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CHAPTER TWENTY-EIGHT  Short Nose
353
Closure and dressing of the surgical site were done in the
usual fashion.
CASE 3
A 32-year-old woman had undergone two previous reduc­
tion rhinoplasty procedures to “make the nose smaller.”
She presented with an excessively shortened nose and
overrotated tip. She also had a deep and low nasion that
started caudal to her superior palpebral fissure (Figure
28-5). The goal was to correct her severely retracted nose.
The nose was recessed and the SSTE was elevated.
Exposure of the lower lateral cartilages revealed bossae of
the right intermediate crus, and this was conservatively
reduced. Autologous costal cartilage was simultaneously
Figure 28-3  Placement of a three-layered tip graft comprised of autolo­
gous conchal cartilage.
Figure 28-4  Preoperative (A, C, E) and 12-month postoperative (B, D, F) photographs of a 30-year-old man with a congenitally short, upturned nose
after dome division, wedge resection of membranous septum, and placement of a columellar strut and a multilayered conchal cartilage tip graft.
A
B
D
F
C
E

354
Michael M. Kim • Tom D. Wang
dorsum and into a columellar pocket, respectively. A
wedge was resected from the caudal aspect of the dorsal
graft to accommodate the anterior-most portion of the
columellar graft. These were then sutured in place to
create a stable L-strut. Then, the lower lateral cartilages
were stabilized onto the columellar graft in a tongue-
and-groove manner. Subsequently, a multilayered tip
graft was placed and the nose was closed and dressed.
CASE 4
A 63-year-old Asian woman presented 45 years after aug­
mentation rhinoplasty performed in Japan with a dorsal
Silastic implant. She featured a severely retracted and
overrotated nose and refused to consent for costal carti­
lage harvest (Figure 28-6). After an open approach and
harvested. An obliquely oriented incision over the left
eighth rib was made with a No. 15 blade. Dissection of
the musculature was achieved by spreading down to the
level of the rib cartilage. The anterior portion of perichon­
drium and costal cartilage was incised medially and later­
ally. The posterior perichondrium was left intact while the
cartilage was removed from the patient in a subperichon­
drial plane. Saline irrigation was poured into the wound,
and a Valsalva maneuver was provided by the anesthesia
team. After confirming the absence of an air leak, the
wound was closed in layers.
The outer cortex of the costal cartilage was removed
off from the central core. The remaining cartilage was
allowed time to warp. Once the cartilage had stabilized to
its natural curvature, a canoe-shaped dorsal graft and a
columellar strut were fashioned and placed over the
Figure 28-5  Preoperative (A, C) and 6-month
postoperative (B, D) photographs of a 27-year-
old woman after revision rhinoplasty, which
included costal cartilage harvest for placement of
a dorsal augmentation graft with interdigitating
columellar strut and a layered cartilage tip graft.
Bilateral malar implants were also placed.
A
B
D
C

CHAPTER TWENTY-EIGHT  Short Nose
355
Figure 28-6  Preoperative (A, C, E, G) and 5-month post­
operative (B, D, F, H) photographs of a 63-year-old woman
following revision rhinoplasty, which included the removal
of a previously placed Silastic implant and placement of a
MedPor sheet for columellar grafting and a Gore-Tex SAM
implant for dorsal reaugmentation. The patient also under­
went concomitant revision blepharoplasty and revision face
and neck lift.
E
F
A
B
C
D
Continued

356
Michael M. Kim • Tom D. Wang
G
H
Figure 28-6, cont’d.
elevation of the SSTE, a displaced dorsal Silastic implant
was removed. An open septoplasty was performed expos­
ing the caudal end of the septal cartilage. A Medpor sheet
was cut in a triangular shape and sutured to the septal
cartilage as a caudal septal extension graft. Subsequent
tongue-and-groove fixation of the lower lateral cartilages
to the extension graft was performed. Last, a layered tip
graft created from autologous auricular cartilage was
placed and the dorsum was reaugmented with a carved
Gore-Tex SAM dorsal implant. The nose was then closed
and dressed in the usual fashion. The patient also under­
went concomitant revision blepharoplasty and revision
face and neck lift.
SUMMARY
Lengthening the short nose is one of the most challenging
problems facing rhinoplastic surgeons, and many different
nasal lengthening techniques have been described. As is
the case with many surgical challenges, the presence of
myriad operative techniques underscores the fact that
there is not one single ideal technique. However, a working
knowledge of using these operative maneuvers alone
and in combination is necessary to produce optimal
outcomes.
REFERENCES
1. Millard DR. Three very short noses and how they were
lengthened. Plast Reconstr Surg. 1980;65:10–15.
2. Powell N, Humphreys B. Considerations and components of
the aesthetic face. In: Smith JD, ed. Proportions of the
Aesthetic Face. New York: Thieme-Stratton Inc; 1984:20–26.
3. Naficy S, Baker SR. Lengthening the short nose. Arch
Otolaryngol Head Neck Surg. 1998;124:809–813.
4. Jackson IT, Reid CD. Nasal reconstruction and lengthening
with local flaps. Br J Plast Surg. 1978;31:341–348.
5. Dingman RO, Walter C. Use of composite ear grafts in
correction of the short nose. Plast Reconstr Surg. 1969;43:
117–123.
6. Kamer FM. Lengthening the short nose. Ann Plast Surg.
1980;4:281–285.
7. Giammanco PF. Lengthening the congenitally short nose. Arch
Otolaryngol Head Neck Surg. 1987;113:1113–1116.
8. Gruber RP. Lengthening the short nose. Plast Reconstr Surg.
1993;91:1252–1258.
9. Gunter JP, Rohrich RJ. Lengthening the aesthetically short
nose. Plast Reconstr Surg. 1989;83:793–800.
10. Toriumi DM. New concepts in nasal tip contouring. Arch
Facial Plast Surg. 2006;8:156–185.
11. Dyer WK, Beaty MM, Prabhat A. Architectural deficiencies of
the nose: treatment of the saddle nose and short nose
deformities. Otolaryngol Clin North Am. 1999;32:89–112.
12. Guyyron B, Varghai A. Lengthening the nose with a tongue-
and-groove technique. Plast Reconstr Surg. 2002;111:
1533–1539.
13. Toriumi DM, Patel AB, DeRosa J. Correcting the short nose in
revision rhinoplasty. Facial Plast Surg Clin North Am. 2006;
14:343–355.
14. Burke AJ, Wang TD, Cook TA. Irradiated homograft rib
cartilage in facial reconstruction. Arch Facial Plast Surg.
2004;6:334–341.
15. Anderson JR. A reasoned approach to nasal base surgery.
Arch Otolaryngol Head Neck Surg. 1984;110:349–358.

357
C H A P T E R T W E N T Y - N I N E 
Asian Rhinoplasty
Samuel M. Lam
Cosmetic surgery for the Asian nose stands in marked
contradistinction to that for the Western nose in that its
objectives can be the opposite in many cases (i.e., aug­
mentation rather than reductive rhinoplasty). However,
an Occidental ideal for rhinoplasty has often been used
for the Asian patient, leaving an individual with too high
a nasal dorsum and too narrow a tip for his or her ethnic­
ity. This monograph will introduce modified standards for
the ethnic nose so that a surgeon who is unfamiliar with
the Asian patient can create an aesthetically pleasing
result that is ethnically sensitive but, even more impor­
tant, that appears natural. A dimension that should not
be ignored during the preoperative evaluation is the
unusual cultural motivations that may drive an Asian
patient’s decision to undergo aesthetic rhinoplasty among
other facial enhancement procedures. For example, a
higher dorsum may signify wealth and fortune for an
individual and a distinctly visible nostril show from a
frontal view has been thought to indicate the potential for
monetary loss. Although a Western surgeon may regard
these ideas as unfounded, failure to explore this percep­
tion explicitly before surgery may lead to dissatisfaction
postoperatively. Finally, a strategy will be developed for
both primary and revision rhinoplasty for the Asian nose,
taking into consideration the widespread popularity of
solid silicone implants in Asia and the need to understand
the role and results of this alloplast even if the surgeon
does not desire to use this material (as I myself no longer
do).
CULTURAL ISSUES
The first priority for surgeons should be to understand the
patient before trying to understand the operation. What
has emerged as a frequent comment from my colleagues
is the failure to comprehend the enigmatic nature of the
Asian patient and that miscommunication has led to sur­
gical failure even when the surgical result may have been
deemed a technical success. This lack of clear communi­
cation may only be partly blamed on the language barrier
of some first-generation immigrants. There are two glaring
failures that may in fact underscore the miscommu­
nication: a lack of cultural sensitivity and a lack of
understanding ethnic identity. This section will cover the
former aspect of the purported problem.
Some of the folkloric cultural beliefs that inform
Asians—who either live abroad, who have recently immi­
grated to the West, and even for those who are several
generations later born and reared in the West—should be
explored herein. As alluded to in the introduction, some
Asian patients may desire undergoing aesthetic rhino­
plasty solely for nonaesthetic reasons. For instance, the
larger nose has been regarded as a sign of wealth and
fortune for the bearer of this feature, or by turns offers
the individual who acquires this attribute even via surgery
to attain that level of monetary gain. I clearly recall a
Chinese chef who ascribed his job promotion to his higher
nose bridge and was more elated with his enhanced
fortune in life brought on, in his view, by his higher nasal
dorsum, than with the aesthetic outcome of his rhino­
plasty surgery. However, with regard to the height of the
nasal dorsum, the surgeon should always respect the
parameters that would preserve a natural result. This
topic will be discussed in the following section. The second
most common request or desire that may have cultural
underpinnings is to have less visible nostril show from a
frontal view. Accordingly, anything that would lead to
greater nostril show (no matter how narrow the nostrils
are to begin with) could lead to patient dissatisfaction.
That is why a dome-binding suture that leads to nasal tip
refinement may not be a wise surgical option in many
Asian patients. Besides the unaesthetic feature of widely
visible nostrils, the motivating factor for the Asian patient
may be the folkloric belief that visible nostrils may engen­
der monetary loss. I recall a Vietnamese patient of mine
who was born and raised in the United States but who
wanted to have a higher bridge and less visible nostrils
because a fortuneteller had informed him of the impor­
tance of doing so to change his fortune in life. He also
desired nasal enhancement for aesthetic reasons and with
preoperative imaging appeared to have realistic goals.
However, the surgeon who is contemplating proceeding
with surgery in the patient who is profoundly motivated
by cultural beliefs risks the uncontrollable outcome that
a patient has not attained the desired station in life
perhaps due to a surgeon’s failure to accomplish sufficient
structural change to the nose. These cultural elements

358
Samuel M. Lam
a very important area to narrow in order to achieve the
optimal aesthetic results. In reality, I rarely perform an
alar base reduction, as I find it unnecessary unless the alar
base is extremely broad.
Using photographs of Asian models and reviewing a
surgeon’s “before and after” results can be helpful to any
prospective Asian patient seeking to align aesthetic goals
with a surgeon. There are two caveats that should be
expressed: at times a patient can be more enamored with
the overall composite of a model’s face and not necessarily
just the nose itself and the same pitfall may arise when
reviewing a surgeon’s results if the patient likes the face
more than the nose. Assuming that an individual is wholly
embracive of maintaining ethnicity can also be erroneous.
Today’s globalized marketplace has placed an emphasis
on models of mixed racial heritage. Also, with increased
interracial marriage rates, offspring can strike a more
ethnically blended aesthetic. I have also observed anecdo­
tally that Asians who are partnered with Caucasians may
seek to blunt their ethnic features to appeal more to their
significant other. However, many Caucasians are drawn to
Asians who exhibit more ethnic features and may not want
those attributes significantly softened. At times, an open
conversation including the prospective patient’s signifi­
cant other may be a wise decision when electing aesthetic
rhinoplasty or any facial enhancement procedure in the
Asian patient.
When I perform Asian rhinoplasty (or almost any
aesthetic endeavor for that matter), I rarely make great
accommodations to a patient’s wishes if those desires do
not align well with my own aesthetic judgment. It is not
out of fear of betraying my own sense of ethnicity but
more out of reticence to make a result that would com­
promise my own aesthetic philosophy.
USE OF SILICONE FOR
AUGMENTATION RHINOPLASTY
Augmentation rhinoplasty with a single solid silicone
implant has remained the most popular choice throughout
Asia. When I started my career in Asian rhinoplasty, I was
heavily influenced by this technique that appeared to be
so pervasively the choice in the Far East where I had spent
5 months of apprenticeship. However, after a couple of
years of using solid silicone implants, even very soft and
tapered versions, I found multiple problems with them
which have encouraged me to abandon this technique
entirely. Nevertheless, any surgeon contemplating under­
taking Asian rhinoplasty must understand the nature of a
silicone implant since he or she will encounter a patient
for revision rhinoplasty who already has a silicone implant
that must be addressed.
Many of my senior colleagues in Asia have had
remarkable success with solid silicone so I am not here to
cast a shadow on their accomplishments. I only want to
should almost always be explored to determine the can­
didacy for undertaking rhinoplasty based on mutually
aligned and attainable goals.
Other examples of folkloric beliefs related to the face
may be illustrative and impart further insight for the
Western surgeon who desires to work on the Asian patient.
Freckles may be considered an endearing feature in the
West, but any skin blemishes for the Asian patient may
be remarked as unattractive and further thought to affect
adversely one’s good fortune. Like a large nose, large ears
are also believed to designate the bearer as an individual
who holds great wealth and wisdom. Consequently, reduc­
tive otoplasty is less commonly undertaken in the Far
East. Dimples are thought to impart fertility and increase
one’s marriage prospect. Exploring these complex and
multilayered motivations may help establish and align
realistic objectives with the patient.
PRESERVING ETHNICITY IN
THE ASIAN PATIENT
Many patients select me as a surgeon simply because of
my own ethnicity. They believe that as a fellow Asian (I
am Chinese), I will be more sensitive to their own cultural
motivations and ethnic features. Perhaps this may be true.
However, through this chapter, every surgeon attempting
Asian rhinoplasty can attain this level of sensitivity. This
section will focus primarily on what constitutes an ethni­
cally sensitive rhinoplasty that preserves rather than
effaces ethnicity. Following the trend of Asian eyelid
enhancement over the past two decades, the creation of a
supratarsal crease has moved away from the unnatural
“Westernized” look that dominated in the 1980s where
the crease was made very high and significant postseptal
fat was removed. Today, the crease is much lower and the
fullness is preserved. The same trend can be spotted in
most ethnic surgeries with the current goal to be ethnic
preservation rather than effacement. In the same way the
Middle Eastern nose should not be overly reduced, the
Asian nose should not be overly elevated in height.
What exactly are the standards for ethnically sensitive
surgery then? For the nose, the dorsal height should not
in most cases exceed the mid-pupil as the starting point
for the radix. In many cases, the Occidental surgeon uses
the Occidental standard of the supratarsal crease as the
proposed radix height. This often can be too high for the
Asian individual. Of course, facial features, like the depth
of the nasofrontal angle, etc. will dictate aesthetic goals,
which can be modified based on artistic judgment and
communication with the prospective patient. The nasal tip
can also be made too sharply defined and could appear
unnatural for the Asian patient. Strategies of varying
degrees of nasal tip definition from slightly rounder to
slightly sharper will be elaborated upon later in this
chapter. Finally, the alar base has often been considered

