Understanding the Anatomy of the Transverse Nasalis Aponeurotic Fibers and Its Importance in Asian Rhinoplasty

Background A complete release of the transverse nasalis aponeurotic fibers (TNAFs) during Asian rhinoplasty is critical for accurate positioning of the nasal implant and lengthening of the short nose. The objectives of this article are to clarify the anatomy of the TNAFs using cadaveric dissections and to present the clinical results after complete TNAF release in Asian rhinoplasty. Methods An anatomical dissection was performed in 8 cadavers to study the TNAFs, specifically the origin, insertion, and boundary of the TNAFs and the effect of the TNAF release on nasal length. Between January 2012 and December 2014, 2314 open implant augmentation rhinoplasties (1777 primary and 537 secondary) were performed by the senior author (J.J.). The records of these patients were retrospectively reviewed for results of TNAF release. A separately designed prospective clinical study was performed to document the nasal envelope extension after TNAF release in 52 consecutive patients. Results In the cadaver study, the anatomy and the boundaries of the TNAFs were clearly visualized and documented. With accurate release of the TNAFs, the ideal pocket for nasal implant can be defined, and the effect of the release of the TNAFs recorded. Release of the TNAFs also allows extension of the nasal envelope. However, measurements of the nasal envelope were not studied in the cadaver because the skin was degloved. From the clinical study with a follow-up ranging from 6 months to 1.5 years, the overall complication of open rhinoplasty using silicone implants incorporating TNAF release was 6%. In this group, 3.4% of patients required revision rhinoplasty. Releasing the TNAFs ensures an accurate implant pocket reducing the risk of implant deviation and implant visibility and increases the nasal length by 2.1 mm. Conclusions Complete release of the TNAFs is especially important in Asian rhinoplasty to facilitate accurate pocket dissection, allowing the extension of the nasal envelope in order to correct short nose or secondary contracted nose.