Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

144
J.D. Weissman and S.P. Most
[ 37 ] , anatomic alar cartilage reconstruction [ 45 ] ,
alar rim reconstruction [ 46 ] , and alar contour
grafts [ 47 ] . Full discussion of alar rim deformi-
ties is beyond the scope of this chapter given its
primarily reconstructive nature, though it is cov-
ered elsewhere in this text.
12.7
Other Considerations
Thus far, this chapter has discussed different
surgical techniques to address the nasal valves
directly and lateral wall collapse. It would not
be complete, however, without mentioning
surgical treatment of the septum and inferior
turbinates.
12.7.1 Septum
The septum can affect nasal air fl ow at the level
of the internal nasal valve as well as more poste-
riorly in the nasal cavity. While septoplasty is
often performed in conjunction with rhinoplasty,
it is important to properly address the septum
when a signi fi cant high anterior de fl ection
exists. Such cases will not be adequately treated
with standard septoplasty technique, as such a
procedure would risk attenuating tip support
if the strut is weakened or resected [ 15 ] .
Extracorporeal septoplasty, instead, has been
advocated for these instances [ 48, 49 ] . The senior
author uses a modi fi cation of the extracorporeal
septoplasty, termed anterior septal reconstruc-
tion [ 15 ] , which is a more conservative technique
in that it preserves a dorsal strut so as to avoid
destabilization of the keystone area. Once the
septum is exposed along with an external rhino-
plasty approach and the upper lateral cartilages
are separated, most of the septal cartilage is
removed except for a dorsal strut that is 1.5 cm
along the anteroposterior axis, with vertical
height of approximately 1 cm. The reconstructed
anterior septum is then secured on the concave
side of the midvault, where it serves as spreader
graft and splint. The septum and its surgical cor-
rection are addressed more fully elsewhere in
this book.
12.7.2 Inferior Turbinates
The inferior turbinate should also not be forgot-
ten when addressing functional nasal surgery.
There still exists controversy over which of the
surgical techniques is best [ 50, 51 ] , though
microdebrider-assisted submucosal resection has
been shown in one study [ 52 ] to have longer last-
ing effects beyond those of radiofrequency-
assisted turbinoplasty. However, both were shown
to be effective in the more near term.
Fig. 12.6 Cephalic turn-in: The cephalic portion of the
LLC is folded inward underneath the caudal segment and
secured. Care must be taken to preserve at least 6–8 mm
of caudal cartilage. (Tellioglu and Cimen [ 41 ] )

145
12 Trends in Functional Rhinoplasty
Conclusions
Our literature is replete with surgical tech-
niques that can be utilized during rhinoplasty
to maintain or improve the nose’s functional
integrity. However, it is not clearly established
which of these procedures leads to the best
results. The responsibility of better assessing
outcomes falls on our shoulders and should be
performed and reported whenever possible
utilizing the most appropriate measures. As of
this writing, the NOSE scale is arguably the
most appropriate patient-based measure of
performance in surgery on the nasal valves
and lateral nasal wall. Further research efforts
should be aimed toward the development of an
objective outcomes measure that will allow
for a more standardized comparison of surgi-
cal procedures and better care for our
patients.
References
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16. Roofe SB, Most SP (2007) Placement of a lateral
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(2008) Evidence supporting functional rhinoplasty or
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20. Spielmann PM, White PS, Hussain SS (2009) Surgical
techniques for the treatment of nasal valve collapse: a
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21. Rhee JS (2009) Measuring outcomes in nasal surgery:
realities and possibilities. Arch Facial Plast Surg
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22. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239
23. Alsarraf R, Murakami C (1999) The saddle nose defor-
mity. Facial Plast Surg Clin North Am 7: 303–310
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25. Yoo S, Most SP (2011) Nasal airway preservation
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26. Park SS (1998) The fl aring suture to augment the
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29. Friedman O, Cook TA (2009) Conchal cartilage
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30. Guyuron B, Michelow BJ, Englebardt C (1998) Upper
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2169–2177
31. Islam A, Arslan N, Felek SA, Celik H, Demirci M,
Oguz H (2008) Reconstruction of the internal nasal
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approach. Laryngoscope 118(10):1739–1743
32. Dutton JM, Neidich MJ (2008) Intranasal Z-plasty for
internal nasal valve collapse. Arch Facial Plast Surg
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33. Schulte DL, Sherris DA, Kern EB (1999) M-plasty
correction of nasal valve obstruction. Facial Plast
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35. Regnault P, Alfaro A (1980) The Skoog rhinoplasty: a
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578–590
36. Seren E (2009) A new surgical method of dynamic
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37. Gunter JP, Friedman RM (1997) Lateral crural strut
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38. Mendelsohn MS, Golchin K (2006) Alar expansion
and reinforcement: a new technique to manage nasal
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39. Paniello RC (1996) Nasal valve suspension. An effec-
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40. Friedman M, Ibrahim H, Syed Z (2003) Nasal valve
suspension: an improved, simpli fi ed technique for
nasal valve collapse. Laryngoscope 113(2):381–385
41. Tellioglu AT, Cimen K (2007) Turn-in folding of the
cephalic portion of the lateral crus to support the alar
rim in rhinoplasty. Aesthetic Plast Surg 31(3): 306–310
42. Murakami CS, Barrera JE, Most SP (2009) Preserving
structural integrity of the alar cartilage in aesthetic
rhinoplasty using a cephalic turn-in fl ap. Arch Facial
Plast Surg 11(2):126–128
43. Menger DJ (2006) Lateral crus pull-up: a method for
collapse of the external nasal valve. Arch Facial Plast
Surg 8(5):333–337
44. Friedman M, Ibrahim H, Lee G, Joseph NJ (2004) A
simpli fi ed technique for airway correction at the nasal
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519–524
45. Menick FJ (1999) Anatomic reconstruction of the
nasal tip cartilages in secondary and reconstructive
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46. Troell RJ, Powell NB, Riley RW, Li KK (2000)
Evaluation of a new procedure for nasal alar rim and
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Otolaryngol Head Neck Surg 122(2):204–211
47. Rohrich RJ, Raniere J Jr, Ha RY (2002) The alar con-
tour graft: correction and prevention of alar rim defor-
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in
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48. King ED, Ashley FL (1952) The correction of the
internally and externally deviated nose. Plast Reconstr
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49. Gubisch W (2005) Extracorporeal septoplasty for the
markedly deviated septum. Arch Facial Plast Surg
7(4):218–226
50. Cavaliere M, Mottola G, Iemma M (2005) Comparison
of the effectiveness and safety of radiofrequency
turbinoplasty and traditional surgical technique in
treatment of inferior turbinate hypertrophy. Otolaryngol
Head Neck Surg 133(6):972–978
51. Bhandarkar ND, Smith TL (2010) Outcomes of sur-
gery for inferior turbinate hypertrophy. Curr Opin
Otolaryngol Head Neck Surg 18(1):49–53
52. Liu CM, Tan CD, Lee FP, Lin KN, Huang HM (2009)
Microdebrider-assisted
versus
radiofrequency-
assisted inferior turbinoplasty. Laryngoscope 119(2):
414–418

147
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_13, © Springer-Verlag Berlin Heidelberg 2013
13
13.1
Background
Classically, the Caucasian female has a leptor-
rhine (thin) nose, which consists of a thin dorsum
and slender nostrils. This is in contrast to the
platyrrhine (broad) nose of African descent and
the mesorrhine (intermediate width) nose of
Asian descent (Fig. 13.1 ). There is a great deal of
variability within the leptorrhine nose itself. The
three primary subgroups within this population
are the Greek nose (straight pro fi le), the Roman
nose (convex pro fi le), and the Armenoid nose
(convex pro fi le with ptotic nasal tip).
Among leptorrhine noses, the architecture of
the straight nasal dorsum has persevered as the
most aesthetically desirable variant. Perhaps this
is because the identi fi cation of facial aesthetics
began with the ancient Greek philosophers and
artists [ 1 ] . Facial harmony was de fi ned by the
Greek philosophers as having equal proportions
of the horizontal thirds and vertical fi fths of the
face. These teachings were revived during the
Renaissance period by Leonardo da Vinci and
others and continue to be used by rhinoplasty sur-
geons [ 2 ] . Behavioral science studies have vali-
dated these standards of beauty by demonstrating
subjective preference for symmetrical and pro-
portional facial architecture [ 3– 5 ] .
Nasal–facial relationships play a vital role in
the Caucasian female patient’s overall facial
aesthetic after rhinoplasty. Standardized mea-
surements of the nasofrontal angle, nasolabial
angle, nasal projection, nasomental relationship,
horizontal facial thirds, and vertical facial fi fths
were established for Caucasian females more
than 25 years ago and have served as the stan-
dard by which most rhinoplasty surgery has
been measured since that time (Fig. 13.2 ). These
measurements have evolved to include variabil-
ity in ethnicity and gender [ 6– 8 ] , but Western
ideals remain dominant, especially for the
Caucasian patient. For all patients, it is essential
that an appropriate balance and harmony of the
nasal and nasofacial relationships are kept
intact.
Media and marketing continue to play an inte-
gral role in further de fi ning aesthetic ideals. As
early as the 1940s, the popular Caucasian female
Primary Caucasian Female
Rhinoplasty
Babak Azizzadeh and Michael J. Reilly
B. Azizzadeh , M.D., FACS ()
Department of Facial Plastic and Reconstructive Surgery ,
Cedars-Sinai Medical Center ,
Los Angeles CA , USA
The Center for Advanced Facial Plastic Surgery , 9401
Wilshire Blvd., Suite 650 , Beverly Hills , CA 90212 ,
USA
The Center for Facial and Nasal Plastic Surgery ,
8670 Wilshire Blvd., Suite 200 , Beverly Hills ,
CA 90211 , USA
Division of Head and Neck Surgery ,
David Geffen School of Medicine at the University
of California, Los Angeles , 120 South Spalding Drive,
Suite 340 , Beverly Hills , CA 90212 , USA
e-mail: drazizzadeh@gmail.com , md@facialplastics.info
M. J. Reilly , M.D.
Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology – Head & Neck Surgery , Georgetown
University Hospital , 3800 Reservoir Rd. NW, 1st Floor
Gorman Building , Washington DC 20007 , USA
e-mail: mikereillydc@gmail.com,
mjr100@gunet.georgetown.edu

148
B. Azizzadeh and M.J. Reilly
nose was very petite, concave, and even upturned –
perhaps as a way of emphasizing ethnic differ-
ences. For this reason, the majority of rhinoplasty
efforts in the ensuing half-century were toward
reduction rhinoplasty. Over time, this exagger-
ated version of the Caucasian female nasal anat-
omy has gradually shifted toward a more moderate
or natural appearing nose, with aesthetic propor-
tions more consistent with those established by
the ancient Greeks [ 9 ] .
13.2
Nasal Structures
The bony and cartilaginous structures of the
female Caucasian rhinoplasty patient may con-
vey certain anatomic limitations to surgery. It is
necessary to thoroughly evaluate the size, shape,
orientation, and strength of the nasal bones as
well as the framework of the upper lateral and
lower lateral cartilages. The inherent qualities of
these anatomic structures will lay the foundation
for the fi nal rhinoplasty result, regardless of the
extent of surgery. In our practice, for the Caucasian
female rhinoplasty patient, undesirable anatomy
is commonly seen in one of the following fi ve
con fi gurations: (1) dorsal hump, (2) overprojected
tip, (3) asymmetry, (4) bulbous tip, and (5) ten-
sion due to excessive posterior septal angle
(Fig. 13.3a and 13.3b ) [ 10 ] .
Proper appreciation of the overlying skin of
the nose is a crucial factor in optimizing the over-
all result of rhinoplasty surgery. Skin that is either
too thick or too thin will translate to more limited
surgical outcomes. Thin skin will more likely
reveal small irregularities of the underlying nasal
anatomy, while thick skin will not allow as much
visibility of the surgically altered skeletal struc-
tures. Skin complexion is most often categorized
by Fitzpatrick skin type, a scale that is based on
the propensity for skin to burn when exposed to
sunlight [ 11 ] . Caucasian skin lies on the lower
end of the scale and is typically of Fitzpatrick
type 1, 2, or 3. Generally, a lower rank on the
Fitzpatrick Scale translates to thinner, less seba-
ceous skin.
13.3
Surgical Approaches
There has been much debate about the internal
versus external approach to rhinoplasty. Ideally,
the skilled surgeon has a mastery of both these
Fig. 13.1 Rendering of the
leptorrhine, mesorrhine, and
platyrrhine nasal shapes
Fig. 13.2 Rendering of the ideal Caucasian female
aesthetic, demonstrating harmony between the vertical
facial fi fths

