Ethnic rhinoplasty, a procedure changing the features of noses of East Indians, Creoles, Afro-Americans, Afro-Caribbeans, Asians and Hispanics or Arabs, is one of the most frequently sought after facial cosmetic procedures in Trinidad and the Caribbean.
It is the specifics of the underlying anatomy of the bony and cartilaginous framework of the nose, which make ethnic rhinoplasty really a different ball game than Western rhinoplasty, almost a completely different discipline. The grand objective of the procedure however is very similar. Ethnic clients desire extremes of appearance to be corrected and brought closer to what they consider the norm for their ethnic group and in harmony with their individual faces. It is rare that we see ethnic clients who desire the looks of a ”Western” nose. We approach this rare desire with extreme caution as it may not be technically possible to satisfy it while at the same time it could be evidence of lack of identification with the natural ethnic group, a psychological phenomenon which cannot and should not be approached with surgery.
The anatomical difficulties in ethnic rhinoplasty affect all layers of the nose. The often extremely thick and oily skin particularly over the tip of the nose acts like a thick blanket smudging the contours of the underlying cartilages of the nasal tip. The looks of a sculpted, chiseled tip often seen in fair skinned Western models or actresses / actors are thus often impossible to achieve. Attempts to thin the skin envelope to a degree that the shape of tip cartilages ”shines through” may result in incorrectible disasters. The nose of a now deceased American pop icon sets an example for posterity. The only advantage of thick skin in ethnic clients is the natural camouflage it provides to even substantial irregularities of the framework of bone and cartilages, which may arise after rhinoplasty. The problem of skin thickness is not uniform across ethnic subgroups. It ranges from manageable in some East Asians and East Indians to extremely difficult in some Afro-Caribbeans and Hispanics with strong Indio influences.
The overwhelming majority of noses in Afro-Caribbeans and East Asians as well as numerous Hispanics of Indio descent are characterized by a low and flat bridge, an extremely wide and amorphous tip without projection beyond the height of the bridge but with large nostrils. The bony and cartilaginous framework of the nose is weak in its entirety.
As opposed to classic rhinoplasty in ”Western” noses augmentation of the tip as well as the bridge are necessary under these circumstances to strenghten the framework and achieve increased tip projection as well as height of the bridge, but the base of the nose with its wide nostrils has to be substantially reduced. All in all the exact opposite of the surgical manoeuvers most frequently performed in Caucasian noses. Thus ethnic rhinoplasty is not just a variant of rhinoplasty, it is really an entirely different operation and clients as well as their surgeons should better get their mindset adjusted to this difference before planning a trip to the operating room.
From a technical standpoint augmentation of the nose is a master class exercise, with some trapdoors and no shortcuts. Augmenting both the tip and the bridge requires a considerable amount of material to achieve visible effects in addition to possible internal stents to maintain or improve breathing function. The amount of material needed is in excess of what the only rational donor site in the nose itself, the wall separating the two halves of the nose on the inside, can provide. Donor sites outside the nose thus are necessary. Ignoring this necessity is one of the major pitfalls in ethnic rhinoplasty as it directly opposes the dictum ”Do not get caught, least of all in a difficult nose, without enough donor sites and graft material”. The principal graft material for nose augmentation (just another term for ethnic rhinoplasty) is cartilage, the rubbery material you can feel when you pinch your ears. It is available easily from the ears and ribs. Harvest usually does not leave any deformity at either site if done with sufficient expertise. However, it would not be ethnic rhinoplasty if there were not a catch. In those clients with the greatest need for grafting, namely Afro-Caribbeans and Afro-Americans, there is a non negligible risk of unfavorable scarring at both the rib and ear donor sites. In our experience with several hundred autologous grafts taken from these donor sites for various purposes including ethnic rhinoplasty this risk is significantly lower in all other ethnicities. The other structural graft material is bone. Used much less frequently today, it is available from ribs as well as skull. The latter is usually understimated as a donor site in cosmetic surgery and often regarded as ”difficult” and ”lengthy” to harvest. For craniofacial surgeons however it is the bread and butter bone donor site for facial applications, which has served us well during our academic careers in craniofacial surgery and now continues to deliver in private practice. In ethnic clients it has the advantage of a donor site well camouflaged by most popular female hairstyles with a very low risk of keloid formation even in Afro-Caribbeans. Lastly, soft wraps similar to the peel of a sausage used to envelope firm structural grafts are obtained through a small scalp incision from connective tissue on top of the skull’s bone.
