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

Full text

1110-2098 © 2020 Faculty of Medicine, Menoua University DOI: 10.4103/mmj.mmj_301_19
Original article 675
Introduction
Rhinoplasty is one of the most performed cosmetic
surgeries. e most popular indications for tip
rhinoplasty among Egyptian patients are bulbous
nasal tip, inappropriate tip projection, or rotations.
e Egyptian nose has specic anatomical and
morphological features of ethnic nature. ick 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].
e 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 dierence, whereas the middle
and medial crura are insucient[2].
e middle and lateral crura of LLC orientation and
position should be interpreted preoperatively, as they
aect nasal tip renement. According to the severity
and causes of the underlying nasal tip deformity, the
dierent surgical techniques will be chosen regarding
tip sutures and grafts[3].
Noninvasive nose reshaping have become popular. It
includes Botox, threads, and ller[autologous fat and
synthetic injectable such as hyaluronic acid (HA)].
ey include simple procedures that are done in the
outpatient clinic under local anesthesia with high
patient satisfaction. Noninvasive rhinoplasty is less
nancially demanding with less downtime. HA can
be injected in the interdomal area, columellar space,
and over the nasal spine to manipulate tip denition
support and projection correspondingly[4].
e patients who generally tend to show good results
are those with mild hump nose, mild nasal deviation,
high nasal tip with a at radix, slight imbalance from
Invasive and noninvasive tip rhinoplasty in a group of Egyptian
thick-skinned patients
Tarek F. Keshk, Ahmed A. Taalab, Ahmed Fergany, Mohamed M. Ghoneim,
Hanan A. Dawoud
Objective
The aim was to evaluate the indications, contraindications, and complications of surgical and
ller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MenouaUniversityHospital,Egypt.
Patientsweredividedinto two groups: invasive(surgery)and noninvasive (ller). Patient
data(age,sex,andcomorbidities),nasaltipanalysis(denition,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signicant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,ller,nose,surgery,thickskin
Department of Plastic and Reconstructive
Surgery,Menoua UniversityHospital,
Menoua,Egypt
Correspondence to Hanan A. Dawoud, Shebin
Elkoom,Menoua, Egypt
postal code 32511
Tele: 00201002463926
e‑mail: ps.hanandawoud@gmail.com
Received 29 September 2019
Revised 13 November 2019
Accepted 23 November 2019
Published 27 June 2020
MenouaMedical Journal2020, 33:675–682
Menoua Med J 33:675–682
©2020FacultyofMedicine,MenouaUniversity
1110‑2098
This is an open access journal, and arcles are distributed under the terms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new
creaons are licensed under the idencal terms.
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

676 MenouaMedical Journal,Volume 33 | Number 2 | April‑June 2020
surgery, and so forth. ose with severe hump nose,
sever nasal deviation, cephalic tip rotation, and the
bulbous tip will not achieve good results from ller
alone[5].
e aim of this study was to evaluate the indications,
advantages, disadvantages, and complications of
invasive and noninvasive techniques used to create a
rened, aesthetically pleasing nasal tip in Egyptians.
e appropriated technique will be chosen based
on the degree of nasal tip deformities, the needed
modications, 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
is is a prospective cohort study that was conducted
in Menoua University Hospitals, Egypt, between
December 2017 and March 2019, after the approval of
Menoua Ethical Committee on the study proposal.
irty‑two patients with nasal tip deformities were
included in this study. e 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.
e patients in the study were divided into two groups:
surgery group included 21 patients, and ller 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) e good general condition of the patient
(6) Age range from 14 to 50years.
Exclusion criteria
e following were the exclusion criteria:
(1) Postburn nasal tip deformity
(2) Age less than 14years and more than 50years
(3) e poor general condition of the patient.
e 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. e
used technique was selected based on the severity of the
tip deformity and patient’s desires. e 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. e 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
is 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. Inltration 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 xation in place, then tip sutures were
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.
Figure 1
d
c
b
f
a
e
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

Invasive and noninvasive tip rhinoplasty Keshk, et al. 677
done, and then closure with insertion of nasal pack was
done(Fig.1).
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
strut was 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
denition. e 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 camouage irregularities and
enhance tip projection. Extended columellar strut was
placed between the medial crura and extended between
the domes above the tip dening points to add more
projection to the tip.
Closure and dressing
e nasal skin was redraped, and the transcolumellar
incision was closed with 6/0 proline sutures. e
marginal incision was closed using 4/0 vicryl stitches.
Transxation suture with 4‑0 proline at the junction of
dorsal aesthetic lines and tip dening 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. ere 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 ller group.
Noninvasive group (ller)
is 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. e used
ller is HA light for the tip and columellar space,
whereas for the nasal spine injection, we used medium
HA. e 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 rst 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 ngers.
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
subsupercial 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 ller group. Pvalue less
than 0.05 was signicant.
Results
Invasive surgery group I
is 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 (Fig.2 and Table2).
Noninvasive group II
is group included 11 (34.4%) patients. All cases
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