CHAPTER TWENTY-NINE  Asian Rhinoplasty
359
remove it and simultaneously replace it with a smaller
dorsal implant. If the bridge is only slightly too high or of
appropriate nasal height, a simultaneous revision rhino­
plasty may be warranted (Figure 29-1). However, what I
have found is that removal of the implant can often be all
that is needed to restore a patient to a more pleasing nasal
configuration without need for a revision rhinoplasty
(Figure 29-2). Many individuals worry that implant
removal alone will lead to a return to their former nose
shape. This is rarely the case. The scar tissue and remain­
ing encapsulation lead to a result that lies somewhere
halfway between the original nose and the overaugmented
nose with a silicone implant.
The major caveat that the patient should be aware of
is the risk of pressure necrosis that a large silicone implant
can impart to the nasal tip cartilages. Removal of an
implant can expose the mangled nature of the nasal tip
cartilages that may require surgical intervention to correct.
This problem should be diligently explained to the patient
who may not be aware of this potential outcome. Because
I use liquid silicone microdroplets to correct minor nasal
deformities, I can often camouflage the problem without
having to proceed to surgery. However, major loss of nasal
tip projection and or deformity would mandate a surgical
remedy.
Why then go through an extra procedure of nasal
implant if the likelihood for a revision rhinoplasty is high?
First, it may not be if the surgeon has a more conservative
perception of how an Asian nose should appear, especially
within the context of a previously overaugmented nose.
Second, more important, silicone implant removal should
express the limitations that I have personally encountered
which have compelled me to abandon use of the material.
I will take ownership for any technical errors that I may
have committed that may have contributed to my failure.
Here are the problems that I witnessed with solid silicone.
Because the implant tends to undergo encapsulation under
very thin nasal skin, the edges can become visible over
time and make the implant more visible-imparting an
almost “shrink-wrapped” appearance. The thickness of
the implant even when shaved paper thin with the added
encapsulation that occurs over time made most of my
efforts appear too high for my aesthetic taste. I am much
more conservative with dorsal augmentation, as discussed
previously. The major problem I encountered was distal
migration of the implant downward over the nasal tip
after a year or two (or sometimes sooner) that could occur
spontaneously for no apparent reason (i.e., no history of
inciting trauma could be elicited in many cases). The
weight of silicone as compared with expanded poly­
tetrafluoroethylene (ePTFE), which will be discussed, can
predispose to eventual descent of the implant. I was taught
to scrape the periosteum of the nasal bone vigorously
immediately before implant insertion to minimize this
consequence. Despite diligent attention to this surgical
maneuver, I still found many instances when the implant
shifted downward over the nasal tip.
Because of my prior use of silicone implants, I have
become more experienced with handling the complica­
tions that can arise, which the reader should be familiar
with. Often, the first instinct with an overly augmented
silicone implant (which I find most of them are) is to
Figure 29-1  The patient had a previous solid silicone augmentation rhinoplasty that was removed and underwent a simultaneous revision rhinoplasty
using a two-ply sheet of ePTFE intended for dorsal augmentation rhinoplasty and a double-layer onlay septal cartilage tip graft. (From Lam SM. Revision
rhinoplasty for the Asian nose. Semin Plast Surg. Reprinted by permission.)
A
B

360
Samuel M. Lam
visualization using a headlight, the surgeon can grasp the
observed implant. The incision is then closed with inter­
rupted 5-0 chromic sutures.
The only exception to an easy implant removal is the
presence of calcifications along the dorsum. The skin
surface of the nose should be palpated, and if irregulari­
ties are observed, the patient may need sedation; if the
dorsum is not too high, then a simultaneous revision rhi­
noplasty may be a wiser option. I have personally taken
out silicone implants laden with calcifications in the office,
and it is never an enjoyable experience. With careful and
tedious dissection, the implant can be removed in its
entirety in 30 to 45 minutes rather than the otherwise to
be expected 5 minutes.
One of the most devastating complications that can
arise with previous silicone implant is a foreshortened
nasal tip. The pressure that the silicone implant creates
on the nasal-tip tissue can lead to one of three problems:
distorted loss of the underlying cartilage (as mentioned),
pressure changes to the overlying skin if not frank pene­
tration, and a foreshortened nasal tip. Often the patient
who undergoes repeated silicone implantation in the past
with or without episodes of infection is more likely to
experience this devastating outcome. With the foreshort­
ened nose, revision rhinoplasty is mandated, which is not
an easy task.
An open rhinoplasty technique is the preferred method
of surgical approach with a transcolumellar incision made
near the columellar–labial junction so as to permit recruit­
ing white upper lip tissue as needed to extend the con­
tracted columella. Extended spreader grafts are then
be a 5-minute office procedure under local anesthesia
with no sedation. For the right-handed surgeon, the right
marginal incision is more easily approached. After a
topical anesthetic is applied within the nasal vestibule on
the right side, 1% lidocaine with 1:100,000 epinephrine
(typically 1 to 2 ml is sufficient) is infiltrated through
the marginal incision into the nasal tip to blanch it
and to achieve adequate anesthesia. Of course, a small
30-gauge needle is used and the anesthesia very slowly
infiltrated so that the patient does not feel any discomfort.
The surgeon need not anesthetize the entire nasal
dorsum.
After 10 minutes are allowed to elapse for adequate
vasoconstriction and anesthesia, a No. 15 Bard-Parker
blade is used to incise the marginal incision just along the
vestibular recess, about 1 cm in length. The incision does
not need to be continued all the way across the inferior
aspect of the lower lateral cartilage. Metzenbaum scissors
are used blindly to “feel out” the implant (i.e., dissect
above and below the implant to break the encapsulation).
A curved hemostat is inserted through the marginal inci­
sion and is blindly (i.e., by palpation) used to take a firm
grasp of the implant. One should not take a partial,
tenuous grasp of the implant. It will otherwise tear and
make removal close to impossible. With a firm grasp, the
implant is slowly and deliberately tugged until the entire
implant is removed in one piece. A very slow, deliberate
and constant application of traction will release the entire
implant from its recessed position. If the implant is not
easily grasped, tiny double-hook retractors are used to
gently lift the marginal incision upward, and with direct
Figure 29-2  The patient is shown before augmentation rhinoplasty with a “one-piece” solid silicone implant (A), after rhinoplasty (B) with the nasal
bridge profile aesthetically too high, and after removal of the implant (C) with a result that lies somewhere between the before and after results, at a height
that is aesthetically conservative and attractive. (From Lam SM. Revision rhinoplasty for the Asian nose. Semin Plast Surg. Reprinted by permission.)
A
B
C

CHAPTER TWENTY-NINE  Asian Rhinoplasty
361
rounded contour in the superior aspect and an arrowed
triangular shape inferiorly to fit between the medial crura
(Figure 29-3). All edges of the implant are crimped along
the outer 1-mm border using an empty needle driver
before insertion. With a Converse-style retractor elevating
the skin pocket, the implant can be inserted by using a
variety of instruments based on the surgeon’s preference.
necessary to relengthen and maintain the position of the
contracted lower lateral cartilages in a more normalized
position. The lower lateral cartilages can also be distorted
and require reconstruction. Often, the septal cartilage
remains intact since the surgeon who typically uses silicone
implants does not rely on septal cartilage as grafting mate­
rial. Use of conchal onlay grafts may likely be necessary
as well. In the face of graft depletion, costal harvesting for
this purpose may be required. At times, the infratip lobular
skin can be contracted upward and bunch up in the
supratip region to cause an excess of skin in that region. I
have a recently published paper that I have co-written with
an esteemed Korean colleague, which discusses a novel
rotation flap aimed at correcting this deformity.
SURGICAL STRATEGY FOR
ASIAN RHINOPLASTY
Although completely autogenous materials can be used for
Asian rhinoplasty, I prefer a combination of alloplast for
the dorsum and autograft for the nasal tip. ePTFE is the
preferred material for dorsal augmentation and septal
cartilage for tip grafting with or without use of conchal
cartilage in rare conditions where additional grafting
material is required. The interesting trend in the Far East
recently has been away from “one-piece augmentation”
with solid silicone in favor of “two-piece augmentation”
with solid silicone only for the dorsum and autogenous
cartilage for the nasal tip. I do not have any personal
experience with the latter technique but moved from one-
piece augmentation with solid silicone to my current strat­
egy of using ePTFE for the dorsum and autogenous
cartilage for the nasal tip.
Almost all my rhinoplasty procedures are performed
via an external transcolumellar incision for ease of access
and operative visualization. A standard inverted-V inci­
sion is preferred. This chapter will not reiterate the basic
techniques of external rhinoplasty. Instead, this technique
section will focus more on philosophical approach and the
pertinent details of how this technique differs from Occi­
dental rhinoplasty. The section on operative technique will
encompass technical specifications on dorsal augmenta­
tion and methods for nasal tip improvement.
As mentioned, ePTFE is my preferred method for
dorsal augmentation. ePTFE in the form of flat sheets,
formerly marketed as SAM sheets by W.L. Gore (Flagstaff,
AZ), is preferred over solid block implants of the same
material. Now that W.L. Gore has stopped manufacturing
Gore-Tex, two other manufacturers have stepped in to fill
this void in the market, viz., Surgiform (Columbia, SC)
and Implantech (Ventura, CA). ePTFE sheets of 1, 2, and
3 mm can be used to create the dorsal height that is
desired. Stacking sheets of ePTFE can attain various
modifications to the bridge height. The ePTFE sheet is cut
into a rectangle to fit the nasal dorsum with a gently
Figure 29-3  A, A 3-mm ePTFE sheet is cut into a rectangle to fit the
nasal dorsum. B, The edges are crimped with a needle driver in order to
create a smoother transition from the augmented implant to the unaug­
mented sides of the nose. C, The implant is shown crimped and cut to the
requisite shape for insertion with a gently rounded superior aspect and a
triangular point to be recessed between the medial crura inferiorly.
A
B
C

