Technique for Ethnic Rhinoplasty by the Closed Technique

Shruti C. Tannan

Clayton Crantford

Mark B. Constantian

DEFINITION

Closed rhinoplasty allows the surgeon to achieve the patient’s aesthetic and functional goals as accurately as possible without introducing new deformities with the surgical approach.
Ethnic rhinoplasty refers to surgery of the non-Northern European nose that respects the aesthetics and particular challenges associated with a patient’s unique ethnic background. However, in practice, the distinction is somewhat artificial because each patient, regardless of his or her ethnic background, deserves a result that matches, as much as possible, the patient’s aesthetic goals and that takes into account the degree of change (or preservation) of ethnic, familial, or personal characteristics that the patient desires.
Specifically, some patients with distinctive familial, ethnic, or personal characteristics may wish to retain them, whereas others may want a type change. It is critical that the surgeon be aware of these expectations to prevent patient dissatisfaction with the surgical result.
As with all preoperative discussions, a conversation with the patient about his or her goals and expected outcomes should be a critical part of every rhinoplasty, ethnic or not.
The principles of forming and then performing the surgical plan do not differ; thus, ethnic rhinoplasty in many ways does not differ from any other rhinoplasty.
The surgeon must consider the technique that allows him or her to deliver what the patient wants while also maintaining his or her personal identity.
One of the most common motivations for secondary rhinoplasty is the loss of a familial, ethnic, or personal nasal characteristic.¹ For example, the surgeon may assume the dorsal hump is to be taken down, but the patient may prefer that the dorsal hump remain as a distinctive feature; this and all areas to be addressed during rhinoplasty should be discussed together preoperatively.
A detailed discussion of specific aesthetic goals with the patient is imperative. The closed approach offers the surgeon the ability to see the result on the table; therefore, it is possible to set goals and deliver.
Some patients intend to maintain some of the characteristics of their noses that are a part of their shared heritage, whereas others wish to alter them; it is up to the surgeon to initiate this discussion for a thorough understanding of the operative plan.

ANATOMY

Although there is a large spectrum of variability in the so-called ethnic nose, there are common characteristics and features. It is important to recognize these findings in advance so that a preoperative discussion is complete and so the operative plan addresses the concerns the patient wishes to alter while maintaining the characteristics the patient wishes to preserve.
Four anatomic findings place all patients at high risk for unfavorable results and should be identified preoperatively.²
- Low radix or low dorsum
  - Dorsal length and height, balanced against lower nasal size, determine the attractiveness of nasal proportion. A low radix or low dorsum begins caudal to the level of the upper lash margin with the patient’s eyes in primary gaze.
  - When the radix begins low, nasal length is shorter and the nasal base size therefore appears larger. The surgeon must raise the dorsum segmentally or entirely to balance the patient’s nasal base. In thicker-skinned patients, the strategy is particularly attractive because it requires less soft tissue contraction.
  - However, dorsal length must also be balanced against nasal base size. In patients with a very short nasal base (eg, some Asian noses), the radix should begin lower than the upper lash margin. Ethnicity and patient preference is one aspect; good nasal proportion is another.
- Inadequate tip projection
  - Tip projection reflects cartilage strength, not skin volume, specifically the length of the alar cartilage middle crust. Adequate tip projection, in which the tip supports itself independent of dorsal height, is necessary for a straight profile line.
  - A tip with inadequate projection is any tip that does not project to the level of the anterior septal angle. Adequately projecting tips do not need increased support, whereas inadequately projecting tips do.
  - A patient may have a large nasal base but still have inadequate tip projection. An oversized, unbalanced lower nose does not mean that the patient has excessive tip projection.
  - Failure to recognize inadequate tip projection causes dorsal over-resection, supratip deformity, and deformity from soft tissue contraction.
- Narrow middle vault
  - A narrow middle vault signals an internal valve that is already compromised.
  - The middle vault narrows following cartilaginous roof resection, so hump removal can inadvertently worsen the airway. Resection of even 2 mm of the cartilaginous roof during hump removal ablates the stabilizing confluence that braces the middle vault, which can now collapse toward the anterior septal edge, restricting airflow at the internal valves and producing a characteristic inverted “V deformity.”
  - Reconstruction of incompetent internal valves by either dorsal or spreader grafts doubles mean nasal airflow in most patients.³
- Alar cartilage malposition
  - Describes cephalically rotated lateral crura whose long axes run toward the medial canthi instead of toward the lateral canthi.
  - The abnormal cephalic position of the lateral crura places them at special risk if an intercartilaginous incision is made at its normal intranasal position. This will transect the entire rotated lateral crus instead of splitting the intended cephalic portion.
  - The majority of malpositioned lateral crura do not provide adequate external valvular support, leading to external valvular incompetence in addition to boxy or ball tips.
  - Adequate treatment of cephalic rotation of the lateral crura requires resection and replacement of these structures, relocation of the lateral crura to support the external valves, or supporting the areas of external valvular collapse with autogenous grafts.
  - Correction of external valvular incompetence doubles mean nasal airflow in most patients.⁴

PATIENT HISTORY AND PHYSICAL FINDINGS

Patient history
- Airway and aesthetic concerns
- History of prior nasal trauma
- Airway obstruction
Internal nasal exam
- Valves
- Septum
- Turbinates
External nasal exam
- Cartilage size and substance
- Bony vault length
- Nasal sidewall stiffness
- Soft tissue thickness/distribution
  - Soft tissue thickness determines the degree of reduction possible and the character of augmenting or stabilizing grafts. Soft tissue distribution determines ultimate nasal size and proportion.
- Nasal shape overall: width, length, bridge contour, tip shape, nostril size, columella and upper lip position, and any asymmetries.

IMAGING

Software imaging systems exist that allow improved communication between surgeon and patient, although it represents a simulated, not guaranteed result. Imaging is only useful if the surgeon can simulate those structural and contour changes that the patient’s anatomy and biological principles will permit.

SURGICAL MANAGEMENT

The objectives of ethnic rhinoplasty are in keeping with the goals of as any other rhinoplasty: to achieve the patient’s aesthetic and functional goals as accurately as possible without introducing new deformities.
The closed approach to ethnic rhinoplasty offers many advantages.
Closed rhinoplasty requires less dissection, always allowing the surgeon an undisturbed view of the nasal surface, which determines 50% of the final outcome.
Closed rhinoplasty allows the surgeon the ability to control tip contours more accurately because there is less intraoperative soft tissue manipulation and the dorsal and tip skin never leave their preoperative positions.
Tip grafts are easier to place in precise pockets in closed rhinoplasty because they do not have to be sutured into place. Multiple grafts of different thickness and substance can be placed to create particular aesthetic goals because the surgeon controls the soft tissue pocket. These techniques are not possible through the open approach.
Columellar struts are never needed because the medial crura are not routinely disrupted from the adherent columellar skin and tip projection is not routinely lost through the closed approach access.
Fewer variables are introduced by the surgical approach, and this reduces postoperative problems and greatly decreases the chance of new iatrogenic deformities.
Closed rhinoplasty avoids problems that are almost unique to open rhinoplasty: columellar widening or notching, significant alar rim, and alar cartilage distortions.
There are no contraindications to the closed approach to rhinoplasty, as this approach allows the surgeon to minimize morbidity in even the most difficult of cases.