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Open structure rhinoplasty for management of the non-Caucasian nose
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OPEN STRUCTURE RHINOPLASTY FOR MANAGEMENT OF THE NON-CAUCASIAN NOSE DEAN M. TORIUMI, MD, JONATHAN M. SYKES, MD, CALVIN M. JOHNSON, JR, MD
Aesthetic surgery of the non-Caucasian nose frequently requires aggres sive surgical manuevers to attain the desired changes in nasal contour. Unfortunately, thick, sebaceous skin of the non-Caucasian nose is at great risk for increased scar contracture, which could deform an already weak nas al structure. To prevent deformity, we use the open structure rhinoplasty technique to add support to the nasal structure in the form of columellar struts and sutured-in-place tip grafts. In this art icle, specific modifications of the open structure rhinoplasty technique are described for management of the non-Caucasian nose. KEY WORDS: Non-Caucasian rhinoplasty/open structure rhinoplasty/open rhinoplasty/external rhinoplasty/tip graft.
Rhinoplasty performed in the non-Caucasian nose presents perhaps the most difficult challenge to the rhinoplastic surgeon. Surgical maneuvers performed to achieve major alterations often require extensive remodeling of the underlying structure of the nose . These aggressive maneuvers may severely compromise already weak cartilaginous structures. A weakened nasal structure in combination with scar contracture of a thick, poorly conforming skin-soft tissue envelope (S-STE) may result in a disastrous result. Surgical management of the non-Caucasian nose requires strengthening weak cartilaginous structures, preservation of major support mechanisms, and careful manipulation of the S-STE. Open structure rhinoplasty incorporates the external (open) approach to the nose, conservative cartilage resection, and a sutured-in-place columellar strut and sutured-in-place shield-shaped tip graft. 1 One of the primary indications for open structure rhinoplasty is the non-Caucasian nose. Several special modifications of the technique must be instituted with the non-Caucasian nose to account for the anatomic differences between the Caucasian and non-Caucasian nose. A discussion of the charateristics of the nonCaucasian nose, special considerations in surgical management, and a description of the technique wiII be presented. The principles and techniques described can be applied to any nose with similar structural deformities. From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Department of Otolaryngology-Head and Neck Surgery , University of California, Davis, Sacramento, CA; Hedgewood Surgical Center, New Orleans, LA. Address reprint requests to Dean M. Toriumi, MD, Assistant Professor, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL 60612. © 1990 by W.B. Saunders Company. 1043·1810/9010104-0002$05.00/0
CHARACTERISTICS OF THE NON-CAUCASIAN NOSE When discussing the .non-Caucasian nose, we are referring primarily to the black nose, even though the Oriental nose has many similar characteristics. Careful preoperative analysi s of every nose is necessary to identify the deformities and determine the appropriate surgical management. Typically, the non-Caucasian nose is flat, broad, and short with an infantile dorsum lacking projection from the nasal tip to the nasofrontal angle (Fig 1). The nasal tip tends to be rounded and foorly defined, with less projection than the Caucasian. The decreased nasal pro jection is accentuated by the increased width of the nose as well as the protrusive lips. The acute nasolabial angle is one of the most consistent findings in the nonCaucasian nose (Fig 2).3 This angle is also exaggerated by the prominence of the protruding upper lip. Underdevelopment of the anterior nasal spine is considered one of the major anatomic findings that contributes to the acute nasolabial angle. 3 The columella is short, thick, hidden, and tends to diverge superiorly and inferiorly. The alae are thick, flaring, wide-based, and overhan.f the columella acting to hide it on lateral view (Fig 2). The skin of the ala is thick, fatty, and inelastic, with numerous sebaceous glands. The nostrils are round or horizontally ovoid (Fig 3). . The nose appears short because the nasal tip tends to be rounded and the starting point of the nose (deepest point of the nasofrontal angle) is frequently poorly defined. The starting point of the nose should be welldefined and located at or just below the level of the superior palpebral fold. 1 In many cases, the dorsum is low with a long sweeping slope up to the glabella without any definition of a distinct nasal starting point (Fig 4). In the non-Caucasian nose, the anterior septal angle is usually more obtuse and is set more cephalically than in the Caucasian nose." Furthermore, the quadrilateral sep-
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FIGURE 3. Non-Caucasian nose with ovoid, horizontally oriented nostrils.
tal cartilage is not only relatively smaller, but also thinner and shorter than in the Caucasian? The pyriform aperture is wide and the ratio of bone -to-cartilage of the nasal vault is smaller than in Caucasians. The nasal bones are oriented at a more obtuse angle along the dorsum just as the angle at the domes are also set at a more obtuse angle. Not all non-Caucasian noses will possess all of these characteristics. Actual analysis of such a population shows that there is a great deal of latitude in the expression of these nasal characteristics. Some patients show all of these characteristics, while some have a nose with many features of a Caucasian nose. The most difficult nose is the one that demonstrates the extreme of all of these characteristics, presenting many limiting factors to the surgeon.
FIGURE 1. Non-Caucasian nose that is flat, broad, and short with an infantil e nasal dorsum. (A) Frontal view, (B) lateral view, (C) oblique view, (D) basal view.
FIGURE 2. Non-Caucasian nose with an acute nasolabial angle and thick ala that overhang a retracted columella. (A) Frontal view, (B) lateral view, (C) oblique view, (D) basal view.