149
13 Primary Caucasian Female Rhinoplasty
a
b
Fig. 13.3a Dorsal hump reduction, one of the most common Caucasian female rhinoplasty complaints. ( a ) Preoperative.
( b ) Postoperative

150
B. Azizzadeh and M.J. Reilly
approaches and is able to select the best approach
based on the surgical plan for each individual
patient.
The internal approach to the nose may be
divided into the nondelivery and delivery
approaches. The nondelivery approach is recom-
mended in patients with minimal tip bulbosity,
intermediate skin thickness, and natural tip sym-
metry due to the maintenance of natural tip
support mechanisms that often lead to more pre-
dictable postoperative healing course (Fig. 13.4 ).
The delivery approach is reserved for patients
with a wider nasal tip, bi fi d tip, or excessively
bulbous lower lateral cartilages. In these cases,
the lower lateral cartilages may be delivered
through a combination of intercartilaginous and
marginal incisions, leaving the ala attached only
to the underlying nasal mucosa (Fig. 13.5 ). This
a
b
Fig. 13.3b Nasal tip re fi nement for asymmetrical, bulbous tip. ( a ) preoperative. ( b ) postoperative

151
13 Primary Caucasian Female Rhinoplasty
approach allows for narrowing and reposition of
the lower lateral cartilages through a combination
of cephalic cartilage reduction, interruption, and
reapproximation of the alar cartilage strip, and/or
suture techniques to bring the lower lateral carti-
lage together.
Although the delivery endonasal approach
gives adequate visualization of the tip architec-
ture, the authors prefer the external approach for
cases where the delivery approach is indicated.
This external approach affords the surgeon the
opportunity to perform the spectrum of tip
re fi nement procedures done through the dome
delivery approach, while maintaining the tip in its
anatomic position and allowing for wider expo-
sure as well as extensive structural grafting.
The external approach allows for maximal
exposure of the tip and middle nasal vault
through marginal and midcolumellar incisions
(Fig. 13.6 ). The exposure itself does not disrupt
any of the major tip support mechanisms, but the
surgeon must preserve and/or restore stable tip
architecture. The pitfalls of this approach are the
possibility of poor tip skin redraping and/or col-
umellar scar.
13.4
The Nasal Tip
13.4.1 Overview
Shaping of the nasal tip is of paramount impor-
tance in rhinoplasty for the Caucasian female. In
this patient population, it is frequently the desire
for a more slender nasal tip that prompts the
surgical consultation. Caucasian skin is fre-
quently thin and will often show even with slight
irregularities or asymmetries of tip architecture.
In these patients, minimal intervention will maxi-
mize predictable healing of the soft tissue enve-
lope, thereby providing the best opportunity for
obtaining the desired results.
The goal of rhinoplasty is to achieve a desirable
aesthetic result without compromising the integrity
Fig. 13.4 Internal approach
Fig. 13.5 Delivery approach
Fig. 13.6 External approach

152
B. Azizzadeh and M.J. Reilly
of nasal air fl ow. In order to accomplish this, it is
necessary to understand the tripod concept as well
as the major and minor tip support mechanisms
that have been outlined extensively in other chap-
ters of this text. It is the tripod concept that allows
the surgeon to recognize the interplay between
rotation and projection that occur with changes to
the lower lateral cartilage structure [ 12, 13 ] .
There are various options for nasal tip re fi nement
such as judicious cephalic trim, lower lateral carti-
lage repositioning, suture reconstitution, and struc-
tural reinforcement. Aggressive resection of nasal
tip architecture should be avoided to reduce the
potential sequelae of uncontrolled postoperative
healing and loss of tip support. Factors to consider
in the operative approach to this region include tip
rotation, tip projection, the proportions of the tip to
the rest of the nose, the orientation, strength, and
shape of the lower lateral cartilages, as well as the
patient’s desired tip appearance. Avoiding excess
concavity and convexity in the lateral crura while
softly narrowing the tip-de fi ning points is the key
goal of tip rhinoplasty. A methodical approach to
evaluating each aspect of the nasal tip architecture
is recommended.
13.4.2 Surgical Techniques
Several objectives may be accomplished by the
manipulation of the alar cartilages. These include
volume reduction, domal narrowing, structural
reinforcement, and alteration in tip projection
and rotation. Most patients undergoing nasal tip
surgery will require a combination of these
interventions.
13.5
Volume Reduction
Historically, much of tip re fi nement has centered
on volume reduction. However, the role of aggres-
sive lateral crural resection has waned over the
past two decades. Judicious volume reduction
may be accomplished through cephalic trim of the
lower lateral cartilages, while reconstituting or
maintaining an intact strip of cartilage. In its sim-
plest form, cephalic trim can be achieved through
a nondelivery technique using a transcartilaginous
approach. This technique allows for re fi nement of
the tip along with a small amount of tip rotation
that occurs in the postoperative healing process.
Healing will be most predictable if this technique
is performed in an appropriate candidate who does
not have cephalically oriented lower lateral carti-
lage and has excellent preexisting tip support and
projection (Fig. 13.7 ). Patients who present with
moderate to severe tip bulbousness, bi fi dity, and/
or thick skin will require an external approach if
volume reduction is indicated. Cephalic reduction
must maintain at least 7 mm of an intact or recon-
stituted lateral crura. The senior author’s prefer-
ence is to maintain 10 mm of intact strip and keep
the trimmed portion of the cephalic lateral crura
intact to the vestibular mucosa and rotate it into
the scroll area (scroll reconstruction) in order to
avoid future collapse of the region (Fig. 13.8 ).
Furthermore, lateral crural strut grafts (Fig. 13.9 )
and alar rim grafts (Fig. 13.10 ) are utilized in
many patients to maintain support and contour of
the lateral crura.
13.6
Narrowing the Wide Nasal Tip
Although cephalic trim can result in mild domal
narrowing in patients with thin skin, suture
techniques are the authors’ primary choice for
narrowing a mild to moderately widened nasal
tip. There are two broad categories for suture
techniques that are used in our practice: intra-
domal and interdomal suture techniques.
Intradomal horizontal mattress sutures are
placed within a single lower lateral cartilage to
recreate the intermediate crus and hence de fi ne
the ipsilateral tip-de fi ning point (Fig. 13.11 ).
Interdomal sutures are used to bind the interme-
diate crura of both lower lateral cartilages,
thereby approximating the bilateral tip-de fi ning
points and narrowing the overall nasal tip
(Fig. 13.12 ). These sutures are often used in
combination (Fig. 13.13 ) [ 14 ] . It is important to
avoid creating a “uni-tip” appearance by over-
narrowing the tip with these techniques. The
surgeon must also be cognizant of avoiding con-
cavity at the junction of the dome and lateral
crura that can result in poor tip aesthetics. As
mentioned above, lateral crural strut grafts and

153
13 Primary Caucasian Female Rhinoplasty
a
b
c
Fig. 13.8 Disraption of the scrdl with cephalic trim may require suture resuspension to prevent collapse of the nasal valve
a
b
Fig. 13.7 ( a ) Preoperative patient with mild bulbousness and normally oriented lower lateral cartilage. ( b ) Rhinoplasty
with endonasal transcartilaginous cephalic trim and dorsal hump reduction

154
B. Azizzadeh and M.J. Reilly
alar rim grafts are often used in combination
with suture techniques to structurally support
the lower lateral cartilages.
Dome division with suture reconstitution
should be considered in patients with signi fi cantly
widened, convex, and/or enlarged lower lateral
cartilages. Lateral crural overlay technique is the
preferred approach by the senior author. This
approach allows preservation and reinforcement
Fig. 13.9 Lateral crural strut graft
Fig. 13.11 Intradomal suture technique for tip re fi ne ment
Fig. 13.10 Alar rim graft

155
13 Primary Caucasian Female Rhinoplasty
of the structural integrity while reducing the bul-
bosity of the nasal tip. Dome division and suture
techniques can also be combined with lateral cru-
ral strut and alar rim grafts as needed.
13.7
Tip Projection
All rhinoplasty patients require assessment and
management of their tip projection. External as
well as endonasal approaches result in loss of the
tip support structures that frequently lead to
deprojection during the postoperative period.
Pollybeak deformity (Fig. 13.14 ) is the unfortu-
nate outcome of the over resected lower third and/
or under-resected middle third. Most patients will
require structural reinforcement at the time of the
primary rhinoplasty to present this.
Patients who present with moderate tip sup-
port mechanisms and adequate tip projection
should be considered for columellar struts in
order to strengthen and maintain the fi nal tip
projection. In the underprojected Caucasian
patient who is undergoing primary rhinoplasty,
columellar struts and dome-binding sutures with
lateral crural steal (Fig. 13.15 ) will typically
suf fi ce in improving the position and strength of
the tip. Onlay grafts from crushed or bruised car-
tilage may augment the projection but should be
camou fl aged with temporalis fascia in thin-
skinned noses (Fig. 13.16 ) [ 15 ] . More substantial
tip grafts should be used with extreme caution in
thin-skinned individuals who require further
improvement in tip projection (Fig. 13.17 ) [ 16 ] .
Treatment of the overprojected tip is also a
key component of addressing the overall tip–
bridge aesthetics. A full trans fi xion incision at
the junction of the caudal septum and medial
crura provides the most straightforward approach
to deproject the nasal tip. Columellar struts or
tongue-in-groove technique can then be used to
set the fi nal position of the tip. If a great deal of
deprojection is desired, an interrupted strip tech-
nique may be necessary. The decision where to
cut the lower lateral cartilage when employing
this technique depends on whether the patient
requires rotation or counterrotation. The medial
crural overlay technique will cause counterrotation
Fig. 13.12 Interdomal suture
technique for tip re fi nement
Fig. 13.13 Combination of
intradomal and interdomal suture
technique

156
B. Azizzadeh and M.J. Reilly
of the nose and shortening of the columella
(Fig. 13.18 ) [ 17 ] . The lateral crural overlay
technique will increase the tip rotation and
shorten the sidewall of the nasal dome (Fig. 13.19 )
[ 18 ] . Lateral and medial crural overlay techniques
in combination will provide signi fi cant deprojec-
tion without change in rotation of the nose.
Extreme caution must be used with any of the
interrupted strip techniques as there are inherent
healing unpredictabilities that occur from the
Fig. 13.15 Lateral crural steal technique
a
b
Fig. 13.14 Pollybeak deformity. ( a ) Preoperative. ( b ) Postoperative

157
13 Primary Caucasian Female Rhinoplasty
disruption of the natural nasal architecture,
support mechanisms, and soft tissue envelope.
Structural support with lateral crural strut grafts,
alar rim grafts, columellar struts, or tongue-in-
groove technique is required to maintain long-
term tip support.
13.8
Tip Rotation
The nasolabial angle is one of the key determin-
ing factors for the overall appearance of the nose.
Aesthetic goals involve creating a natural rota-
tion that fi ts the patient’s overall appearance and
ethnicity. Caucasian female patients can tolerate
shorter noses and hence increased tip rotation
when compared to women of other ethnicities.
However, excessive shortening of the nose creates
an unappealing and “operated” aesthetic and
should be approached with extreme caution.
Conservative tip rotation in Caucasian patients
can be achieved through endonasal transcartilagi-
nous cephalic trim. Unfortunately, this approach
does not lead to predictable results as the rotation
occurs secondary to postoperative healing forces.
Fig. 13.16 Crushed cartilage covered with temporalis
fascia
Level of
columellar
pocket
Developing pocket
in nasal tip
Cartilage graft
in place
Fig. 13.17 Endonasal placement of structural tip graft

158
B. Azizzadeh and M.J. Reilly
a
c
b
d
Fig. 13.18 Medial crural overlay technique. ( a ) Preoperative. ( b ) Postoperative with cephalic trim, intra and
interdomal suturing and dorsal hump reduction

