This potentially difficult surgery requires special surgical techniques and postoperative protocols
Most rhinoplasties are simple dorsal reductions, tip revisions, or both, and the “closed” rhinoplasty approach is adequate. However, many of the ethnic patients in my practice are not ideal candidates for this procedure. Intricate cartilaginous, soft-tissue, and bony anatomies necessitate direct visualization for reconstruction of the tip and dorsum in most ethnic rhinoplasty.
This is especially true for the burgeoning number of non-Caucasian plastic surgery patients, who present with specific physical characteristics that require a more thoughtful approach. The “open” rhinoplasty technique gives the physician a broader range in which to accomplish the patient’s goals.
A secondary objective is to minimize the swelling and bruising during the healing process following open rhinoplasty by using the best surgical techniques and presurgical and postsurgical therapies, such as arnica montana and vitamin C. By studying the basics of open-nose rhinoplasty, plastic surgeons will put themselves in the best position possible to cater to the needs of all of their patients.
Responding to the Future
According to figures from the US Census Bureau, Hispanic and Asian populations have grown at a much faster rate than the US population as a whole; they reached 39.9 million and 13.5 million, respectively, in 2003. In addition, the African-American population in the United States grew 4.4% during a 39-month period that ended in 2003, and it now comprises 38.7 million Americans.1
Population projections indicate that this diversification will only increase in the coming decades. By 2050, Hispanic and Asian populations in the United States are expected to increase to 102.6 million and 33.4 million, respectively, and the African-American community is expected to grow by approximately 26 million people.2 In comparison, the Caucasian population in the United States is expected to increase by only 7% during the same time period, accounting for 210.3 million citizens. This surge in non-Caucasian populations is likely to occur primarily in urban centers and the surrounding suburbs—the locations of many of our practices.
These changes in the nation’s racial and ethnic distribution are occurring at a time when aesthetic plastic surgery is becoming more popular. Increasingly affordable procedures, enhanced surgical technology, and improved patient safety have all contributed heavily to the recent increase in the number of aesthetic plastic surgery procedures performed in this country.
This increase has certainly not been limited to Caucasian patients. The Amer-ican Society of Plastic Surgeons reports that Hispanics underwent 553,000 aesthetic plastic surgery procedures in 2004, up 49% from 4 years earlier, and the most among minorities. African-Americans and Asians underwent 461,000 and 276,000 procedures, respectively, during the same year—a 24% increase for both groups since 2000.3
One might think that, when taken to-gether, the surge in the minority population and the increasing acceptance of aesthetic plastic surgery in this country would be enough to merit significant interest from practitioners. However, in my experience, this is not yet the case. If we surgeons are going to give our minority patients the best care possible, it is necessary that we educate ourselves about their particular needs.
Characteristics of Ethnic Noses
Along with breast augmentation and liposuction, rhinoplasty is consistently among the most common aesthetic surgical procedures requested by individuals from minority groups. It also is a procedure that can be highly challenging for surgeons because of the unique anatomic features of ethnic noses (known as platyrrhine or mesorrhine noses). Whereas rhinoplasty in Caucasian patients with relatively minor defects can take as little as 45 minutes, the equivalent procedure in ethnic patients is considerably more difficult and can take upward of 2 hours to complete.
To successfully perform rhinoplasty on ethnic noses, it is necessary for cosmetic surgeons to recognize and understand the specific physical traits of these noses.
The typical African-American nose (Figure 1) has three main features:
a wide, bulbous tip—due to weak lower lateral cartilages and thicker skin—with marked fibrofatty tissue in the tip or lower half of the nose;
a low dorsum with the nasofrontal angle depressed to varying degrees; and
wide, flared nostrils.
The typical Asian nose is similar to the African-American nose in that it lacks dorsal height. The tip is generally wide and bulbous.
The typical Mediterranean nose (Greek, Italian, or Arabic) is similar in that the tip has generous proportions (length and width), and is even hooked in appearance (the “tension nose”). The dorsum can be nonspecific or have a major bony pronouncement, a feature commonly referred to as the “dorsal hump.”
