Non-Caucasian Rhinoplasty

Anatomic Considerations

The term non-Caucasian covers a broad demographic group, so the surgeon cannot make uniform guidelines that cover it in its entirety. African American, Asian, and Hispanic individuals represent a large portion of this population, and major distinctions are apparent between their noses and the Occidental nose. These three ethnic groups also share many common traits in terms of nasal anatomy, but to varying degrees. In some respects, these cultures span a continuous spectrum of deviation from those in the Occident in terms of skin thickness, size and strength of nasal cartilages, and nasal tip definition.

Initial analysis for all rhinoplasty patients must be thorough and complete, but special focus on a few areas must be made with this group. Although it is true that most ethnic noses have thicker skin, this cannot be generalized uniformly, because variability exists and must be accounted for. Furthermore, excess skin thickness can be found in different areas, such as the alar lobules. The size, strength, and integrity of the LLCs must be analyzed, because deficiencies here can lead to an altered surgical plan. Nasal bones are often shorter than those of Caucasians, and narrowing through osteotomies is often not fruitful. The nasal platform—the bony nasal sill and piriform aperture—is often deficient and in need of augmentation. These important distinctions are largely determined through careful palpation of the nose, and this part of the examination cannot be overemphasized in this patient population.

Specific anatomic features characteristic of the non-Caucasian nose include thicker skin with abundant subcutaneous fibrofatty tissue, a weaker cartilaginous framework, short nasal bones, an underdeveloped anterior nasal spine, low nasal sill, smaller quadrilateral septal cartilage, and inferior turbinate hypertrophy ( Fig. 33.1 ). The associated cutaneous findings include a wide and underprojected dorsum; a low radix and nasion; a nasal tip that is bulbous, lacking definition, underprojected, and either ptotic or overrotated (short nose); a short columella; and an alar base that is wide and flaring ( Table 33.1 ). The thicker skin can be an important differentiating feature, because it allows for great acceptance of nasal implants, including alloplastic implants, and it camouflages augmentation grafts in a more natural fashion. It also obscures minor changes performed on the cartilaginous framework, necessitating overcorrection as a rule.

In addition to the thicker tip skin, the LLCs are weak and pliable, making the creation of tip definition a challenging task. Cephalic trim and dome-binding sutures are often inadequate; reinforcing struts and projecting cap grafts tend to be more effective. The short columella merits some consideration when placing a transcolumellar incision for an external approach. Because the tip often requires some projection, the surgeon should place the transverse incision slightly lower, allowing it to rise with increased tip projection. Intranasally, most non-Caucasian noses are characterized by a straight septum with widely patent internal nasal valves, large inferior turbinates, and a low bony nasal sill. The size of the quadrilateral septal cartilage is typically smaller and thinner, ironically leading to a dearth of desirable donor material in a setting where augmentation is often needed. Consequently, one of the primary sources of augmentation material in Asia remains alloplastic materials.

The short and wide nasal bones make traditional osteotomies more challenging because the bone cuts easily drift into the ascending process of the maxilla. They also predispose to the inverted-V deformity during the hump reduction. Fortunately, the wide internal valve and thick overlying skin make clinical nasal obstruction from this etiology a rare entity in non-Caucasians. The flat nasal bones and nasal root extend inferiorly onto the cartilaginous dorsum; therefore most patients require augmentation to the dorsum as well as to the radix area.

The ethnic patient is generally at a greater risk for unfavorable scarring from skin incisions, be it from pigmentation problems or hypertrophic scarring or even keloid formation. Although transcolumellar scars usually heal well, this is more applicable to donor-site scars on the ear and chest. A careful history is warranted preoperatively.

Aesthetic Considerations

The ethnic patient generally does not desire a Western nose; most individuals would like a nose that has better balance with their cultural features and preserves their heritage. This is especially important to bear in mind during the initial nasal analysis because the typical angles and landmarks we use for the “aesthetic” nose are derived from Western faces and do not necessarily apply across all ethnicities. For example, the nasion, the nasolabial angle, and the alar base width are defined differently, with “ideal” measurements that are not the same throughout cultures. Transplanting those ideals onto the ethnic nose will create an unnatural and artificial appearance. Similarly, this group of patients may complain of a flat nasal tip, and although more definition would be viewed favorably, these patients usually still desire a softer and rounder tip than their Western counterparts. In addition, the surgical steps applied to the Western nose to achieve a given goal may not be valid and productive in the thicker-skinned ethnic nose.

