirty-two patients with nasal tip deformities were included in this study. The primary objective is to perform the most suitable technique to achieve the most pleasing and satisfying results according to the severity of the nasal tip deformity and patient's desires. The patients in the study were divided into two groups: surgery group included 21 patients, and filler group included 11 patients.

Inclusion criteria

Patients with nasal tip deformities were included according to the following criteria:

  1. Primary rhinoplasty
  2. Secondary rhinoplasty
  3. Congenital nasal tip deformities
  4. Post-traumatic nasal tip deformities
  5. The good general condition of the patient
  6. Age range from 14 to 50 years.


Exclusion criteria

The following were the exclusion criteria:

  1. Postburn nasal tip deformity
  2. Age less than 14 years and more than 50 years
  3. The poor general condition of the patient.


The patients were selected from the university outpatient clinic who complained of nasal tips deformity and sought tip rhinoplasty. We reached the sample size by selecting the appropriate patients from the clinic in the determined period of the study. The used technique was selected based on the severity of the tip deformity and patient's desires. The patients were selected by the main author who obtained the consent for the operation and photography (preoperative and postoperative photos) before the procedure from each case separately. The results were evaluated by the doctor and also included patient satisfaction and complications.

All the patients were subjected to full history taking, external and internal nasal examination, and preoperative and postoperative photographs taking in six standard views: frontal, lateral, oblique, and basal.

Invasive surgery group

This group included 21 (65.6%) patients. All cases were operated under general anesthesia in the operating room. All cases were done in a well-equipped operation room with a good light source and antiseptic measures. Supine and centralized position of the patient with head up was maintained. Scrubbing of nose and face with betadine solution was done. Infiltration of the nose with vasoconstriction agent (Adrenaline 1/200 000, Healthcare Logistics, Mangere, Manukau city 2022, Newzland) was done. Infracartilaginous incision in closed rhinoplasty, as well as transcolumellar incision in open rhinoplasty was done. Supraperichondrial and subperiosteal dissections were done. Graft harvesting and preparation was done, followed by insertion of the graft and fixation in place, then tip sutures were done, and then closure with insertion of nasal pack was done [Figure 1].
Figure 1: Intraoperative details of the surgery group (a) transcolumellar incision of the open technique; (b) exposure of the LLCs and septum; (c) cephalic trim of the lateral crus; (d) extended columellar strut; (e) wound closure; (f) taping the nose.

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Cephalic and caudal trim of the lateral crura of the lower lateral cartilages

Cephalic trim of the lateral crura was done leaving at least 6 mm of the cartilage in each side. Columellar strutwas carved and placed in a pocket between the medial crura. It was sutured with 5-0 prolene sutures. It was used to increase tip projection and support. Regarding tip sutures (mattress sutures), transdermal sutures were achieved between the domes in both sides to decrease the domal divergence angle and increase tip definition. The medial crural caudal septal suture was done to improve the cephalic rotation of the tip.

Tip grafts

Shield graft (sheen graft) with beveled edge was placed adjacent to the caudal margins of the middle crura anteriorly and extended over the nasal tip. It was sutured with 5-0 proline sutures. Onlay tip graft, pentagon or hexagon in shape, with beveled edges, was situated horizontally over the domes and sutured with 5-0 proline sutures to camouflage irregularities and enhance tip projection. Extended columellar strut was placed between the medial crura and extended between the domes above the tip defining points to add more projection to the tip.

Closure and dressing

The nasal skin was redraped, and the transcolumellar incision was closed with 6/0 proline sutures. The marginal incision was closed using 4/0 vicryl stitches. Transfixation suture with 4-0 proline at the junction of dorsal aesthetic lines and tip defining points was done. Vaseline gauze was used for nasal packing to decrease hematoma and swelling and was removed after 48 h. Taping the nose with steristrips was done. Overlapping strips were applied, across the dorsum of the nose, including the supratip area. Nasal splint for 2 weeks was applied. A splint of plaster of Paris was used over the nasal dorsum only. Dressing with mustache extension was applied to catch any nasal discharge. Postoperative follow-up was done. There were no serious complications apart from columellar skin necrosis, which was managed conservatively, and head with a visible scar in one patient, whereas long postoperative edema for 2 weeks was observed in most patients (66.6%). However, overall good patient satisfaction was seen and was higher than the filler group.