362
Samuel M. Lam
A standard DeBakey forceps or Bayonet forceps will ade­
quately do the job. It is important after implant placement
that the implant edges be observed for any folding or
crimping that can be seen by looking directly into the
pocket and then by palpating the dorsal skin for any
uneven edges with the skin flaps returned down to their
resting position. As stated, the inferior aspect of the
implant should rest between the medial crura as a trian­
gular inset. No osteotomies are necessary for Asian rhino­
plasty and would otherwise flatten the nasal profile or
disrupt the position of the dorsal implant.
The dorsal implant insertion is completed before
approaching the nasal tip. The principal method for nasal
tip projection and definition in most cases relies on various
onlay grafts rather than a cephalic lower-lateral cartilage
trim and dome-binding suture. This lies in contradistinc­
tion to the technique typically used for the Occidental
nose. With the very thin skin of the Caucasian nose, in
most cases a cephalic trim and dome-binding suture can
be very effective, whereas an onlay graft may become
visible over time as the skin “shrink-wraps” down over
the new architecture. The opposite is true in the Asian
nose. Reducing the architecture of the nose through a
cephalic trim under the thick nasal tip skin in the Asian
patient can at times lead to scar production and a thicker
nasal shape. With the wider stance of the nasal base, a
dome-binding suture may cause untoward rotation of the
nasal tip and lead to unintended nostril show, which can
be both unaesthetic and also unlucky (as discussed).
Instead, the nasal architecture must be built forward to
push against the very thick nasal skin so as to create suf­
ficient nasal tip projection and definition.
There are two major methods for nasal-tip definition
depending on a few factors. For the individual who
desires a softer and rounder shape, the nasal tip can be
augmented by using oval-shaped septal onlay grafts
immediately over the nasal tip (Figure 29-4). This
method achieves a less angular look to the nasal tip,
which can be desirable. Multiple, stacked onlay grafts
can be used to achieve the desired degree of tip projec­
tion. As an alternative, for a slighter and sharper appear­
ance to the nasal tip, a shield graft that has its distal
aspect rest 1 to 2 mm anterior to the native lower-lateral
cartilage domes can be used to create a more favorable
nasal tip definition and projection (Figure 29-5). The
shield graft can also be beneficial to correct columellar
retraction that is often present in the Asian patient with
a premaxillary retrusion. Of course, both techniques can
be combined as needed to achieve the desired degree of
projection and definition. Often, the supratip fat can be
debulked from the undersurface of the supratip skin in
order to decrease the round appearance of the nasal tip
in the Asian patient. For added projection when cartilage
grafting is depleted, the removed supratip fat can be
used as the final augmentation material over the stacked
onlay grafts (Figure 29-6).
An alternative method for nasal tip refinement uses
Fernando Pedroza’s conchal seagull graft that literally
replaces the native lower lateral cartilages with conchal
versions of them. This method for nasal tip enhancement
can prove particularly useful when the entire framework
to the lower lateral cartilages has been compromised by
trauma or prior silicone implant (Figure 29-7). The tech­
nique employs the cymba concha of one ear (Figure 29-8)
that is divided in turn lengthwise into two equal halves
(Figure 29-9). These halves are trimmed so that one end
resembles the narrower medial crus and the other end the
broader lateral crus (Figure 29-10). A 5-0 Vicryl suture
is used as a mattress to bend one end of each cartilage
piece to resemble the natural curvature of the medial and
lateral crus (Figures 29-11 and 29-12). The two pieces
are sutured together (Figure 29-13) to create an entirely
new lower lateral cartilage to be used in an onlay fashion
over the partially attenuated native cartilages (Figure
29-14).
The alar base is the final topic of discussion. In my
opinion too many alar base reductions are performed
unnecessarily. It is very important to evaluate the width
of the nasal lobule relative to the alae. With a very broad
nasal lobule, reduction of the side alae can cause the rela­
tive size of the lobule to look even larger (i.e., worse). Care
should be undertaken to ensure that the nasal lobule
remains in good proportion to the alar width. There are
two techniques for alar base reduction that can be per­
formed depending on what is necessary. A nasal sill reduc­
tion can reduce a broad nostril that has a long nasal sill
(Figure 29-15). A Sheen flap can be used to reduce the
flare of the outer alar margin. At times, a nasal sill reduc­
tion performed in isolation can increase the lateral curva­
ture of the nose that would in turn mandate the use of a
Sheen flap. At times, simply lengthening the nasal tip and
elevating the nasal dorsum are sufficient to create the
impression of narrowing the nose without having to do so.
As the nose tip is lengthened and the bridge raised, the
alar width appears relatively smaller in size. By avoiding
an alar-base reduction in many circumstances, the surgeon
avoids two major pitfalls: overly narrowing the base can
appear unnatural for the Asian individual and prolonged
if not indefinite scarring that is more likely along the alar
side wall from alar-base reduction.
CONCLUSIONS
Asian rhinoplasty requires an entirely different philosoph­
ical approach and surgical armamentarium than for an
Occidental counterpart. Hopefully, this chapter has helped
elucidate some of the fundamental aspects of cultural
biases, ethnic sensitivity, and technical execution that are
inherent features of any successful cosmetic rhinoplasty
endeavor, whether for primary or revision surgery in the
Asian individual.

CHAPTER TWENTY-NINE  Asian Rhinoplasty
363
Figure 29-4  A, Onlay septal tip grafts
are used to increase tip projection but to
maintain a softer, rounded appearance to
the nasal tip. B–E, This patient is shown
before (B, D) and after (C, E) single-layer
ePTFE onlay graft for the dorsum and a
double-stacked onlay tip graft with septal
cartilage. (From Lam SM. Revision rhino­
plasty for the Asian nose. Semin Plast Surg.
Reprinted by permission.)
B
C
D
E
A

364
Samuel M. Lam
Figure 29-5  A, Shield grafts made of septal cartilage are used to attain a more defined nasal tip configuration than onlay grafts can. Also, shield grafts
help to create a more favorable columellar show in the patient with a retruded premaxilla. B–E, This patient is shown before (B, D) and after (C, E) external
rhinoplasty and full facial fat transfer. She had a shield graft and single-layered blocking graft placed to her tip and a two-ply 1-mm ePTFE sheet to the dorsum.
She had fat transferred to her brow, anterior cheek, lateral cheek, and anterior chin to narrow the shape of her face and to provide more dimensionality
to it. (From Lam SM. Asian rhinoplasty. Fac Plast Surg 2008;24[3]. Reprinted by permission.)
A
B
C
D
E

CHAPTER TWENTY-NINE  Asian Rhinoplasty
365
Figure 29-6  At times, the debulked supratip fat can be sutured on top
of the cartilage onlay grafts for added nasal tip projection.
Figure 29-7  This 16-year-old Korean girl
sustained traumatic injury to her nasal tip that
caused loss of nasal tip projection through pos­
sibly a septal hematoma and consequent erosion
of her inferior septum. She underwent a seagull
reconstruction of her nasal tip (see Figure 29-8
and beyond) that rebuilt her deprojected lower
lateral cartilages and also helped her to breathe
much better.
A
B
C
D

366
Samuel M. Lam
Figure 29-8  The cymba concha cartilage is shown removed as an intact
single piece to be used to reconstruct the lower lateral cartilage by Pedro­
za’s method that he calls the “seagull” graft. (From Lam SM. Asian rhino­
plasty. Fac Plast Surg 2008;24[3]. Reprinted by permission.)
Figure 29-9  The conchal cartilage is then divided lengthwise into
approximately equal halves. (From Lam SM. Asian rhinoplasty. Fac Plast Surg
2008;24[3]. Reprinted by permission.)
Figure 29-10  The two pieces are then trimmed so that they are of
equal size and so that one narrower end resembles the medial crus. Calipers
are used to ensure accurate measurements for symmetry. (From Lam SM.
Asian rhinoplasty. Fac Plast Surg 2008;24[3]. Reprinted by permission.)
Figure 29-11  A 5-0 Vicryl suture is used as a mattress to bend the
narrower end over to create the new dome. (From Lam SM. Asian rhino­
plasty. Fac Plast Surg 2008;24[3]. Reprinted by permission.)
Figure 29-12  The two sutured pieces are shown adjacent to one
another in the configuration that they will assume as the new lower lateral
cartilage replacements. (From Lam SM. Asian rhinoplasty. Fac Plast Surg
2008;24[3]. Reprinted by permission.)
Figure 29-13  The medial crura are then sutured together to form
the natural joined arc of the newly fashioned lower lateral cartilages. (From
Lam SM. Asian rhinoplasty. Fac Plast Surg 2008;24[3]. Reprinted by
permission.)

Figure 29-14  The graft is shown sutured as an onlay over the existing
lower lateral cartilages. (From Lam SM. Asian rhinoplasty. Fac Plast Surg
2008;24[3]. Reprinted by permission.)
Figure 29-15  The patient is shown before (A, C,
E) and after (B, D, F) external rhinoplasty that involved
a single-ply 1-mm ePTFE sheet for the nasal dorsum,
a one-layered septal cartilage onlay graft, and a septal
columellar strut that was positioned lower than her
natural medial crura to extend her columella inferiorly.
She also had a nasal sill reduction. (From Lam SM.
Asian rhinoplasty. Fac Plast Surg 2008;24[3].
Reprinted by permission.)
A
B
D
C
F
E

368
Samuel M. Lam
SUGGESTED READINGS
1. McCurdy Jr JA, Lam SM. Cosmetic surgery of the Asian face.
2nd ed. New York: Thieme Medical Publishers; 2005.
2. Lam SM. Aesthetic facial surgery for the Asian male. Fac Plast
Surg. 2005;21:317–323.
3. Pedroza F, Anjos GC, Patrocinio LG, et al. Seagull wing graft:
a technique for the replacement of lower lateral cartilages.
Arch Fac Plast Surg. 2006;8:396–403.
4. Jung DH, Moon HJ, Choi SH, Lam SM. Secondary rhinoplasty
of the Asian nose: correction of the contracted nose, Ann Plast
Surg. 2004;28:1–7.
5. Lam SM, Kim YK. Augmentation rhinoplasty of the Asian nose
with the ‘bird’ silicone implant. Ann Plast Surg. 2003;51:
24–56.
6. Shirakabe Y, Suzuki Y, Lam SM. A systematic approach to
rhinoplasty in the Japanese nose: a thirty-year experience.
Aesthet Plast Surg. 2003;27:397–402.
7. Jung DH, Choi SH, Moon HJ, Lam SM. A cadaveric analysis of
the ideal costal-cartilage graft for Asian rhinoplasty. Plast
Reconstr Surg. 2004;114:545–550.
8. Jung DH, Lin RY, Jang HJ, Claravall HJ, Lam SM. Correction
of pollybeak and dimpling deformities of the nasal tip in the
contracted, short nose by the use of a supratip transposition
flap. Arch Facial Plast Surg. 2009;11(5):311-319.

369
C H A P T E R T H I R T Y 
African American Rhinoplasty
Paul S. Nassif
Rhinoplasty in the African American population presents
a unique set of challenges, including skin and soft tissue
envelope thickness, alar base width, and inherent ethnic
considerations. A delicate balance of patient satisfaction,
achieving an aesthetically pleasing result, and maintain­
ing a natural appearance are three goals to stay focused
on during the surgical planning and execution phases of
these procedures. Among these, meeting the patient’s
expectations can sometimes require redirecting and dem­
onstrating alternatives to patients with unrealistic expec­
tations who may at first desire an overly narrow Caucasian
nose. Some patients may even choose to bring celebrity
photographs to the consultation, requesting a particular
result, despite the absence of a match with the subject’s
face, skin type, body habitus, or ethnic background.
Occasionally, one of the surgeon’s most important tasks is
to demonstrate to patients that their requested result is
unrealistic, nonfunctional, aesthetically incongruous, or
out of harmony with the patient’s facial or other features
and is at times in fact outright unachievable given their
skin characteristics. Morphing software may serve as a
visual aid in this demonstration. Only after this task is
accomplished should the surgeon proceed with a careful
review of the history and physical examination. A com­
prehensive understanding of nasal anatomy, function, and
surgical techniques is paramount. Having an extensive
preoperative discussion encompassing patient expecta­
tions, surgical goals, and a detailed list of potential com­
plications with the patient preoperatively can prevent
miscommunication. This is best accomplished by review­
ing the exam, previous operative summary, photographs,
nasal analysis sheet, problem list, and surgical plan preop­
eratively before proceeding with the surgical treatment.
African American rhinoplasty can be one of the most
difficult and challenging of the multitude of ethnic rhino­
plasty procedures primarily because of the imbalance
between the weak nature of the cartilaginous framework
and thick skin–soft tissue envelope. One of the most
common pitfalls in African American rhinoplasty occurs
while attempting to accomplish a less bulbous nasal tip.
The experienced rhinoplasty surgeon will be in tune with
this inherent anatomic imbalance and avoid aggressive
lower lateral cartilage over-resection. Aggressive lower
lateral cartilage reduction usually results in:
• Loss of tip support
• Decreased tip projection
• Counterrotation (ptotis)
• Decreased tip definition (and, in fact, more pronounced
bulbosity)
• Possible nasal tip contour irregularities
• Proclivity for long-term collapse after primary
rhinoplasty
For all rhinoplasty procedures, especially ethnic rhi­
noplasty, aggressive cartilage removal is a procedure of
the past. Concepts such as limited cartilage excision and
adding nasal support with structural grafting and tip
suturing techniques are being taught in both training
programs and meetings. Proceeding in this fashion may
lead to a decrease in the need for a future secondary
rhinoplasty.
This chapter will discuss some of the nuances of the
anatomy of the African American nose, followed by goals,
preoperative nasal evaluation with surgical planning, sur­
gical sequence and techniques, postoperative nasal care,
risks and complications, pearls, as well as preoperative
and postoperative photography techniques.
ANATOMY
A brief description of the African American nose is
discussed and the descriptions described are present in
the majority, but not all, of the typical African American
noses (Figure 30-1). These include the following
characteristics:
• The skin–soft tissue envelope is thick with abundant
fibrofatty tissue.
• The radix is deep, low, and inferiorly set.
• The nasal bridge and dorsum feature short, wide, and
flat nasal bones.
• The nasal tip is bulbous, thick-skinned, poorly pro­
jected, and counterrotated (ptotic) with abundant
fibrous nasal superficial musculoaponeurotic system
plane (SMAS) and broad domes; it has minimal tip
definition and weak lower lateral cartilages.

