Rhinoplasty is at the moment one of the top five requested cosmetic procedures for both men and women in plastic surgery worldwide. The prominent position of the nose in the center of the face and its significance for the appearance of its bearer certainly contribute to the large number of rhinoplasties performed annually. Good results in rhinoplasty are dependent upon an understanding of the complex framework of bone and cartilage that make up the nose. Rhinoplasty surgery changes the shape of this framework which is then revealed through the overlying skin. Once the framework is crooked, the nose is crooked. However the the framework is configured thus the nose will appear.
Rhinoplasty is thus the one operation in cosmetic surgery where ethnicity of the client assumes an importance exceeding any other procedure in plastic surgery. While examples of ethnic preferences influencing the desired outcome of a procedure performed in areas of fairly uniform anatomic characteristics across ethnicities abound (e. g. buttock augmentation, tummy tuck, breast augmentation), rhinoplasty in Caribbean clients means dealing with anatomic variations, which are unique in each ethnic subgroup (East Indians, Afro-Caribbeans, Creoles, Hispanics, Arabs, East Asians and so forth). Ethnic preferences are sociocultural phenomena, anatomic variants on the other hand arise as a consequence of differences in the genetic programming responsible for facial growth and development – a biologic phenomenon.
It is hard to think of any other operation in cosmetic surgery where experience, technical and artistic capability as well as understanding of the materials bone, cartilage and skin by the surgeon play as big a role as in rhinoplasty. A lot of it can be taught and learned, but unfortunately not those fine nuances that transform a good into a brilliant result. In the daily reality of the practice of cosmetic surgery brilliant results may get a paper accepted in a major journal or a presentation at one of the more important meetings in the field, good results are those, which are good enough to meet the client’s expectations.
One can picture the nose as a house. The shingles are the overlying skin, the framework and timbers are the cartilage and bone, and the drywall the nasal lining. The support that lies underneath the highest roof angle is the septum. What makes anyone’s nose look the way it does, like a house, is a reflection of how the framework is structured and the roof (skin) that drapes over this framework.
As plastic surgeons we think of the nose as four areas, the upper third which is bone, the middle third known as the middle vault which is all straight cartilage, and the lower third or the tip of the nose which is a combination of scroll-shaped cartilages that come together over the septum and give everyone their unique tip shape, which differs in subtle ways in any two individuals. The fourth area is the skin, which dependent upon its thickness, can show the underlying framework well if it is thin but can hide much of it if it is thick.
Ethnic variations in nasal anatomy affect skin thickness, height and width of the framework, its degree of structural stability as determined by the firmness of its components and so forth. Rhinoplasty in the Caribbean is thus really a world apart from the operation bearing the same name in Europe or North America, just the same way as adobe hacienda is structurally very different from brick building while both fall into the category “house”.
Rhinoplasty means surgically changing the framework of cartilage and bone of the nose. Examples of such changes are the reduction of the height of the gable of the nose (reducing the hump of the bridge of the nose), shaping of the lower scroll shaped cartilages to refine the tip of the nose, narrowing the gable of the nose by osteotomies (controlled fractures of the bones of the nose) or an increase of the height of the gable by inserting cartilage or bone grafts.
Due to the complexity of how all of these framework structures come together, most rhinoplasties today are done ‘open’ with a small incision across the pillar in between the two nostril openings. While this used to be a controversial area (what was known as the most contested 6 millimeters of skin on the body), it is now accepted to produce the best results in most nose surgeries. All that this means is the skin is lifted off of the tip of the nose so all the framework structures can be seen. To no surprise, you can shape better what you can see better. This only leaves a nearly imperceptible scar at the middle of the skin between your nostrils. (known as the columella) This is a very small price to pay for a better rhinoplasty result!
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