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LIMITING FACTORS IN NON'·CAUCASIAN RHINOPLASTY There are several characteristics of the non-Caucasian nose that limit the 'degree of aesthetic improvement that can be attained. First and foremost is the thick, inelastic nature of the S-STE. Despite radical changes in shape of the underlying nasal structure, if the S-STE does not drape over the structures, these changes will not be manifested as the expected change in nasal contour. After the nasal structure is augmented and the tip is projected, thick, nonelastic skin in combination with a short columella may preclude closure of the transcolumellar incision. Weak or thin lateral crura provide little support and any resection of cartilage will further compromise the stability of the lower third of the nose. Thin septal cartilage does not provide sufficient support for grafts and may require multiple-layered grafts to add strength. Furthermore, the limit in the amount of septal cartilage that can be harvested may require harvesting auricular cartilage. Features of the non-Caucasian patient that are difficult
FIGURE 4. Non-Caucasian nose with a long, sweeping, poorly projected dorsum that lacks a distinct nasal starting point. OPEN STRUCTURE RHINOPLASTY
to safely alter surgically include the size and thickness of the alae and protruding lips. The surgeon and patient must be realistic about what aspects of the nose can be safely altered. Finally, the ethnicity of the non-Caucasian nose must be preserved to prevent a severe aesthetic deformity.
OPEN STRUCTURE RHINOPLASTY AND THE NON-CAUCASIAN NOSE Once the deformities are identified, the surgeon must set realistic goals for surgical management. In most cases, reasonable goals for surgical management of the nonCaucasian nose will incude: increasing nasal projection; improving nasal tip definition; narrowing the nose; augmenting the nasal dorsum; decreasing alar flare; and narrowing the alar base. Obviously, each case is different, with some requiring more modification than others. Open structure rhinoplasty techniques use the external rhinoplasty approach to the nose, permitting maximal visualization and control. The external approach also permits precise resection of subdermal fibro-fatty tissue. Other key features of this technique include the suturedin-place columellar strut and sutured-in-place shieldshaped tip graft. The columellar strut is sutured between the medial crura and provides support to the lower third of the nose (Fig 5). The strut will preserve projection; however, it will not increase projection unless it is balanced on the nasal spine or premaxilla. The strut should' not be balanced on the nasal spine because it may shift to one side, tilting the tip of the nose (Fig 6). With the strut in position, the tip graft is sutured to the medial crural! columellar strut complex (Fig 7). The tip graft provides projection, support, and a bidomal tip configuration. The tip graft position and shape can be altered to increase or decrease rotation and add length to the nose. Once the structure of the lower third of the nose is constructed, the rest of the nose can be augmented or narrowed as needed.
TECHNIQUE For the non-Caucasian nose, standard open structure rhinoplasty techniques can be used with specific modifications to account for differences in the anatomy." Autologous septal cartilage is typically harvested via a Killian incision. If the caudal septum is deviated, then a hemitransfixion incision can be used to gain access to the caudal septum. The nose should be injected with lidocaine (1%) with 1:100,000 epinephrine.! The transcolumellar incision in the non-Caucasian nose should be placed just below the mid-columellar level (Fig 8). This is necessary because a mid-columellar incision may be moved up into the region of the infratip lobule if the nose is augmented and the skin of the nose is advanced cephalically. The transcolumellar incision is connected to bilateral marginal incisions and the flap is carefully elevated off of the medial and lateral crura using three-point-countertraction (Fig 9). Once exposed, the medial and lateral crura can be carefully examined to evaluate the shape and strength of the cartilages (Fig 10). At this point, a pocket is dissected between the medial crura, which should not extend down to the nasal spine. The caudal aspect of the pocket can be opened to provide TORIUMI, SYKES, AND JOHNSON
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FIGURE 5. Columellar strut located in a pocket between the medial crura. Note how the strut does not extend down to the nasal spine. (Mid-sagittal plane). (Reprinted with permission. © Calvin M. Johnson, Jr, MO, 1990.)
FIGURE 6. If the columellar strut is placed in a deep pocket near the premaxilla, it may shift to one side of the nasal spine acting to tilt the tip of the nose. (Reprinted with permission. © Calvin M. Johnson, Jr, MO, 1990.)
FIGURE 7. Sutured-in-place shield-shaped tip graft. Note how the leading edge of the tip graft is projected 1 to 2 mm above the old domes. The tip graft is sutured to the caudal margin of the medial crura. (Reprinted with permission. © Calvin M. Johnson, [r, MO, 1990.)
FIGURE 8. Inverted-V transcolumellar incision is placed just below the level of the mid-columella.
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better visualization; however, the cephalic aspect of the pocket should be left intact (Fig 11). A carefully sculpted cartilaginous strut is sutured between the medial crura (Fig 12). In some cases, the cartilage is very thin, providing minimal support. In this case, a double-layer cartilage graft can be used as a columellar strut. With the strut sutured into position, the surgeon should be able to detect a significant increase in support in the region of the medial crura. In many Caucasian noses, some degree of tip rotation is desirable, so cephalic trim of the lateral crura is performed in conjunction with resection of a triangular seg-
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FIGURE 9. Three-point-countertraction. A wide two-prong retractor is placed along the alar rim, a medium two-prong is placed on the vestibular side of the lateral crus, and a narrow two-prong is placed on the columellar flap.
FIGURE 10. Inspection of lower lateral cartilages.
FIGURE 11. Pocket for columellar strut is dissected between the medial crura.
FIGURE 12. Columellar strut is stabilized between the medial crura with a carefully positioned mattress suture.