370
Paul S. Nassif
patient’s wishes and goals. Does he or she have realistic
expectations? This is one of the most important details
that the astute surgeon needs to focus on from the inter­
view. What is the focus of the patient’s dissatisfaction—a
bulbous tip or a low dorsum? During the history, the
surgeon should be able to identify if the patient is a good
surgical candidate. Will your conservative rhinoplasty
make the patient happy? Poor patient selection can lead
to an unhappy patient and considerable amount of stress
to both patient and surgeon.
Ascertain if the patient has nasal obstruction, although
this symptom is uncommon. If nasal obstruction is present,
is it static or dynamic? Is it present with normal or deep
inspiration? What alleviates and worsens the nasal
obstruction? What are the characteristics of the nasal
obstruction? The physical examination follows.
For the physical examination, I use a nasal analysis
worksheet (Figure 30-2) and perform a detailed visual
and tactile evaluation of the nose. Visualize the bilateral
paramedian vertical light reflexes along the dorsum and
look for symmetry. I then use an ungloved finger to palpate
the nose, examining the bony and cartilaginous skeleton,
tip, and skin–soft tissue envelope characteristics in frontal,
head-down, oblique, lateral, and base views.
In patients with nasal obstruction, whether for a
primary or revision rhinoplasty, I observe them during
normal and deep inspiration on frontal and basal views.
Often, the diagnosis is easily identifiable as supra-alar,
alar, and/or rim collapse (slitlike nostrils) during static or
dynamic states. External valve collapse (lower lateral car­
tilage pathology) can be evaluated by supporting the area
of nasal obstruction with the firm end of a cotton swab
while occluding the contra­lateral nostril. Often, nasal
obstruction in the supra-alar region may signify an overly
• The columella is short and retracted with minimal colu­
mellar show.
• The alae are wide, thick, and horizontal and the nostrils
are flared.
• Nasolabial junction: retracted, acute nasolabial angle
(<90 degrees), underdeveloped nasal spine.
• Maxilla: retruded and/or hypoplastic.
GOALS
The usual primary goals in African American rhinoplasty
can include the following:
• Bridge: moderately thinner on frontal view.
• Dorsum: augmented height on lateral view.
• Tip: improve definition, increase projection, increase
rotation.
• Base: vertical-oblique nostrils and nasal base approxi­
mating an equilateral triangle.
• Columella: Increased columellar “show” and length.
• Nasolabial junction: obtuse nasolabial angle (>90
degrees).
• Maxilla: less retruded.
• Skin–soft tissue envelope: moderate thickness that
allows good tip definition.
PREOPERATIVE NASAL EVALUATION AND
SURGICAL PLANNING
Excellent physician-patient communication is one of the
most important features of the consultation process. While
a detailed history is performed, listen very carefully to the
Figure 30-1  A, Frontal view of an African American female nose. B, Lateral view.
B
A

CHAPTER THIRTY  African American Rhinoplasty
371
Figure 30-2  Nasal analysis worksheet. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
• Skin Quality:
Thin Medium Thick Sebaceous Telangiectasias
• Primary Description:
Big Twisted Large Hump Boxy Pinched Bulbous
FRONTAL VIEW
• Dorsum:
Twisted Deviated Straight Convex: R L Bony
Bony-Cartilaginous Cartilaginous
• Width:
Narrow Wide Normal Wide-Narrow-Wide Depressed L R
• Tip:
Normal Deviated Bulbous Asymmetric Amorphous
Pinched Parenthesis Deformity
• Support:
Normal Weak
• Medial Canthal–Alar Relationship:
Wide Normal Narrow Sill Weir
• Tip-Defining Points:
Uni Double Narrow
• Nasal Bones:
Short Normal Long
• Middle Vault/Upper Lateral Cartilages: Narrow Normal Subluxed Asymmetric
BASE VIEW
• Trapezoidal
Triangular
• Tip:
Deviated Bulbous Wide Bifid Asymmetrical
• Base:
Wide Narrow Normal Dislocated Caudal Septum: No Yes R L
• Rim Aperture:
Narrow R L Normal
• Columella:
Columellar/ Lobule Ratio (2:1) Normal Abnormal
• Medial Crural Footplates:
Wide Normal
LATERAL
• Nasofrontal Angle:
Shallow Deep Normal
• Nasal Starting Point:
High Low Normal
• Nasal Length:
Normal Short Long
• Dorsal Hump:
Y N Bony Cartilaginous Over-resected Bone Cartilage
• Tip Projection:
Normal Decreased Increased Ratio (.55–.60)__________ (TDP-
AFJ/Nasion-TDP)
• Alar-Columellar Relationship:
Normal Abnormal A-C Show ________mm
• Naso-Labial Angle:
Obtuse Acute Normal ___________ degrees
• Infratip Lobule:
Over-rotated Counter-rotated Normal
• Supratip Break:
Y N
• Nasal Ptosis
Y N With Smiling: Y N
• Infratip Break:
Y N
• Chin:
Normal Microgenia Macrogenia
Patient Name:__________________________________________________
Date: __________________
• Columella:
Normal Hanging (Septum Medial Crura Soft Tissue)
Retracted (Base)
• Ala:
Normal Hanging Retracted R L
• Pollybeak:
Y N Cartilaginous Soft Tissue

372
Paul S. Nassif
INTRANASAL
• Septum:
Deviated Y N Spur R L

Caudal Deviation Y N R L

__________% Obtsruction R

__________% Obstruction L

Edematous Mucosa Y N Erythematous Mucosa Y N

Perforation Y N If yes, where ____________________
• Turbinates:
Hypertrophic Y N R L Normal
• Internal Nasal Valve:
Narrow Normal
• External Nasal Valve:
Collapsed Intact
• More Prominent Ear:
R L
PROBLEM LIST/PLAN:
Alar Batten Grafts L R Alar Rim Grafts L R Lateral Crura Strut Grafts L R
Columellar Strut Infratip Lobule Graft Dome Graft Shield Graft Plumping Grafts
Composite Grafts L R Medial Crural Overlay Lateral Crural Overlay Dome Sutures
Tongue-In-Groove Spreader Grafts L R Septal Extension Graft Reposition LLC
Conchal Cartilage L R Costal Temporalis Fascia L R
Onlays: Lateral Nasal Wall L R Radix Bony Vault Middle Vault
Alar Base Reduction: Sills Weir I II1 Septoplasty Turbinoplasty
Osteotomies Double R L Hump Reduction Bone Cartilage
Functional:
Cosmetic:
______________________
_________________
Paul S. Nassif, MD, FACS
Date
Figure 30-2, cont’d.
narrowed pyriform aperture secondary to low lateral oste­
otomies. Elevate the ptotic nasal tip and see if this helps
alleviate the nasal obstruction. The Cottle maneuver can
help assess internal valve collapse. Although this test is
generally nonspecific, internal nasal valve pathology
caused by supra-alar pinching or a narrowed angle
between the upper lateral cartilage and septum can be
diagnosed. On basal view, examine the medial crura feet
and the recurvature of the lower lateral cartilage to iden­
tify if these impinge into the nasal airway.
Following a thorough external nasal evaluation, the
endonasal examination ensues. At a minimum, perform
anterior rhinoscopy. Evaluate the nasal septum for perfo­
rations, deviation, and septum characteristics, as the
African American patient will usually have a short septum
with insufficient cartilage for grafting. Other causes of
nasal obstruction to identify are hypertrophic inferior tur­
binates, synechiae between the lateral nasal wall and
septum, nasal masses, and middle turbinate abnormalities
(concha bullosa, among others).
As the examination progresses, create a list of prob­
lems with solutions, followed by documentation on your
nasal analysis sheet, such as (1) bulbous, poorly projected
tip with a plan of open rhinoplasty, (2) low dorsum with
a plan of augmentation with diced cartilage wrapped in
deep temporalis fascia, and (3) wide ala with a plan of
bilateral alar base reduction. If structural grafting is nec­
essary, decide what material may be used. A thorough
understanding of the types of autologous (septal, conchal,
costal cartilage and deep temporalis fascia) or alloplastic
grafting is needed as well as being facile with the harvest­
ing techniques required for each one.
Computer imaging and morphing software may be an
extremely useful method of communication if patients are
made well aware that the final image will not represent
their postoperative photograph. However, despite proper
notification and consent, there have been reports of law­
suits filed by patients for outcomes that are different than
what was generated by the surgeon. Computer imaging
can give clues to the patient’s expectations. Unrealistic
expectations can be identified when a conservative image
is generated by the surgeon and the patient desires a
radical change. Therefore, computer imaging can be a
powerful tool in evaluating patients for surgery. There

CHAPTER THIRTY  African American Rhinoplasty
373
infiltration of local anesthetic helps me hydrodissect the
perichondrium off the lower lateral cartilages (Figure
30-3). This technique will aid in dissecting the SMAS/
perichondrium (Figure 30-4) from the nasal tip to use as
an onlay or camouflage graft and assist in fine-tuning
nasal tip definition. A subperiosteal dissection over the
nasal dorsum is performed if dorsal augmentation is to be
performed.
NASAL TIP SURGERY
Surgery of the nasal tip is among the most critical and
challenging aspects of rhinoplasty in the African Ameri­
can patient. Trying to achieve definition, a narrower tip,
increased projection (the more projection, the narrower
the tip will appear), and rotation are frequent goals. Com­
monly, the infratip lobule is overrotated; this can be nicely
addressed using a bruised infratip lobular graft. I prima­
rily use a combined septal extension/columellar strut and
a shield graft to provide maximum projection.
A conservative cephalic trim of the lateral crura of
lower lateral cartilages can be carried out, making sure to
leave at least 7 mm of cartilage in vivo (Figure 30-5).
Next, I find undermining the vestibular tissue from the
posterior surface of the alar cartilages (lateral and medial
crura) (Figure 30-6) will release any constraints from
the cartilage and possibly enable natural projection
facilitating the lateral crural steal procedure.1 This tech­
nique increases nasal tip projection and tip rotation. The
lateral crura are advanced onto the medial crura, thereby
projecting and rotating the nasal tip. The lateral crura are
advanced adjacent to the domes medially (Figure 30-7).
Finally, bilateral interdomal and transdomal sutures are
placed using 5-0 absorbable suture material.
Figure 30-3  Local injection used to hydrodissect mucoperichondrium
from the right lower lateral cartilage (arrow). (From Nassif PS. Asian rhino­
plasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
have been numerous instances when I have decided not
to perform rhinoplasty surgery secondary to the patients
having unrealistic expectations only being identified by
the computer morphing. An additional use for the com­
puter image is to use it as a goal in surgery. Often in
African American rhinoplasty, the patient has microgenia,
and a chin implant would benefit the overall aesthetic
appearance. Computer imaging will help the patient make
a decision to have a chin implant. Prior to surgery, stan­
dardized rhinoplasty photographs are taken.
SURGICAL SEQUENCE AND TECHNIQUES
The sequence I find useful is to start with the septoplasty
with septal harvesting and possible inferior turbinoplasty.
This is followed by rhinoplasty incisions and skeletoniza­
tion; I favor the external approach primarily—nasal tip
surgery with harvesting/placement of autologous grafts,
osteotomies as needed, dorsal augmentation with autolo­
gous and/or alloplastic grafts, and finally alar base
reduction.
SEPTOPLASTY AND INFERIOR
TURBINOPLASTY
Rarely will an African American nose have a deviated
septum. If a deviated septum is present, a standard sep­
toplasty is performed. If the septum is not deviated, septal
cartilage harvesting is performed leaving approximately
10 mm of a caudal and dorsal strut. Commonly, a small
amount of cartilage will be available to harvest and
patients are always informed that the need may arise to
harvest auricular or costal cartilage if dorsal grafting is to
be performed. The details regarding the septal harvest and
correction of the deviated septum are covered elsewhere.
Commonly, hypertrophic turbinates will be present and
the turbinoplasty of choice will be performed. Turbinec­
tomy is disfavored as it carries the risk of empty nose
syndrome and ozena.
EXTERNAL APPROACH RHINOPLASTY
INJECTION
In the majority of African American rhinoplasties, an
external rhinoplasty is performed. The nose is infiltrated
with local anesthetic (lidocaine 1% with epinephrine
1 : 100,000) to assist in hydrodissecting the cartilage
framework from the skin–soft tissue envelope and to aid
in hemostatic control. Subdermal dissection over the nasal
tip is performed to leave the SMAS lying dorsal to the
cartilage mucoperichondium. Once the skin–soft tissue
envelope has been elevated, I find repeating the

Figure 30-4  A–D, Nasal SMAS/mucoperichondrium excised from nasal tip.
A
B
C
D
Figure 30-5  Cephalic trim performed, leaving a 7-mm caudal remnant
of lower lateral cartilage. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg
Clin North Am 2010;18:153-171.)
Figure 30-6  Released lower and medial lateral cartilages (arrows) from
the adherent vestibular tissue to aid in increasing tip projection. (From Nassif
PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)