678 MenouaMedical Journal,Volume 33 | Number 2 | April‑June 2020
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 ller for primary
aesthetic causes (Table1). Tip under projection and
under rotation were the most frequent preoperative
analysis(Fig.3 and 4 and Table2).
Patient and surgeon satisfaction
ere is a signicant relationship between patient
and doctor satisfaction and the used technique, with
high satisfaction among surgery group. is may be
related to the predominant anatomical features of the
Egyptian nose(Table3).
Table 1 Sociodemographic data of the participants in relation to the type of operation (n=32)
Items Invasive (n=21) [n (%)] Noninvasive (n=11) [n (%)] Testof signicanceand P
Sex
Male 6 (28.6) 0 (0) Fisher’s exact=3.9 P=0.07 (>0.05)
Female 15 (71.4) 11 (100)
Age
Mean±SD 28.05±7.2 30.6±5.4 t test=1.05 P=0.30 (>0.05)
Minimum‑maximum 18‑42 24‑38
Previous nasal surgery
Yes 5 (23.8) 0 (0) Fisher’s exact=3.1 P=0.14 (>0.05)
No 16 (76.2) 11 (100)
Indication of operation
Aesthetic 14 (66.7) 11 (100) χ2=4.7 P=0.09 (>0.05)
Postcleft palate 4 (19) 0 (0)
Post‑traumatic 3 (14.3) 0 (0)
Table 2 Preoperative in the participant in relation to the type of operation (N=32)
Items Invasive (n=21) [n (%)] Noninvasive (n=11) [n (%)] Testof signicanceand P
Thick skin
Yes 14 (66.7) 6 (54.5) Fisher’s exact=0.45 P=0.70 (>0.05)
No 7 (33.3) 5 (45.5)
Tip asymmetry
Yes 4 (19) 0 (0) Fisher’s exact=2.4 P=0.27 (>0.05)
No 17 (81) 11 (100)
Bulbous tip
Yes 14 (66.7) 0 (0) Fisher’s exact=13.04 P=0.00**(≤0.001)
No 7 (33.3) 11 (100)
Overprojection
Yes 2 (9.5) 0 (0) ‑
No 19 (90.5) 11 (100)
Underprojection
Yes 6 (28.6) 9 (81.8) Fisher’s exact=0.42 P=0.68 (>0.05)
No 15 (71.4%) 2 (18.2)
Cephalic rotation
Yes 0 (0) 0 (0) ‑
No 21 (100) 11 (100)
Caudal rotation
Yes 15 (71.4) 9 (81.8) Fisher’s exact=3.9 P=0.07 (>0.05)
No 6 (28.6) 2 (18.2)
Ill‑denedtip
Yes 13 (61.9) 8 (72.7) Fisher’s exact=0.38 P=0.70 (>0.05)
No 8 (38.1) 3 (27.3)
Table 3 Patient and doctor satisfaction among participants in both groups (N=32)
Items Invasive (n=21) [n (%)] Noninvasive (n=11) [n (%)] Testof signicanceand P
Patient satisfaction
Unsatised 0 0 Fisher’s exact=3.7 P=0.072 (>0.05)
Intermediate 6 (28.6) 7 (63.6)
Excellent 15 (71.4) 4 (36.4)
Doctor satisfaction
Unsatised 0 0 Fisher’s exact=10.5 P=0.003*(≤0.05)
Intermediate 2 (9.5) 7 (63.6)
Excellent 19 (90.5) 4 (36.4)
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

Invasive and noninvasive tip rhinoplasty Keshk, et al. 679
Discussion
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 denition.
e preoperative nasal analysis must respect the mixed
ethnic nature of the Egyptian nose. e 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. is 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 renement, which requires
major modications and reconstruction.
Our study included 32 patients who underwent tip
rhinoplasty either by surgery or ller. 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 ller
rhinoplasty (group II) and comprised 11 patients.
However, patients with severe nasal tip deformities
that cannot be corrected with ller 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 ller 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%). e procedures were
done under local anesthesia in the outpatient clinic.
Moreover, Hirsch etal. [8] used topical aesthesia for
nasal ller 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 ller rhinoplasty for treatment
of the internal nasal valve. He treated internal nasal
valve collapse with ller injection at the apex of the
value to work as a spreader graft. Kontis [10] used
ller for revision rhinoplasty to camouage 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 brosis 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%).
ese patients were selected to the surgery group
because their nasal tip deformities were moderate to
severe, and these deformities could not be addressed
with ller injection. e 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
(a) Preoperative frontal view of a case with bulbous nasal tip and
thickskin;(b)postoperativefrontalviewshowsthetransxionstitch;
(c)preoperativelateralviewshowsmilddorsalhump;(d)postoperative
lateralviewshowsthetransxionstitchandcorrectionofthedorsal
hump with a cephalic rotation of the tip.
Figure 2
d
c
b
a
(a)Preoperativefrontal view ofacase ofill‑denedunder‑rotated
nasal tip; (b) postoperative frontal view shows tip denition with
ller; (c) preoperative lateral view; (d) postoperative lateral view
shows correction of the dorsal hump with a cephalic rotation of the tip.
Figure 3
d
c
b
a
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