159
13 Primary Caucasian Female Rhinoplasty
Furthermore, in the long-term follow-up, the tip
tends to deproject and counterrotate if it is not
structurally supported at the time of surgery. In
the authors’ experience, columellar struts and
tongue-in-groove techniques via an external rhi-
noplasty approach produce much more predict-
able and long-lasting results in Caucasian
patients. The angle of columellar strut can dictate
the level of tip rotation as it is secured in between
the medial crura. If a patient has an excessive
caudal septum or signi fi cant tip ptosis, a tongue-
in-groove technique can be a more powerful
method to increase the tip rotation. With this
technique, the medial crura are secured to the
caudal septum thereby structurally supporting
the entire tip complex as one unit.
The need to counterrotate the tip in a primary
Caucasian rhinoplasty patient is unusual. The
treatment of an excessively short nose is beyond
the scope of this chapter; however, if counterrota-
tion is required during primary rhinoplasty, colu-
mellar struts can be fashioned and angled to allow
for placement of the tip complex into a more
appropriate position. Septal extension and
extended spreader grafts can also be utilized in
conjunction with columellar struts to achieve the
desired nasal length and nasolabial angle.
13.9
The Nasal Pro fi le
13.9.1 Overview
The position of the tip in relation to the upper and
middle thirds of the nose de fi nes the dorsal
pro fi le. In the Caucasian nose, the height of the
bony nasal vault is often more prominent than
that of mesorrhine or platyrrhine noses. Currently,
the concave or “ski jump” nose of years past has
given way back to a more ethnically appropriate
straight nasal dorsum. Overresection of the dor-
sum will also obscure the shadows of the dorsal
aesthetic lines on anterior view.
The ideal starting point for the radix and nasal
dorsum in the Caucasian female is the superior
palpebral fi ssure. Alignment of the dorsum must
be made in conjunction with the fi nal placement
of the nasal tip. In the Caucasian female, a soft
but de fi ned supratip break is desirable. This may
be obtained by appropriately setting and stabiliz-
ing the nasal tip, followed by judicious dorsal
hump reduction at the level of the middle nasal
vault and nasal bones.
13.9.2 Surgical Techniques
Dorsal hump modi fi cation may be accomplished
via an external or internal (transcartilaginous or
intercartilaginous) approach. Excessive bone and
cartilage may then be removed in continuity,
using a sharp scalpel to shave the cartilaginous
septum and continuing the bony resection with a
sharp Rubin osteotome. It is crucial to position
this osteotomy along a line continuous with the
established dorsal cartilaginous pro fi le. After
resection of the dorsal hump, rasping is per-
formed to eliminate any palpable or visible
abnormalities. Copious irrigation must be per-
formed to remove any remnant bone fragments.
a
b
Fig. 13.19 Lateral crural overlay
technique ( a ) Preoperative.
( b ) Postoperative

160
B. Azizzadeh and M.J. Reilly
Many Caucasian patients will require narrow-
ing of the bony vault after resection of the dor-
sum. To address this, lateral osteotomies must be
performed. Medial osteotomies are performed if
the dorsal hump resection has not resulted in an
open roof deformity. This is accomplished using
a 3-mm curved osteotome angled 15–20° later-
ally from the vertical midline. This will allow a
more controlled fracture line once the lateral
osteotomies are performed.
The lateral osteotomies are done in a high-
low-high fashion through a stab incision in the
lateral nasal mucosa, just superior to the anterior
head of the inferior turbinate (high). The curved
guarded osteotomes are then anchored securely
into the maxillary bone to the level of the nasofa-
cial junction (low) before curving superiorly and
medially to intersect with the medial osteotomies
(high). For the novice surgeon, it may prove
advantageous to place surgical markings on the
skin of the area overlying the planned osteoto-
mies for additional guidance (Fig. 13.20 ).
In the authors’ practice, most patients who
undergo dorsal hump reduction will require
spreader grafts and reconstitution of the middle
nasal vault to avoid collapse during the healing
phase. Furthermore, many patients will also
require radix grafts to improve the dorsal pro fi le
and reduce the need for excessive dorsal hump
modi fi cation. This is most often accomplished
with a crushed cartilage graft secured into posi-
tion with an absorbable transcutaneous suture in
the immediate postoperative period.
Conclusions
As with all rhinoplasty, thorough preoperative
evaluation is key to the ultimate success of rhi-
noplasty for the Caucasian female. Foremost
is the need to establish each individual patient’s
motivations and expectations. In addition,
there should be a comprehensive assessment
of the bony and cartilaginous nasal structures,
the overlying skin, and the nasal–facial rela-
tionships, all of which are inextricably related
to the patient’s unique ethnic identity. Precise
planning and execution of the appropriate sur-
gical maneuvers will render an aesthetic and
ethnically harmonious result for the Caucasian
female rhinoplasty patient.
References
1. Powell N, Huphreys B (1984) Proportions of the aes-
thetic face. Thieme-Stratton, New York
2. Farkas LG, Hreczko TA, Kolar JC, Munro IR (1985)
Vertical and horizontal proportions of the face in
young adult North American Caucasians: revision of
neoclassical canons. Plast Reconstr Surg 7: 328–338
3. Enquist M, Arak A (1994) Symmetry, beauty, and
evolution. Nature 372(6502):169–172
4. Leong SC, White PS (2006) A comparison of aes-
thetic proportions between the healthy Caucasian
nose and the aesthetic ideal. J Plast Reconstr Aesthet
Surg 59(3): 248–252
5. Pearson DC, Adamson PA (2004) The ideal nasal
pro fi le: rhinoplasty patients vs the general public.
Arch Facial Plast Surg 6(4):257–262
6. Springer IN, Zernial O, Nölke F, Warnke PH, Wiltfang
J, Russo PA, Terheyden H, Wolfart S (2008) Gender
and nasal shape: measures for rhinoplasty. Plast
Reconstr Surg 121(2):629–637
7. Mowlavi A, Meldrum DG, Wilhelmi BJ (2003)
Implications for nasal recontouring: nasion position
Fig. 13.20 Schematic of medial and lateral osteotomies

161
13 Primary Caucasian Female Rhinoplasty
preferences as determined by a survey of white North
Americans. Aesthetic Plast Surg 27(6):438–445
8. Leong SC, White PS (2004) A comparison of aes-
thetic proportions between the Oriental and Caucasian
nose. Clin Otolaryngol Allied Sci 29(6):672–676
9. Yellin SA (1997) Aesthetics for the next millenium.
Facial Plast Surg 13(4):231–239
10. Rowe-Jones J, Carl van Wyk F (2010) Special consid-
erations in northern European primary aesthetic rhi-
noplasty. Facial Plast Surg 26(2):75–85
11. Fitzpatrick TB (1975) Soleil et peau. J Med Esthet
2:33034
12. Larrabee WF (1989) The tripod concept. Arch
Otolaryngol Head Neck Surg 115(10):1168–1169
13. Adamson PA, Litner JA, Dahiya R (2006) The M-Arch
model: a new concept of nasal tip dynamics. Arch
Facial Plast Surg 8(1):16–25
14. Papel ID (2005) Interlocked transdomal suture tech-
nique for the wide interdomal space in rhinoplasty.
Arch Facial Plast Surg 7:414–417
15. Peck GC (1983) The onlay graft for nasal tip projec-
tion. Plast Reconstr Surg 71(1):27–39
16. Sheen JH (1993) Tip graft: a 20-year retrospective.
Plast Reconstr Surg 91(1):48–63
17. Soliemanzadeh P, Kridel RW (2005) Nasal tip over-
projection: algorithm of surgical deprojection tech-
niques and introduction of medial crural overlay. Arch
Facial Plast Surg 7(6):374–380
18. Kridel RW, Konior RJ (1991) Controlled nasal tip
rotation via the lateral crural overlay technique. Arch
Otolaryngol Head Neck Surg 117(4):411–415

163
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_14, © Springer-Verlag Berlin Heidelberg 2013
14
14.1
Anatomical Considerations
Asians include people living in Eastern Asia,
Southeast Asia, India, and the Middle East who
have different ethnic origins and different aesthetic
features. As a result of the diverse ethnicities in
these populations, the anatomic characteristics of
Asians vary greatly. Although there are substantial
variations, in the typical Asian nose, the nasal skin
tends to be thicker than Caucasian noses, with
abundant subcutaneous soft tissue. The tip of the
nose is usually low and the lower lateral cartilages
are small and weak. The nasal bones are poorly
developed and thick, thus having low radix. The
septal cartilage is thin and small. The amount of
harvestable septal cartilage is usually insuf fi cient
for simultaneous use for multiple grafts [ 1 ] .
Altogether, when compared with Caucasian noses,
the typical Asian nose appears to be relatively
small and fl at and has poor tip de fi nition. In aes-
thetic analysis of nasal pro fi le, the nasolabial
angles of the Asians are typically more acute than
those of Caucasians, but the nasofrontal angles did
not differ greatly [ 2 ] .
14.2
Dorsal Augmentation
14.2.1 General Consideration
Dorsal augmentation is the most commonly
addressed issue in Asian rhinoplasty and also the
most common reason for revision surgery. When
performing augmentation rhinoplasty on Asians, it
is preferable or mandatory to fi rst perform tip sur-
gery using autologous cartilage, followed by dor-
sal augmentation using available implant material.
The thickness of the patient’s skin must be taken
into consideration. If excessive dorsal augmenta-
tion is performed on a patient whose skin is too
thin, there is a risk of implant visibility through the
skin or an extrusion of the implant. Conversely,
too thick skin can decrease the effect of nasal aug-
mentation. Therefore, with patients who have thin
skin, it is preferable to use soft implants such as
Gore-Tex or autologous tissues such as morselized
cartilage or fascia rather than silicone. In patients
with thick skin, a relatively solid material such as
silicone, reinforced Gore-Tex, or costal cartilage
can be used, not causing signi fi cant problems.
14.2.2 Implant Material
Various implant materials have been used for dor-
sal augmentation. Materials used in rhinoplasty
can be divided largely between biologic tissues
(autologous and homologous tissue) and the allo-
plastic materials [ 3 ] . In rhinoplasty for Caucasians,
Asian Rhinoplasty
Yong Ju Jang
Y. J. Jang , M.D., Ph.D.
Department of Otolaryngology , Asan Medical Center,
University of Ulsan College of Medicine ,
388-1 Pungnap-2dong , Songpa-gu, Seoul 138-736 ,
South Korea
e-mail: jangyj@amc.seoul.kr

164
Y.J. Jang
use of alloplastic implant, especially silicone, on
the nasal dorsum has been condemned [ 4 ] . In
Asian rhinoplasty, however, alloplastic implants
still play a role due to the differing anatomical
characteristics of Asians, such as thick skin and
poorly
developed
cartilaginous
framework.
Alloplastic implants generally need to be biocom-
patible, nontoxic, chemically safe, and nonimmu-
nogenic [ 3 ] . Additionally, during recovery, these
implants should maintain their original size,
shape, and hardness. At present, the most com-
monly used alloplastic implants that meet these
conditions are silicone and Gore-Tex.
14.2.2.1 Autologous Tissue
The advantage of autologous material for the dor-
sal augmentation of the nose cannot be questioned
as these implants are well tolerated and carry the
least risk of infection. However, if any autologous
tissue other than septal cartilage is selected, the
additional operative time required to harvest the
graft and donor site morbidity become limiting
factors. Common autologous tissues used for dor-
sal augmentation include septal cartilage, conchal
cartilage, costal cartilage, and fascia. As it is easy
to harvest and shape the septal cartilage, it can be
used to moderately elevate the nasal dorsum, to
camou fl age a partial concavity on the dorsum, and
for nasal tip surgery. Since Asian patients have
relatively small noses, it is practically dif fi cult to
harvest enough amount of septal cartilage, leaving
at least 1 cm width of the L-strut, suitable for a
full-length dorsal graft [ 1 ] . Unlike septal carti-
lage, conchal cartilage has an intrinsic curvature
that hampers its routine use in a dorsal augmenta-
tion in its original shape. Rather, in surgery for
Asian noses, conchal cartilage is more frequently
used for nasal tip surgery, to camou fl age a partial
concavity, or to cover the tip of the silicone
implant to prevent extrusion. In addition, the con-
chal cartilage is frequently too small to yield a
cartilage piece suitable for one piece dorsal aug-
mentation. To reduce the visibility and migration
of the septal cartilages, and to overcome the limi-
tation in size, the author prefers to place the septal
cartilage onto the nasal dorsum after gentle crush-
ing using a cartilage crusher. Also, when using
conchal cartilage, it may be necessary to overlap
pieces of cartilage in opposite directions of their
curvature to neutralize their intrinsic curvature.
Although costal cartilage is dif fi cult to harvest
and is associated with more serious donor site
morbidity such as pneumothorax, as well as the
problem of warping, it is the most useful autolo-
gous cartilage for substantial augmentation or for
patients who have experienced complications
with alloplastic implants (Fig. 14.1 ) [ 5 ] . Although
strongly advocated by some surgeons of its rou-
tine use for Asian rhinoplasty [ 6 ] , during the pri-
mary rhinoplasty, it is very dif fi cult to persuade
Asian women to use costal cartilage because the
harvesting procedure leaves scars on the chest.
One other critically important limitation of autol-
ogous tissue is that except for only a few highly
experienced surgeons, most rhinoplasty surgeons
have dif fi culty using these implants to form an
aesthetically pleasing nose, resulting in a high
revision rate. Warping, graft visibility, and unnat-
urally looking noses are common complications
of augmentation using costal cartilage. Although
autologous cartilage has the lowest risk of infec-
tion among graft materials, autologous cartilage
including costal cartilage is associated with a
signi fi cant risk of revision surgery, with rates as
high as 15.5% [ 7 ] . The primary reasons for this
high revision rate is that autologous tissue is usu-
ally used to treat more dif fi cult cases and use of
these implants is associated with unpredictable
scarring, warping, and at times visible graft con-
tours (Fig. 14.2 ).
Autologous fascia, including temporalis fas-
cia, can be used in rhinoplasty as radix graft or
dorsal onlay grafts. However, harvesting autolo-
gous fascia requires an additional incision and
hence is associated with additional morbidity.
Furthermore, it is not always possible to harvest
suf fi cient fascia of reasonable thickness, because
harvested fascia shrinks in volume as it dries, and
when wet, it is hard to manipulate.
14.2.2.2 Homologous Tissue or Tissue
Allograft
Homologous costal cartilage, which is not associ-
ated with harvesting morbidity or additional oper-
ation time, could serve as an alternative graft
material. For example, homologous costal cartilage