CHAPTER THIRTY  African American Rhinoplasty
375
Figure 30-7  Lateral crural steal aids in increased nasal tip projection and rotation. The lateral crura are advanced onto the medial crura to project the
nasal tip and to rotate the tip. The lateral crura are advanced adjacent to the dome medially. Finally, bilateral interdomal and a transdomal suture is placed
with 5-0 absorbable suture of choice.
B
A
C
Figure 30-8  A, B, Columellar strut (large arrow) carved from septal cartilage placed in a pocket between the medial crura (small arrows). (From Nassif
PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
Releasing the lower and medial lateral cartilages from
the adherent vestibular tissue, as described earlier, with
the placement of an extended or basic columellar strut
may be all that is necessary to increase tip projection.
Numerous grafts may modify tip projection such as a basic
columellar strut (Figure 30-8), a shield tip graft (Figure
30-9), bruised onlay dome and/or infratip lobular grafts
(Figure 30-10), or a combination of these grafts. In nearly
100% of the ethnic rhinoplasties I perform, a columellar
strut is placed. This sets the foundation for tip projection
as the nasal tip is rebuilt. I favor carving the columellar
strut from septal cartilage, although auricular cartilage or
rib cartilage can also be used. If the patient has undergone
a septoplasty in the past, preoperative intranasal palpa­
tion of the septum may help determine if any significant
cartilage remains available. In many instances, cartilage
is present along the dorsal septum. In addition to the
endonasal approach, dorsal septal cartilage may be har­
vested from the open approach by elevating the middle
vault mucoperichondrium from the septum following
Figure 30-9  Shield graft carved from septal cartilage. (From Nassif PS.
Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)

376
Paul S. Nassif
Figure 30-10  Lateral (A) and frontal (B) views of a bruised infratip lobular graft. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
A
B
Figure 30-11  A, B, Two short segments of septal cartilage sutured to one another toward their distal ends, creating a columellar strut. (From Nassif PS.
Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
Figure 30-12  An auricular cartilage columellar strut created by suturing
a double-layered segment with the concave sides facing one another.
(From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
release of the caudal end of the upper lateral cartilages.
Dorsal septum may be harvested without loss of dorsal
support as long as at least 1 cm of septum is preserved.
If the septal cartilage harvested is short, two segments
may be sutured to one another toward their distal ends
(Figure 30-11). To augment the nasolabial region or sub­
nasale, plumping grafts or a posterior septal extension
graft may be used.
A columellar strut may be created with auricular car­
tilage by suturing a double-layered segment with the
concave sides facing one another (Figure 30-12). In addi­
tion to adding tip projection, a shield graft or infratip
lobular graft will add length to the infratip lobule and
create the proper tip-defining points. Shield grafts
made from auricular cartilage are usually less rigid
than septal grafts but either will suffice. If the graft
extends a moderate amount above the native tip, a

CHAPTER THIRTY  African American Rhinoplasty
377
Figure 30-13  Lateral (A) and
straight-on (B) views of a buttress
graft (arrow) preventing bending
of a shield graft (arrowhead).
(From Nassif PS. Asian rhino­
plasty. Fac Plast Surg Clin North
Am 2010;18:153-171.)
A
B
Figure 30-14  Mucoperichondrium (arrow) placed over a shield graft
to prevent visibility of the graft through the skin. (From Nassif PS. Asian
rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
Figure 30-15  Deep temporalis fascia used for augmentation or to
cover cartilage grafts. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin
North Am 2010;18:153-171.)
Figure 30-16  Deep temporalis fascia draped over the nasal tip and
grafts. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
buttress graft (Figure 30-13) is placed behind the shield
graft to prevent “bending” of the graft. Additionally, rim
grafts may be added to create a balanced alar–dome
contour. Once all grafts are sutured into place, either
SMAS/mucoperichondrium (Figure 30-14) or deep tem­
poralis fascia (Figure 30-15) can be placed over the tip
complex (Figure 30-16) to prevent skin contraction with
eventual visibility of the grafts through the skin.
The tongue-in-groove technique may also be used.2
In essence, the medial crura are advanced on the anterior
caudal septum using 5-0 permanent suture. This can also
increase tip projection and rotation as desired (Figure
30-17).
If additional cartilage is needed, autologous cartilage
is the preferred choice. Auricular cartilage (Figure 30-18)
harvesting from the concha cavum and cymba concha

378
Paul S. Nassif
Figure 30-17  A, Diagram of the tongue-in-groove technique. B, The 5-0 PDS suture is being passed through the posterior caudal medial crural ligament
(arrow) from the outside to the inside (toward the septum). The suture can also be passed through the posterior medial crura cartilage. C, The suture is
passed through the anterior septal angle. D, The suture is finally passed in the opposite direction exiting the medial crural ligament (shown here) or the
medial crura cartilage. Overhead (E) and frontal (F) views of the tip with increased tip projection. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North
Am 2010;18:153-171.)
A
B
C
D
E
F

CHAPTER THIRTY  African American Rhinoplasty
379
may be approached from the anterior (Figure 30-19)
surface; however, it is usually harvested from the pos­
terior surface (Figure 30-20) (>90% of my cases). Costal
cartilage (Figure 30-21) is my autologous cartilage of
choice for dorsal reconstruction. Costal cartilage harvest­
ing has been well described in many publications and will
not be discussed here; however, it is worth mentioning for
logistical purposes that while I harvest the temporalis
fascia graft (which I use in the majority of cases), a
second team of surgeons harvest the rib.
OSTEOTOMIES
Conservative management of the nasal bones should be
considered since many African American patients have
low nasal bones. Osteotomies in patients with low nasal
Figure 30-18  Convex auricular cartilage used for tip reconstruction.
(From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
Figure 30-19  A, Auricular cartilage harvested from the anterior approach. B, Anterior surface of the ear following incision closure and coapting sutures
placed through the concha cavum and cymba (arrow). C, Healing anterior auricular incision. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North
Am 2010;18:153-171.)
A
B
C

380
Paul S. Nassif
Figure 30-20  Postauricular closure following conchal cartilage harvest­
ing. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
Figure 30-21  Costal (rib) cartilage carved into a columellar strut (left),
rim grafts (middle), and alar batten grafts (right). (From Nassif PS. Asian
rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
Figure 30-22  Layered 1- to 2-mm polytetrafluoroethylene sheeting.
(From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;
18:153-171.)
Figure 30-23  Typical silicone L-strut used for dorsal augmentation.
(From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;
18:153-171.)
bones are typically difficult to perform and carry a higher
than average risk of being asymmetric. If osteotomies are
to be performed, infiltrating the nasal mucosa medial to
the pyriform aperture with a solution containing local
anesthetic and epinephrine will aid in hemostasis. I usually
find that performing low-to-low osteotomies followed by
fading medial osteotomies and ensuring bones are mobile
and infractured will prevent green stick fractures or rocker
deformities.
RADIX AND DORSAL AUGMENTATION
The pocket for the graft must be of adequate size or just
larger than the graft. Autologous grafts, including septal,
conchal, or costal cartilage, are preferred to alloplastic
grafts such as layered 1- to 2-mm polytetrafluoroethylene
(PTFE) sheeting (Figure 30-22). I prefer not to use sili­
cone implants (Figure 30-23) because of the higher risk
of infection and subsequent extrusion. For minimal radix
and/or dorsal augmentation, my preference is to use nasal
SMAS/mucoperichondrium or deep temporalis fascia
(see Figure 30-15). For moderate radix and/or dorsal
augmentation, bruised cartilage (septal, conchal, or costal)
is placed posterior to the harvested scar tissue/
mucoperichondrium or wrapped in deep temporalis fascia
(Figure 30-24). Diced cartilage wrapped in fascia (DCF)
(Figure 30-25) popularized by Calvert et al.3 has become
my preference for significant dorsal augmentation. The
diced cartilage is placed in a 1-ml tuberculin syringe with
the distal end of the syringe removed. Enlarging the distal
end of the syringe will allow the diced cartilage to flow
easily through the syringe. Deep temporalis fascia is
wrapped around the syringe and secured with a running
5-0 chromic suture. To create a smooth dorsal
augmentation, the DCF graft should extend to the cepha­
lad supratip region. En bloc cartilage grafts placed over

CHAPTER THIRTY  African American Rhinoplasty
381
the dorsum may warp, look unnatural, or reabsorb; there­
fore, I prefer not to use them in my practice.
ALAR BASE REDUCTION
In brief, alar base reduction in the African American
patient can be subdivided into techniques that narrow the
alae with or without modifying the vestibular component
(nostril), the nasal sill/floor, or a combination of these.
Rarely do I encounter the need to carry out an excision of
the nasal sill region within this patient population. Fur­
thermore, I find that this maneuver narrows the nostril
and nasal floor with subsequent narrowing of the airway
without reducing the alar lobule (Figure 30-26). With this
technique, the only way to obtain some alar reduction is
to make the standard sill incision at the junction of the
ala and nostril. This is demonstrated in Figure 30-27 in
an Asian patient. If the African American patient refuses
to undergo a standard alar lobule reduction, the described
technique may be used with limited results. In my experi­
ence and for the majority of my patient population, the
Figure 30-24  A, Bruised cartilage placed on deep temporalis fascia. B, Bruised cartilage wrapped in deep temporalis fascia. C, (Before) bruised cartilage
wrapped in deep temporalis fascia used as a radix/cephalad dorsal graft (arrow) and fascia placed over the dome. D, After view. (From Nassif PS. Asian
rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
C
D
Figure 30-25  Diced cartilage wrapped in deep temporalis fascia (DCF).
The diced cartilage is placed in a 1-ml tuberculin syringe with the distal end
of the syringe removed. Enlarging the distal end of the syringe will allow
the diced cartilage to flow easily through the syringe. Deep temporalis fascia
is wrapped around the syringe and secured with a running 5-0 chromic
suture. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)

382
Paul S. Nassif
alar lobule needs to be reduced to achieve harmony and
balance during the African American rhinoplasty.
Sheen4 has described several ways to reduce the alar
lobule and nostril, which, if performed properly, will
create an aesthetically pleasing result with a minimally
visible scar (Figure 30-28). To make this simple, vestibu­
lar (nostril) = decreased nostril size and cutaneous (alar
lobule) = modified alar lobule and contour. Two frequently
encountered types of alar base configuration in the African
American nose (Figure 30-29) are described:
• Type I: Larger than ideal alar lobule with appropriately
sized nostrils
• Type II: Larger than ideal alar lobule with larger than
ideal nostrils
Figure 30-26  A, Preoperative base view of the standard nasal sill incision. B, Postoperative view of the nasal sill procedure revealing a narrowed nostril
and nasal floor with subsequent narrowing of the airway without reducing the alar lobule. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am
2010;18:153-171.)
A
B
Figure 30-27  A, Preoperative base view of the lateral nasal sill/alar incision. B, Postoperative view of the lateral nasal sill/alar incision with a mild to
moderate amount of alar lobule reduction. The nostril is also narrowed with subsequent narrowing of the airway. (From Nassif PS. Asian rhinoplasty. Fac
Plast Surg Clin North Am 2010;18:153-171.)
A
B
Figure 30-28  Minimally visible lateral alar base scar (arrow).

CHAPTER THIRTY  African American Rhinoplasty
383
Figure 30-29  A, Base view of Type I: excessive alar lobule with normal sized nostrils. B, Base view of Type II: large nostrils and excessive alar lobules.
(From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
Figure 30-30  Type I only excises the alar lobule (cutaneous) without vestibular skin. It involves an external alar exision along the entire border of the
alar lobule. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
C
D
Addressing the Type I configuration involves cutane­
ous excision of the alar lobule (cutaneous) without ves­
tibular skin by means of an alar base excision along
the alar groove (Figure 30-30). In general, 3–4 mm of
reduction will provide a significant degree of change;
however, it is prudent to be conservative with this very
powerful technique until significant experience has been
accrued with it. For unique situations, I have removed
as much as 5 mm of alar lobule, which is not common
practice.