FIGURE 13. Conservative cephalic trim is performed with resection of a cephalically based triangle of cartilage in the region of the domes. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.)
ment of the lateral crura with suturing of both cut ends to reconstitute the intact strip (Fig 13). However, in most non-Caucasian noses, the degree of rotation desired can be achieved solely by using the sutured-in-place tip graft. In fact, the major problem with using sutured-in-place tip grafts in non-Caucasian noses is that one can easily overrotate the tip. This is especially true in male patients. For these reasons, no cephalic trim is performed, except for in selected cases where significant degrees of rotation are desired. In preserving the cephalic margin of the lateral crura (recurvature or scroll), one of the major supportive mechanisms of the lower third of the nose is left intact. To correct the obtuse angulation of the domal angle, some type of manipulation of the domal region is usually necessary. If cartilage is resected from the domes, some degree of rotation will result. To avoid rotation, the lateral crura are divided at the domes (no cartilage is resected), then both cut ends of the cartilage are resutured to form a more acute domal angle (Fig 14). This simple maneuver does not weaken any of the major support mechanisms of the lower third of the nose. If necessary, conservative dorsal hump removal can be performed. In most cases, non-Caucasian noses require dorsal augmentation, and not hump removal. If a dorsal hump is present with a low dorsum, cartilage grafts can be placed above and below the hump to provide a straight dorsal line. In some cases, the skin is too tight to allow dorsal augmentation, tip grafting, and still be able to dose the columellar incision. In these cases, medial and lateral osteotomies must be performed to narrow the upper third of the nose. Dorsal augmentation in itself will give the illusion of narrowing the upper two thirds of the nose (Fig 15). If dorsal augmentation is to be performed with no medial and lateral osteotomies, a small pocket just large enough to accept the graft is dissected over the nasal dorsum. Then, a custom sculpted graft is placed in the carefully designed pocket. If the skin and periosteum have already been elevated to perform other bony work, the dorsal grafts can be sutured or glued into position (Fig 16). Careful sculpting of the grafts is critical in order to avoid irregularities of the dorsum. Tip graft shape and placement is extremely critical in the non-Caucasian patient because it is relatively easy to over-rotate the nasal tip. There are several factors that must be carefully evaluated when tip grafting the nonCaucasian patient. A major factor to consider is the angulation of the caudal surface of the medial or intermediate crura of the lower lateral cartilages. In the Caucasian patient, the medial and intermediate crura tend to
FIGURE 14. (A,B) The free cut ends of the lower lateral cartilages are reapproximated with a strategically placed 6-0 Prolene mattress suture. (C) Reconstitution of the intact strip changes a widely arched, obtuse domal angle to a more acute domal angle.
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OPEN STRUCTURE RHINOPLASTY
have less of a curvature than the non-Caucasian patient (Fig 17). If a tip graft is sutured to a surface that is angulated cephalically, the tip graft will also be angulated cephalically. Another major consideration involves the combination of weaker cartilage for the tip graft and thick, tight, nonelastic skin. When the columellar incision is closed, the thick skin exerts force on the weak tip graft, resulting in cephalic rotation of the leading edge of the tip graft (Fig 18). Excessive cephalic rotation of the tip graft may result in an over-rotated tip. Several maneuvers can be performed to prevent overrotation of the tip graft. The caudal margin of the medial crura can be trimmed toward the base to change the orientation of the tip graft (Fig 19). In many cases, the surgeon will also need to use multiple-layer tip grafts, with the leading edge much thicker than the base of the graft (Fig 19). Two and even three-layered cartilage tip grafts can be used to provide length to the nose and prevent over-rotation of the lower third of the nose (Fig 20). In our experience, multiple-layered grafts do well; however, we do not suggest layering any more than three pieces of cartilage. When suturing multiple-layer tip grafts into position, the sutures at the leading edge of the graft must be sutured to the back layer of the graft to get the full effect of the multiple-layer graft (Fig 21). In Caucasian patients with thin skin, a blending stitch is placed at both corners of the leading edge of the tip graft to the domal region. Placement of this stitch is re-
FIGURE 16. A finely sculpted two-layer cartilage graft is sutured into position over the dorsum of the nose.
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FIGURE 15. Dorsal augmentation will give the illusion of narrowing the upper two thirds of the nose. Note how nasal width "A" appears narrower after the dorsum is augmented. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) FIGURE 17. (A) Favorable angulation and curvature of the caudal margin of the medial crura of a Caucasian patient to accept a tip graft. (B) Cephalically angulated surface of the caudal margin of the medial crura of a non-Caucasian patient provides a base for the tip graft that will create an over-rotated appearance unless some modification of the caudal margin of the medial crura is performed. FIGURE 18. (A) Note the good position of the tip graft before the columellar incision is closed. (B) After the columellar incision is closed, the thick, nonelastic skin exerts force on the weak tip graft resulting in cephalic rotation of the leading edge of the tip graft. FIGURE 19. (A) Positioning of the cartilage tip graft resulting in over rotation of the tip. The dotted line represents the location of the columellar strut. To correct this problem, the infero-caudal margin of the medial crura can be trimmed (cross-hatched lines) to set a more favorable plane for the tip graft. (B) A longer double-layer tip graft is used to decrease the degree of tip rotation provided by the tip graft. The double-layer graft is stronger so there is less of a tendency for the graft to bend cephalically after the columellar incision is closed. The dotted line shows the location of the columellar strut. TORIUMI, SYKES, AND JOHNSON
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FIG 18
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B
FIG 19
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FIGURE 20. Multiple-layer tip graft sutured into position to prevent over rotation or add length to the dorsal line of the nose. (A) Lateral view, (B) view from above. A
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FIGURE 21. (A) Note how the back layer of the tip graft is sutured to the caudal margin of the medial crura to get the full effect of the multiple-layer tip graft. Dotted line-columellar strut. (B) Multiple-layer tip graft being sutured into position. (C) If the front layer of the multiple-layer tip graft is sutured to the caudal margin of the medial crura, the graft will be pulled back between the medial crura losing the effect of the multiple-layer graft. (D) Multiple-layer tip graft sutured into position (lateral view). A
B
FIGURE 22. (A) Note the good position and angulation of the tip graft before placement of a blending stitch. (B) After placement of the blending stitch (arrow), note how the tip graft has been rotated cephalicallyl.