165
14 Asian Rhinoplasty
Fig. 14.1 ( Left ) Preoperative. ( Right ) Postoperative following rhinoplasty using autologous costal cartilage for man-
agement of complication of previously implanted silicone onto the dorsum

166
Y.J. Jang
harvested from cadaveric donors and processed in
various ways has been shown to be useful in rhino-
plasty [ 8– 10 ] . Homologous costal cartilage can be
used in revision rhinoplasties requiring structural
reconstruction of the nasal framework, but in
which patients resist harvesting their own costal
cartilage. The use of homologous costal cartilage
in rhinoplasty has shown con fl icting results regard-
ing the degree of resorption and warping [ 8– 10 ] .
From the author’s own experience, a signi fi cant
number of patients had unpredictable complica-
tions such as resorption, warping, and graft visibil-
ity when this cartilage was used as full-length
dorsal graft. The high complication rate associated
with homologous cartilage may limit its utility for
dorsal augmentation [ 11 ] .
Tutoplast-processed fascia lata (TPFL) is a
type of commercially available homograft fascia
(Fig. 14.3 ) [ 12– 14 ] . TPFL can be used for smooth-
ening grafts for dorsal irregularity following
correction of a deviated nose, as additional graft
material when an inadequate amount of septal or
conchal cartilage is available for dorsal augmen-
tation, for patients who dislike using of alloplastic
material for dorsal augmentation, and for compli-
cated revision surgery in which silicone has been
used on the dorsum (Fig. 14.4 ). The soft contour
of TPFL means that it can be nicely blended with
the overlying skin–soft tissue envelope. Although
TPFL has very low risks of infection, displace-
ment, and extrusion, an unpredictable degree of
resorption could be a problem [ 13 ] .
14.2.3 Silicone
Nasal dorsal augmentation with silicone rubber is
the most popular rhinoplasty procedure in Eastern
Asia. Due to its stable chemical structure, silicone
has several advantages including its low degree of
Fig. 14.2 ( Left ) Preoperative. ( Right ) Postoperative showing warping of dorsally implanted autologous costal
cartilage

167
14 Asian Rhinoplasty
Fig. 14.3 ( Left ) Tutoplast-processed fascia lata. ( Right ) Placement of the Tutoplast-processed fascia lata on the nasal
dorsum
Fig. 14.4 ( Left ) Preoperative. ( Right ) Postoperative after dorsal augmentation using Tutoplast-processed fascia lata

168
Y.J. Jang
tissue reaction and ease of handling. Moreover, the
availability of ready-made products makes appli-
cation convenient and the relative hardness of sili-
cone makes it suitable for fashioning the desired
nasal shape for Asians with thick skin [ 4, 15, 16 ] .
The prefabricated products can be divided largely
into L- and I-shaped implants. Some surgeons
favor an L-shaped or a variation of I-shaped sili-
cone (covering the nasal tip) capable of covering
from the radix all the way down to the nasal tip.
However, because the nasal tip is an area that is
always exposed to exterior stimulation, the use of
L-shaped silicone carries a higher risk of extrusion
regardless of the thickness of nasal subcutaneous
tissue in Asians. Thus, a placement of I-shaped
implant at the nasal dorsum area and tip plasty
using an autologous material (septal cartilage,
conchal cartilage) at the nasal tip area is the more
preferred surgical method. In addition to using
prefabricated silicone implants, the author has
used silicone sheeting for nasal dorsal augmenta-
tion, which is more versatile but carries no
increased risk of complications [ 17 ] . In trimming
the silicone, it should preferably be about
3.5 ~ 4.0 cm long and about 8 mm wide and the
edge should be as thin as possible. Revision rhino-
plasty after silicone implants may be needed for
implant deviation, fl oating, displacement, extru-
sion, impending extrusion, and infection [ 17 ] .
14.2.4 Gore-Tex
Gore-Tex
(expanded
polytetra fl uoroethylene:
ePTFE), next to silicone, is the most widely used
alloplastic implant in Asian noses. Gore-Tex
implants are porous, inducing the surrounding tis-
sue to grow inward through the pore, and have the
advantages of increased stability and lower risk of
capsule formation. In addition, the risk of extru-
sion is lower with Gore-Tex than with silicone.
The soft texture of Gore-Tex reduces patient dis-
comfort and the occurrence of unnatural visible
implant contours through the skin. One important
disadvantage of Gore-Tex is that it decreases in
volume after insertion [ 18 ] . In addition, it is more
dif fi cult to remove a Gore-Tex implant than a sili-
cone implant. Reports of delayed in fl ammation
are increasing, thus one must be cautious when
using Gore-Tex in the presence of in fl ammation
within the nasal cavity (sinusitis, vestibulitis, and
active acne). Moreover, when performing opera-
tions that may create microcommunication with
the nasal cavity (e.g., osteotomy or septal recon-
struction), there is an increased risk of infection. It
has been reported that infection rate in primary
surgery is 1.2%, while infection rate in secondary
surgery is 5.4% [ 19 ] .
14.3
Surgery of the Nasal Tip
The typical endonasal approach for Caucasian
noses involves cephalic resection through deliv-
ery or nondelivery approach and placements of
transdomal and interdomal sutures and columellar
strut. This approach can also be used for the place-
ment of shield or onlay graft. However, cephalic
resection using the nondelivery approach is
impractical for Asian patients because tip surgery
requiring only a cephalic resection is very rare in
Asian patients. The external rhinoplasty approach
is a versatile approach that enables the surgeon to
precisely diagnose nasal tip deformity and to tai-
lor treatment using various tip surgery techniques.
The most common of these tip surgery techniques
include columellar struts, shield, onlay, and septal
extension grafts, and transdomal, interdomal, and
septocolumellar sutures [ 20 ] . Selection of the
speci fi c maneuver is dependent on the shape of
the patient’s deformity, the availability of grafting
material, and the surgeon’s preference. Among
the multitude of tip surgery techniques, the fol-
lowing have an important role and should be
emphasized for the Asian tip.
14.3.1 Cartilage Graft Technique
This technique is the most common method of tip
surgery for improving the tip projection, rotation,
and de fi nition. It is also effective for improving
the tip support [ 21, 22 ] . As graft material, septal
cartilage is preferred, but when there is an
insuf fi cient amount, conchal cartilage or costal
cartilage may also be used.

169
14 Asian Rhinoplasty
14.3.2 Shield Graft (Infratip
Lobular Graft)
This is a graft that is positioned above the middle
and medial crus of the lower lateral cartilages, and
the name shield graft derives from the fact that it is
deemed proper to shape it in the form of a shield.
This technique is usually effective in lengthening
the infratip lobular segment and thereby enhanc-
ing the tip projection. The shape of the graft should
take on a shield or gingko leaf shape and, to enable
both ends to display the tip de fi ning points, the
width of the upper margin should be 6–8 mm.
However, while performing this procedure on
patients, there is a risk of overrotation of the tip
due to a blunting of the columellar lobular angle or
the infratip lobule made unnaturally large. In addi-
tion, it is dif fi cult to obtain a cartilage strong
enough to push up thick skin after the skin is cov-
ered up again. Therefore, even when a leading
edge higher than the existing dome is created, in
reality, the cartilage will become compressed and
bent by the weight of the thick skin so that it will
be dif fi cult to look forward to a tip projection. To
solve this problem and maintain an appropriate
projection, it is recommended to place a shield
supporting graft cephalically.
14.3.3 Multilayer Tip Grafting
Technique
Vertically oriented shield grafts, popularized by
Sheen, are widely used particularly for Caucasian
patients. The horizontally oriented onlay graft
placed on the dome area, popularized by Peck, is
another effective method of enhancing tip aes-
thetics. The effectiveness of both of these proce-
dures relies on the shape and orientation of the
underlying
LLC
(lower
lateral
cartilage).
However, the LLC shape and orientation in Asian
patients is often not ideal for those procedures.
An underprojected tip often presents with a round
tip contour, and a vertically oriented shield graft
or onlay graft can actually worsen the nasal tip
shape. Therefore, it is not always possible to use
procedures effective in Caucasian patients in
Asian patients. In this scenario, a multilayer tip
graft technique can be a nice technical alternative
that can bring about desirable tip aesthetics [ 23 ] .
This technique is usually preceded by caudal
extension of the septum, columellar strut place-
ment, modi fi cation of the LLC, dome suturing,
and/or trimming of skin–soft tissue envelope
(SSTE). Following those procedures, the fi rst
cartilaginous shield graft layer is placed on the
dome. Further shield graft layers are then placed
on top of the fi rst layer. The more caudal layer is
placed so that its leading (superior) edge is always
higher than the height of the existing dome and
the layer(s) beneath it (Fig. 14.5 ). The numbers
of graft layers applied depend on how much pro-
jection was required and was determined intraop-
eratively. The multilayer cartilaginous tip grafting
technique could maintain the advantages of
shield-shaped tip grafts which help to improve
nasal tip projection and de fi nition, and overcome
issues relating to thick skin, soft tissue, and weak
cartilaginous framework often encountered in
Asian rhinoplasty patients (Fig. 14.6 ).
14.3.4 Modi fi ed Vertical Dome
Division Technique
Vertical dome division (VDD) is a powerful and
versatile technique for re fi ning nasal tip appear-
ance. VDD can be used for various nasal deformi-
ties, including overprojection or underprojection,
suboptimal rotation, disproportionate lobule
ratios, and broad or asymmetric tips. Asian nasal
tips require more structures to project into the
thicker skin to gain the desired re fi nement because
Asians have thick skin in comparison to
Caucasians. Therefore, it is dif fi cult to gain the
desired nasal tip re fi nement using VDD alone in
Asians. The most signi fi cant features of modi fi ed
VDD technique were the way of dividing domal
region and routine use of a tip graft to effectively
re fi ne the nasal tip [ 24 ] . The incisions on the
domes were designed to borrow a large amount of
cartilage from the caudal margin so that the lateral
view of the medialized cartilage had a triangular
projection shape in an anterocaudal direction
(Fig. 14.7 ). This technique makes it easier to place
an additional tip graft such as a shield or onlay

170
Y.J. Jang
Fig. 14.5 The multilayer tip grafting technique
Fig. 14.6 ( Left )
Preoperative. ( Right )
Postoperative following tip
surgery using multilayer
shield graft