Noninvasive group (filler)

This group included 11 (34.4%) patients. All cases were operated under local anesthesia in a special room in the outpatient clinic. Application of local anesthetic ointment was done for 30–45 min, followed by nasal scrubbing and marking of the nasal midline and the areas to be injected. First, making entry point was done with a sharp needle, and then injection was completed via a small blunt cannula (27 G) using the threading technique with aspiration before injection. The used filler is HA light for the tip and columellar space, whereas for the nasal spine injection, we used medium HA. The product of choice was Restylane (Q-Med, Uppsala, Sweden), a high-G' product (512 Pa) with HA concentration of 20 mg/ml. Nasal spine injection (supraperiosteal) was done first to increase the nasolabial angle and provide support to the tip: 0.3+ or –0.2 ml of HA was injected with a blunt cannula. Columellar space injection with 0.2+–0.1 cm3 HA was done to increase nasal tip support while compressing the membranous septum with the other hand fingers. Injection of the interdomal area (deep dermal) was done last to decrease the angle of divergence and increase tip projection with 0.2+ or –1 ml of HA in the subsuperficial musculoaponeurotic system level in the midline. Molding was done after injection of each area. It was mandatory to inject depressor septi nasi muscle with Botox (average 0.3 ml) to avoid the tip ptosis with smiling in patients with dynamic tip. Application of ice packs for 20 min was done. No dressings were needed. Follow-up was done after 2 weeks for retouch if needed.

Statistical analysis

Data were collected, tabulated, statistically analyzed using an IBM personal computer with Statistical Package for the Social Sciences version 20 (2011; IBM Corporations, Armonk, New York, USA) and Epi Info 2000 programs (CDC Atlanta City, Georgia State, USA). We use Fisher's exact test in our descriptive analysis between surgery and filler group. P value less than 0.05 was significant.


  Results Top


Invasive surgery group I

This group included 21 (65.6%) patients. All cases were operated under general anesthesia in the operating room. Most patients were females (71.4%), with a mean age of 28.05 years. Indication for surgery involved post cleft nasal deformity, post-traumatic, and anesthetic causes [Table 1]. Bulbous nasal tip, tip asymmetry, thick skin, and caudal tip rotation were the most frequent preoperative analysis measures [Figure 2] and [Table 2]).
Table 1: Sociodemographic data of the participants in relation to the type of operation (n=32)

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Figure 2: (a) Preoperative frontal view of a case with bulbous nasal tip and thick skin; (b) postoperative frontal view shows the transfixion stitch; (c) preoperative lateral view shows mild dorsal hump; (d) postoperative lateral view shows the transfixion stitch and correction of the dorsal hump with a cephalic rotation of the tip.

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Table 2: Preoperative in the participant in relation to the type of operation (N=32)

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Noninvasive group II

This group included 11 (34.4%) patients. All cases were operated under local anesthesia in the outpatient clinic. All patients were females, with a mean age of 30.4 years, and all patients did filler for primary aesthetic causes [Table 1]. Tip under projection and under rotation were the most frequent preoperative analysis [Figure 3] and [Figure 4] and [Table 2]).
Figure 3: (a) Preoperative frontal view of a case of ill-defined under-rotated nasal tip; (b) postoperative frontal view shows tip definition with filler; (c) preoperative lateral view; (d) postoperative lateral view shows correction of the dorsal hump with a cephalic rotation of the tip.

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Figure 4: (a) Preoperative frontal view of a case of bulbous, slightly under-rotated nasal tip; (b) postoperative frontal view shows well-defined tip; (c) preoperative lateral view; (d) postoperative lateral view shows cephalic rotation of the tip.

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Patient and surgeon satisfaction

There is a significant relationship between patient and doctor satisfaction and the used technique, with high satisfaction among surgery group. This may be related to the predominant anatomical features of the Egyptian nose [Table 3].
Table 3: Patient and doctor satisfaction among participants in both groups (N=32)

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  Discussion Top


Rhinoplasty is a common cosmetic surgery. Nasal tip is an intricate anatomical structure that requires a deep understanding of its dynamics to achieve the appropriate tip rotation, projection, and definition.