384
Paul S. Nassif
Addressing the Type II configuration involves excising
primarily the alar lobule (cutaneous incision) with a
limited amount of vestibular tissue (although significantly
less than the cutaneous component). The same types of
incision and amounts of resection are performed as during
a Type I incision, with the exception that the incision
extends into the vestibular lining of the nose, resecting a
limited amount of vestibular tissue. The techniques
described do not include routine nostril sill/floor excisions,
which may be incorporated into either of the described
alar base reduction techniques (Figure 30-31).
To obtain the most aesthetically pleasing scar, the
following pearls should be considered. Traditional teach­
ing instructs that the incision be approximately 1 mm on
the nasal side of the alar–facial junction. After noticing
on occasion a few visible scars at the cephalad alar lobule
due to the placement of the incision despite meticulous
closure techniques, I now make the incision in the alar–
facial junction, which heals beautifully. The incision is
beveled and a medial flap technique is used when vestibu­
lar tissue is resected. The medial flap technique (Figure
30-32) involves making the alar–facial incision initially
while extending medially along the alar base and stopping
short of the last 2 to 3 mm. A back cut that preserves a
Figure 30-31  Base view of combined alar lobule and nostril sill/floor alar base reduction technique. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg
Clin North Am 2010;18:153-171.)
A
B
C
small triangular (medial) flap is made followed by the
superior cut. A wedge of tissue is excised and the natural
continuity of the lateral nasal sill is preserved. Figures
30-33 and 30-34 demonstrate a female and male patient’s
nasal base view following the medial flap technique.
Bipolar cautery can be used sparingly for hemostasis
followed by subcutaneous closure using 5-0 Vicryl for the
deep tissues and a running 6-0 Prolene for the skin
closure. If any vestibular resection is performed, 5-0
chromic is used in a running or interrupted pattern. The
sutures are typically removed in 7 days.
POSTOPERATIVE NASAL CARE
• Meticulous cleansing of incisions
• Basic saline nasal sprays
• Suction bulb to suction nose as needed
• Head elevation
• Cold compresses
• Postoperative nighttime taping for 6 to 10 weeks
• A mixture of 0.4 mL 5-fluorouracil and 0.04 mL
of Kenalog 5 mg/mL is injected after 4 weeks as
needed

CHAPTER THIRTY  African American Rhinoplasty
385
Figure 30-32  Surgical markings of the lateral base (A) and lateral view (B) of the medial flap technique. C, D, The medial flap is preserved following
removal of the alar lobule. (From Nassif PS. Asian rhinoplasty. Fac Plast Surg Clin North Am 2010;18:153-171.)
A
B
C
D
Figure 30-33  Preoperative (A) and postoperative (B) base view of an African American female’s nose following the medial flap technique for alar base
reduction. Note the natural continuity of the alar lobule is maintained.
A
B

386
Paul S. Nassif
Figure 30-34  Preoperative (A) and postoperative (B) base views of an African American male’s nose following the medial flap technique for alar base
reduction. Note the natural continuity of the alar lobule is maintained.
A
B
RISKS AND COMPLICATIONS
• Overaggressive cartilage removal, causing loss of pro­
jection and ptosis
• Prolonged bruising or hyperpigmentation
• Infection
• Prominent alar scarring
• Excessive alar reduction
• Abnormal appearing ala
• Flat ala with loss of natural base curves
• Nasal asymmetry, graft irregularity, displacement and
extrusion
• Graft absorption
• Prolonged swelling
PEARLS
• Carefully evaluate the nasal anatomy, physiology, and
the patient’s expectations.
• Establish realistic goals for the patient and for
yourself.
• Prepare a detailed preoperative evaluation and surgical
plan.
• Maintain or improve nasal airway function.
• Perform revision procedures only when truly
warranted.
REFERENCES
1. Kridel RWH, et al. Advances in nasal tip surgery: The lateral
crural steal. Arch Otolaryngol Head Neck Surg.
1989;117:1206–1212.
2. Kridel RWH, et al. The tongue-in-groove technique in
septorhinoplasty. Arch Facial Plast Surg. 1989;1:246–256.
3. Calvert JW, Brenner K, DaCosta-Iyer M, et al. Histological
analysis of human diced cartilage grafts. Plast Reconstr Surg.
2006;118(1):230–236.
4. Sheen JH. Adjunctive techniques. In: Aesthetic Rhinoplasty. St.
Louis (MO): The Mosby Company; 1987:255-258.

387
C H A P T E R T H I R T Y - O N E 
Middle Eastern Rhinoplasty
Babak Azizzadeh • Grigoriy Mashkevich
Aesthetic rhinoplasty in patients of Middle Eastern extrac­
tion poses a specific set of challenges for the rhinoplasty
surgeon. As is true in other geoethnic groups, several
unique anatomic features define the appearance of the
“Middle Eastern nose” and require a tailored approach to
achieve aesthetic refinement. Implicit in the surgical
methodology for this group is the prevention of “Westerni­
zation rhinoplasty” and preservation of the native ethnic
look (the word “ethnic” is used loosely throughout text
and refers to all ethnicities of the Middle East). Middle
Eastern rhinoplasty also highlights the fundamental sur­
gical tenets of cartilage sparing and structural grafting.
These are particularly applicable to this group of patients,
who consistently demonstrate inherent cartilaginous
weakness as well as thick overlying nasal skin. This
chapter explores the common nasal characteristics shared
by people of the Middle Eastern origin and reviews the
essential elements of a rhinoplasty consultation. Various
surgical techniques that have been found effective by
authors in the aesthetic refinement of the Middle Eastern
nose are discussed in detail.
BACKGROUND AND DEMOGRAPHICS
While the term “Middle East” refers to a geographic
region, its precise borders have been poorly defined and
blurred over the centuries by migration and intermixing
of various populations. The phrase “Middle East” has its
origins in the United Kingdom at the turn of the twentieth
century and refers to regions of Western Asia and North
Africa. Numerous modern nations presently comprise this
subcontinent and are home to almost a billion people1
(Table 31-1). Some historians argue that several large
adjacent countries, such as Armenia, Afghanistan, Paki­
stan, and India, also belong in the Middle Eastern cate­
gory. While this discussion is beyond the scope of the
present chapter, it is not surprising that people inhabiting
these neighboring countries certainly share many of the
nasal characteristics reviewed in detail here.
The Middle East is also home to a wide range of
ethnic and religious diversity. This may partially explain
variations in the aesthetic desires for rhinoplasty between
various geographic areas within Middle East. For instance,
it has been suggested that people living outside of the
Arabian Peninsula and Gulf regions (Saudi Arabia,
Kuwait, Qatar, UAE, Oman, and Iran) desire more sig­
nificant changes from rhinoplasty, such as greater dorsal
reduction and tip projection.2
In the United States, the estimated size of the Middle
Eastern diaspora varies according to the source, but nev­
ertheless provides a sense of its demographic impact.
According to a recent population census, more than 1.2
million people of strictly Middle Eastern origins reside in
United States.3 This number expands to “at least 3.5
million” as per the Arab American Institute.4 While the
residence of this ethnic group has been documented in all
50 states, an overwhelming 94% reside in large metro­
politan areas (Los Angeles, Detroit, and New York are the
top three cities).
VISUAL AND ANATOMIC
CHARACTERISTICS OF
THE “MIDDLE EASTERN” NOSE
Several unique features define the ethnic appearance of a
Middle Eastern nose (Table 31-2, Figure 31-1). These can
be readily appreciated in some of the well-known political
figures from the Middle East (Figure 31-2).
One of the chief distinguishing characteristics of a
Middle Eastern nose is its relatively thick overlying skin–
soft tissue envelope (SSTE). Numerous pilosebaceous
units dotting its surface produce an oily texture and
further contribute to skin thickness. These anatomic
properties of SSTE significantly influence the appearance
of the lower third of the nose by effectively blunting the
configuration of the underlying cartilaginous framework.
Specific findings include an effacement of the supratip
region and concealment of tip definition. This results in
an overall amorphous appearance of the nasal tip. In the
postoperative period, the above-mentioned features of
SSTE promote scarring, which in turn predisposes to con­
tracture forces and formation of a pollybeak deformity.

388
Babak Azizzadeh • Grigoriy Mashkevich
Weak structural integrity of the lower lateral carti­
lages represents an additional defining property of the
nasal tip. Medial crura are typically thin and contribute
minimal support to the tip. The lateral crura are com­
monly rotated in a cephalic orientation and variably con­
tribute to tip fullness. Overactive depressor septi nasi
muscle and alar flaring are also frequently seen, especially
in people from the West African regions of the Middle
East.
RHINOPLASTY CONSULTATION
The initial rhinoplasty consultation for a Middle Eastern
patient allows the surgeon to form a fertile ground for
understanding patient concerns, goals, and motivations
for surgery. The concept of maintaining ethnic identity
should be clearly communicated on both sides of the table.
A surgeon should be wary of patients requesting a drastic
change in their appearance, which may cause an unnatu­
ral result (or “Westernization”) down the line and result
in an unsatisfied patient.
It is generally a good idea to include a family member
in the consultation process. His or her opinion may rep­
resent important feedback and help avert a potential mis­
understanding. Digital photography and morphing can
greatly assist in conveying the proposed changes and help
communicate more effectively. These should be used as a
point of reference, without implicit guarantees as to the
result. Various points discussed in the previous and later
sections should be kept in mind when altering patient
images (Table 31-3). If requested, “before and after”
photographs of previously operated patients can be used
as well. This may also help in clarifying the differences
Both of these can be controlled with specific surgical
maneuvers and steroid injections respectively, as outlined
in sections that follow.
High radix and a strong dorsum, with an associated
dorsal hump, commonly frame the upper two thirds of a
Middle Eastern nose. This visual feature is almost always
accentuated by the underprojected and hanging nasal tip,
thereby enhancing an illusion of increased dorsal height.
As such, elevating tip position goes a long way in visually
reducing the dorsum. Moreover, establishing an improved
nasal harmony by elevating the tip avoids an overresec­
tion of the nasal dorsum.
Source: mideastweb.org, cia.gov
Table 31-1  Present Middle Eastern Nations and Their Respective Population Estimates
Country
Population
Country
Population
Algeria
32,930,091
Oman
3,102,229
Bahrain
698,585
Palestine
3,889,248
Egypt
78,887,007
Qatar
885,359
Iran
68,688,433
Saudi Arabia
27,019,731
Iraq
26,783,383
Sudan
41,236,378
Israel
7,260,000
Syria
18,881,361
Jordan
5,153,378
Tunisia
10,175,014
Kuwait
2,418,393
Turkey
70,413,958
Lebanon
3,874,050
UAE
2,602,713
Libya
5,900,754
Yemen
21,456,188
Morocco
33,241,259
Total
465,263,512
Table 31-2  Common Visual Features Associated With a
Middle Eastern Nose
Skin–soft tissue
envelope
Thick skin with numerous
pilosebaceous units, contributing
to an amorphous appearance of
the nasal tip and supratip fullness.
Upper third
Overprojecting bony dorsum and
high radix; excessive and
sometimes irregular dorsal width
resulting in poor brow-tip dorsal
aesthetic line.
Middle third
Widening of the osseous and
cartilaginous vaults.
Nasal tip
Amorphous and hanging nasal tip,
cephalic orientation of the lower
lateral crura, weak medial crura,
acute nasolabial angle.
Nostrils
Variable degree of alar flaring.

Figure 31-1  Unique features define the ethnic appearance of a Middle Eastern nose.
Figure 31-2  Nasal features in some of the well-known Middle Eastern political figures, exemplifying typical visual attributes of a Middle Eastern nose.
A, Prince Abdullah of Saudi Arabia. (This image is from Wikimedia and is a work of an employee of the Executive Office of the President of the United States,
taken or made during the course of the person’s official duties. As a work of the U. S. federal government, the image is in the public domain. http://
commons.wikimedia.org/wiki/File:Saudi_Crown_Prince_Abdullah_and_George_W._Bush.jpg). B, Benazir Bhutto. (This image is from Wikimedia and is
courtesy of SRA Gerald B. Johnson, United States Department of Defense. This image is a work of a U. S. military or Department of Defense employee,
taken or made during the course of an employee’s official duties. As a work of the U. S. federal government, the image is in the public domain. http://
commons.wikimedia.org/wiki/File:Benazir_bhutto_1988_cropped.jpg).
A
B
Table 31-3  Surgical Concepts and Techniques Commonly Used for Aesthetic Refinement of the Middle Eastern Nose
Skin–soft tissue
envelope
Defatting into the subdermal plane, especially in the supratip region; postoperative observation
and conservative Kenalog (triamcinolone acetonide) injections to prevent pollybeak formation.
Upper third
Maintenance of high radix during dorsal hump reduction; elevation of the tip to create a
harmonious dorsum–tip relationship, rather than aggressive reduction of the dorsum.
Middle third
Medial and lateral osteotomies; placement of spreader grafts to avoid internal valve narrowing
and an inverted-V deformity.
Nasal tip
Cartilage-sparing maneuvers with preferential use of suture techniques for the dome region;
placement of strong supporting grafts (columellar strut or septal extension graft, shield or
cap grafts); possible placement of lateral crural batten grafts and alar rim grafts.
Nostrils
Alar base modification as needed