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FIGURE 23. Batten graft (cross-hatched graft) placed behind the leading edge of the tip graft to help support the graft and keep it from rotating cephalically. This graft will also permit the leading edge of the tip graft to blend in with surrounding structures.
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FIGURE 24. III situ carving of the tip graft to be sure it blends in with surrounding structures. There should be no sharp edges on the tip graft.
FIGURE 25. Premaxillary plumping grafts can be placed through the columellar incision to Correct an acute nasolabial angle. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) OPEN STRUCTURE RHINOPLASTY
quired to ensure that the edges of the tip graft blend in with surrounding structures. The problem with this stitch is that its placement may pull the leading edge of the tip graft cephalically, increasing rotation (Fig 22). This problem with cephalic rotation of the tip graft after placement of the blending stitch is most pronounced in the non-Caucasian patient with cephalic angulation of the medial and intermediate crura of the lower lateral cartilages (Fig 17B). In non-Caucasian patients with thick skin, this stitch may be omitted to prevent excessive rotation . The thick skin hides the graft that may be projecting 1 to 3 mm above the old domes. If the graft can be seen or felt through the skin, a small piece of cartilage (batten graft) can be placed behind the leading edge of the graft to fill in any dead space and help the graft blend in with surrounding structures (Fig 23). This graft will also help to stabilize the leading edge of the graft to prevent it from rotating cephalically after closure of the columellar incision. The edges of the tip graft should be shaved ill situ to round off sharp edges and set the final level of tip projection (Fig 24). One stitch can be placed in the columellar incision to see how the tip graft will look and feel after closure. If there is excessive tension on the columellar incision, the tip graft must be deprojected to allow easy closure. If improved tip definition is desired in a nose with excessive fibrofatty tissue, careful subdermal excision of this fibrofatty tissue can be performed under direct visualization. Under no circumstances should dermis be violated or tissue be excised from the columellar flap. In patients with skin of thin to moderate thickness, subcutaneous tissue padding the graft should be left in place to help hide the edges of the tip graft. Small cartilage plumping grafts can be placed through the lower columellar incision into the premaxillary region to help blunt the nasolabial angle (Fig 25). These grafts should be placed into a precise pocket to prevent graft migration. The columellar incision should be closed with 6-0 nylon suture, taking great care to evert skin edges. If there is any tension on the incision, subcutaneous buried sutures of 6-0 PDS (Polydioxanone, Ethicon, Somerville, NJ) can be used to help eliminate any tension on the incision. Alar flare can be decreased by performing selective alar base excisions (Fig 26). Over-excision of the ala will result in loss of the curvature of the ala as it meets the face.
This is an unnatural look and should be avoided. Narrowing of the alar base can be accomplished by using a basal bunching suture." This suture is placed by making small stab incisions just within the alar bases about 3 to 4 mm from the alar rim . A 3-0 prolene suture on a large curved needle is inserted, advanced below the medial crura just above the nasal spine to exit a stab wound on the opposite alar base, and brought back and tied at its subcutaneous site of entry. If bilateral alar base reductions are performed, the basal bunching suture can be inserted through the incisions used for alar base reduction (Figs 27 and 28). This basal bunching suture not only narrows the alar base, but it also blunts the nasolabial angle, making it less acute. If this suture is tied too tight, it will result in deformity. If the stitch is unsatisfactory, it can be easily removed through a small stab incision in the office. Actual incisions in the sill or base of the nostril tend to leave scars, and therefore should only be performed in selected cases .
POSTOPERATIVE CARE The columellar sutures should be removed at 4 to 5 days, keeping this incision taped for at least 6 weeks to keep tension off of the scar. The cast is removed at 7 days, using adhesive remover to loosen the adhesive tape and prevent skin elevation away from the nasal structure as the cast is removed. Postoperatively, these patients should be seen every 3 to 4 weeks for the first 6 months to monitor healing. In many cases, Kenalog (triamcinolone acetonide, 10 mg/dL) will need to be injected sub-
'" FIGURE 26. Selective alar base excisions. (A) Decreases alar flare and narrows the alar base. (8) Primarily narrows alar base. (C) Primarily decreases alar flare. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) A
FIGURE 27. (A) Alar base excisions in combination with a basal bunching suture. This suture (3-0 prolene) acts to narrow the alar base and will also help correct an acute nasolabial angle. (8) Note the narrowing of the alar base.
FIGURE 28. (A) Wide alar base with flared ala. Surgical marking pen used to outline extent of alar base excisions. (8) Note the decreased alar flare and narrowing of the alar base after performing alar base excisions with a basal bunching suture. TORIUMI, SYKES, AND JOHNSON
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FIGURE 29. Non-Caucasian rhinoplasty. (A, C, E, G) Preoperative, (6, 0, F, H) postoperative.