Cultural definitions of beauty vary widely, and it is not the desire of all non-Caucasians to acquire Occidental features nor do the aesthetic norms of Western beauty transition to all ethnic faces. An attractive Asian nose, for example, has a slightly lower nasion, which is somewhat below the upper eyelash line. Textbook normative data of the radix and nasion describe the supratarsal crease for the Caucasian face as the ideal landmark, best matching the angular topography of the Caucasian face. Asians have a flatter contour, and on an Asian face, the high radix would appear unnatural. Because the dorsum is often flat and wide, it occasionally requires lateral osteotomies to narrow the bony aperture in addition to the dorsal augmentation. In regard to tip aesthetics, projection , rotation , and volume are the three most important factors to consider. These three factors influence one another in creating an ideal tip shape. The angulated tip with clear tip-defining points is not the ideal appearance for most non-Caucasians. A more rounded and lobular tip is preferred in this group because it best blends with the cherubic facial shape and cheekbones. It is common among these non-Caucasian patients for a retruded premaxilla to coexist with the small nose, creating a retrusive columella and an acute nasolabial angle. A plumping graft to efface the nasolabial angle can improve balance and create the illusion of tip rotation. A wide alar base with flaring of the alar lobules can be found in African-Americans and descendants of Southeast Asians (Filipinos and Malaysians). Northeast Asians (Japanese and Koreans) tend not to have the same degree of alar flaring.

For the ethnic patient, nuances exist with regard to the motivation for undergoing rhinoplasty. In addition to the common concerns with all rhinoplasty candidates, such as expectations and psychosocial motivations, the ethnic patient may also be concerned about seeming to deny or abdicate his or her cultural heritage. This may be a personal concern or a fear that others may perceive the patient as acting on such a motivation; either way, it is an important consideration in the preoperative consultation.

Augmentation Rhinoplasty

Choice of Augmentation Material

Before deciding which augmentation material to use, numerous factors must be considered: the amount of augmentation needed, the availability of septal and conchal cartilages, skin thickness, and certainly the patient's preferences. The potential disadvantages of alloplastic implants are widely recognized, but the severity and likelihood of occurrence of complications remain controversial. The risk of rejection and extrusion of alloplastic implants is of paramount concern, but contemporary porous materials, particularly when used under thicker ethnic skin, may reduce that risk. Thorough patient education and informed consent are imperative during this preoperative consultation. Common alloplastic implants include Medpor (porous high-density polyethylene; Porex, Newnan, GA), expanded polytetrafluoroethylene, and silicone ( Fig. 33.2 ).

Autogenous tissue remains the gold standard but can have limitations and potentially significant comorbidities. Limited availability is a first concern in non-Caucasian noses. Even in primary surgery, the volume of available septum is limited, and conchal cartilage is generally less predictable in terms of resorption. Costal cartilage has an unlimited supply but is associated with greater morbidity and investment. Long-term warping of the rib graft is the primary complication and is best avoided by carefully carving out the central core of the graft or by obliquely cutting the rib into symmetrical cortical portions.

Patients in need of only a limited degree of dorsal augmentation are usually excellent candidates for autologous implants with septal or conchal cartilages. The surgeon must carefully inspect and palpate the septum to verify the presence of adequate cartilage. With revision rhinoplasties, the volume of native septal cartilage cannot be counted on, and alternative sources should be planned. It is usually necessary to stack multiple layers of cartilage on one another, including ear cartilage; the surgeon should suture-secure the pieces of cartilage together and carefully bevel all the edges ( Fig. 33.3A and B ). Rib cartilage affords adequate volume to augment major deficiency of the dorsum and provides the rigidity needed to lengthen the nose through a caudal extension graft or strong L-strut ( Fig. 33.3C ).