The preoperative nasal analysis must respect the mixed ethnic nature of the Egyptian nose. The predominant feature of the Egyptian nasal tip is thick skin, weak cartilage, and bulbous appearance. Regarding the anatomical analysis, 70% of our patients had moderate to severe tip deformities, which is related to the predominate anatomy of their nose, and they were candidates for surgery. This agrees with Pontius et al.[6] and Chin and Uppal[7]. Rowe-Jones[3] mentioned that LLC contour, position, and orientation is a cornerstone in nasal tip refinement, which requires major modifications and reconstruction.

Our study included 32 patients who underwent tip rhinoplasty either by surgery or filler. Preoperative patient counseling, nasal analysis, and patient desires determined the selected techniques. Patients with minor tip defects who desired minor and rapid change without surgery were the candidates for filler rhinoplasty (group II) and comprised 11 patients. However, patients with severe nasal tip deformities that cannot be corrected with filler underwent surgical rhinoplasty (group II) and comprised 21 patients. Most patients in both groups were females (71% of patients were females in group I and all patients in group II were females).

In our study, all patients who underwent filler rhinoplasty had minor degrees of nasal tip deformities (thick skin 54.5%, tip asymmetry 0%, bulbous tip 0%, over projection 0%, under projection 0%, cephalic rotation 0%, and caudal rotation 81.8%). The procedures were done under local anesthesia in the outpatient clinic. Moreover, Hirsch et al.[8] used topical aesthesia for nasal filler injection, but also they used maxillary block technique in patients who could not tolerate the pain.

Our results showed that all the indications in group II were aesthetic (100%), with no functional demands; however, Nyte[9] used filler rhinoplasty for treatment of the internal nasal valve. He treated internal nasal valve collapse with filler injection at the apex of the value to work as a spreader graft. Kontis[10] used filler for revision rhinoplasty to camouflage surface irregularities and tip improvement. In our study, any patients who had history of previous nasal surgery were excluded from group II for indications of fibrosis and the altered vasculature of the nasal tip, which increase the risk of the intravascular injection.

In group I, all patients with postcleft lip nasal deformity (19%) and post-traumatic and secondary cases (14.4) were candidates for surgery, in addition to cases with pure aesthetic indications (66.6%). These patients were selected to the surgery group because their nasal tip deformities were moderate to severe, and these deformities could not be addressed with filler injection. The preoperative analysis of group I included thick skin (66.7%), tip asymmetry (in postcleft lip cases) (19%), bulbous tip (66.7%), overprojection (9.5%), underprojection (28.6%), cephalic rotation (0%), and caudal rotation (71.4%). A study was done by Hodges et al.[11] on Egyptian patients and showed that bulbous nasal tip was the most common nasal tip deformity among patients in the study. This may be related to the predominant anatomical features of the Egyptian nasal tip.

In group I, for surgical management of bulbous nasal tip, we did interdomal fat excision in 66.6% of patients who had recognized interdomal fat that contributed to tip enlargement, interdomal and transdomal sutures in 100% of the patients to decrease the interdomal area and to improve tip definition, and cephalic with or without caudal trim of the lateral crus in 76.2% to decrease the size of the lateral crus and reposition it. However, Hodges et al.[11] used only sutures and some aggressive techniques such as dome division and cartilage transection to correct bulbous nasal tip. In our study, we did not use such aggressive techniques owing to the weak nature of the nasal cartilage of the Egyptian nose. Bulbous nasal tip was not an indication for filler rhinoplasty, as it is hard to be corrected with filler because it is already augmented and needs surgical reduction. Filler has limited indications for big noses. The study by Moon[5] recorded that upturned nose and bulbous nasal tip showed poor results with filler alone. Moreover, Adamson et al.[12] stated that filler could not achieve precise correction in severe nasal deformities.