All sounds involved, lengthy and somewhat costly? And you just watched that video on the internet, less than five minutes total running length, where Dr. Ozandso, a famous hemorrhoid specialist, just put some rubber implant in through a hidden incision, squirted some permanent filler around it for good measure, and done? In nasal augmentation a shortcut is truly tempting. Interestingly, artificial implants are the older method of nasal augmentation. Joseph’s famous book already describes implants for the nasal bridge made from ivory or gold, without giving any mention to long term results, side effects or complications. Off the shelf implants are made today of medical grade silicon or derivatives of polytetrafluorethylene. On paper they represent attractive options for nasal augmentation, for surgeons and clients alike. The results after implantation are immediate, permanent and more significant than what can be achieved with the body’s own material. As opposed to the limited donor sites available for cartilage and bone, artificial implants are mass produced without any shortages. No additional scars or potential problems are created at donor sites. The procedure to insert them is short, with little postoperative swelling and a brief recovery phase. Nasal augmentation with artificial implants is likely the most frequent variant of ethnic rhinoplasty worldwide due to the large number of procedures performed in East Asia and Pacific Rim countries, usually under local anesthesia in an office setting as a true lunchtime procedure (note that we did not say that any of this is pleasant or pain free).
However, as you are likely aware by now, there are no free lunches in plastic surgery. The downsides of artificial nasal implants are significant. Sliding and mobility of implants with a subsequently very funny looking nose are one. The most serious complications are infection and exposure of the implant, often through the external nasal skin after thinning and often some loss of the overlying soft tissue envelope, a true worst case scenario and the one disaster in rhinoplasty that can only be incompletely corrected in this world. Dr. Ozandso says he has never seen any of these complications? Probably true, as once a major implant related disaster occurs after nose surgery, affected clients predictably congregate in the offices of those few rhinoplasty specialist – capital R, capital S – who are for one willing to deal with the issue and for other have the technical capabilities and experience to make the best out of a worst case scenario. In the not so distant past the true magnitude of implant related problems in rhinoplasty was by and large unknown. Most ”Western” plastic surgeons only performed a limited number of ethnic rhinoplasties and were trained to perform the procedure without the use of implants. Sure, we all were referred the occasional implant disaster, often in returning medical tourists from South America, Eastern Europe or Middle East, and whenever it occurred we renewed our vows to keep our hands off these devilish little devices for eternity. The big wake-up call came when Asian plastic surgeons with extensive experience in the use of artificial implants in the nose (and we are talking about thousands of procedures) finally started to publish their results in major Western plastic surgery journals. The numbers were appalling – even though often only problems serious enough to warrant removal of the implant either due to malposition, infection or exposure were reported as true complications and they did not really worry about silly little things such as the client maybe not liking the result, the rate of occurrence of these worst case scenarios often exceeded ten to fifteen percent. In other words, after nasal augmentation with artificial implants performed by the best of the best in this field, at least one out of ten to one out of seven patients ended up with an incompletely correctable problem. The issue is not surgical technique or bad luck, but the fact that a foreign body is implanted into a location where it has no business of being in the first place, which is an error in surgical judgment and procedure design. Permanent fillers in the nose, touted as ”non surgical” or ”minimally invasive” rhinoplasty on Dr. Ozandso’s radio ad have exactly the same drawbacks as solid implants, maybe even more severe as they can only be incompletely removed. Due to consumer choices we have however the impression that in our own practices the number of patients referred to us for filler related disasters in the nose will in the not so distant future exceed the number of worst case scenarios after use of artificial implants in the nose.