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FIGURE 30. Non-Ca ucasian rhinoplasty. (A, C, E, G) Preoperative, (8, 0, F, H) postoperative. OPEN STRUCTURE RHINOPLASTY
dermally in the supratip region to decrease edema and prevent scar tissue formation. The initial injection can be given 1 week after the cast comes off and can be repeated every 4 to 6 weeks. A 3D-gauge needle is used to reduce patient discomfort. The Kenalog must be injected below the dermis using less than 0.2 mL per treatment to prevent skin atrophy. Close postoperative follow-up is critical to attaining a good result.
FINAL COMMENTS Non-Caucasian rhinoplasty is extremely challenging, requiring aggressive surgical management to attain aesthetic goals. Open structure rhinoplasty techniques pro vide a means of dramatically changing the contour of the non -Caucasian nose without significantly decreasing the stability of the overall nasal structure (Figs 29 to 31). Successful non-Caucasian rhinoplasty requires a good understanding of the limitations of this surgery and the preservation of the patient's ethnicity.
REFERENCES 1. Johnson CM, [r, Toriumi DM: Op en Structure Rhinoplasty. Philadelphia, PA, \V.B. Saunders Co, 1990 2. Bernstein L: Rhinoplasty for the Negroid nose. Otolaryngol Clin North Am 8:783-795, 1973 3. Stucker FJ ir: Non -Caucasian rhinoplasty and adjunctive reduction cheiloplasty. Otolaryngol Clin North Am 20:877-894, 1987 4. Kamer FM, Parkes ML: The conservative management of the Negro nose. Laryngoscope 85:551-558, 1975
FIGURE 31.
Non-Caucasian rhinoplasty. (A, C, E, G) Preoperative, (B, D, F, H) pas toperative. TORIUMI, SYKES . AND JOHNSON
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OPEN STRUCTURE RHINOPLASTY FOR MANAGEMENT OF THE NON-CAUCASIAN NOSE DEAN M. TORIUMI, MD, JONATHAN M. SYKES, MD, CALVIN M. JOHNSON, JR, MD
Aesthetic surgery of the non-Caucasian nose frequently requires aggres sive surgical manuevers to attain the desired changes in nasal contour. Unfortunately, thick, sebaceous skin of the non-Caucasian nose is at great risk for increased scar contracture, which could deform an already weak nas al structure. To prevent deformity, we use the open structure rhinoplasty technique to add support to the nasal structure in the form of columellar struts and sutured-in-place tip grafts. In this art icle, specific modifications of the open structure rhinoplasty technique are described for management of the non-Caucasian nose. KEY WORDS: Non-Caucasian rhinoplasty/open structure rhinoplasty/open rhinoplasty/external rhinoplasty/tip graft.
Rhinoplasty performed in the non-Caucasian nose presents perhaps the most difficult challenge to the rhinoplastic surgeon. Surgical maneuvers performed to achieve major alterations often require extensive remodeling of the underlying structure of the nose . These aggressive maneuvers may severely compromise already weak cartilaginous structures. A weakened nasal structure in combination with scar contracture of a thick, poorly conforming skin-soft tissue envelope (S-STE) may result in a disastrous result. Surgical management of the non-Caucasian nose requires strengthening weak cartilaginous structures, preservation of major support mechanisms, and careful manipulation of the S-STE. Open structure rhinoplasty incorporates the external (open) approach to the nose, conservative cartilage resection, and a sutured-in-place columellar strut and sutured-in-place shield-shaped tip graft. 1 One of the primary indications for open structure rhinoplasty is the non-Caucasian nose. Several special modifications of the technique must be instituted with the non-Caucasian nose to account for the anatomic differences between the Caucasian and non-Caucasian nose. A discussion of the charateristics of the nonCaucasian nose, special considerations in surgical management, and a description of the technique wiII be presented. The principles and techniques described can be applied to any nose with similar structural deformities. From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Department of Otolaryngology-Head and Neck Surgery , University of California, Davis, Sacramento, CA; Hedgewood Surgical Center, New Orleans, LA. Address reprint requests to Dean M. Toriumi, MD, Assistant Professor, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL 60612. © 1990 by W.B. Saunders Company. 1043·1810/9010104-0002$05.00/0
CHARACTERISTICS OF THE NON-CAUCASIAN NOSE When discussing the .non-Caucasian nose, we are referring primarily to the black nose, even though the Oriental nose has many similar characteristics. Careful preoperative analysi s of every nose is necessary to identify the deformities and determine the appropriate surgical management. Typically, the non-Caucasian nose is flat, broad, and short with an infantile dorsum lacking projection from the nasal tip to the nasofrontal angle (Fig 1). The nasal tip tends to be rounded and foorly defined, with less projection than the Caucasian. The decreased nasal pro jection is accentuated by the increased width of the nose as well as the protrusive lips. The acute nasolabial angle is one of the most consistent findings in the nonCaucasian nose (Fig 2).3 This angle is also exaggerated by the prominence of the protruding upper lip. Underdevelopment of the anterior nasal spine is considered one of the major anatomic findings that contributes to the acute nasolabial angle. 3 The columella is short, thick, hidden, and tends to diverge superiorly and inferiorly. The alae are thick, flaring, wide-based, and overhan.f the columella acting to hide it on lateral view (Fig 2). The skin of the ala is thick, fatty, and inelastic, with numerous sebaceous glands. The nostrils are round or horizontally ovoid (Fig 3). . The nose appears short because the nasal tip tends to be rounded and the starting point of the nose (deepest point of the nasofrontal angle) is frequently poorly defined. The starting point of the nose should be welldefined and located at or just below the level of the superior palpebral fold. 1 In many cases, the dorsum is low with a long sweeping slope up to the glabella without any definition of a distinct nasal starting point (Fig 4). In the non-Caucasian nose, the anterior septal angle is usually more obtuse and is set more cephalically than in the Caucasian nose." Furthermore, the quadrilateral sep-
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FIGURE 3. Non-Caucasian nose with ovoid, horizontally oriented nostrils.
