|
Ethnic Rhinoplasty
Caution: Some of the medical photographs that you will view in this section are graphic in nature.
Ethnic Rhinoplasty Outline
African American Nasal Anatomy
- Skin: Thick, Abundant Fibrofatty tissue
- Radix: Deep, Inferiorly-Set & Low
- Nasal Bridge & Dorsum: Short Nasal Bones, Wide & Flat
- Tip: Bulbous, Thick-Skinned, Under-Projected, Derotated (Ptotic), Abundant Nasal Soft Tissue, Broad Domes, Minimal Definition
- Base: Wide, Thick, Horizontal & Flaring Nostrils
- Nasolabial Junction: Retracted, Acute Nasolabial Angle (< 90 degrees), Under-Developed Nasal Spine
- Maxilla: Usually Retrusive & Hypoplastic
Hispanic Nasal Anatomy
- Skin: Thick, Abundant Sebaceous Glands
- Radix: Low to Normal
- Nasal Bridge: Wide
- Dorsum: Convex (Nasal Hump)
- Tip: Bulbous, Thick-Skinned, Under-Projected, Occasionally Derotated to Normal, Abundant Nasal Soft Tissue, Broad Wide Domes, Minimal Definition
- Columella: Short to Normal
- Base: Wide, Thick, Horizontal & Flaring Nostrils
- Nasolabial Junction: Retracted & Acute Nasolabial Angle (< 90 degrees)
- Maxilla: Within Normal Limits
Asian Nasal Anatomy
- Skin: Heavy, Thick & Sebaceous
- Radix: Deep & Flat
- Nasal Bridge & Dorsum: Low, Wide & Flat
- Tip: Bulbous, Thick-Skinned, Under-Projected, Ptotic, Abundant Fibrofatty Tissue, Broad Domes, Minimal Definition
- Columella: Short, Minimal Show (Retracted)
- Base: Wide, Thick, Oblique & Flaring Nostrils
- Nasolabial Junction: Retracted & Acute Nasolabial Angle (< or = 90 degrees)
- Maxilla: Usually Retrusive
Desired Rhinoplasty Goals
- Bridge: Moderately Thinner
- Dorsum: Higher (Augmented)
- Tip: Refined, Increased Projection, Increased Rotation
- Base: Vertical-Oblique Nostrils & Triangular Nasal Base
- Columella: Increased Columellar ?Show? & Length
- Nasolabial Junction: Obtuse Nasolabial Angle (> 90 degrees)
- Maxilla: Less Retrusive
- Skin-Soft Tissue Envelope: Moderate Thickness that Provides Good Tip Definition
Preoperative Nasal Evaluation & Surgical Planning
- Excellent Physician-Patient Communication
- History & Physical Examination
- Patient?s Goals? Realistic?
- Discuss Expectations & Anticipated Results
- Computer Morphing
- Chin Implant?
- Surgical Plan: Nasion, Bridge and Dorsum, Tip, Base, Grafts and Septum and Turbinates
Surgical Sequence
- Septoplasty with/without Graft Harvesting +/- Turbinoplasty
- Incisions and Skeletonization (Primarily Open Technique)
- Nasal Tip Surgery
- Osteotomies
- Harvest/Placement of Autologous and/or Alloplastic Grafts
- Alar Base Reduction
Septoplasty & Turbinoplasty
- Preoperative Nasal Obstruction Infrequent
- Deviated Septum Infrequent
- Standard Techniques Used
- Hemi-transfixion or Killian Incision
- Graft Harvesting (Dorsal Augmentation, Plumping Grafts & Extended Columellar Strut)
- Conservative Turbinoplasty
Incisions & Skeletonization
- Primarily Open Technique Utilized
- Subdermal Dissection Over Nasal Tip
- Subperiosteal Dissection Over Nasal Dorsum
- Excise & Save Subcutaneous/Fibrofatty /Mucoperichondrial Tip Tissue (Aids in Tip Definition and may be used for Camouflaging Grafts)
|
|
|
Hydrodissection |
Tip Dissection |
Fibrofatty Tissue |
Nasal Tip Surgery
- Cephalic Trim (Leave 7 mm in place)
- Undermine Vestibular Skin from Undersurface of Alar Cartilage (Lateral & Medial Crura)
- Lateral Crural Steal*
- Increases Nasal Tip Projection & Tip Rotation
- Lateral Crura Advanced onto the Medial Crura to Project the Nasal Tip Anteriorly and to Rotate the Tip Superiorly
*Kridel RWH, et al: Advances in nasal tip surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg 117:1206-1212, 1989
Lateral Crural Steal
- Advance Lateral Crura Adjacent to the Dome Medially
- Trans- & Inter-Domal Sutures with 5-0 Clear Nylon
 Nasal Tip Surgery
- Extended Columellar Strut (as needed)
- Shield Graft (as needed)
- Plumping Grafts (Septal & Cephalic Trim Cartilage)
- Depressor Septi Muscle Myectomy
- Tongue-In-Groove Technique*
- Advancing Medial Crura (Low) to Caudal Septum (High) with 5-0 Nylon
- Increases Tip Projection & Rotation (as needed)
* Kridel RWH, et al: The Tongue-in-Groove Technique in Septorhinoplasty:Arch Facial Plast Surg 1:246-256, 1989
Tongue -In-Groove Technique
|
|
|
|
|
|
|
|
|
 |
|
|
| |
Final Tip & Shape |
|
 |
 |
Columellar Strut Graft
|
Shield Graft |
Osteotomies
- Low Nasal Bones usually Present
- Infiltrate Nasal Mucosa with Local
- Fading Medial followed by Low to Low Osteotomies Percutaneous Osteotomies (if needed)