171
14 Asian Rhinoplasty
graft. The triangular shape of the medial limbs
may not only increase tip projection but may also
stabilize the shield graft because the borrowed
domal cartilage plays a role as the blocking
graft [ 24 ] .
14.3.5 Onlay Tip Graft
Onlay tip grafting is a procedure that places one
or several layers of graft horizontally at the dome
of the tip. It can be performed on a patient with
proper tip support to increase the tip projection or
to camou fl age a tip irregularity. If just several
layers of onlay graft are positioned at the tip
without any special manipulation of the lower
lateral cartilage, even though the tip projection
may be improved to some extent when viewed
from the lateral side, the infratip lobule area can
become excessively long when viewed from the
basal side, causing an unnatural appearance.
Therefore, it is desirable that the columellar strut
be fi rst applied to project the middle crus further
and strengthen the support and then an onlay
graft be positioned. Such a form of graft is called
an umbrella graft [ 20 ] .
14.3.6 Septal Extension Graft
Although the underprojection of the tip among
Asians frequently results from an inadequately
developed lower lateral cartilage, it may also be
caused by poor caudal septal support. If an ade-
quate quantity of septal cartilage can be obtained
after preserving its L-strut, this cartilage can be
used as a septal extension graft to project the
anterior septal angle of the septal cartilage as
well as to strengthen the support [ 25, 26 ] . As a
result, the tip support can be strengthened along
with the creation of a signi fi cant projection. One
of the advantages of this technique is that besides
the projection/rotation of the tip, it can be useful
in correcting short nose deformity, which can be
commonly found among Asians (Fig. 14.8 ). In
particular, in patients with a retracted columella,
a caudal extension of the graft can be particularly
effective in improving the columellar retraction,
as well as correcting the caudal septal de fl ection.
In performing septal extension graft surgery, it is
preferable to position the graft at both sides of the
caudal septal cartilage due to the reduced risk of
causing nostril asymmetry, as well as the stronger
nature of the grafting. In reality, however, it is
Fig. 14.7 Modi fi ed vertical dome division technique

172
Y.J. Jang
Fig. 14.8 ( Upper ) Preoperative. ( Lower ) Postoperative after septal extension graft technique

173
14 Asian Rhinoplasty
dif fi cult to obtain suf fi cient cartilage to place the
graft on both sides and hence the procedure is
generally performed only on one side.
Conclusions
In rhinoplasty for Asians, tip surgery using
autologous cartilage followed by dorsal aug-
mentation using available implant material is
the most widely performed surgical procedure.
Cartilage grafting procedures including shield
graft, onlay graft, multilayer tip graft, modi fi ed
vertical dome division, and septal extension
graft are mainstay in building up relatively
poorly developed Asian tip. Surgeons must be
familiar with the pros and cons of various dor-
sal implant materials and be able to select cor-
rect procedures in dorsal augmentation based
on the proper consideration on the skin thick-
ness, associated deformities, and aesthetic
goal of the patients.
References
1. Kim JS, Khan NA, Song HM, Jang YJ (2010)
Intraoperative measurements of harvestable septal car-
tilage in rhinoplasty. Ann Plast Surg 65(6): 519–523
2. Wang JH, Jang YJ, Park SK, Lee BJ (2009)
Measurement of aesthetic proportions in the pro fi le
view of Koreans. Ann Plast Surg 62(2):109–113
3. Stucker FJ, Shaw G, Ephrat M (2002) Biologic tissue
implants. In: Papel ID (ed) Facial plastic and reconstruc-
tive surgery, 2nd edn. Thieme, New York, pp 73–78
4. McCurdy JA (2002) The Asian nose: augmentation
rhinoplasty with L-shaped silicone implants. Facial
Plast Surg 18(4):245–252
5. Guerrerosantos J (1991) Nose and paranasal augmen-
tation: autogenous fascia and cartilage. Clin Plast Surg
18(1):65–86
6. Toriumi DM, Swartout B (2007) Asian rhinoplasty.
Facial Plast Surg Clin North Am 15(3):293–307
7. Bateman N, Jones NS (2000) Retrospective review of
augmentation rhinoplasties using autologous cartilage
grafts. J Laryngol Otol 114(7):514–518
8. Welling DB, Maves MD, Schuller DE (1988) Irradiated
homologous cartilage grafts. Long-term results. Arch
Otolaryngol Head Neck Surg 114(3):291–295
9. Strauch B, Wallach SG (2003) Reconstruction with
irradiated homograft costal cartilage. Plast Reconstr
Surg 111(7):2405–2411
10. Lefkovits G (2004) Nasal reconstruction with irradiated
homograft costal cartilage. Plast Reconstr Surg 113(4):
1291–1292
11. Song HM, Lee BJ, Jang YJ (2008) Processed costal
cartilage homograft in rhinoplasty: the Asan Medical
Center Experience. Arch Otolaryngol Head Neck
Surg 134(5):485–489
12. Jang YJ, Wang JH, Sinha V, Song HM, Lee BJ (2007)
Tutoplast-processed fascia lata for dorsal augmenta-
tion in rhinoplasty. Otolaryngol Head Neck Surg
137(1):88–92
13. Jang YJ, Kim JH (2011) Use of tutoplast-processed
fascia lata as an onlay graft material for tip surgery in
rhinoplasty. Otolaryngol Head Neck Surg 144(4):
528–523
14. Jang YJ, Song HM, Yoon YJ, Sykes JM (2009)
Combined use of crushed cartilage and processed fas-
cia lata for dorsal augmentation in rhinoplasty for
Asians. Laryngoscope 119(6):1088–1092
15. Tham C, Lai YL, Weng CJ, Chen YR (2005) Silicone
augmentation rhinoplasty in an oriental population.
Ann Plast Surg 54(1):1–5
16. Erlich M, Parhiscar A (2003) Nasal dorsal augmenta-
tion with silicone implants. Facial Plast Surg Clin
North Am 19(4):325–330
17. Wang JH, Lee BJ, Jang YJ (2007) Use of silicone
sheets for dorsal augmentation in rhinoplasty for
Asian noses. Acta Otolaryngol Suppl 558:115–120
18. Jung YG, Kim HY, Dhong HJ, Park KN, Lee HJ, Lim
YJ, Min JY (2009) Ultrasonographic monitoring of
implant thickness after augmentation rhinoplasty with
expanded polytetra fl uoroethylene. Am J Rhinol
Allergy 23(1):105–110
19. Godin MS, Waldman SR, Johnson CM Jr (1999)
Nasal augmentation using Gore-Tex: a 10-year expe-
rience. Arch Facial Plast Surg 1(2):118–121
20. Gunter JP, Landecker A, Cochran CS (2006)
Frequently used grafts in rhinoplasty: nomenclature
and analysis. Plast Reconstr Surg 118(1):14e–29e
21. Vuyk HD (1995) Suture tip plasty. Rhinology
33(1):30–38
22. Jin HR, Won TB (2009) Nasal tip augmentation in
Asians using autogenous cartilage. Otolaryngol Head
Neck Surg 140(4):526–530
23. Jang YJ, Lau BC, Min JY (2011) A multilayer carti-
laginous tip grafting technique for improved nasal tip
re fi nement in Asian rhinoplasty. Otolaryngol Head
Neck Surg 145(2):217–222
24. Yu MS, Jang YJ (2010) Modi fi ed vertical dome divi-
sion technique for rhinoplasty in Asian patients.
Laryngoscope 120(4):669–672
25. Byrd HS, Andochick S, Copit S, Walton KG (1997)
Septal extension grafts: a method of controlling tip
projection shape. Plast Reconstr Surg 100(4):
999–1010
26. Hubbard TJ (2000) Exploiting the septum for maxi-
mal tip control. Ann Plast Surg 44(2):173–180

175
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_15, © Springer-Verlag Berlin Heidelberg 2013
15
15.1
Introduction
Beauty is dif fi cult to de fi ne—it is, after all, in the
eye of the beholder. For instance, Leonardo da
Vinci helped establish the canon that the base
width of the nose should equal the width of the
eye. An aesthetic consensus known as the neo-
classical canon was developed among artists in
the nineteenth century. Cephalometrics in the
1950s de fi ned facial harmony as the best of aver-
age European American facial features. Beauty
has even been studied from a mathematical per-
spective: can attractive faces have properties that
match a mathematical formula?
In any race, culture, or ethnicity, harmony and
balance between facial components seem to be
standard markers of beauty. Beautiful noses are
symmetric, vertically aligned, and between the
eyes [ 1 ] . These markers may have evolved to
phenotypically represent genetic fertility and
health [ 2 ] .
Standards of beauty have changed over the
years, but the communications media (pop cul-
ture, fashion models, fi lm stars, etc.) have spread,
and popularized, the Caucasian or Western
(Occidental) look as the universal accepted stan-
dard of beauty [ 3, 4 ] . For a long time, the Western
nose was considered to be the goal in rhinoplasty:
moderately thin, tapered, angular, and slightly
projecting [ 3 ] . All of this has probably in fl uenced
how immigrants and their children believe they
should look.
In the United States, “ethnic rhinoplasty” is
usually thought of as a procedure to reshape an
African-American or Asian nose. However,
Hispanics are now the largest minority popula-
tion within the United States, and rhinoplasty in
this population will become more frequent over
time. Facial plastic surgery is well established in
Latin America, but only in the last few decades
has it become a more commonplace procedure
for Hispanics in the United States [ 5 ] .
Who is Hispanic? The US government census
uses the term Hispanic to describe Latin
Americans and their descendants, regardless of
race.
15.2
Why Hispanic Patients Seek
Rhinoplasty
As plastic surgery becomes more mainstream [ 6,
7 ] , Hispanic patients are becoming increasingly
aware of the options available for their skin type
and facial features. Mainstreaming has also
helped erase the social stigma once associated
with plastic surgery; improved technology,
scienti fi c advances, and reduced costs have also
contributed to the rising demand. And the gradual
upward socioeconomic movement of the Hispanic
population is putting them into a position where
they can now seek elective plastic surgery [ 8 ] .
Hispanic Rhinoplasty
Ali Sajjadian
A. Sajjadian , M.D., FACS
Private practice , Newport Beach ,
CA 92663 , USA
e-mail: sajjadiana@yahoo.com

176
A. Sajjadian
Hispanic noses, as a general rule, differ from
Western noses in terms of skin thickness, projec-
tion, tip de fi nition, and dorsal prominence [ 8 ] .
Most Hispanic females want fi ner, thinner noses
with a slightly more concave dorsum; however,
Hispanic males usually prefer a “macho” nose
with a higher, somewhat convex, dorsum (in fact,
some males speci fi cally request that the surgeon
preserve their dorsal hump) [ 2 ] . Additionally, a
wide alar base is almost universally disliked, and
tip shape is of great importance [ 9 ] .
When Hispanic patients seek primary rhino-
plasty, it usually means altering the nose while
preserving its original ethnic character (racial
preservation)—it is no longer a foregone conclu-
sion that all ethnic nasal features must be elimi-
nated. However, some still want to eliminate their
ethnic features and achieve a classic Western
nasal contour (racial transformation). Hispanic
patients seeking secondary (revision) rhinoplasty,
like any other patients, usually want to correct an
unnatural or awkward-appearing nose perhaps
due to substandard surgery or miscommunication
between the original surgeon and the patient.
15.3
Race, Ethnic, and Cultural
Issues Involved in Hispanic
Rhinoplasty
Race is the genetic heritage you were born with,
regardless of location; ethnicity is the learned
cultural behavior of a particular group (behav-
iors, beliefs, and values) [ 10 ] . How a person per-
ceives their place within each of these groups
affects his or her self-image and approach to cos-
metic surgery. Even within the same race and cul-
ture, facial characteristics can be appreciated
differently. For example, a recent Hispanic immi-
grant may have different cosmetic surgery goals
than a third-generation transplant or a foreign
national [ 8 ] . The surgeon must determine the
patient’s wishes before surgery and never make
assumptions—it is inappropriate to assume that
all Hispanics want a “standard” nose.
As an ethnic nose exhibits well-de fi ned racial
characteristics [ 4 ] , applying a Western standard of
beauty may not produce results that are harmonious
with other ethnic facial features. The ideal Hispanic
rhinoplasty is a mixture of preserving ethnic iden-
tity mixed with a trend toward the Western “ideal”
nose. That being said, the goal is also facial har-
mony—a good ethnic rhinoplasty will transform
the existing nasal architecture into a more attractive
contour that harmonizes with the surrounding eth-
nic facial features, creating an ethnically appropri-
ate, attractive, and natural-appearing nose.
When interacting with Hispanic patients, sur-
geons must provide culturally competent care. As
de fi ned by the US Department of Health and
Human Services (HHS), Of fi ce of Minority
Health (OMH), “cultural competence” is com-
municating without cultural differences hinder-
ing the conversation, but rather enhancing it. This
is a challenge as both patient and surgeon bring
their individual patterns of language and culture
to the meeting and these must be transcended to
communicate effectively. The surgeon is encour-
aged to learn about Hispanic culture and its
approach to health care. The HHS OMH website
is a good place to start: minorityhealth.hhs.gov.
15.4
Treatment Goals
Patient satisfaction is the surgeon’s primary goal.
The surgeon wants to comply with the patient’s
desires as much as possible and obtain harmony,
balance, and an aesthetically pleasing result—
creating a nose that looks normal and natural
and not “operated” or “artistic” (e.g., Michael
Jackson’s nose). However, the surgical plan must
also be realistic enough to be surgically possible.
This means taking into account the patient’s
racial characteristics and limitations.
An often overlooked goal, but of utmost
importance, is effectively communicating with
the patient. It is important for the surgeon to
understand what the patient wants and for the
patient to know what the surgeon envisions as a
realistic goal for the surgical result. Computer
imaging can be extremely useful for communi-
cating this information and for educating the
patient; it can provide examples for the patient to
choose from; and a digital photograph of the
patient can be morphed from before to after,