tal cartilage is not only relatively smaller, but also thinner and shorter than in the Caucasian? The pyriform aperture is wide and the ratio of bone -to-cartilage of the nasal vault is smaller than in Caucasians. The nasal bones are oriented at a more obtuse angle along the dorsum just as the angle at the domes are also set at a more obtuse angle. Not all non-Caucasian noses will possess all of these characteristics. Actual analysis of such a population shows that there is a great deal of latitude in the expression of these nasal characteristics. Some patients show all of these characteristics, while some have a nose with many features of a Caucasian nose. The most difficult nose is the one that demonstrates the extreme of all of these characteristics, presenting many limiting factors to the surgeon.
FIGURE 1. Non-Caucasian nose that is flat, broad, and short with an infantil e nasal dorsum. (A) Frontal view, (B) lateral view, (C) oblique view, (D) basal view.
FIGURE 2. Non-Caucasian nose with an acute nasolabial angle and thick ala that overhang a retracted columella. (A) Frontal view, (B) lateral view, (C) oblique view, (D) basal view.
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LIMITING FACTORS IN NON'·CAUCASIAN RHINOPLASTY There are several characteristics of the non-Caucasian nose that limit the 'degree of aesthetic improvement that can be attained. First and foremost is the thick, inelastic nature of the S-STE. Despite radical changes in shape of the underlying nasal structure, if the S-STE does not drape over the structures, these changes will not be manifested as the expected change in nasal contour. After the nasal structure is augmented and the tip is projected, thick, nonelastic skin in combination with a short columella may preclude closure of the transcolumellar incision. Weak or thin lateral crura provide little support and any resection of cartilage will further compromise the stability of the lower third of the nose. Thin septal cartilage does not provide sufficient support for grafts and may require multiple-layered grafts to add strength. Furthermore, the limit in the amount of septal cartilage that can be harvested may require harvesting auricular cartilage. Features of the non-Caucasian patient that are difficult
FIGURE 4. Non-Caucasian nose with a long, sweeping, poorly projected dorsum that lacks a distinct nasal starting point. OPEN STRUCTURE RHINOPLASTY
to safely alter surgically include the size and thickness of the alae and protruding lips. The surgeon and patient must be realistic about what aspects of the nose can be safely altered. Finally, the ethnicity of the non-Caucasian nose must be preserved to prevent a severe aesthetic deformity.
OPEN STRUCTURE RHINOPLASTY AND THE NON-CAUCASIAN NOSE Once the deformities are identified, the surgeon must set realistic goals for surgical management. In most cases, reasonable goals for surgical management of the nonCaucasian nose will incude: increasing nasal projection; improving nasal tip definition; narrowing the nose; augmenting the nasal dorsum; decreasing alar flare; and narrowing the alar base. Obviously, each case is different, with some requiring more modification than others. Open structure rhinoplasty techniques use the external rhinoplasty approach to the nose, permitting maximal visualization and control. The external approach also permits precise resection of subdermal fibro-fatty tissue. Other key features of this technique include the suturedin-place columellar strut and sutured-in-place shieldshaped tip graft. The columellar strut is sutured between the medial crura and provides support to the lower third of the nose (Fig 5). The strut will preserve projection; however, it will not increase projection unless it is balanced on the nasal spine or premaxilla. The strut should' not be balanced on the nasal spine because it may shift to one side, tilting the tip of the nose (Fig 6). With the strut in position, the tip graft is sutured to the medial crural! columellar strut complex (Fig 7). The tip graft provides projection, support, and a bidomal tip configuration. The tip graft position and shape can be altered to increase or decrease rotation and add length to the nose. Once the structure of the lower third of the nose is constructed, the rest of the nose can be augmented or narrowed as needed.
TECHNIQUE For the non-Caucasian nose, standard open structure rhinoplasty techniques can be used with specific modifications to account for differences in the anatomy." Autologous septal cartilage is typically harvested via a Killian incision. If the caudal septum is deviated, then a hemitransfixion incision can be used to gain access to the caudal septum. The nose should be injected with lidocaine (1%) with 1:100,000 epinephrine.! The transcolumellar incision in the non-Caucasian nose should be placed just below the mid-columellar level (Fig 8). This is necessary because a mid-columellar incision may be moved up into the region of the infratip lobule if the nose is augmented and the skin of the nose is advanced cephalically. The transcolumellar incision is connected to bilateral marginal incisions and the flap is carefully elevated off of the medial and lateral crura using three-point-countertraction (Fig 9). Once exposed, the medial and lateral crura can be carefully examined to evaluate the shape and strength of the cartilages (Fig 10). At this point, a pocket is dissected between the medial crura, which should not extend down to the nasal spine. The caudal aspect of the pocket can be opened to provide TORIUMI, SYKES, AND JOHNSON
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FIGURE 5. Columellar strut located in a pocket between the medial crura. Note how the strut does not extend down to the nasal spine. (Mid-sagittal plane). (Reprinted with permission. © Calvin M. Johnson, Jr, MO, 1990.)
