20 The Ethnic Nose

Shahryar Tork and Ashkan Ghavami

Abstract

Success in ethnic rhinoplasty can be achieved through accurate preoperative analysis, recognition of the common and variable features within each ethnic group, and precise technical maneuvers. The open approach allows for precise intraoperative anatomic diagnosis and the construction of an ethnically congruent nose. Familiarity with a range of cartilage grafting techniques is critical to the surgeon’s repertoire. A combination of tip suturing techniques is needed in ethnic rhinoplasty; however, overly exaggerated modification is to be avoided. Skin redraping is done throughout the process of dorsal modification and tip shaping to assess the influence of each maneuver on the external surface. The cartilaginous frame should be fashioned by maneuvers that increase tip support and add refinement. Selective debulking of the nasal skin/soft tissue envelope improves its contractile response to the underlying architecture. Ethnic patients, in particular, are counseled on the prolonged postoperative healing and instructed on self-taping to help with edema.

Although ethnic rhinoplasty is far more complicated than in Caucasian patients, excellent outcomes can be obtained by experienced surgeons who recognize that the ultimate goal is nasofacial harmony.

Ethnic rhinoplasty – open rhinoplasty – African nose – Middle Eastern nose – Hispanic nose

20 The Ethnic Nose

Key Points

Patient selection and management of expectations are prerequisites to achieving good outcomes and patient satisfaction in ethnic rhinoplasty.

Although a variable spectrum of nasal morphology exists within each ethnic group, certain characteristics are generally present and can overlap with other ethnicities (Table 20.1).

**Table 20.1** A summary of ethnic variations and common anatomic features in the African, Middle Eastern, and Hispanic nose
	Caucasian	Black	Middle Eastern	Hispanic
	Caucasian	Black	Middle Eastern	Castilian	Mexican American	Mestizo	Creole
Frontal view	Equally proportioned vertical fifths and horizontal thirds of face	Wider middle fifth, shorter middle third of face	Equally proportioned vertical fifths and horizontal thirds of face	Equally proportioned vertical fifths and horizontal thirds of face	Equally proportioned vertical fifths and horizontal thirds of face	Variable vertical fifths and horizontal thirds of face	Wider middle fifth, shorter middle third of face
	Nasal length two-thirds of midfacial height	Short nasal length	Short nasal length	Nasal length two-thirds of midfacial height	Nasal length two-thirds of midfacial height	Nasal length two-thirds of midfacial height	Short nasal length
	Symmetric DAL	Symmetric DAL	Asymmetric DAL	Symmetric DAL	Symmetric DAL	Symmetric DAL	Symmetric DAL
	Bony vault 80% of base width	Wide dorsum	Wide dorsum	Bony vault 80% of base width	Bony vault 80% of base width	Wide dorsum	Wide dorsum
	Alar base width equals intercanthal distance	Wide alar base width	Alar base width equal to or less than intercanthal distance	Alar base width equals intercanthal distance	Alar base width equals intercanthal distance	Wide alar base width	Wide alar base width
	Symmetric tip defining points	Bulbous tip; less-defined tip defining points	Bulbous tip; less-defined tip defining points	Symmetric tip defining points	Symmetric tip defining points	Bulbous tip; less-defined tip defining points	Bulbous tip; less-defined tip defining points
Lateral view	Radix between lash line and supratarsal crease	Less projected and caudally located radix	Overprojected and cranially located radix	Radix between lash line and supratarsal crease	Caudally located radix	Radix between lash line and supratarsal crease	Less projected and caudally located radix
	Smooth dorsum	Low dorsum	Dorsal hump	Increased projection	Illusion of dorsal hump	Underprojected tip	Low dorsum
	Projection two-thirds of ideal length	Decreased projection	Increased projection	Projection two-thirds of ideal length	Decreased projection	Projection two-thirds of ideal length	Decreased projection
	Supratip break	No supratip break	No supratip break	Supratip break	No supratip break	Supratip break	Supratip break
	NLA (male, 90–95 degrees; female, 95–100 degrees)	Increased NLA; retracted columella	Decreased NLA; hanging columella; dependent tip	NLA (male, 90–95 degrees; female, 95–100 degrees)	Decreased NLA	NLA (male, 90–95 degrees; female, 95–100 degrees)	Increased NLA
Basal view	Appears as equilateral triangle	Variable shape	Deviated and overprojected tip	Appears as equilateral triangle	Underprojected tip	Underprojected tip	Variable shape
	Tip to columella ratio is 1:2	Short columella	Short columella	Tip to columella ratio is 1:2	Tip to columella ratio is 1:2	Short columella	Short columella
	Symmetric nostrils with teardrop shape	Horizontally oriented nostrils; splayed MFP	Asymmetric nostrils; splayed MFP; deep soft triangles	Symmetric nostrils with teardrop shape	Symmetric nostrils with teardrop shape	Symmetric nostrils	Asymmetric nostrils; splayed MFP
Abbreviations: DAL, dorsal aesthetic lines; MFP, medial crural footplates; NLA, nasolabial angle. Source: Adapted from Villanueva NL, Afrooz PN, Carboy, JA, Rohrich RJ. Nasal analysis: considerations for ethnic variation. Plast Reconstr Surg 2019;143(6).