- Proper Infracturing of Nasal Bones
- Prevent Green Stick Fractures or Rocker Deformities
Dorsal Augmentation
Gore-Tex Implant
|
- Adequate (Barely Larger than the Graft) Dorsal Pocket
- Autologous Grafts (Septal or Conchal Cartilage)
- Prefer Layered Septal Cartilage
- Thick Skinned Patients
- Covered with Tip Fibrofatty Tissue
- Alloplastic Graft (Gore-Tex)
- Layered 1 & 2 mm Sheeting
- Utilize Graft Guide Sutures (5-0 Vicryl) with Tuberculin Syringe Technique
- Graft extends from Nasofrontal Angle to just Short of Supratip Break
Dorsal Augmentation - Tuberculin Syringe Technique
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
| Dorsal Augmentation - 1 Week Post-Op - 3mm Layered Gore-Tex
|
Alar Base Reduction - Nasal Sill & Floor Excision
- Wide Alar Base (Lateral to Medial Canthus)
- Internal Only
- Conservatively Reduces Flare & Alar Bulk
- Reduces Nostril Size
- Fusiform or Wedge Excision
- 3 mm at most
Alar Base Reduction Nasal Sill & Floor Excision
|
|
|
Alar Base Reduction - Type I & II Sheen Excisions
- Incision 1 mm on Nasal Side of Alar-Facial Junction Bevel Incision
- Medial Flap used when Vestibular Skin Resected
- 5-0 Vicryl for Deep Closure
- 6-0 Prolene for Skin Closure
- 5-0 Chromic for Vestibular Closure
- Vestibular (Nostril) = Decreases Nostril Size
- Cutaneous (Alar Lobule) = Modifies Alar Lobule & Contour
- Type I: Excessive Alar Lobule with Normal Sized Nostrils
- Type II: Large Nostrils & Excessive Alar Lobules
Alar Base Reduction - Type I Sheen Excisions
- Excise Lobules (Cutaneous)
- Not Vestibular Skin
- External Alar Excision
- 3 mm at most
- Entire Border of Alar Lobule
Alar Base Reduction - Type II Sheen Excisions
- Excise Lobules (Cutaneous)
- Some Vestibular Skin (< than Cutaneous)
- External Alar & Internal Vestibular Excision
- 3 mm at most
- Entire Border of Alar Lobule
Alar Base Reduction Medial Flap
- Extend Medially along Alar Base
- Stop Short of the last 2 to 3 mm
- Back Cut that Preserves Small Triangular (Medial) Flap is Made
- Superior Cut Made
- Excise Wedge of Tissue
- Natural Continuity of Nasal Sill Preserved
Post-operative Nasal Care & Instructions
- Meticulous Cleansing of Incisions
- Basic Saline Nasal Sprays
- Suction Bulb to Suction Nose PRN
- Head Elevation
- Ice Compresses
- post-operative Nighttime Taping for 6-10 Weeks
- Kenalog 10 mg/cc after 4 Weeks PRN
Risks & Complications
- Bleeding
- Prolonged Bruising or Hyperpigmentation
- Infection
- Prominent Alar Scarring
- Excessive Alar Reduction
- Abnormal Appearing Ala
- Flat Ala with Loss of Natural Base Curves
- Nasal Asymmetry, Graft Irregularity, Displacement and Extrusion
- Graft Resorption
- Prolonged Swelling
- Revision Surgery ? 1 Year
Pearls
- Carefully Evaluate the Nasal Anatomy & Physiology and Patient?s Mental State
- Establish Realistic Goals for the Patient and for Yourself
- Prepare a Detailed Preoperative Evaluation and Surgical Plan
- Maintain Nasal Airway Function
- Perform Revision Procedures only when Truly Warranted
Ethnic Rhinoplasty Results
Westernization Rhinoplasty Presentation
African American patient desiring a more westernized nose without looking overdone.
Open rhinoplasty revealing the thick, fibrous tissue overlying the nasal tip. This tissue (nasal SMAS) prevents the tip from having definition.
The nasal SMAS is being removed.
 
Tip cartilage exposed after removing SMAS.
To help increase nasal tip projection, the vestibular tissue is dissected away from the nasal tip cartilage.
A columellar strut is carved from septal cartilage and will be placed inbetween the tip cartilage to help add nasal tip projection.
A shield graft and coluemllar strut added to the nasal tip to aid in nasal tip definition and projection.
Layered goretex placed over the nasal dorsum.
Horizontal view of the nose revealing increased height of the nasal dorsum and nasal tip.
One week postoperative views revealing increased nasal tip projection and alar base reduction thin scar.
One week postoperative view revealing healing alar base scar.
One week postoperative photos revealing oblique, frontal and base views and healing alar base scars.
11 months postoperative photos.
Suggested Reading
- Hoefflin, S.H.: Ethnic Rhinoplasty. New York, 1998, Springer-Verlag.
- Sheen, J.H.: Alar Resection. Aesthetic Rhinoplasty. St. Louis, 1987, The C.V. Mosby Co., p. 251.
- Kridel RWH, et al: Advances in Nasal Tip Surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg 117:1206-1212, 1989
|