Regarding the types of tip grafts used in group I, Sheen was used in 23.8%, cap in 47.6%, extended columellar strut in 28.6%, and columellar strut in 100% to adjust nasal tip support projection and rotation. Moreover, cephalic trimming of the lateral crus of the LLC was done in 76.2% of patients. It was mandatory to reduce the characteristic large saucer-shaped lateral crus of the Egyptian nose that contribute to the bulbous nature of their nasal tip and achieve adequate cephalic tip rotation, as mentioned by El-Shaarawy[1]. Ghareeb et al.[13] who did his study on middle eastern and Egyptians, preferred lateral, cephalic, and caudal resection of the LLC to achieve appropriate cephalic tip rotation in patients with broad lateral crus.

Our results showed that interdomal fat pad was recognized and excised in 66.6% of patients of group I, for correction of the bulbous nasal tip. The excess interdomal fat pad was proven to cause bulbous tip by the anatomical study done by Coskun et al.[14].

Underprojection and caudal rotation of the nasal tip were mutual indications between filler (81.8%) and surgery (28.6 and 28.6%, respectively) techniques. However, only minor degrees of deformities were chosen to do filler rhinoplasty. In contrast, nasal tip overprojection (9.2%) was an indication for surgery as it cannot be addressed with filler as mentioned by Moon[5].

Regarding the surgical approach, 76.2% of the patients underwent nasal tip surgery via open approach (severe tip deformities and postcleft lip nasal deformities). It allows better visualization and manipulation of the nasal framework and gives the surgeon the change to modify his plane according to the intraoperative analysis. However, columellar strut (100%) was mandatory for adequate nasal support owing to the weak nature of the nasal cartilage and thick skin of most of the Egyptian nose as reported by El-Shaarawy[1]. This is in contrast to Hodges et al.[11] who preferred the endonasal approach for tip rhinoplasty because it is less destructive.

The columellar strut was placed between the two medial crura. The septal cartilage was the source in 66.6% of cases, whereas costal cartilages were used in the post cleft lip and secondary rhinoplasty cases (19 and 14.4%, respectively) in which the septal cartilage was harvested previously or a large amount of the cartilage was required. However, Hodges et al.[11] used only cartilage harvested from the septum as they did their study on primary cases that had septal cartilage as a good source for cartilage.

For improvement of tip definition and projection, we used sheen graft in 23.8% of patients, onlay graft in 47.6% of patients (also to cover LLC irregularities), and extended columellar strut in 28.6% of patients to add more projection to the tip of the nose. Hodges et al.[11] used only tip graft in 14%, plumping and caudal extension grafts for 10% each, and sheen graft for only 8% of patients.

We used tip transfixion stitch at the end of the operation after wound closure. It is a full-thickness stitch at the meeting point of the dorsal aesthetic lines and tip definition. It has a useful role in lessening the dead space and postoperative edema as mentioned by Ghareeb et al.[13] to overcome the strong memory of the nasal tip skin and help redrape the thick skin over the manipulated cartilages.

In group I, in the early postoperative period, one (4.8%) patient complained of superficial necrosis of the trans-columellar wound. It was caused most probably by wound closure under tension; the cloumellar incision was designed as a V shape in a postcleft lip rhinoplasty female patient. It was managed conservatively with slightly visible scar. This is in accordance with Rettinger[15], who experienced 6% of cases with a visible scar after tip rhinoplasty.

Approximately 66.7% of patients in group I complained of postoperative edema related to thick skin, which gradually subsided over 3 weeks. It is related to thick skin bulbous nasal tip of the Egyptian nose. However, we used tip transfixion stitch to lessen postoperative tip edema and nasal tape. We did not experience any functional problems, suture protrusion, septal perforation, or tip asymmetry. However, Skouras et al.[16] reported postoperative sequelae including platyrrhine nasal tip (2%) and graft displacement (2%).

In group II, fillers were used in all cases (100%), whereas Botox was used in 81.8% for dynamic nasal tip. Botox was injected in the depressor septi nasi muscle and can lift the nasal tip slightly, whereas Helmy[4] used filler in 55% of his cases, filler in 33.4%, and threads in 11.7% of cases. We preferred HA fillers because it has an antidote (hyaluronidase) that helps reverse the undesired effects. Helmy[4] used HA fillers in 89.5% of his patients, and calcium hydroxylapatite in 10.5% of cases.