A wide variety of cultures and backgrounds fall under the blanket term “Hispanic”; this makes it difficult to attribute one nose type to these patients. In general, the noses of this group tend to fall into three categories: mestizo (European mixed with Native American), Castilian (of Span-ish background and closest to the Caucasian nose), and Mexican-American (a combination of mestizo and Castilian features). Physical characteristics are distinct in each group, and different surgical strategies are required.
Issues of Heritage
Naturally, it is common for minority patients seeking rhinoplasty to express concerns that, by changing the shape of their nose, they are somehow failing to honor their ethnicity. This is not unlike the woman who complains that her nose is too masculine but also expresses a pang of guilt because it is her father’s nose. The nose may have a harmonious appearance on her father’s face, but it is not in harmony with her own facial features. In these cases, it is important to explain to the patient that rhinoplasty can refine the appearance of her nose, and at the same time can respect conceptions of beauty distinct to her culture.
Computer imaging is an invaluable tool for giving patients a realistic view of what can be achieved and a sense of what the final outcome will be. It is also critical for helping the surgeon discover, prior to surgery, which patients may have unrealistic expectations, thereby enabling him or her to avoid operating on patients that may have “supratentorial” issues. In my practice, computer imaging is essential during every rhinoplasty consultation.
Three Steps to a Nicer Nose
In my practice, rhinoplasty on African-Americans accounts for the highest percentage of procedures that I perform on ethnic patients. Approximately 95% of my African-American patients seek a narrower, more defined tip and a higher nasal dorsum.
My three-step approach comprises adding dorsal height, narrowing the nostrils, and adding structure to the tip. The dorsum can be augmented with cartilage or a variety of prosthetic implants. My preference is either 1-mm expanded poly(tetrafluoroethylene) (ePTFE) sheets (rolled up like a cigarette) or a custom-carved elastic silicone implant. The tip is reconstructed using the patient’s own cartilage harvested from the septum, ear, or rib to create a more structured and defined tip as well as to add support. The nostrils are addressed from the horizontal and vertical directions.
The addition of a bridge is a major component of nearly all of the rhinoplasties I perform on African-Americans. It is ex-tremely important to contour the bridge to the patient’s bone structure. I avoid mass-produced, “one-size-fits-all” bridges at all costs. I can optimally produce the look patients are seeking only by using a custom-carved silicone bridge or through precise placement of ePTFE graft material. This maneuver may require multiple attempts because it takes practice with custom carving and placement to achieve the desired look (Figure 2).
Next, it is necessary to address the tip of the nose. In African-American patients, the tip is usually characterized by a bulbous and broad shape, with little cartilage support. The skin is often sebaceous with excess subcutaneous fibrofatty tissue, which obscures the underlying structure of the nose and contributes to the soft, round appearance of the tip (Figure 3).
Patients most often request that the tip be “less flat, with smaller nostrils.” Because of the lack of structural support and the condition of the skin, contouring the tip of the African-American nose is complicated. To do so, I remove fibrofatty tissue from the lower half of the nose and use septal cartilage, which adds tip support and projection, and creates a more defined, angular tip. Occasionally, using additional pieces of ePTFE or silicone may be necessary for the desired tip configuration.
In my approach to narrowing the nostrils, I use a combination of vertical alar incisions (incisions in the nostril to reduce the height) and elliptical intracollume-lar–alar incisions (to narrow the width) (Figure 4). Despite the reluctance by some in the surgical community to make incisions in the body of the alae or multiple perinasal incisions, it has been my experience that the patients and the surgeon find the postoperative healing aesthetically acceptable, without scarring and keloid formation. Occasionally (approximately 5% of the time), alar incisions are revised 4 weeks after surgery.
Optimal performance of these procedures, especially in some ethnic noses with unique features, requires the surgeon to “go deep” into the nose. Because of this, nearly all but the simplest cases must be done using open-approach rhinoplasty. This allows for the best viewing of the cartilage and its inherent flaws, and it is absolutely essential for defatting the tip of the nose. In addition, open-approach rhinoplasty is vitally important for ensuring the proper placement of the tip cartilage and greatly facilitates the carving of the custom implants. The only disadvantage to the open approach may be increased surgery time. However, as surgeons gain experience, the amount of time decreases.