390
Babak Azizzadeh • Grigoriy Mashkevich
guided into position with a 6-0 chromic suture on a Keith
needle. A knot is then tied over the skin at the site of the
transcutaneous suture placement, further securing the
graft in the postoperative period. This suture can be
removed in approximately 1 week.
In most cases where patients have dorsal hump reduc­
tion, the authors place spreader grafts to avoid internal
valve narrowing and an inverted-V deformity.
As previously discussed, a dependent position of the
nasal tip partially contributes to the appearance of exces­
sive dorsal height. Judicious tip projection and rotation,
in turn, create an illusion of a lowered dorsum. Tip modi­
fication is almost always necessary in a Middle Eastern
rhinoplasty, allowing for a more conservative reduction of
the nasal dorsum.
After dorsal hump modification and middle nasal
vault reconstruction, the lower lateral cartilages are exam­
ined for inherent weakness. Nasal tip reconstruction
begins by placing a columellar strut and securing it to
both medial crura. Kridel’s tongue-in-groove technique or
septal extension graft can be used in place of strut as
deemed appropriate for the nose.8,9 When projecting the
tip, it should be kept in mind that the supratip break
should never be as prominent as in the ideal Caucasian
nose. In male patients, it is especially desirable to only
have a minimally visible break in the supratip region.
Cartilage suturing techniques (intradomal sutures, lateral
crural steal dome sutures, etc.) and additional grafting
as necessary (shield or cap grafts) are used to improve
tip projection and definition.10–12 Judicious nasal skin
de-fatting may be performed at this point, in the subder­
mal plane (Figure 31-4).
Minimal resection of the cephalic margin of the lower
lateral cartilages should be performed. Lower lateral car­
tilages are typically weak structures and minimally con­
tribute to tip fullness. The authors prefer to reinforce the
in rhinoplasty goals for Caucasian and Middle Eastern
noses.
MIDDLE EASTERN RHINOPLASTY
The basic tenets of Middle Eastern rhinoplasty include the
avoidance of overresection and preservation of ethnic
appearance.5,6 Westernization, through application of
standards suitable for a Caucasian nose, should be avoided
in this patient group. Not adhering to this concept carries
a risk of establishing a disharmonious and unnatural
nasal–facial relationship. General concepts, discussed in
detail later, include a very conservative lowering of the
radix and dorsum, providing adequate tip projection, and
rotating the nasal tip while maintaining a hint of an acute
nasolabial angle (less than 95 degrees). These and other
goals for the Middle Eastern rhinoplasty are summarized
in Table 31-3.
The authors prefer an external rhinoplasty approach
in this patient group, as it affords superior visualization
of internal structures and allows precise modification of
the tip and osseocartilaginous framework. An endonasal
approach is used only when patients have natural tip
aesthetics with good tip support requiring only dorsal
modification. In the authors’ experience, the columellar
scar from an external approach heals exceptionally well
in this patient group, making an open incision not an
issue. This observation has been corroborated by Foda,7
who performed a columellar scar analysis on 600 patients
of Arabic extraction. In his series, only 1.5% of patients
found the columellar scar to be unacceptable (cited
reasons were scar widening, hyperpigmentation, and colu­
mellar rim notching).
The philosophy of open structure rhinoplasty under­
lies the surgical approach to the Middle Eastern nose. It
is imperative to add sufficient structure to the cartilagi­
nous framework, in light of the weak inherent cartilage
strength and thick overlying SSTE. The latter structure
becomes a significant risk factor in the postoperative
period for soft tissue contracture, which can easily over­
whelm any unaltered native cartilage.
Following an open rhinoplasty exposure, the upper
two thirds of the nose are addressed with a conservative
dorsal hump and radix modification (Figure 31-3). Main­
tenance of sufficient dorsal height, in harmony with a high
radix, is critical in preserving an ethnic appearance in a
Middle Eastern nose. These structures must be conserved
to a greater extent than in a Caucasian nose. Gender dif­
ferences in the height of the radix must also be carefully
considered with male patients requiring a higher radix
than their female counterparts. Overall, a low radix can
accentuate the dorsal height. Correction of the radix-
dorsum disproportion improves the overall dorsal balance
and reduces its prominence. A crushed cartilage graft is
an effective means of filling the radix bed and can be
Figure 31-3  Dorsal hump reduction
Cartilaginous
hump

CHAPTER THIRTY-ONE  Middle Eastern Rhinoplasty
391
tip cartilages with lateral crural strut grafts and place rim
grafts along the alar margin.13,14 These maneuvers provide
an additional layer of protection against postoperative
collapse of the vestibule, as well as against alar rim notch­
ing and retraction. The key factor is to create a straight
structurally sound lateral crura avoiding excessive convex­
ity or concavity. Figure 31-5 highlights structural tech­
niques commonly used in Middle Eastern rhinoplasty.
Tip rotation should be conservative and aim to create
a nasolabial angle of approximately 95 degrees or less.
This can be achieved in most instances with a combina­
tion of strut placement, dome suturing, and a conservative
triangular caudal septal excision with the base at the
anterior septal angle. Vertically oriented lateral crura may
prevent cephalic rotation of the tip tripod, necessitating
an additional lateral crural overlay15 or caudal reposition­
ing of the lateral crura. If either scenario is used, lateral
crural strut grafts are used for reinforcement.
At the conclusion of the procedure, medial and
lateral osteotomies are performed. Medial osteotomies
Figure 31-4  Excessive subcutaneous soft tissue found during rhino­
plasty in patients of Middle Eastern extraction. Endonasal approach is shown
with the delivery of lower lateral cartilages. Soft tissue overlying the cartilage
is elevated to depict its thickness.
Figure 31-5  Structural techniques commonly utilized in Middle Eastern rhinoplasty: A, lateral crural strut grafts; B, alar rim grafts; C, columellar strut
grafts, and D, middle nasal vault reconstruction.
A
B
Columellar
strut
Medial
crura
C
Continued

392
Babak Azizzadeh • Grigoriy Mashkevich
Spreader graft
Horizontal spreader graft
Autospreader graft
Butterfly graft
Lateral battens
D
Figure 31-6  Medial and lateral osteotomies. Medial osteotomies typi­
cally fade laterally. Lateral osteotomies are performed in a high-low-high
fashion.
Figure 31-5, cont’d.
are performed in a lateral fading fashion at the osseocar­
tilaginous junction (Figure 31-6). If the patient has
open roof deformity, medial osteotomy is avoided. Lateral
osteotomies are performed in a high–low–high fashion.
If necessary, alar base modification is completed fol­
lowing osteotomies, keeping in mind that mild alar flaring
is an important feature of the Middle Eastern nose (Figure
31-7). The type of alar base modification will depend on
two key factors: alar flaring and interalar–intercanthal
distance. If the patient has normal interalar–intercanthal
relationship (usually should be 1 : 1), then “alar wedge
resection” is performed. Alar wedge resection avoids sill
incision. If the patient’s interalar distance is significantly
wider than intercanthal distance, then a sill incision will
also be necessary. Sill incisions must be made medial to
the nostril axis. Middle Eastern patients can tolerate to
keep the alar base slightly wider than the intercanthal
distance.16
COMPLICATIONS AND PITFALLS
Several undesirable outcomes may complicate the
Middle Eastern rhinoplasty. These usually arise from a
combination of factors, not the least of which is surgical
execution.
In both men and women, overly aggressive resection
of the dorsum and/or excessive lowering of the radix can
take away an important ethnic characteristic of a Middle
Eastern nose. Reestablishing adequate tip projection
should avoid the need to significantly lower the dorsum.
Pollybeak deformity represents a real concern in this
patient group due to excessive thickness and elevated
glandular content of the SSTE. Avoiding overresection of
the dorsum in combination with defatting of the supratip
region in the subdermal plane and vigilant observation in
the immediate postoperative period can help avoid this
dreaded complication. Of particular assistance is triamci­
nolone acetonide (Kenalog-10; Bristol-Myers Squibb,
Princeton, NJ).17 Triamcinolone acetonide can be injected
as soon as 1 week postoperatively. Injections can be
repeated once every 4 weeks for several cycles until the
desired effect is attained. The judicious use of smaller
volumes and lighter concentrations of triamcinolone ace­
tonide should reduce complications such as cutaneous

CHAPTER THIRTY-ONE  Middle Eastern Rhinoplasty
393
Figure 31-7  Alar base modification is
completed following osteotomies, keeping
in mind that mild alar flaring is an important
feature of the Middle Eastern nose. A, Alar
wedge resection; B, Alar sill resection; C,
Alar wedge and sill resection.
A
B
C
Figure 31-8  Preoperative (A, C, E) and postoperative (B, D, F) photographs of revision rhinoplasty in a Middle Eastern patient. (Azizzadeh B, Mashkevich
G. Middle eastern rhinoplasty. In: Fac Plast Surg 2010;18[1].)
A
C
E
B
D
F

394
Babak Azizzadeh • Grigoriy Mashkevich
A
B
C
D
E
F
Figure 31-9  Preoperative (A, C, E, G, I) and postoperative (B, D, F, H, J) photographs of ethnic rhinoplasty in a Middle Eastern patient.

CHAPTER THIRTY-ONE  Middle Eastern Rhinoplasty
395
G
H
I
J
Figure 31-9, cont’d.
atrophy and pigmentary skin changes. We rarely use
steroid injections but do reserve it for this purpose.
Tip descent may occur secondary to inadequate struc­
tural grafting of the columella and failure to preserve
sufficient native cartilage. Placement of a strong columel­
lar strut with concomitant medial crural binding sutures,
septal–columellar tongue-in-groove technique, and/or
placement of a septal caudal extension graft is essential
to counteract forces of scarring and preserve tip projection
postoperatively.
Aggressive rotation of the tip, resulting in an obtuse
nasolabial angle, can create an unnatural appearance for
this patient population. While tenets of Caucasian rhino­
plasty dictate an ideal nasolabial angle of 95 to 110
degrees in women, the same angle in a Middle Eastern
nose risks overrotation and an incongruous appearance.
A practical goal of less than 95 degrees of rotation should
be followed to avoid this complication.
Figures 31-8 and 31-9 represent preoperative and
postoperative photographs of Middle Eastern individuals
who underwent successful ethnic rhinoplasty.
CONCLUSION
Aesthetic rhinoplasty in patients of the Middle Eastern
extraction epitomizes primary goals of ethnic nasal
surgery, which include avoidance of aggressive maneu­
vers, preservation and modification of native structures,
and addition of supporting grafts capable of withstanding
postoperative forces of contracture. These same guide­
lines, in the framework of a conservative and methodical

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Babak Azizzadeh • Grigoriy Mashkevich
surgical approach, underlie the basic tenets of Middle
Eastern rhinoplasty. Preservation of native racial features
through approaches described in this chapter should help
achieve a natural aesthetic refinement in patients under­
going the “Middle Eastern” rhinoplasty.
REFERENCES
1. The World Factbook. United States Central Intelligence
Agency.
2. Bizrah MB. Rhinoplasty for Middle Eastern patients.
Fac Plast Surg Clin North Am. 2002;10(4):381–396.
3. US Census Bureau. Census 2000.
prod/2003pubs/c2kbr-23.pdf
4. The Arab American Institute. Demographics. http://

5. Rohrich RJ, Ghavami A. The Middle Eastern nose. In: Gunter
JP, Rohrich RJ, Adams WP, eds. Dallas rhinoplasty: nasal
surgery by the masters. St Louis: Quality Medical Publishing;
2007:1139–1165.
6. Romo T 3rd, Abraham MT. The ethnic nose. Fac Plast Surg.
2003;19(3):269–278.
7. Foda HM. External rhinoplasty for the Arabian nose: a
columellar scar analysis. Aesthet Plast Surg. 2004;28(5):
312–316.
8. Kridel RW, Scott BA, Foda HM. The tongue-in-groove
technique in septorhinoplasty. A 10-year experience. Arch Fac
Plast Surg. 1999;1(4):246–256.
9. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts:
a method of controlling tip projection shape. Plast Reconstr
Surg. 1997;100(4):999–1010.
10. Baker SR. Suture contouring of the nasal tip. Arch Fac Plast
Surg. 2000;2:34–42.
11. Rohrich RJ, Adams WP. The boxy nasal tip: classification and
management based on alar cartilage suturing techniques.
Plast Reconstr Surg. 2001;107(7):1849–1863.
12. Toriumi DM. New concepts in nasal tip contouring. Arch Fac
Plast Surg. 2006;8(3):156–185.
13. Gunter JP, Friedman RM. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast Reconstr Surg.
1997;99(4):943–952.
14. Rohrich RJ, Raniere J, Ha RY. The alar contour graft:
correction and prevention of alar rim deformities in
rhinoplasty. Plast Reconstr Surg. 2002;109(7):2495–2505.
15. Foda HMT, Kridel RWH. Lateral crural steal and lateral
crural overlay. An objective evaluation. Arch Otolaryngol
Head Neck Surg. 1999;125:1365–1370.
16. Kridel RW, Castellano RD. A simplified approach to alar base
reduction: a review of 124 patients over 20 years. Arch Fac
Plast Surg. 2005;7(2):81–93.
17. Hanasono MM, Kridel RW, Pastorek NJ, et al. Correction of
the soft tissue pollybeak using triamcinolone injection. Arch
Fac Plast Surg. 2002;4(1):26–30.