Regarding the postoperative period in group II, it was a smooth period with lack of significant complications apart from erythema and bruising in 54.5% of patients, which were managed conservatively within a few days. Helmy[4] recorded postoperative infection in the supratip area after filler injection. Sterilization, handling, and withdrawal during filler injection are necessary preoperative measures to avoid infections. The longevity of the results of HA injections ranged from 6 to 18 months, whereas the results of Helmy[4] lasted only 6 months.

Our results show that patient and doctor satisfaction among group I is higher than group II. This may be related to the longevity of the results and the ability of the surgical techniques to modify the anatomical nature of the Egyptian nose (thick skin, weak cartilages, and bulbous tip).

In our study, awareness of nasal tip vascular anatomy and injection precautions helped us to avoid intravascular bolus, and we did not experience any complications related to intravascular injection. Erythema and bruising occurred in six (54.5%) patients and subsided shortly. We and Saban[17] also focused on anatomy orientation before injection to prevent catastrophic complications of intravascular injections and to improve the outcomes. The junior doctors must know the nasal anatomy before starting nasal injection job. We should have hyaluronidase during injection to be prepared if any intravascular injection happens. The injections were done under supervision of the senior author.

Conclusion and recommendations

Egyptian nose has a unique anatomy with the predominance of thick skin, weak cartilage, and bulbous nasal tip. Preoperative nasal analysis and determining the degree of nasal deformity is a necessary step to choose suitable surgical or nonsurgical techniques. However, surgery is a clear indication for the big nose and moderate to severe nasal deformities.

Selection of the operative techniques depends on the preoperative analysis of the nasal tip deformities and patient desires, but the predominant anatomic nature of Egyptian nose (thick skin and weak saucer-shaped cartilage) made the invasive techniques suitable to correct nasal tip deformity and achieve satisfactory permanent results.

Limitations of the study

The main limitation of the present work is that the number of the patients could not exceed 32.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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2.
Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg 2009; 123 :1343–1354.  Back to cited text no. 2
    
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4.
Helmy Y. Nonsurgical rhinoplasty techniques using filler, botox, and thread remodeling: retro analysis of 332 cases outcome. J Cosmet Laser Ther 2018; 20 :293–300.  Back to cited text no. 4
    
5.
Moon HJ. Injection rhinoplasty using filler. Facial Plast Surg Clin North Am 2018; 26 :323–330.  Back to cited text no. 5
    
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Pontius AT, Chaiet SR, Williams EFIII. Midface injectable fillers: have they replaced midface surgery? Facial Plast Surg Clin North Am 2013; 21 :229–239.  Back to cited text no. 6
    
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Chin KY, Uppal R. Improved access in endonasal rhinoplasty: the cross cartilaginous approach. J Plast Reconstr Aesthet Surg 2014; 67 :781–788.  Back to cited text no. 7
    
8.
Hirsch RJ, Brody HJ, Carruthers JD. Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid. J Cosmet Laser Ther 2007; 9 :182–185.  Back to cited text no. 8
    
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Nyte CP. Spreader graft injection with calcium hydroxylapatite: a nonsurgical technique for internal nasal valve collapse. Laryngoscope 2006; 116 :1291–1292.  Back to cited text no. 9
    
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Kontis TC. The art of camouflage: when can a revision rhinoplasty be nonsurgical? Facial Plast Surg 2018; 34 :270–277.  Back to cited text no. 10
    
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Hodges JM, Tantawy AE, Omran TE, El-Bahrawy AT, Anany AM, Moneem SA, et al. Concepts and techniques of nasal tip surgery. ZUMJ 2013; 19 :307–316.  Back to cited text no. 11
    
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Coskun N, Yavuz A, Dikici MB, Sindel T, Islamoglu K, Sindel M. Three-dimensional measurements of the nasal interdomal fat pad. Aesth Plast Surg 2008; 32 :262–265.  Back to cited text no. 14
    
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Rettinger G. Risks and complications in rhinoplasty. GMS Curr Topic Otorhinolaryngol 2007; 6 :1865–1911.  Back to cited text no. 15
    
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Skouras A, Asimakopoulou FA, Skouras G, Divritsioti M, Dimitriadi K. Use of the Goldman technique to correct both the over projected and the broad nasal tip. Aesth Plast Surg 2012; 36 :54–61.  Back to cited text no. 16
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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