680 MenouaMedical Journal,Volume 33 | Number 2 | April‑June 2020
in the study. is 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 denition, 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 ller rhinoplasty, as it is hard to be corrected with
ller because it is already augmented and needs surgical
reduction. Filler has limited indications for big noses.
e study by Moon [5] recorded that upturned nose
and bulbous nasal tip showed poor results with ller
alone. Moreover, Adamson etal. [12] stated that ller
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. e 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 ller (81.8%) and
surgery (28.6 and 28.6%, respectively) techniques.
However, only minor degrees of deformities were
chosen to do ller rhinoplasty. In contrast, nasal tip
overprojection (9.2%) was an indication for surgery
as it cannot be addressed with ller 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].
is is in contrast to Hodges etal. [11] who preferred
the endonasal approach for tip rhinoplasty because it is
less destructive.
e columellar strut was placed between the two medial
crura. e 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 denition 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 transxion 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
(a) Preoperative frontal view of a case of bulbous, slightly under‑rotated
nasaltip;(b)postoperative frontal view showswell‑denedtip;
(c) preoperative lateral view; (d) postoperative lateral view shows
cephalic rotation of the tip.
Figure 4
d
c
b
a
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

Invasive and noninvasive tip rhinoplasty Keshk, et al. 681
and tip denition. 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 supercial 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. is 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 transxion 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, llers 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
ller in 55% of his cases, ller in 33.4%, and threads
in 11.7% of cases. We preferred HA llers because it
has an antidote(hyaluronidase) that helps reverse the
undesired eects. Helmy [4] used HA llers 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 signicant 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 ller injection. Sterilization,
handling, and withdrawal during ller injection are
necessary preoperative measures to avoid infections.
e 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. is 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. e 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. e
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
e main limitation of the present work is that the
number of the patients could not exceed 32.
Financial support and sponsorship
Nil.
Conictsofinterest
ere are no conicts of interest.
References
1 El‑Shaarawy EA. Morphological and morphometric study of the
cartilaginous framework of the dorsum and tip of the nose among
Egyptianpopulations:acadavericstudy.FoliaMorphol2016;75:316–325.
2 Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast
ReconstrSurg2009;123:1343–1354.
3 Rowe‑Jones J. Rening the nasal tip: an anatomical approach. Facial
PlastSurg2014;30:113–122.
4 Helmy Y. Nonsurgical rhinoplasty techniques using ller, botox, and
thread remodeling: retro analysis of 332 cases outcome. J Cosmet Laser
Ther2018;20:293–300.
5 MoonHJ.Injectionrhinoplastyusingller.FacialPlastSurgClinNorthAm
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]

682 MenouaMedical Journal,Volume 33 | Number 2 | April‑June 2020
2018;26:323–330.
6 Pontius AT, Chaiet SR, Williams EFIII. Midface injectable llers:
have they replaced midface surgery? Facial Plast Surg Clin North Am
2013;21:229–239.
7 Chin KY, Uppal R. Improved access in endonasal rhinoplasty: the cross
cartilaginousapproach.JPlastReconstrAesthetSurg2014;67:781–788.
8 Hirsch RJ, Brody HJ, Carruthers JD. Hyaluronidase in the ofce: a
necessity for every dermasurgeon that injects hyaluronic acid. J Cosmet
LaserTher2007;9:182–185.
9 Nyte CP. Spreader graft injection with calcium hydroxylapatite: a
nonsurgical technique for internal nasal valve collapse. Laryngoscope
2006;116:1291–1292.
10 Kontis TC. The art of camouage: when can a revision rhinoplasty be
nonsurgical?FacialPlastSurg2018;34:270–277.
11 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.
12 Adamson PA, Warner J, Becker D, Romo TJ III, Toriumi DM. Revision
rhinoplasty:paneldiscussion,controversies,andtechniques.FacialPlast
SurgClinNorthAm2014;22:57–96.
13 Ghareeb FM, Nassar AT, Talaab AA, Alkashty S. Anatomically based
optimization of outcomes in middle eastern rhinoplasty. Plast Reconstr
SurgGlobOpen2018;6:e1862.
14 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.
15 Rettinger G. Risks and complications in rhinoplasty. GMS Curr Topic
Otorhinolaryngol2007;6:1865–1911.
16 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.
17 Saban Y, Amodeo CA, Bouaziz D, Polselli R. Nasal arterial vasculature:
medicaland surgicalapplications.Arch FacialPlastSurg2012;14:429–
436.
[Downloaded free from http://www.mmj.eg.net on Saturday, March 18, 2023, IP: 5.151.28.193]