Introduction
The Asian nose is characterized by less height and length, less tip projection, and a wider nasal base than its Caucasian counterpart.1Another clinically meaningful anatomic difference can be found in the soft-tissue envelope over the nasal framework, which consists of a denser fibromuscular layer and a thicker fatty layer.2These Asian features have prompted a need for augmentation rhinoplasty for the dorsum, and as a result, a number of techniques that increase nasal tip projection have been devised. The lower lateral cartilages of Asians are small, the medial crura is underdeveloped in most cases, and the soft tissue envelope of the tip is thick. For these reasons, it is difficult to make significant changes to nasal tip shape or position by applying suture techniques to lower lateral cartilages. To obtain sufficient nasal tip projection, structural supporting grafts such as the columellar strut graft or septal extension graft are required in most Asians.1The columellar strut graft is the graft most commonly employed for nasal tip projection. According toa comparative study performed by Young Chul Suh et al. on septal extension and double-layered conchal cartilage extension grafts, the latterbetter preserves septal support, and may be an effective and safe alternative option for rhinoplasty.3
Current views of nasal tip plasty remodeling in Asia are at odds with classical understanding of nasal tip biomechanics. Though several techniques were developed based on tripod theory first suggested by Anderson in 1966, an increasing number of rhinoplasty surgeons now appear to be following the “quadripod” concept of the nasal tip, whereby the anterior caudal septum constitutes the fourth leg.4
Cephalic tip rotation is a potential side effect of increasing projection and resultsin frontal nostrilexposure and nasal shortening.5We designed a more effective means of achieving nasal tip projection, especially in terms of columellar strutstrength, that simultaneously increases nasal tip protrusion and controls cephalic rotation, by using a non-incisional, back-to-back, bent double-layered, conchal cartilage extension graft in combination with a pagoda-shaped onlay graft.