397
C H A P T E R T H I R T Y - T W O 
Mestizo Rhinoplasty
Roxana Cobo
Most individuals have an interest in being perceived by
others as attractive, regardless of their ethnic heritage,
racial background, or country of origin. Over time, migra­
tory movements have contributed to the ethnic and racial
melting pot responsible for the diversity we have come to
expect in major metropolitan areas. Industrialized coun­
tries in the world today constantly receive immigrants
from developing countries seeking more freedom or better
working opportunities than they experienced in their
country of origin.1 Latin America has not been the excep­
tion to this phenomenon. The United States, Canada, and,
to a lesser degree, Europe have seen significant migratory
movements arising from Latin American countries. Today
one of the fastest growing and largest minority groups
among these recipient countries are the “Hispanics” or
“mestizos.”2
Among the number of available aesthetic facial plastic
surgical procedures, rhinoplasty is one of the most popular
procedures. Elective aesthetic procedures have become
more accessible to people of different parts of the world
and from different socioeconomic backgrounds. Even
though paradigms of beauty have shifted throughout the
years, some publications still hold the “Caucasian” or
“Western” features as ideals for aesthetic standards of
beauty. In many textbooks and medical articles, the ideal
nose is still defined as moderately thin, angular, tapered,
and slightly projected.
Facial plastic surgeons today contend with the fact
that the established standards, and proportions once con­
ceived with the Caucasian ideals of beauty in mind, do
not necessarily hold true across different ethnic back­
grounds, including Hispanic patients. It behooves us to
accurately redefine the ethnically correct standard of
beauty so that patients can be delivered a surgical result
that is in line and closer to their aesthetic ideal.3
MESTIZO RACE
“Hispanic” is a term derived from Hispania, a Greek word
for the Iberian Peninsula (modern-day Spain, Portugal,
Andorra, and Gibraltar) that is commonly used to describe
Spanish-speaking people from Spain and Central and
South America. Patients originating from territories once
under the rule of the Spanish crown, especially countries
from Latin America, are referred to as Hispanic patients.
This population is also known as “Latinos” or “mesti­
zos.”4 The U.S. Census Bureau does not consider
Portuguese-speaking individuals as Hispanic.
The term “mestizo” is defined as a mixture of races.
In Latin America, this meant the mixture of the local
Indian tribes with the Caucasian European conquerors
during the fifteenth and sixteenth centuries. The introduc­
tion of the African slave trade in the eighteenth century
added a new ethnic and racial variation, and the term
meant the mixture of three predominant races: Indian,
Caucasian, and black.5 Today, the mestizo race is charac­
terized by distinct phenotypical features without a pre­
dominant racial pattern in Latin America. Racial features
vary depending on the geographic zone. Mexican patients
typically have a stronger Indian influence; some parts of
Central America typically have a stronger African influ­
ence; Argentina is predominantly European; other coun­
tries such as Colombia have a heterogeneous mix of all of
these.6,7
The Hispanic population in the United States is com­
posed of mestizo patients who migrate mainly from
Mexico, Central America, the Caribbean (including Cuba
and the Dominican Republic), and South American coun­
tries. This mix of populations had initially established
communities along the southwestern U.S. border, Florida,
and New York City but have since transcended these ter­
ritories, and they can be found throughout the nation and
across international borders.2
MESTIZO FACIAL AND NASAL
CHARACTERISTICS
Mestizo facial and nasal characteristics are different from
the universally accepted ideal “Caucasian” proportions.
Although phenotypical variations are as diverse as the
origins of the racial backgrounds leading to them, the
mestizo face tends to be broad with a relatively small
underprojected, ptotic nose. The skin tends to be thicker
and more sebaceous with a resulting skin–soft tissue enve­
lope (SSTE) that is thicker and harder to redrape and for
whom changes will be less noticeable. Malar eminences

398
Roxana Cobo • William Numa
more dramatic change resembling the “Caucasian”
ideal
3. Complete history and physical exam (including
disclosure of all previous nasal procedures as well
as an internal and external nasal examination)
4. Discussion of a realistic surgical plan and discussion
of potential complications and limitations
PHYSICAL EXAMINATION
FUNCTIONAL EVALUATION
A complete external and internal nasal examination must
be performed to evaluate the function of the nose. The
examination is usually performed through palpation, as
well as with a nasal speculum, and can be complemented
with nasal endoscopy.
Functionally, the following aspects should be noted:
1. Alar collapse
2. Compromise of internal or external nasal valve
3. Septal deviations/availability of septal cartilage for
harvesting
4. Turbinate hypertrophy
5. Sinus disease
Aesthetic Evaluation
When evaluating a mestizo patient for aesthetic rhino­
plasty, several criteria must be defined to delineate an
adequate surgical plan (Table 32-2):
1. General facial characteristics
2. Skin type/thickness of soft tissue envelope
3. Nasal characteristics: upper third, middle third,
lower third of nose
4. Underlying structural framework
5. Diagnosis of deformities and asymmetries
Once the consultation and physical exam have been
completed, it is important to obtain a set of standard
rhinoplasty photographs. This set includes frontal view,
basal view, right and left lateral views, and right and left
oblique views. Computer imaging is indispensable to
demonstrate the existing challenges and to demonstrate a
plan of how to overcome them with surgery. It is critical
to have the patient understand the limitations of the
procedure and be able to define a surgical plan within
the context of realistic expectations and clear lines of
communication.
Photography is useful for both the presurgical consul­
tation and an intraoperative reference. Postsurgical results
are also evaluated photographically, and photographs
should be obtained ideally at 6 months and 12 months
after surgery. This serves to help critically analyze aes­
thetic outcomes as well as surgical techniques.
tend to be slightly more prominent and eyelids have a
heavier look with more lid hooding. Heavy skin is a term
that can commonly be used when describing these patients.
The noses of patients of Hispanic origin will tend to
have an underlying cartilaginous architecture showing
poor structural support. Nasal bones can be small, short,
and slightly wide, with weak cartilaginous vaults. Tip
support is poor due in part to a weak caudal septum, a
small nasal spine, and soft alar cartilages. Externally, the
Hispanic nose can exhibit a wide nasal bridge, a low
nasion, a wide nasal base, a short columella, an acute
nasolabial angle, and nostrils that tend to have a more
flaring and horizontal shape4 (Table 32-1, Figure 32-1).
PREOPERATIVE EVALUATION
CONSULTATION
It is important to be able to have the time and the ability
to communicate with the patient in an adequate manner.
The following points should be covered during the
consultation:
1. Acknowledgment of the patient’s ethnic
background with explanation of key issues
2. Understanding of the patients’ desires and
expectations: a more balanced result preserving
some of the patient’s nasal ethnic features or a
Table 32-1  Mestizo Nasal Characteristics
Mestizo Noses
Caucasian Noses
Type of skin
Oily, thick SSTE
Normal to thin
SSTE
Upper third of
nose
Wide nasal bridge
Normal nasal
bridge
Normal to low
radix
Normal to high
radix
Short nasal bones
Normal to long
nasal bones
Middle third of
nose
Weak upper lateral
cartilages
Normal upper
lateral cartilages
Lower third of
nose
Weak,
unsupportive alar
cartilages
Normal to thick
alar cartilages
Normal to acute
nasolabial angle
Normal to obtuse
nasolabial angle
Poor tip recoil
Normal tip recoil
Flaring, horizontally
shaped nostrils
Oval-shaped
nostrils

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
399
possible approaches and surgical techniques could be used
with these patients, it is easiest to do so by focusing on
the different problems encountered. Pertaining to usual
generalizations, these patients tend to have:
1. Thick skin
2. Short nasal bones
3. Bulbous undefined nasal tips
4. Weak alar cartilages
5. Weak bony and cartilaginous support structures of
the nose
All documentation from patients, including photogra­
phy, must be kept as part of the medical record and serve
as future reference for both medical and legal matters,
should the latter arise.
APPROACHES TO THE MESTIZO NOSE
When evaluating mestizo patients, there are great ana­
tomic variations depending on the predominant race of
the patient. This makes it difficult to categorize these
patients into a specific group. When defining what
Figure 32-1  Mestizo nasal characteristics. A, Broad faces with an SSTE that tends to be thicker and slightly more oily; noses tend to be small with wide
nasal bridge and short nasal bones; nasal tips typically look bulbous and undefined. B, On the lateral view, the radix tends to be low and is often associated
with a small bony hump; the nasolabial angle tends to be acute. C, Base view: short columella with nostrils that tend to be more horizontally shaped and
flaring.
C
B
A

400
Roxana Cobo • William Numa
patients are frequently low and wide and can have small
convexities.
Surgically, the dorsum can be managed in several
ways: To narrow a wide dorsum without an existing hump,
medial and lateral osteotomies are performed routinely. In
cases where there is a shallow radix with a small dorsal
convexity, instead of lowering the hump to the level of the
radix, a radix cartilage graft is used with excellent post­
surgical results.8 This helps give the appearance of a
stronger dorsum without making the nose much larger12
(Figure 32-2).
One of the problems with ethnic patients is that sig­
nificant amounts of cartilage are usually needed for struc­
tural grafting of the nose and usually the septum does not
have enough to address all the essential regions. When
dorsal augmentation is needed and if there is enough
cartilage, dorsal onlay grafts are used, preferably from
septal cartilage. If an insufficient amount of cartilage is
available and the required dorsal augmentation is signifi­
cant, alloplastic material such as expanded polytetrafluor­
oethylene (ePTFE, Gore-Tex; Implantech Associates,
Ventura, CA) or porous high-density polyethylene implants
(Medpor; Porex Surgical, Newnan, GA), which have excel­
lent long-term outcome with low complication rates, can
be used as alternatives in patients who prefer not to
undergo a costal cartilage graft harvest.1,13
MIDDLE THIRD OF THE NOSE
Mestizo noses very frequently have short nasal bones and
weak upper lateral cartilages. This is a real problem for
the surgeon if the cartilages are not strengthened properly.
In general, mestizo patients seek noses that look
smaller and more defined. This typically means a nar­
rower dorsum, a more defined and projected nasal tip, and
a narrower base. Our challenge as surgeons is to carry out
surgical techniques that give defining structural support
without making the nose look much bigger. The external
rhinoplasty approach is used in most of these patients.
Surgical techniques will be discussed focusing on the areas
of the nose where the most important problems are
encountered.
UPPER THIRD OF THE NOSE
Mestizo patients tend to prefer a smaller dorsum to a high
profile nose with a prominent tip.4 The dorsum in these
Table 32-2  Cosmetic Evaluation Sheet
• General facial characteristics: facial asymmetries,
nose-chin balance
• Skin type: thin, thick/oily, dry
• Nasal dorsum: high, low/hump/deviation/depression
• Nasal bridge: wide or narrow
• Middle third of nose (upper lateral cartilages): wide/
narrow/unilateral depression
• Nasal tip (alar cartilages): strong, flimsy/wide, narrow
• Nasolabial angle: acute/obtuse
• Nasal base: wide, normal, narrow
• Nostril orientation: vertical, horizontal, oval/flaring,
nonflaring
• Tip support: weak, strong/tip recoil
Figure 32-2  Approach to the upper third of the nose. A, Lateral presurgical view showing a low radix with a small osteocartilaginous hump and small
nasal bones. B, Illustration of radix graft. C, Lateral postsurgical view after placement of radix graft harvested from septum and conservative hump removal.
A
Radix
graft
B
C

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
401
Patients with small nasal bones, weak upper lateral
cartilages, and dorsal septal deviations are at greater risk
of resulting in inverted-V deformities, deviation of the
middle vault, and collapse of the upper lateral cartilages
with a resulting compromise of the internal nasal valve.9
The use of bilateral spreader grafts as a preventive surgi­
cal technique strengthens the middle nasal vault, main­
tains a normal contour of the middle third of the nose,
and avoids the formation of a postsurgical inverted-V
deformity (Figure 32-3 and 32-4). In cases where dorsal
hump removal is going to be performed, strengthening of
the middle third of the nose becomes imperative to avoid
late postsurgical deformities.
NASAL TIP PROCEDURES
The lower third of the nose can be divided into two cat­
egories: the base of the nose and the nasal tip lobule.
When modifying the lower third of the nose in mestizo
patients, several principles must be followed. A stable
nasal base must be created to guarantee a strong founda­
tion, to support the necessary tip modifications. The least
disruptive surgical techniques must be used on the tip
lobule to obtain predictable aesthetics; aggressive tech­
niques should be reserved for more prominent deformities.
The alar cartilages must be analyzed in the vertical and
horizontal planes; surgical options should be based accord­
ing to anatomic findings. Finally, the techniques per­
formed should be planned, starting with simple procedures
and evolving gradually toward more complex and aggres­
sive ones (Table 32-3).
Following these principles will help prevent postsurgi­
cal loss of tip projection, asymmetries, tip deviations, or
visible bossae formation. Although there are no standard
tip procedures used in mestizo patients, some techniques
are used more often than others. The desired outcome is
to increase rotation, projection, and definition of the nasal
tip lobule.
PROCEDURES FOR THE NASAL BASE
Creating a stable nasal base is critical when dealing with
mestizo noses. Most of our patients have weak structures
lacking support in the nasal lobular complex. If left
unsupported, loss of projection will likely occur postsurgi­
cally. The techniques used most frequently include colu­
mellar struts or the caudal septal extension grafts.4,12
The columellar strut has been used routinely in rhi­
noplasties carried out through the external approach to
stabilize and add support to the medial crura and create
an adequate medial crural–septal relationship. The strut
is carved according to the patient’s needs, placed in a
pocket dissected between the medial crura, and fixed in
place with 5-0 Vicryl sutures. Fixation should not be
placed too anteriorly in the medial crura to preserve the
natural double break of the columella. If a long strut that
extends to the nasal spine is going to be used, this is
secured inferiorly so that it does not move from the nasal
spine. This strut gives additional support to the tripod,
corrects any asymmetries or buckling of the medial
crura, and helps maintain or increase tip rotation and
projection.
The caudal extension graft has a special indication in
mestizo rhinoplasty patients. This graft is extremely useful
Table 32-3  Nasal Tip Surgical Procedures
Procedures aimed at addressing the nasal base
• Columellar strut
• Caudal extension graft
• Fixation of medial crura to caudal septal border
Procedures aimed at addressing the nasal tip lobule
  Intact strip procedures
• Cephalic trim of the lateral crura
• Transdomal suture narrowing technique
• Double-dome unit technique
• Lateral crural steal
  Incomplete strip procedures
• Lateral crural overlay technique
• Medial crural overlay technique
• Grafts
• Shield graft
• Shield graft + cap graft
• Lateral crural strut grafts
• Plumping premaxilla grafts
• Alar rim grafts
• Morselized cartilage over the tip
• Alar batten grafts
Figure 32-3  Illustration depicting placement of a bilateral spreader
graft.