177
15 Hispanic Rhinoplasty
showing the patient what is realistically possible.
Computer imaging can also promote discussion
of the speci fi cs (e.g., “I want a nose like this pic-
ture.”), rather than just generalities (e.g., “I want
a narrower nose.”), and may prevent misunder-
standings. (Remember that revision rhinoplasty
is common and arises from misunderstanding the
patient’s desires, as well as from surgical incom-
petence or mistakes.)
Another aspect of patient-surgeon communi-
cation that must be appreciated is that of lan-
guage—English may be a second language for
these patients, and many may not speak English
at home. In fact, some may even need to use an
interpreter. The surgeon must ensure that he or
she is communicating effectively with the
Hispanic patient.
Note that nasal function should never be com-
promised in the interest of beauty and should
always be a primary goal.
15.5
Con fl icts Between Patient
and Surgeon Goals
Sometimes achieving a patient’s goals is simply
not surgically possible. In this case, the surgeon
must work with the patient to rede fi ne achievable
and realistic surgical goals. Sometimes achieving
a patient’s goals is surgically possible but will not
produce a desirable outcome. Again, the surgeon
should work with the patient to modify the
patient’s expectations. Realistic expectations are
the key to a satis fi ed patient!
Surgeons are strongly cautioned not to impose
their own aesthetic ideals or perceptions/expecta-
tions on the patient and should never try to produce
a standard Hispanic nose. Additionally, there can
be a problem of “other-race” facial perception—a
surgeon of one race might be less sensitive to the
distinguishing facial features of another race and
may not appreciate the facial detail that exists
between the racial groups [ 8 ] . Unfortunately, these
con fl icts with patient desires may not become
apparent until after the surgery is completed.
Note that even the best surgeon cannot work
with poor tissue, and surgery is best avoided in
this circumstance.
15.6
Anatomic Features
of the Hispanic Nose
After the Spanish conquest of Mesoamerica, mix-
ing of the white and native races occurred. The
later introduction of African slaves to the Caribbean
region added another element to the blend. Ideals
of facial beauty get more complex when there is
more than one racial group. Also, bone structure
and skin elasticity, texture, and thickness differ
among the races.
The nasal index is an anthropometric tech-
nique that compares the width of the base of the
nose with the height of the nose [100 × (nasal
breadth)/(nasal height)]. In Caucasians, the index
value is approximately 70; in African-Americans,
the index value can range from 85 to 95; and in
Hispanics, the index value of the Mestizo nose is
approximately 75 (as is the Asian nose) [ 8 ] .
The Hispanic nose is complex to describe, as
there is signi fi cant variability due to the racial
mixture. Nevertheless, some generalizations have
been made. Hispanic noses, as a general rule, dif-
fer from Western noses in terms of skin thick-
ness, projection, tip de fi nition, and dorsal
prominence. Various studies have con fi rmed the
observation that the “typical” Hispanic nose has a
tip which projects to a lesser extent, that the base
is wider than the Western nose, and that the alae
depend on lateral view [ 8 ] . The next section will
describe the various types in detail.
15.7
Hispanic Nose Types
and Features
The racial and ethnic features of anyone’s nose
are determined by both the underlying framework
of bone and cartilage and by the skin and soft tis-
sue covering the framework. These characteris-
tics are determined at a genetic level but may be
in fl uenced later by environmental factors, such as
nutrition, aging, and trauma.
While not all Hispanic noses conform to a
speci fi c type(s), there are nevertheless certain
generalizations that can be observed. Daniel’s
2003 paper, Hispanic Rhinoplasty in the United
States, with Emphasis on the Mexican American

178
A. Sajjadian
Nose, offers a practical classi fi cation system
based on type of deformity, rather than on geo-
graphic origins (as was previously used) [ 6 ] .
Classifying according to type can be bene fi cial
for analyzing and formulating surgical treatment
plans for Hispanic patients. Daniel identi fi es
four distinct types of nasal deformities (they are
also associated with more familiar older
terminology):
Type I (the Castilian nose) is characterized by
normal radix height, a high-arched osseocarti-
laginous vault, and a tip with nearly normal pro-
jection (Fig. 15.1 ).
Type II (the Mexican American nose) is char-
acterized by a low radix height and upper dor-
sum, a nearly normal bridge, and a dependent tip
(an under-projecting tip), which creates the illu-
sion of a major dorsal hump (Fig. 15.2 ).
Prominent
vault
High
dorsum
Normal
radix
Normal
tip
projection
Type I
Fig. 15.1 Type I Hispanic
nose
Normal
vault
Low
radix
Dependent
tip with
decreased
projection
Type II
Fig. 15.2 Type II Hispanic
nose

179
15 Hispanic Rhinoplasty
Type III (the Mestizo nose) is characterized by
a dorsum-base disproportion attributable to a
heavy wide/broad base with minimal de fi nition
and wide tip (under-projection of the tip), which
is complicated by a thick skin envelope.
Type IV (the Creole nose) is similar to the
African-American nose with an inter-alar width
>45 mm, an exceedingly fl at dorsum, and an
under-projecting tip. The necessity for a full-
length dorsal augmentation differentiates these
cases from the Type III Mestizo nose.
Table 15.1 summarizes the anatomical charac-
teristics and recommended surgical procedures
for Hispanic rhinoplasty on the fi rst three Hispanic
nose types de fi ned by Daniel [ 6 ] .
Daniel has offered the four general types of
Hispanic noses mentioned above. However, other
authors have also offered classi fi cations. Higuera
et al. offer three “archetypes” in their 2009 paper:
Rhinoplasty in the Hispanic Patient [ 5 ] . Type I is
characterized by a high radix and prominent
vault; type II is characterized by a dependent tip
with inadequate projection; and type III is char-
acterized by a broad nasal base with thick skin
and a wide (Fig. 15.3 ).
15.8
Similarities and Differences
with Other Ethnic Noses
The Hispanic nose has some similarities to other
ethnic noses. Morphology is similar to the
African-American nose: weak, wide, and fl at car-
tilage; wide alar base (usually combined with
round nostrils); and low/ fl at dorsum. Nasal bones
are stronger than those present in African-
American noses. Morphology can also be similar
to Mediterranean/Middle Eastern noses: dorsal
hump, long nasal bones, poor tip projection, and
moderate tip bulbosity [ 9 ] .
15.9
Problems Hispanic Noses May
Present to the Surgeon
Rhinoplasty is widely regarded as the most
dif fi cult of all cosmetic plastic surgery proce-
dures—and Hispanic rhinoplasty can be espe-
cially challenging. Even small changes require a
thorough understanding of Hispanic nasal anat-
omy and appropriate surgical techniques. Surgeons
attempting Hispanic rhinoplasty should be willing
to dedicate the time and effort necessary to master
this complex operation—start with the easy cases,
critically analyze the results, and, as experience
increases, then take on the more dif fi cult cases.
Hispanic noses, especially the type II (Mexican
American), can be extremely challenging from
an analytical viewpoint and require maximal
surgical fi nesse. It is a product of racial mixture,
Table 15.1 Anatomical characteristics and recom-
mended procedures for Hispanic rhinoplasty
Anatomic features
Surgical Techniques
& Manuevers
Type I- Castilian
Normal skin thickness
normal radix height
No need for radix graft
dorsal bony-carilaginous
hump
Incremental bony-cartilag-
inous reduction
wide nasal width
Lateral osteotomies
lack of tip de fi nition and
re fi nement
Multiple tip sutures, as
needed
columellar strut
Type II- Mexican-
American
Thick skin & soft tissue
envelope
Minimal soft tissue
defatting as needed
Hypoplastic radix
Radix graft
Dorsal hump v.s.
“pseduohump”
Incremental bony-cartilag-
inous reduction
Underprojected tip
Tip projected over
columellar strut
Lack of tip de fi nition and
re fi nement
Multiple tip sutures, as
needed
May have wide nasal base Reduction of the base as
needed
Type III-Mestizo
very thick skin
Soft tissue defatting
Underprojected radix
Radix graft
Dorsal- base disproportion structural columellar tip
graft
possible minimal dorsal
hump
Minimal reduction as
needed
Unde fi ned & under-
projected tip
Structural strut, tip and
shield grafts
Multiple tip sutures
extremely wide base
Reduction of nasal base
including sill & alar wedges

180
A. Sajjadian
and no single technique can be used for its cor-
rection. The surgeon is cautioned that techniques
mentioned in the literature should not be used in
all cases [ 4 ] and that using older surgical meth-
ods can result in an outdated rhinoplasty—
scooped out, upturned nose [ 4 ] .
Surgeons need to be very careful in their pre-
surgical analysis and not assume that what is pre-
sented in a Hispanic nose is similar to what they
have seen in the past with Caucasian noses. For
example, the middorsal humps seen in some
Hispanic noses may not be true humps at all, but
rather “pseudohumps” due to the lack of tip pro-
trusion and the low nasal starting points in that
population (female patients are more likely to
exhibit this dorsal pseudohump). Increasing the
tip projection can reduce the necessity and extent
of dorsal hump reduction. Another example is the
ptotic appearance of the Hispanic nasal tip; how-
ever, measurements show that the tip is not nec-
essarily ptotic in relationship to the face as it
appears but that the typical prominence of the
Hispanic premaxilla can make it appear so [ 8 ] .
For the shape of the inside nasal framework to
be seen on the outside, the overlying skin has to
be thin and pliable so that it “drapes” over the
framework. Hispanic noses with thicker and less
pliable skin are dif fi cult to drape gracefully, and
thinning the nasal skin to conform to the underly-
ing framework is not always effective. The
Hispanic nasal cartilage tends to be weak, so a
good plan is to augment and strengthen the under-
lying skeleton with cartilage grafts [ 8 ] .
Expectations can present another problem to
both surgeons and patients. Studies have demon-
strated that surgery on Hispanic noses did not bring
either tip de fi nition or skin thickness to within
Western standards [ 8 ] . There is a common miscon-
ception that reducing the nasal skeleton should
make thick noses more delicate and re fi ned.
However, the Hispanic skin is so thick and the carti-
lages so weak that forming a de fi ned, angular nasal
tip by trimming cartilages is not recommended.
Hispanics (and Asians and African-Americans)
tend not to heal as well as Caucasians because of
the thick, oily quality of their skin. The grafting
often needed can prolong swelling, and it can
take longer to see the fi nal results. Scars can take
longer to mature and are more susceptible to
raised scarring and keloids.
These are just a few of the possible challenges
found in the Hispanic nose. Again, surgeons are
strongly encouraged to educate themselves about
the complex Hispanic nasal anatomy before
attempting surgery and to make sure their skills
and techniques are up to date. The reference list
at the end of this chapter provides additional
sources of detailed information.
Broad tip
Wide nasal base
Thick
nasal skin
Type III
Fig. 15.3 Type III Hispanic
nose

