Revision Rhinoplasty of the Ethnic Nose

13 Revision Rhinoplasty of the Ethnic Nose
Jennifer Parker, Porter

Revision rhinoplasty for the ethnic patient encompasses the usual tenets of revision rhinoplasty, as well as specific problems and complications unique to the ethnic nose. In particular, many variables differ, from the analysis of the nose to the implementation of an indicated surgical technique. Furthermore, many of the problems that crop up at the time of a revision or secondary rhinoplasty could be avoided with careful preoperative planning and elevation of the level of awareness of the basic differences between the nose of the White and non-White patients.

The appearance of the nose of patients with varying ethnic backgrounds, in fact, does differ from the White norm significantly.1–11 These normal differences should be understood, because we seek to create a natural-looking result for the ethnic patient, as opposed to an operated, unnatural look. To cover revision rhinoplasty as it applies to the various ethnic groups within the context of this chapter requires the focus to be on how the “ethnic” nose differs, based on the presentation of the patient, surgical concerns, and the surgical plan. With attention directed toward these issues, we can gain some insight as to how we should best treat these patients. Because the remainder of this book focuses on techniques and approaches to rhinoplasty for the population at large, I refer the reader to the indicated chapters for details on specific techniques, as well as the management of the Asian nose.

Patient Evaluation

Nasal Analysis

Aesthetic differences are seen in patients from a variety of ethnic backgrounds. The reader is referred to other articles for a more detailed discussion of the nuances of evaluation of the ethnic rhinoplasty patient.¹² Analysis of the nose is an essential element of the patient evaluation in preparation for rhinoplasty. Traditionally, nasal analysis was derived from the neoclassical canons of facial proportion developed by the artists and anatomists of the Renaissance. As the canons stand, they were exclusively based on White subjects, which were felt to be the ideal. These canons are the basis of the current methods of nasal analysis¹³; however, the majority of these proportional relationship have been found not to apply to the major ethnic groups that comprise the U.S. population. Increasingly, more studies find distinct differences between the North American White norm and the various ethnic groups.^1–11

Because the standard methods of analysis of the typical rhinoplasty patient are well known, the focus here will be on the differences seen in the patients with varied ethnic backgrounds. First and foremost, the skin thickness is evaluated and never assumed to be thick. The vertical fifths of the face typically reveal a middle third that contains an alar width that is wider than the intercanthal distance. In addition, the middle third of the horizontal thirds of the face is typically shorter than the upper and lower thirds.

On frontal view, there is a group of patients in which a break of the brow tip aesthetic line is seen, where the upper third is washed out secondary to splayed nasal bones and a low nasal dorsum. In addition, the inferior aspect of the brow tip aesthetic line is splayed slightly, related to the widened interdomal distance and increased skin thickness of the nasal tip. This is in contrast to another population of patients who have a convex nasal dorsum and vertically oriented lower lateral cartilages. In these patients, the brow tip aesthetic line is very well defined.

On the lateral view, variations in the height of the nasal dorsum are seen. The position of the nasion relative to the endocanthion can effectively divide patients into a low or high nasal dorsum group, where low nasal dorsum patients have a nasion that is caudal to the level of the endocanthion.⁶ This distinction can be helpful when evaluating the patient with respect to augmentation. In the unoperated ethnic patient, projection of the nasal tip is generally less than that of the White patient. As the height of the nose is generally less, the projection of the nose should be set suitably. The nasolabial angle is generally acute, exceeding 90 degrees in patients with a very short nose.

Examination of the nose from the base view reveals distinct differences, in particular regarding the shape of the nasal base. The shape is variable and deviates from the triangular appearance of the base in the White patient. The ethnic patient may have nostrils that are more rounded, as well as a tip that is bulbous to boxy. The columellar-to-lobule ratio is closer to 1:1 in ethnic patients, with an increase in the size of the lobule and a decrease in the length of the columella. Nostril shapes in the African American patient are highly variable and most often vertically or horizontally oriented, following distantly by the inverted orientation.⁶

Furthermore, in comparison to the White norm, it is noted that the African American nasofacial angle is greater, nasofrontal angle is less obtuse, nasolabial angle is more acute, intercanthal distance is uniformly narrower than the alar width, and columellar-to-lobule ratio is less, on average 1.5:1. Overall, we see changes consistent with increased width of the horizontal proportions.5,6

Although the White aesthetic standard may be applicable to Latino patients of European descent, people from Central America, South America, and the Caribbean have nasal features that are distinct from the White standard. One of the few studies that examined the proportion of the Latino nose was performed by Milgrim et al.¹¹ Grouping subjects based on their heritage, the authors found that Latino patients of Caribbean descent were closely associated with the African American norms, whereas Central and South American populations were more closely associated with the White norms. The authors also noted that the dorsal nasal breakpoint, defined as the cephalic margin of the lower lateral cartilages as viewed on the profile, was in a more cephalad position in the Caribbean population than the Central and South American populations, which in turn are in a higher position than the White population. In addition, the nasolabial angle was more acute in the Latino population than the White population.

