Rhinoplasty Dr Bashar Bizrah Article on: Black and Chinese Patients

General considerations:

• Rhinoplasty on Black and Oriental patients require the finest surgical skills acquired by the surgeon. It is an augmentation procedure that involves tip refinement, dorsum grafting, bony pyramid narrowing, elevation and alar wedge resection.
• There are a few million expatriates living in the Gulf region. Many are of African and Chinese origin (Indonesians, Filipino, etc.). Most of the patients want refinement and wish to maintain most of their ethnic and racial characteristics, but others, in particular those who are living permanently in the Gulf region wish to have the Arab look. They request a high dorsum like the arabic nose and may request the double eyelid procedure.
• The limitations of surgery should be clearly discussed with the patient. The patient should sign a consent form and the possibility of secondary procedures should be made clear. Autogenous tissue is more advantageous for long term results. A sialastic implant may be required in patients with a flat dorsum.

Feature of Black and Asian noses:

1. Nasal bones:
   Short, wide, broad, flattened and depressed.
2. Alar cartilage:
   Weak, flared, small and diverted with excess fibro fatty intercartilagenous tissue.
3. Septum:
   Small and thin.
4. Columella:
   Short and retracted.

Fig 12 - 2. A 19-year-old African lady, requesting rhinoplasty. Aesthetic improvement was achieved by medial and lateral osteotomies, dorsum conchal grafts, new dome creation, division, scoring, undermining, columellar strut, I-beam medial crura fixation and long tip grafts w ith alar wedge resection.

5. Skin:
   Thick.
6. Alar base:
   Flared alar with wide floor.

Surgical goals:

To achieve:

1. Tip elevation, projection with more definition and refinement:
   By new dome creation, suture fixation, scoring, columellar strut and tip grafts.
2. Nasal pyramid, narrowing and elevation:
   By dorsal graft augmentation and osteotomies.
3. Reduce alar flare and nostril size:
   By alar wedge resection.

Surgical Techniques:

1. Adequate conchal graft obtained. (Fig. 17 – 20)
2. Closed rhinoplasty approach.
3. Intercartilagenous and marginal incisions.
4. Septal graft obtained.
5. Alar delivery through marginal incision. (Figs. 17 -12,13,14)
6. Removal of alar and intra-alar fibro fatty tissue.
7. Minimal tip defattening. (Fig. 17 – 13)
8. Minimal cephalic trimming (refreshing) of lateral crus of the alar: Minimal trimming because the cartilage is usually soft and small. (Fig. 17 – 12)
9. New dome creation:
   Two to three mm on the lateral crus is borrowed and added to the medial crus. This will achieve tip elevation, projection and narrowing. (Figs. 8 – 5,6,7 and Figs. 17 – 13,14)
10. Undermining the borrowed segment with preservation of vestibular skin. This undermining will reduce the tension caused by pulling on the alar side walls, thus, reducing postoperative dimpling and pinching.
11. Long columellar strut is stitched to the medial crura with the borrowed lateral crus segment in sandwich-like manner (I-beam medial crura fixation). This technique provides maximum structural support for the tip projection. In addition, it is very useful in cleft lip noses. (Fig. 17 – 28)

Fig. 12 - 3. A 28-year-0ld man or orient.ii origin seeking nasal refinement. The nose was corrected by osteotomies. double conchal dorsum grafts. new dome creation. division. scoring. undermining. columellclr strut. l·bec1m medial crura fix.ition and long tip grafts with nares narrowing.

1. Tip grafts, single or multiple grafts may be shaved, bevelled, positioned and sutured to the caudal margin of the borrowed lateral crura or positioned in an umbrella like manner. Titis will increase tip elevation, narrowing and definition. (Fig.17 -16)
2. Augmentation of the undermined vestibular skin between the lateral portion of the lateral crura and the I-beam, is needed in order to avoid notching.

14. Batten graft to cover the lateral crura and the undermined vestibular skin may be needed to prevent notching and alar collapse and to achieve strong, profound and well oriented tip sidewalls. (Fig. 8 – 30 and Fig. 17 – 23)
15. Dorsal graft preparations:
    – Shaping of the graft to the required length and width.
    – Suturing layered double or triple graft together. (Fig. 11 – 4)
    – Bevelling and trimming of the edges to avoid showing through the skin and skin step deformity. (Fig. 11 – 2 and Fig. 17 – 7)
    – Positioning the graft in the exact site. (Figs. 17 – 21,22)
    – Stabilizing the graft and suturing it to the dorsum septum or dome apex or the use of skin pullout suture.
16. Osteotomies:
    The aim is to narrow and elevate the bony nasal pyramid. A single medial osteotomy is used to split the nasal bone, then lateral osteotomies are performed to mobilize it. A lateral osteotomy is performed externally by two mm osteotome. It is carried out as dose to the face as possible to preserve much of the nasal bony sidewalls, in order to achieve the maximum possible elevation and avoid step deformity. (Fig. 7 – 2)
17. Alar wedge excision:
    To reduce the flared rim and the wide nostril floor:
    Following tip elevation and projection, the flaring of the nostrils will have been reduced and if there’s still excessive flaring of more than three mm outside the medial canthal line, this can be corrected by alar base resection. The first incision follows the alar’ s natural crease but ends in the floor two to three mm medial to the rim insertion. The second incision includes a few millimeters of the rim in a triangular wedge and meets the first incision laterally in a triangular fashion. (Fig. 10 _ 2)
18. Fine refinement of the tip and dorsum.
19. Closure:
    Nasal incisions are closed with 4/0 Dexon
20. Dressing:
    Steri-strips are used to apply a gentle pressure in order to eliminate the dead space and keep the nasal tissue in direct contact with the graft, which is vital for the graft to survive. External splints are applied gently to keep the graft in the middle and for stability of the nose. The conchal donor site is stitched with the application of pressure dressing. (Fig. 17 – 22)
21. Follow-up:
    Patients are instructed to use systemic antibiotics for one week. Strips and plaster are applied for one week. Index finger massage as instructed after plaster removal. Long term follow-up is recommended. (Fig. 2 – 7)
22. In patients with flat dorsum, an L-shaped silastic implant may be used to augment the dorsum and the tip. The suitable implant is pushed through a columellar margin incision into a pocket , which is made between the two alar cartilages and extends downwards above the nasal spine and backwards on the dorsum to just before the nasion. The disadvantages of this type of graft are discussed in the previous chapter. The procedure takes about ten to fifteen minutes to perform under a local anaesthetic. The implant should be sterilized as indicated in its instruction sheet, with no finger touch technique from the autoclave to its nose pocket. Curved forceps are used to push the graft into position. Oral antibiotic cover is given for one week. (Fig. 17 – 22)