181
15 Hispanic Rhinoplasty
15.10 Operative Techniques
for the Hispanic Nose
Among any of the surgical techniques available
to the surgeon, those that allow for less inva-
sive, more conservative, and longer lasting
results are increasingly preferred [ 11 ] . When
planning to correct the Hispanic nose, even
those long-established techniques that have
withstood the test of time may need minor
modi fi cations, and new surgical techniques may
need to be learned. The goal is always a natu-
ral-appearing result.
15.10.1 General Rhinoplasty
Techniques for the
Hispanic Nose
Because of their anatomic tendencies, Hispanic
noses frequently require extensive work on their
internal structures to create the desired appear-
ance. This includes changing the shape of the
bone and cartilage inside the nose. Since this
internal structural work is extensive, the surgeon
is reminded that it can affect the function as well
as the appearance of the nose.
Familiarity with the nasal and facial features
common in the Hispanic nose will let the sur-
geon anticipate and prepare for the challenges.
In general, augmentation rhinoplasty will be
common. Proper choice of technique, coupled
with a realistic appreciation of the limits imposed
by the skin quality and the underlying skeletal
structure, should allow the surgeon to achieve
good results [ 8 ] .
Aesthetic Hispanic rhinoplasty begins with a
comprehensive nasal analysis and surgical plan-
ning. Many surgeons mistakenly concentrate
only on a few problem areas and may ignore the
other potential contributors to the patient’s over-
all appearance. Therefore, a systematic planning
approach is recommended [ 1, 12– 14 ] . The
following should always be considered: symme-
try, balance (the symmetry of the face noted on
frontal view), harmony (relationship of the facial
elements as seen on pro fi le), condition of the dor-
sal pro fi le, tip inclination, projection of the nose
from the face, and condition of the nasal base,
including the relationship of the columella to the
nostril edge. No part of the face should domi-
nate—the goal is always facial balance and
beauty [ 8, 14 ] .
15.10.2 Structural Grafts/Transplants
As Hispanic noses often require augmentation,
surgical grafts (transplants) can be useful. The
surgeon should fi rst plan and determine whether
rigid or soft reconstruction methods are needed.
More recently, less rigid methods of reconstruc-
tion are favored [ 11 ] .
Autologous materials have proven to be the
best graft material [ 1, 11, 15, 16 ] : septal car-
tilage, conchal cartilage, and costal cartilage.
An additional alternative is harvested calva-
rial bone (parietal). A compromise in rigidity
between cartilage and bone can be obtained by
using diced and wrapped cartilage, or crushed
or shaved cartilage. Homologous human car-
tilage has been used, as has allogenic freeze-
dried acellular dermis produced from cadaveric
skin. Synthetic implant materials (polyethylene,
polytetra fl uorethylene) have been used, but there
is a risk of extrusion.
The surgeon should carefully plan and research
the graft material needed to obtain the desired
results—and always be open to using new meth-
ods and new materials. Additionally, the surgeon
should stay current on all research and be aware
of reports of infection, extrusion, or other
unwanted side effects (e.g., Gore-Tex® mesh is
now used less often because of the risk of infec-
tion and extrusion) [ 11 ] .
15.10.3 Speci fi c Rhinoplasty
Techniques for the Hispanic
Nose
Due to the variety of shapes of the Hispanic nose
as a result of the historical racial mixture, the sur-
geon needs to have an individualized plan for
each patient. The surgeon should consider the
techniques in his or her armamentarium—and

182
A. Sajjadian
decide whether new techniques need to be
learned, whether old techniques need to be
modi fi ed, and whether he or she is experienced
enough to attempt each particular Hispanic sur-
gery. This section will present the surgical tech-
niques recommended by Daniel [ 6 ] . These
techniques are commonly used by rhinoplasty
surgeons in the United States:
Type I (Castilian): The Hispanic Castilian
nose typically has a prominent osseocartilagi-
nous vault and nearly normal tip projection;
therefore, the basic surgical goal is to perform a
“functional reduction rhinoplasty”—this gives
the patient the smaller nose they want and retains
or improves their respiratory function.
Type II (Mexican American): Altering the
Hispanic Mexican American nose can be
extremely challenging; it requires maximal surgi-
cal fi nesse. There is normal dorsal height over the
cartilaginous vault and decreased projection in
both the adjacent radix area and the tip. The basic
goal is to perform a “ fi nesse rhinoplasty.”
Type III (Mestizo): The typical Hispanic
Mestizo nose needs to have the dorsum-base dis-
proportion corrected—augment the dorsum and
reduce the base. Additionally, the distal end of
the nose may be large and covered in thick skin.
The basic goal is to perform a “balanced
rhinoplasty.”
Type IV (the Creole nose): The Hispanic
Creole nose is similar to the African-American
nose, and recommended operative procedures are
similar.
Conclusions
The recent upward socioeconomic movement
of the Hispanic population in the United States
now provides them with the opportunity to seek
elective plastic surgery, including rhinoplasty.
The majority of Hispanic patients today want to
maintain their ethnic identity but have their
nasal features improved so their nose is more
harmonious with the rest of their face; they
generally do not want to lose the important
facial features that show their racial character.
While not all Hispanic noses conform to a
speci fi c type, four types can be de fi ned: Type
1 (Castilian), Type II (Mexican American),
Type III (Mestizo), and Type IV Creole
(similar to the African-American nose).
Because of their anatomic tendencies, these
Hispanic noses frequently require extensive
work on their internal structures to create the
desired appearance externally—augmentation
rhinoplasty will be common.
As rhinoplasty is the most dif fi cult of all
plastic surgery procedures, familiarity with
the nasal and facial features common in the
Hispanic nose will let the surgeon anticipate
and prepare for the challenges. Properly
choosing the appropriate surgical techniques,
along with a realistic appreciation of the limits
imposed by the Hispanic skin quality and
underlying skeletal structure, should allow the
surgeon to achieve good results and should
result in a satis fi ed patient (Figs. 15.4 , 15.5 ,
and 15.6 ).

183
15 Hispanic Rhinoplasty
a
b
Fig. 15.4 ( a ) Preoperative. ( b ) One year postoperative

184
A. Sajjadian
a
b
Fig. 15.5 ( a ) Preoperative. ( b ) One year postoperative

185
15 Hispanic Rhinoplasty
a
b
Fig. 15.6 ( a ) Preoperative. ( b ) One year postoperative

186
A. Sajjadian
References
1. Sajjadian A, Guyuron B (2010) Primary rhinoplasty.
Aesthet Surg J 30(4):527–539
2. Patel AD, Kridel RW (2010) Hispanic-American rhi-
noplasty. Facial Plast Surg 26(2):142–153
3. Cobo R (2003) Mestizo rhinoplasty. Facial Plast Surg
19(3):257–268
4. Ortiz-Monasterio F, Olmedo A (1977) Rhinoplasty on
the mestizo nose. Clin Plast Surg 4(1):89–102
5. Higuera S, Hatef DA, Stal S (2009) Rhinoplasty in the
Hispanic patient. Semin Plast Surg 23(3):207–214
6. Daniel RK (2003) Hispanic rhinoplasty in the united
states, with emphasis on the Mexican American nose.
Plast Reconstr Surg 112(1):244–256; discussion
257–258
7. Davis RE (2006) Rhinoplasty and concepts of facial
beauty. Facial Plast Surg 22(3):198–203
8. Leach J (2002) Aesthetics and the Hispanic rhino-
plasty. Laryngoscope 112(11):1903–1916
9. Aston S (2009) Aesthetic plastic surgery. Saunders/
Elsevier, Philadelphia
10. Sturm-O’Brien AK, Brissett AEA, Brissett AE (2010)
Ethnic trends in facial plastic surgery. Facial Plast
Surg 26(2):69–74
11. Daniel RK (2009) Mastering rhinoplasty. Springer,
New York
12. Guyuron B, Behmand RA (2003) Nasal tip sutures
part II: the interplays. Plast Reconstr Surg
112(4):1130–1145; discussion 1146–1149
13. Sajjadian A, Guyuron B (2009) An algorithm for
treatment of the drooping nose. Aesthet Surg J
29(3):199–206
14. Pearlman SJ (2006) Surgical treatment of the nasola-
bial angle in balanced rhinoplasty. Facial Plast Surg
22(1):28–35
15. Sajjadian A, Rubinstein R, Naghshineh N (2010)
Current status of grafts and implants in rhinoplasty:
part I. Autologous grafts. Plast Reconstr Surg 125(2):
40e–49e
16. Sajjadian A, Naghshineh N, Rubinstein R (2010)
Current status of grafts and implants in rhinoplasty:
part II. Homologous grafts and allogenic implants.
Plast Reconstr Surg 125(3):99e–109e

187
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_16, © Springer-Verlag Berlin Heidelberg 2013
16
16.1
Introduction
Some of the most challenging rhinoplasty cases
can be found among persons of Middle Eastern
origin. Dif fi culties intrinsic to the nasal anatomy
among the Middle Eastern population can make
surgical results less predictable and, in some
cases, less enduring. Some of the most common
nasal anatomic features that can present chal-
lenges to rhinoplasty are characterized by a
heavy, thick skin envelope; an overprojecting
osseocartilaginous vault; weak alar cartilages;
and short medial crura. Facial malformations that
can arise due to these intrinsic features include a
bulbous, large nose; a high arching dorsum; an
elongated nose; a drooping, poorly de fi ned tip; a
broad, bony middle vault; a short columellar-
labial angle; and overall nasal asymmetry [ 1– 6 ] .
In order to achieve the best results in Middle
Eastern rhinoplasty, it is essential for surgeons to
have a good understanding of the unique nasal
anatomy and the effective time-proven techniques
in this group of patients. The purpose of this
chapter is to provide information on anatomic
features, treatment goals, and operative tech-
niques that will lead to successful and pleasing
results in Middle Eastern rhinoplasty.
16.2
Anatomic Features Commonly
Observed in Patients of Middle
Eastern Origin
The nasal anatomic features in Table 16.1 are com-
mon but by no means limited to persons of Middle
Eastern origin. Familiarity of Middle Eastern nasal
anatomy is essential in order to create an operative
plan with techniques that will help ensure balanced
and optimal aesthetic results.
16.2.1 Skin-Soft Tissue Envelope
There is a great degree of variation of skin and
soft tissue thickness of the lower portion of the
nose among Middle Eastern rhinoplasty patients.
The degree of thickness depends on the origin of
these patients. For instance, most Middle Eastern
patients have relatively thick skin and soft tis-
sues, with Fitzpatrick skin types III–V. Those
from more northern areas, however, such as
Northern Iran, Armenia, and Turkey, often have
thinner, lighter skin, including that in the lower
nasal area. Clinical experience with patients
(primarily) of Middle Eastern descent seeking
primary rhinoplasty has shown that thick, seba-
ceous skin exists in 36% of patients [ 7 ] . This
observation is based upon a scale ranging from
+3 to −3, with N at the “zero” position represent-
ing normal thickness [ 7, 8 ] . Accordingly, the
majority (64%) patients had skin classi fi ed as N,
+1, or −1. Conversely, others who conducted a
Middle Eastern Rhinoplasty
Ali Sajjadian
A. Sajjadian , M.D., FACS
Private practice , Newport Beach ,
CA 92663 , USA
e-mail: sajjadiana@yahoo.com

188
A. Sajjadian
retrospective analysis of preoperative and post-
operative photographs of the noses of Middle
Eastern patients determined that 90% had thick,
sebaceous skin, especially at the nasal tip [ 9 ] .
Since ethnic origin data were not available, one
could speculate that this difference might have
been due to a relatively large amount of patients
from regions that display traits more in common
with African American, Asian, and Hispanic
persons (i.e., North African and Arabian ethnic
groups), who have thicker skin compared to
those from more northern ethnic backgrounds.
Therefore, assumptions persist that much thicker,
highly sebaceous skin is usually found in this
population. In summary, there is a great deal of
variability of skin thickness among patients of
Middle Eastern origin.
16.2.2 Bony and Cartilaginous
Dorsum
A common procedure in Middle Eastern rhino-
plasty is reduction of the dorsal hump, which
may be quite prominent. The nasal dorsum is
typically composed of approximately equivalent
amounts of bone and cartilage in majority of
Middle Eastern patients, although primarily car-
tilaginous or bony (least common) dorsum may
also be observed.
16.2.3 Nasal Tip
As with other features, the appearance of the nasal
tip in Middle Eastern patients can vary greatly and
is considered to need only minor changes in nearly
a third of those undergoing rhinoplasty. In patients
with good alar anatomy, no signi fi cant operative
procedures may be needed, although sutures may
be placed at the tip to improve de fi nition. Weak
alar anatomy, however, is present in two-thirds of
Middle Eastern patients [ 7 ] . Poor support result-
ing from weak alar anatomy can result in an ill-
de fi ned tip. In addition, thick skin may contribute
to bulbous appearance in some patients.
Other common malformations affecting the tip
are a prominent dorsal hump and a dependent,
underprojecting nasal tip that often present
together as features and require correction.
Moreover, the lower lateral cartilages are also
critical in providing de fi nition of the nasal tip.
Weak middle and medial crura can result in poor
support for the precisely positioned and fragile tip
complex, which is usually located posterocaudal
to the high anterior septal angle. Similarly, patients
with vertically oriented lower lateral crura can
have lack of adequate support and a higher risk of
loss of tip position postoperatively.
16.2.4 Alar Base
Many Middle Eastern rhinoplasty patients have a
wide or prominent alar base that requires excision.
Alar fl aring and wide separation between ala are
also commonly found. Features of the alar base
that often require reduction include the nostril sill
or lateral ala. The alar base disproportions are cor-
rected by alar wedge excision or nostril sill reduc-
tion. Occasionally, these procedures are performed
as combined sill/base excision [ 10 ] . Conservative
management is essential to prevent unsightly scars
and unnatural morphology of ala and alar crease.
16.2.5 Nostrils
The general asymmetry found in Middle Eastern
features can include nostril shape. The lower lateral
Table 16.1 Common anatomical fi ndings in Middle
Eastern rhinoplasty patients
Skin-soft tissue
envelope
Normal to thick
Nostrils
Wide sills, usually asymmetric
Septum
Usually deviated
Nasal vault
Usually wide, sometimes normal
Radix
Normal to low
Dorsal hump
Commonly osteocartilagneous or
cartilaginous
Tip morphology
Usually underprojected and
underrotated
Alar orientation
Usually cephalically malpositioned
Nasal length
Excessive causing downward
rotation of ala
Depressor septi
muscle
Commonly hyperdynamic

