The Clinical Problem ( Fig. 18.1 )
The term Middle Eastern commonly refers to people of Turkish, Persian, Arabic, and North African descent. Although a large variety of nasal features can be seen, the population in Turkey usually presents with a mixture of Middle Eastern and Mediterranean nasal morphology.
Synopsis
Middle Eastern–Mediterranean patients possess a varied combination of nasal characteristics :
- 1.
There is a significant dorsal hump.
- 2.
A poorly defined nasal tip is present.
- 3.
The nasal bones are usually thick and long.
- 4.
Septal deviation is common and is often visible externally.
- 5.
The nasal length is often disproportionately long relative to the tip projection.
- 6.
A droopy nasal tip with an acute columellar-labial angle is seen frequently.
- 7.
The lower lateral crura and medial crura may be long and strong. In these cases, the tip complex is usually displaced caudally, away from the anterior septal angle, which may need significant maneuvers to improve its projection and position. Alar flaring and increased interalar width are also common.
- 8.
Thick nasal skin, with a highly sebaceous texture, is frequently seen, particularly at the nasal tip, lobule, and alar rims.
Thorough preoperative analysis and diagnosis of the deformities are essential for a successful rhinoplasty. After the diagnosis is determined, the goals of surgery are established, and a treatment plan is formulated according to the deformities that are present.
Surgical Preparation and Technique
Reduction of Dorsal Hump
In the vast majority of Middle Eastern–Mediterranean patients, reduction of a dorsal hump is required. The open rhinoplasty approach provides better visualization of nasal dorsum anatomy, including the nasal bones and upper lateral cartilages (ULCs), and easier execution of maneuvers such as hump removal, spreader flaps or spreader grafts, osteotomies, and onlay grafts. I describe a different concept of nasal dorsum dissection the perichondroperiosteal flap (PPF), and I have used this method since 2005 in 1800 cases.
Elevation of the dorsal nasal skin flap is in a supraperichondrial plane. A vertical midline incision is performed to the perichondrium of the medial ULCs, starting from the caudal border of the nasal bone and extending caudally up to the anterior septal angle using a No. 15 blade ( Fig. 18.2A ).
Then, using a semisharp, 2-mm Freer elevator, the perichondrium is elevated on both sides (see Fig. 18.2B ). After elevation of the perichondrium of the ULCs, the periosteal attachments at the caudal border of the nasal bones are divided using a sharp tip dissector or a No. 15 blade. The perichondrium of the ULCs and periosteum of the nasal bone are united, creating a continuous PPF on both sides ( Fig. 18.3 ).
The ULCs are then separated from the septum. The cartilaginous hump is reduced incrementally, preserving the ULCs.
A bony hump reduction is performed using a 6-mm straight osteotome ( Fig. 18.4 ). I avoid using a rasp to reduce a bony hump due to the risk of damage to the dorsal soft tissues and cartilages. Incremental resection of the dorsal hump is a very useful and safe method. It helps avoid excessive reduction from the dorsum and preserves the ULCs. Most Middle Eastern–Mediterranean patients request a conservative dorsal reduction. Excessive hump reduction may produce an ethnic incongruity.
I perform osteotomies using 2-mm straight osteotomes ( Fig. 18.5 ). These delicate tools are less traumatic to the adjacent tissues and produce less swelling compared to the larger osteotomes. In most patients, I perform a medial oblique osteotomy. A medial oblique osteotomy helps define the dorsal aesthetic lines while preserving the nasal bone on the radix area and helps prevent a rocker deformity.
After completion of a medial oblique osteotomy, low to low lateral osteotomies are performed internally. Low to low osteotomies help close any open roof, create a balanced dorsal aesthetic line, and prevent a lateral bony step-off. In most of my patients, I perform a transverse osteotomy as a greenstick fracture, using my thumb. In patients with very thick nasal bones, a wide bony pyramid, or a deviated bony pyramid, I perform an external transverse osteotomy using a 2-mm osteotome.
Spreader flaps are then used to restore the cartilaginous dorsum. The ULCs are used as the flaps are folded in and then sutured to the septum, using three or four horizontal mattress sutures ( Fig. 18.6 ). In most primary rhinoplasty cases, spreader flaps are sufficient for restoring dorsal aesthetic lines and preserving internal nasal valves. However, in patients with dorsal deviation or a narrow cartilaginous dorsum, spreader flaps can be combined with spreader grafts. In these cases, I place suture spreader grafts about 1 mm below the dorsal septum and approximate the ULCs on top of the spreader grafts with sutures ( Fig. 18.7 ). If there is a bony open roof deformity or irregularities, a thin onlay graft can be added. Any resected bony hump can be thinned with a blade to less than 0.5 mm in thickness and replaced between two nasal bones ( Fig. 18.8 ). Alternatively, a cartilage graft from cephalic resection of the lower lateral cartilage or a thin crushed graft from the septum cartilage can be placed to eliminate the open roof deformity and camouflage any irregularities. Suturing the PPFs with 5-0 catgut over the graft provides stable fixation.