Patients generally fall into two categories: those whose desire a nose aligned with Caucasian ideals, and those who want to preserve their ancestral traits.
The surgeon must recognize which presenting traits require which treatments and what combination of techniques will ultimately produce a racially congruent aesthetic result.
Familiarity with a range of cartilage grafting techniques is critical to the surgeon’s repertoire.
A combination of tip suturing techniques is needed in ethnic rhinoplasty; however, overly exaggerated modification is to be avoided.
Regardless of ethnic origin, the ultimate goal is to create nasofacial harmony.

20.1 Preoperative Steps

A thorough approach to nasofacial analysis is critical to achieving harmony and balance in ethnic rhinoplasty.

Appreciate the most common goals in rhinoplasty among different ethnic groups (Table 20.2).

**Table 20.2** A summary of the most common goals in rhinoplasty for the African, Middle Eastern, and Hispanic nose
Black	Middle Eastern	Hispanic
Black	Middle Eastern	Castilian	Mexican American	Mestizo and Creole
Correct dorsal/base disproportions Balance rhinoplasty Dorsal augmentation with/without osteotomies usually needed Skin/soft tissue debulking and wide undermining needed; helps with lateral redraping of nasal skin envelope Enhanced tip projection and definition Reduce, yet maintain subtle alar flaring Decrease interalar distance	Smaller nose Functional reduction rhinoplasty with a moderate dorsal (avoid over resection) Narrow the wide and long nasal bones Debulk fibrofatty tissue (especially in the supratip and paradomal areas) Define nasal tip through controlled, cartilage preserving techniques Avoid overcorrection of NLA and over-rotation of nasal tip Correct tip under-projection with proper rotation and middle/medial crura suturing Address hyperdynamic tip through treatment of depressor septi nasi muscle Reposition/reduce alar bases Correct nostril tip imbalance Use struts and invisible grafting techniques whenever possible	Smaller nose Functional reduction rhinoplasty with a significant dorsal reduction Radix may require reduction/deepening to distinguish nasal root and dorsal profile Usually tip is adequately projected or evenly overprojected, (address through simple volume reduction and tip refinement) Spreader graft if significant open roof or deviation present Need substantial narrowing of the bony vault (use low-to-low and transverse osteotomies for complete mobilization)	Straighter profile with gentle set-off of the tip Finesse rhinoplasty DCFG for radix/dorsal augmentation (avoid partial length grafts); become visible under the thin skin near the rhinion Usually does not require osteotomies nor caudal septal resection Open tip suture technique to reposition/shape alar cartilages (minimal resection) Onlay tip grafts to gain projection and definition if tip suturing alone is inadequate	Correct dorsal/base disproportions Balance rhinoplasty Maximally change the base first, then dorsal augmentation, only if required Skin/soft tissue debulking and wide undermining needed; helps with lateral redraping of nasal skin envelope DCFG if radix/dorsal augmentation needed (common for Creole nose) Usually combined nostril sill/alar wedge resection is needed (reduces both nostril size and alar flaring) Use alar rim grafts to avoid notching of the alar rim Usually no need for osteotomies Tip definition
Abbreviations: DCFG, diced cartilage facial graft; NLA, nasolabial angle. Source: Adapted from Rohrich RJ, Ghavami A. Rhinoplasty for the Middle Eastern nose. Plast Reconstr Surg 2009;123(4).

Evaluate each nose individually, define problematic areas across nasofacial morphologies, and recognize anatomical features that allow for ethnic congruity (Fig. 20.1a–c).

Fig. 20.1 (a) Middle Eastern nasofacial morphology. (b) African American nasofacial morphology.

Fig. 20.1 (Continued). (c) Hispanic nasofacial morphology.