FIGURE 6. If the columellar strut is placed in a deep pocket near the premaxilla, it may shift to one side of the nasal spine acting to tilt the tip of the nose. (Reprinted with permission. © Calvin M. Johnson, Jr, MO, 1990.)
FIGURE 7. Sutured-in-place shield-shaped tip graft. Note how the leading edge of the tip graft is projected 1 to 2 mm above the old domes. The tip graft is sutured to the caudal margin of the medial crura. (Reprinted with permission. © Calvin M. Johnson, [r, MO, 1990.)
FIGURE 8. Inverted-V transcolumellar incision is placed just below the level of the mid-columella.
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better visualization; however, the cephalic aspect of the pocket should be left intact (Fig 11). A carefully sculpted cartilaginous strut is sutured between the medial crura (Fig 12). In some cases, the cartilage is very thin, providing minimal support. In this case, a double-layer cartilage graft can be used as a columellar strut. With the strut sutured into position, the surgeon should be able to detect a significant increase in support in the region of the medial crura. In many Caucasian noses, some degree of tip rotation is desirable, so cephalic trim of the lateral crura is performed in conjunction with resection of a triangular seg-
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FIGURE 9. Three-point-countertraction. A wide two-prong retractor is placed along the alar rim, a medium two-prong is placed on the vestibular side of the lateral crus, and a narrow two-prong is placed on the columellar flap.
FIGURE 10. Inspection of lower lateral cartilages.
FIGURE 11. Pocket for columellar strut is dissected between the medial crura.
FIGURE 12. Columellar strut is stabilized between the medial crura with a carefully positioned mattress suture.
FIGURE 13. Conservative cephalic trim is performed with resection of a cephalically based triangle of cartilage in the region of the domes. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.)
ment of the lateral crura with suturing of both cut ends to reconstitute the intact strip (Fig 13). However, in most non-Caucasian noses, the degree of rotation desired can be achieved solely by using the sutured-in-place tip graft. In fact, the major problem with using sutured-in-place tip grafts in non-Caucasian noses is that one can easily overrotate the tip. This is especially true in male patients. For these reasons, no cephalic trim is performed, except for in selected cases where significant degrees of rotation are desired. In preserving the cephalic margin of the lateral crura (recurvature or scroll), one of the major supportive mechanisms of the lower third of the nose is left intact. To correct the obtuse angulation of the domal angle, some type of manipulation of the domal region is usually necessary. If cartilage is resected from the domes, some degree of rotation will result. To avoid rotation, the lateral crura are divided at the domes (no cartilage is resected), then both cut ends of the cartilage are resutured to form a more acute domal angle (Fig 14). This simple maneuver does not weaken any of the major support mechanisms of the lower third of the nose. If necessary, conservative dorsal hump removal can be performed. In most cases, non-Caucasian noses require dorsal augmentation, and not hump removal. If a dorsal hump is present with a low dorsum, cartilage grafts can be placed above and below the hump to provide a straight dorsal line. In some cases, the skin is too tight to allow dorsal augmentation, tip grafting, and still be able to dose the columellar incision. In these cases, medial and lateral osteotomies must be performed to narrow the upper third of the nose. Dorsal augmentation in itself will give the illusion of narrowing the upper two thirds of the nose (Fig 15). If dorsal augmentation is to be performed with no medial and lateral osteotomies, a small pocket just large enough to accept the graft is dissected over the nasal dorsum. Then, a custom sculpted graft is placed in the carefully designed pocket. If the skin and periosteum have already been elevated to perform other bony work, the dorsal grafts can be sutured or glued into position (Fig 16). Careful sculpting of the grafts is critical in order to avoid irregularities of the dorsum. Tip graft shape and placement is extremely critical in the non-Caucasian patient because it is relatively easy to over-rotate the nasal tip. There are several factors that must be carefully evaluated when tip grafting the nonCaucasian patient. A major factor to consider is the angulation of the caudal surface of the medial or intermediate crura of the lower lateral cartilages. In the Caucasian patient, the medial and intermediate crura tend to
FIGURE 14. (A,B) The free cut ends of the lower lateral cartilages are reapproximated with a strategically placed 6-0 Prolene mattress suture. (C) Reconstitution of the intact strip changes a widely arched, obtuse domal angle to a more acute domal angle.
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OPEN STRUCTURE RHINOPLASTY
have less of a curvature than the non-Caucasian patient (Fig 17). If a tip graft is sutured to a surface that is angulated cephalically, the tip graft will also be angulated cephalically. Another major consideration involves the combination of weaker cartilage for the tip graft and thick, tight, nonelastic skin. When the columellar incision is closed, the thick skin exerts force on the weak tip graft, resulting in cephalic rotation of the leading edge of the tip graft (Fig 18). Excessive cephalic rotation of the tip graft may result in an over-rotated tip. Several maneuvers can be performed to prevent overrotation of the tip graft. The caudal margin of the medial crura can be trimmed toward the base to change the orientation of the tip graft (Fig 19). In many cases, the surgeon will also need to use multiple-layer tip grafts, with the leading edge much thicker than the base of the graft (Fig 19). Two and even three-layered cartilage tip grafts can be used to provide length to the nose and prevent over-rotation of the lower third of the nose (Fig 20). In our experience, multiple-layered grafts do well; however, we do not suggest layering any more than three pieces of cartilage. When suturing multiple-layer tip grafts into position, the sutures at the leading edge of the graft must be sutured to the back layer of the graft to get the full effect of the multiple-layer graft (Fig 21). In Caucasian patients with thin skin, a blending stitch is placed at both corners of the leading edge of the tip graft to the domal region. Placement of this stitch is re-
FIGURE 16. A finely sculpted two-layer cartilage graft is sutured into position over the dorsum of the nose.