Are implants made out of the body’s own tissues without fault just by virtue of being biocompatible? Certainly not. Sometimes the body digests part of them resulting in loss of some of the achieved augmentation, solid implants of bone or cartilage feel hard, sometimes produce visible edges, occasionally warp or slide with concomitant changes in the shape of the nose, just to name a few problems. A major disaster, a worst case scenario after augmentation rhinoplasty with the body’s own cartilage or bone however is like the proverbial black swan, theoretically possible, but very rarely seen in real life. And this is how plastic surgeons actually think – if I do this procedure what is the possible worst case scenario and can I still manage it? If the answer is yes, well, consider doing it, otherwise hands off. As opposed to Dr. Ozandso, who may at some point think better of it and go back doing just hemorrhoids as he was trained to do, as plastic surgeons we are in for the long run. One or two complications we cannot recover from will ruin an otherwise brilliant year – emotionally, physically and for a surgeon’s reputation. So plastic surgeons first and foremost try to avoid complications, particularly in cosmetic surgery, where risk-to-reward ratios tend to be quite narrow and any lingering complication from uncontrolled risk taking behavior, failed shortcuts or unwarranted cost saving efforts will erase the memory of dozens of good to excellent results in no time.
Fortunately, ongoing innovation in the use of cartilage graft has resulted in techniques which today avoid most complications associated with solid grafts. Instead of the large pieces of cartilage with their risk of sliding and warping we manufacture those grafts during the operation. Any piece of cartilage regardless of size and shape is diced, much the way onions are for cooking. These small morsels are then packed into a connective tissue tube. The entire construct resembles a sausage – outside peel, inside content. It continues to be fully biocompatible, has no sharp edges, is relatively soft, does not warp, can be filled with diced cartilage according to the amount of augmentation desired (within limits!) and like putty can be shaped after its insertion. There is barely any resorption and the numerous small morsels of cartilage eventually solidify, yet without producing visible edges or warping. Thus what one sees is what one gets. With this improvement of operative technique there really is not any longer any medical reason not to use the body’s own material as grafts. Increased cost of the procedure and donor site issues need to be addressed during consultation.
In ethnic rhinoplasty considerable variation exists in different ethnic groups. Not all require augmentation of the nasal bridge as is indispensable in most East Asians, Afro-Caribbeans, Creoles and Hispanics of Indio descent. In the East Indian ethnic group in the Caribbean we usually observe a high enough bridge, which sometimes has to be narrowed without lowering it. The skin over the nasal tip is usually relatively thick. The tip can made to appear more projecting and sculpted by inserting grafts. Usually the wall separating the two halves of the nose on the inside is able to provide enough material for the tip and any stents needed internally to preserve or improve breathing function. Further along the spectrum are (Castilian, non Indio) Hispanic and Arab ethnic groups. Tip grafts are used more and more often to impart a more sculpted look despite thick skin, projection is usually not an issue as more often than not the bridge of the nose shows humps requiring removal, much like in a Caucasian nose, thus adjusting the relationship between bridge height and tip projection. The need for donor sites outside the nose in these ethnic subgroups becomes an exception.
Whenever grafts are employed, optimum visualization of the underlying anatomy and precise placement with suture fixation of all grafts assumes paramount importance. Thus our technique of choice for all ethnic rhinoplasties is the open approach. The small incision in the external skin of the pillar in between the two nostrils heals well in all ethnicities and becomes virtually imperceptible after a couple of weeks even in very dark Afro-Caribbeans. In ethnic rhinoplasty the small incision necessary for an open approach should even be less a point of contention as additional external incisions are very often necessary where the sidewall of the nostrils join the cheek and lips used to narrow the often markedly wide base of the nose and large nostrils. Fortunately, these incisions heal as well as the incision for the open approach. Overall, a very small price to pay for a better and more complete result in ethnic rhinoplasty.
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