The goal of redefining these relationships for the ethnic patient is not to produce a plethora of angles and proportions that we need to carry around in our head. Nonetheless, we do need to realize the following: (a) there are statistically significant differences found between these groups and the White norm; (b) the White norm should not be used when trying to evaluate non-White patients; (c) there is a tremendous amount of interethnic and intraethnic variability; and (d) if our goal is to achieve natural looking results, as we do for our White patients, then we need to embrace these differences and determine methods of achieving an ideal natural result. With these tenets in mind, we try to decipher what an ideal result would be for a given patient, based on the proportions of his or her face.

Patient Complaints

The initial preoperative consultation is critical to establishing expected outcomes. Based on the patients’ desires, I generally place them into one of two broad categories: those who strive for a nose that is balanced with their face and maintains their ethnic appearance or those patients striving for a more European or “White” look. Although the complaints are often similar for these two groups, it is the degree of correction desired that makes the surgical plan different. In particular, limitations and expectations should be carefully outlined. Because numerous papers have dealt with the ethnic nose and how to make it more White, this first category will be the focus of this chapter. For the ethnic revision rhinoplasty patient, complaints are often for the return to a natural looking nose.

The patient of ethnic descent can present with a multitude of chief complaints. These complaints vary based on whether the surgery is a primary or secondary surgery. Insight into the major complaint for the primary surgery helps us to understand the derivation of the complaints on presentation for the revision or secondary surgery.

Nose Too Big

For both primary and revision rhinoplasty, a frequent complaint is that the nose is too big. Specifics about which components the patient visualizes as too big should be addressed at this juncture with the aid of a mirror, because the dislikes differ from those of the typical White patient. Frequently, the term “big” is referring to the width of the nose. Complaints about width are noted in the upper, middle, and lower third of the nose. The patient often purports that the upper third is wide and there is a lack of a bridge or the nose is too flat. Increased width is also noted down into the region of the nasal tip and the alar base. Occasionally, patients are more concerned with the width of the alar base than the width of the nasal tip. Often, when the alar base width is of concern, the spread of the nose with smiling is a frequent complaint that follows. Again, these complaints may be noted at the revision stage as well. Generally, if the alar base was reduced previously, the alar base width is of little concern for the secondary surgery.

“Big” may also refer to the nose being parrot-like with a high nasal dorsum. As will be discussed later, this is often because of the combination of vertically oriented lower lateral cartilages and a convex nasal dorsum. Frequently, we see patients with persistence of this feature after the first attempt at rhinoplasty.

Revision Rhinoplasty Complaints

Once patients have presented for a second rhinoplasty, the majority of ethnic patients are found to have one of three problems. The first is related to communication with the surgeon, while the other two are related to technical issues.

One of the more common complaints is often related to a sense of miscommunication between the surgeon and the patient; specifically, whether the desired outcome of the surgeon superseded the desire of the patient, specific areas of concern were not addressed, there was no clear identification of the areas of dislike, or the patient failed to divulge true desires.

The second group of complaints is related to profile alignment. Profile changes involve augmentation through grafting or dorsal reduction. A graft placed at the first surgery, be it alloplastic or autogenous, may become dislodged from its intended position, infected pending extrusion, excessive in size, or not large enough. At the other end of the spectrum, the pollybeak deformity is encountered quite often.

The final complaint that is often heard is that there is a general lack of definition. Perhaps unrealistic expectations were set or the wants and desires of the patient were improperly communicated. Plastic surgeons habitually strive to achieve the same degree of nasal definition for ethnic patients as they do for White rhinoplasty patients. The result may be a nose that looks operated and unbalanced or a patient that is sorely disappointed, because the nose did not meet his or her expectations. Many patients seen for revision surgery are unhappy because they have an overreduced “White-looking” nose or there was a total disconnect with the surgeon on the desired outcome.

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