189
16 Middle Eastern Rhinoplasty
cartilages play an important role in nostril shape
appearance. Middle Eastern patients may have rel-
atively short medial and middle crura, which can
contribute to nostril asymmetry. In addition, fl aring
medial crural footplates can cause nostril abnor-
malities. Tip-to-nostril disproportion is also com-
mon fi nding, which can be described as a tip
proportion greater than 40% and a nostril propor-
tion less than 60%. A nostril-to-tip ratio of approxi-
mately 60:40 is considered aesthetically pleasing
[ 11, 12 ] . Depending on the etiology, disproportions
of nostril shape can be corrected by a variety of
techniques and are discussed later in the text.
16.2.6 Septum
Signi fi cant deviation of the caudal septum is often
observed in Middle Eastern persons. Septal deviation
is often one element of a generalized asymmetry
within the face. This should be discussed with the
patient in terms of the appropriateness of correcting
septal deviation on a background of pervasive facial
asymmetry. However, the septum may contribute in a
positive way for providing support in other features
(i.e., tip support) or in a negative sense towards mal-
formations in other features. One important function
of the septum is the role the septal vestibular lining
plays in strength and maintenance of nasal tip position
and shape. On the other hand, a cartilaginous septum
can contribute signi fi cantly to the dorsal hump.
16.2.7 Depressor Septi Muscle
The involvement of the depressor septi muscle is
often a consideration in Middle Eastern rhinoplasty.
A hyperactive depressor septi muscle during speech
and animation can worsen the appearance of a
drooping nasal tip and shorten the upper lip.
16.3
Treatment Goals and
Operative Techniques
Since the nasal anatomy of Middle Eastern rhino-
plasty patients is tremendously varied, there is no
single or standardized surgical approach that will
ensure optimal result success for the majority of
patients. Thus, the importance of a thorough pre-
operative anatomic analysis cannot be overstated.
Details of the anatomical analysis should be dis-
cussed with the patient in order to help align their
expectations and goals with realistic and appro-
priate surgical outcome. Of equal importance are
results that can be realistically achieved for the
patient’s anatomy and avoiding “ethnic incongru-
ity.” A nose with primarily Caucasian features on
the face of an individual with Middle Eastern
facial features does not impart a natural appear-
ance and gives an immediate impression of surgi-
cal alteration. For instance, the goal for correction
of the nasolabial angle (and columellar-labial
angle) should be 95° or less, with an approach to
less correction being preferable. One method for
fi nding a good balance for natural-looking nasal
proportions is to use standard nasal ratios as a
guide, making changes from Caucasian norms to
accommodate a more natural appearance.
Despite the large degree of variation in Middle
Eastern nasal anatomy and need for individualiza-
tion, there are a number of treatment goals that
can be considered common. Examples include
moderate dorsum reduction, narrowing of wide
nasal bones, correction of alar fl aring, correction
of nostril asymmetry, addressing nostril-tip imbal-
ance, and conservative debulking of fi brofatty tis-
sue as needed. Common nasal tip procedures
include creating de fi nition, correcting undersup-
ported and underprojected nasal tip, and address-
ing hyperdynamic nasal tip.
Consideration of operative techniques for
Middle Eastern rhinoplasty should begin with the
skin. As discussed earlier, only about one-third of
patients have thick, heavy skin. Once identi fi ed,
patients with thick skin should undergo a very
conservative defatting of the skin envelope as
needed. It is important to mention that the under-
surface should never be trimmed past the level of
the subdermal plexus. In addition, open structure
tip grafts will be needed to provide tip de fi nition in
those individuals who have thick skin. Operative
techniques for the majority of Middle Eastern
patients who have normal skin thickness are less
variable. For these patients, debulking of the skin
envelope and major tip alteration techniques that

190
A. Sajjadian
are destructive or divisional should be avoided
altogether. Since the treatment for patients with
thick versus normal skin is very different, preop-
erative assessment and planning are essential.
To achieve moderate dorsal reduction, an
incremental approach is the preferred technique.
Reduction may be achieved with a rasp for bony
regions and scissors for cartilaginous regions of
the vault. For predominately bony humps that are
cephalically dominant, reduction may average
2.5 mm or more and will extend into the radix
area. In these patients, burr can be used to estab-
lish appropriate height of radix region. Reduction
of anterior cartilage is usually minimal. Dorsal
humps that are osseocartilaginous will require
greater reduction of cartilage (approximately
3.5 mm) than bone (approximately 1.5 mm).
Accordingly, cartilaginous humps will require
very little bone reduction (<0.5 mm) but may
require cartilage resection of 4 mm or greater.
Due to the signi fi cant amount of cartilage
removed, spreader grafts or Byrd’s “autospreader
fl ap” [ 13 ] is used to stabilize the internal valve
angle in cartilaginous vaults. This added support
can prevent collapse of the midvault, resulting in
an inverted-V deformity. These supportive grafts
will also prevent this deformity in bony or osseo-
cartilaginous humps where there has been an
extensive amount of reduction.
To address undesirable tip position (poor
projection and/or droopy tip) commonly found
in Middle Eastern rhinoplasty patients, a strong
columnar strut is needed to support and recon-
fi gure weak alar cartilages. The columellar strut
is essential for creating a favorable platform to
maintain tip shape and position in the long term.
In addition, columellar strut will also prevent
tip droop upon smiling, especially when open
structure rhinoplasty approach is utilized. Other
procedures that will establish proper tip posi-
tion include removal of excess tissues by per-
forming caudal septal resection and excision of
redundant lining. Severe septal deviation and
dislocation is common in this patient popula-
tion and can create signi fi cant functional and
cosmetic problems. Caudal septal relocation is
commonly performed to address and correct
these anatomic abnormalities.
Sutures alone may be suf fi cient for tip rotation
and re fi nement if the patient has thin skin or wants
a softer, more rounded tip. Suturing for tip improve-
ment involves a number of techniques to achieve
the desired aesthetic result. Occasionally, some
patients of Middle Eastern origin request rotation
above the dorsal line. In these patients, a tip posi-
tion suture can achieve a supratip break and pro-
vide increased projection. The width of the tip can
be managed by use of an interdomal suture. A
wide, bulbous or “boxy” tip can be corrected with
lateral crural convexity sutures. Once the sutures
are in place, the skin may be redraped over the tip
to determine if the degree of re fi nement is suf fi cient.
Suture techniques are powerful tools and can have
great impact on the external appearance of the nose
[ 6, 10, 14, 15 ] . It is important to redrape skin over
the tip throughout the shaping process in order to
assess how different suture techniques are impact-
ing the appearance of the nasal tip.
In other cases, tip re fi nement grafts derived
from alar cartilages may need to be added to the
sutured alar cartilages to achieve adequate tip
de fi nition. A solid open structure tip graft from
septal cartilage may be required for patients with
exceptionally thick skin.
In about half of Middle Eastern rhinoplasty
patients, the alar base width needs to be reduced,
along with narrowing of the nostril sills [ 16 ] . This
procedure will enhance overall nostril shape.
Nostril sill excision extending into the alar crease is
a technique that will minimize any visible scars.
A nostril-to-tip ratio of 60:40 will provide an
aesthetically pleasing appearance. To address
alar fl aring with a large nostril size, complete
wedge excision may occasionally be required.
This operative technique involves an incision that
extends into the vestibule and reduces the fl aring.
Similarly, vestibular sill excision can be used in
patients with wide nostril width. Excessive alar
base narrowing can lead to racial incongruity and
should be avoided.
Septal deviation in Middle Eastern patients is
often integrated with an overall asymmetry in the
face. In terms of rhinoplasty, the patient must
be made aware of the inherent limitations to cor-
recting septal deviation where asymmetry is
pervasive among other facial features. Caudal

191
16 Middle Eastern Rhinoplasty
septal relocation may be required for nearly half of
all patients. However, there are septal procedures
that are integral for correcting other malformations
or important for providing tip support. One impor-
tant function of the septum is the role the septal
vestibular lining plays in strength and maintenance
of nasal tip position and shape. In some cases, cau-
dal septal vestibular resection and suturing may be
required to maintain tip position. In addition, a car-
tilaginous septum that contributes signi fi cantly to
the dorsal hump may require alteration. When sep-
tal resection is performed, the surgeon may harvest
excess cartilage for use as grafts as needed.
Addressing a hyperdynamic tip by treating the
depressor septi muscle can be accomplished by
transection/transposition. This approach will pro-
vide an improvement in lip length, although it is
not entirely clear how much effect there is on a
plunging tip since other Middle Eastern rhino-
plasty procedures are commonly used to elevate
the tip. Preoperative injection of botulinum toxin
is currently being investigated as an approach to
assessing the magnitude of effect the depressor
septi muscle has on the nasal tip [ 17 ] .
16.4
Aesthetic Considerations
Not surprisingly, the focus of rhinoplasty is often
different for the surgeon compared to that of the
patient. This is not an insurmountable barrier to
treatment, but a professional versus a personal
difference. It is best to spend a great deal of time
communicating with patients what would be pos-
sible and aesthetic given the patient’s facial and
nasal features. For patients, it is clear that aes-
thetic improvement is the dominant focus.
However, surgeons are concerned with balancing
size reduction with preservation of nasal func-
tion. Natural-looking rhinoplasty results can be
accomplished by avoiding maneuvers of aggres-
sive rhinoplasty such as pinched tip, overly
reduced dorsum and its associated inverted-V
deformity, and retracted ala rims [ 6, 10, 14, 15 ] .
Dynamics of nasal tip should be considered, and
the drooping of the tip should be addressed in this
patient population. The use of a variety of grafts
can assist the surgeon greatly to achieve a natural
look while preserving nasal function (Figs. 16.1 ,
16.2 , and 16.3 ) [ 18, 19 ] .
Conclusions
Patients of Middle Eastern ancestry who seek
rhinoplasty represent a diverse group that have
a wide variety of anatomic characteristics.
Although some anatomical similarities will be
found, the proportion of patients with the
often-expected thick skin and bony dorsum
will comprise a minority. The pervasiveness
of asymmetry of features, however, should be
discussed with patients in the context of limi-
tations to correcting malformations such as
septal deviation. Further, patients must under-
stand that a small nose with primarily
Caucasian dimensions will not be appropriate
for a Middle Eastern face. A thorough ana-
tomical analysis is essential to designing a
surgical plan that will produce aesthetic results
that will be pleasing and in line with patient
expectations.
Since a large reduction of the dorsum is
common, grafts are often required for support,
especially for a dorsum that is cartilaginous.
Spreader grafts will prevent a postoperative
inverted-V deformity and protect the internal
valve. Structure may be also created through
the use of columnar struts, tip grafts, and, in
some cases, alar rim grafts. Conversely, tip
techniques that are destructive such as aggres-
sive excision or division of the alar rim strips
should be avoided, especially in patients with
normal skin thickness. Such procedures will
remove structure needed for long-term sup-
port. In patients with thinner skin or who desire
a softer, rounded tip, suturing may be the only
procedure needed to achieve an aesthetically
pleasing tip. Surgeons will fi nd that a different
set of surgical techniques will accomplish the
goals and expectations desired by patients in
their mid-twenties and older versus those of
younger patients. With a wide variety of opera-
tive techniques available to individualize treat-
ment for the Middle Eastern nose, surgeons
can be con fi dent that a well-planned rhino-
plasty will give patients a countenance that
they will be proud to show to the world.

192
A. Sajjadian
a
b
Fig. 16.1 ( a , b ) ( Left ) Preoperative 23-year-old patient. ( Right ) One year postoperative

193
16 Middle Eastern Rhinoplasty
a
b
Fig. 16.2 ( a , b ) ( Left ) Preoperative 19-year-old patient. ( Right ) Eighteen months postoperative

194
A. Sajjadian
b
a
Fig. 16.3 ( a , b ) ( Left ) Preoperative 24-year-old patient. ( Right ) Two years postoperative