Help for Healing
Rhinoplasty on ethnic noses tends to have prolonged resolution of tip edema, which is most likely secondary to the disruption of lymphatic and venous drainage, due in part to the number of incisions necessary to achieve the desired results. Although the immediate postoperative recovery period is usually 7–10 days, residual swelling in the tip of the nose lasts 3–4 months, and in some rare cases, as long as 1 year. On occasion, judicious use of triamcinolone, injected into the tip and supratip area, may reduce swelling or scarring.
Immediately after surgery, a nasal splint is placed to reduce edema as the tissue heals, and it is removed at 7 days after surgery. Perinasal and collumelar sutures are removed on day 3, and incisions are reinforced using a commercial body-tissue sealant preparation or collodion-laden sterile strips.
To help offset the swelling and bruising, I ask all of my patients, regardless of their ethnic background, to strictly adhere to a preoperative and postoperative protocol. I instruct them to take vitamin C, as well as staphylococcus- and streptococcus-sensitive antibiotics, before and after surgery to help promote the healing process. Vitamin C is administered at 3,000 mg daily starting 2 weeks before surgery and is continued until 1 week after surgery.
I have found that arnica montana—a homeopathic medicine indicated to help reduce swelling and bruising—is an extremely useful tool in the preoperative and postoperative setting. Homeopathic arnica is prepared from a plant (Figure 5, page 38) native to central Europe, and it has been used in Europe for some time. When used topically in a cream formula for local treatment of bruising and swelling, arnica products present few, if any, complications for patients. However, if it is misapplied to an open wound or sore, it can irritate the skin.
I encourage my patients to take arnica systemically in pellet form every 4 hours beginning 2 days before surgery, then 3 times daily after surgery if the swelling continues. No side effects have been reported when it is taken correctly in either form and prepared with less than 10% arnica extract.
Patient acceptance of the use of arnica montana is increasing as a result of its low cost and low incidence of side effects. After taking this supplement, as well as vitamin C, patients have greater control in the difficult postoperative period when they are back at home and are eager to play an active role in their own recovery.
Communication and Education
Even though the ethnic backgrounds of those seeking aesthetic plastic surgery procedures in the United States are rapidly shifting, the basic tenets of medicine remain the same. No matter who the patient is, effectively communicating the rigors of intensive rhinoplasty and offering supplements such as arnica and vitamin C to speed recovery are the best bets to ensure his or her satisfaction. This begins at the first consultation and does not end until all of the patient’s questions and concerns have been addressed.
Educating yourself on the specific physical characteristics of people in each ethnic group will give you the means to treat such people as unique individuals, with their own goals and desires for altering their appearances. By understanding these characteristics, you will be able to best serve the changing face of America. PSP
Oleh Slupchynskyj, MD, is a double-board-certified plastic surgeon who specializes in aesthetic and reconstructive facial surgery. He is in private practice in New York City and New Jersey. More information on his surgical techniques can be found on his Web sites www.facechange.org and www.africanamericanrhinoplasty.com.
1. Hispanic and Asian Americans increasing faster than overall population [press release]. Washington, DC: US Census Bureau; Jun 14, 2004. Available at: http://[removed]www.census.gov/Press[/removed]-Release/www/releases/archives/race/001839.html Accessed Aug 5, 2005.
2. Census Bureau projects tripling of Hispanic and Asian populations in 50 years; non-Hispanic whites may drop to half of total population [press release]. Washington, DC: US Census Bureau; Mar 18, 2004. Available at: http:[removed]www.census.gov/Press[/removed]-Release/www/releases/archives/population/001720.html Accessed Aug 5, 2005.
3. Half-million cosmetic plastic surgery procedures for Hispanics in 2004—Up 49% from 2000 [press release]. Arlington Heights, Ill: American Society of Plastic Surgeons; Mar 16, 2005. Available at: http://www.plasticsurgery.org/news_room/press_ releases/hispanic-2004.cfm Accessed Aug 5, 2005.