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FIGURE 15. Dorsal augmentation will give the illusion of narrowing the upper two thirds of the nose. Note how nasal width "A" appears narrower after the dorsum is augmented. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) FIGURE 17. (A) Favorable angulation and curvature of the caudal margin of the medial crura of a Caucasian patient to accept a tip graft. (B) Cephalically angulated surface of the caudal margin of the medial crura of a non-Caucasian patient provides a base for the tip graft that will create an over-rotated appearance unless some modification of the caudal margin of the medial crura is performed. FIGURE 18. (A) Note the good position of the tip graft before the columellar incision is closed. (B) After the columellar incision is closed, the thick, nonelastic skin exerts force on the weak tip graft resulting in cephalic rotation of the leading edge of the tip graft. FIGURE 19. (A) Positioning of the cartilage tip graft resulting in over rotation of the tip. The dotted line represents the location of the columellar strut. To correct this problem, the infero-caudal margin of the medial crura can be trimmed (cross-hatched lines) to set a more favorable plane for the tip graft. (B) A longer double-layer tip graft is used to decrease the degree of tip rotation provided by the tip graft. The double-layer graft is stronger so there is less of a tendency for the graft to bend cephalically after the columellar incision is closed. The dotted line shows the location of the columellar strut. TORIUMI, SYKES, AND JOHNSON
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FIG 18
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FIG 19
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FIGURE 20. Multiple-layer tip graft sutured into position to prevent over rotation or add length to the dorsal line of the nose. (A) Lateral view, (B) view from above. A
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FIGURE 21. (A) Note how the back layer of the tip graft is sutured to the caudal margin of the medial crura to get the full effect of the multiple-layer tip graft. Dotted line-columellar strut. (B) Multiple-layer tip graft being sutured into position. (C) If the front layer of the multiple-layer tip graft is sutured to the caudal margin of the medial crura, the graft will be pulled back between the medial crura losing the effect of the multiple-layer graft. (D) Multiple-layer tip graft sutured into position (lateral view). A
B
FIGURE 22. (A) Note the good position and angulation of the tip graft before placement of a blending stitch. (B) After placement of the blending stitch (arrow), note how the tip graft has been rotated cephalicallyl.
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FIGURE 23. Batten graft (cross-hatched graft) placed behind the leading edge of the tip graft to help support the graft and keep it from rotating cephalically. This graft will also permit the leading edge of the tip graft to blend in with surrounding structures.
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FIGURE 24. III situ carving of the tip graft to be sure it blends in with surrounding structures. There should be no sharp edges on the tip graft.
FIGURE 25. Premaxillary plumping grafts can be placed through the columellar incision to Correct an acute nasolabial angle. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) OPEN STRUCTURE RHINOPLASTY
quired to ensure that the edges of the tip graft blend in with surrounding structures. The problem with this stitch is that its placement may pull the leading edge of the tip graft cephalically, increasing rotation (Fig 22). This problem with cephalic rotation of the tip graft after placement of the blending stitch is most pronounced in the non-Caucasian patient with cephalic angulation of the medial and intermediate crura of the lower lateral cartilages (Fig 17B). In non-Caucasian patients with thick skin, this stitch may be omitted to prevent excessive rotation . The thick skin hides the graft that may be projecting 1 to 3 mm above the old domes. If the graft can be seen or felt through the skin, a small piece of cartilage (batten graft) can be placed behind the leading edge of the graft to fill in any dead space and help the graft blend in with surrounding structures (Fig 23). This graft will also help to stabilize the leading edge of the graft to prevent it from rotating cephalically after closure of the columellar incision. The edges of the tip graft should be shaved ill situ to round off sharp edges and set the final level of tip projection (Fig 24). One stitch can be placed in the columellar incision to see how the tip graft will look and feel after closure. If there is excessive tension on the columellar incision, the tip graft must be deprojected to allow easy closure. If improved tip definition is desired in a nose with excessive fibrofatty tissue, careful subdermal excision of this fibrofatty tissue can be performed under direct visualization. Under no circumstances should dermis be violated or tissue be excised from the columellar flap. In patients with skin of thin to moderate thickness, subcutaneous tissue padding the graft should be left in place to help hide the edges of the tip graft. Small cartilage plumping grafts can be placed through the lower columellar incision into the premaxillary region to help blunt the nasolabial angle (Fig 25). These grafts should be placed into a precise pocket to prevent graft migration. The columellar incision should be closed with 6-0 nylon suture, taking great care to evert skin edges. If there is any tension on the incision, subcutaneous buried sutures of 6-0 PDS (Polydioxanone, Ethicon, Somerville, NJ) can be used to help eliminate any tension on the incision. Alar flare can be decreased by performing selective alar base excisions (Fig 26). Over-excision of the ala will result in loss of the curvature of the ala as it meets the face.
This is an unnatural look and should be avoided. Narrowing of the alar base can be accomplished by using a basal bunching suture." This suture is placed by making small stab incisions just within the alar bases about 3 to 4 mm from the alar rim . A 3-0 prolene suture on a large curved needle is inserted, advanced below the medial crura just above the nasal spine to exit a stab wound on the opposite alar base, and brought back and tied at its subcutaneous site of entry. If bilateral alar base reductions are performed, the basal bunching suture can be inserted through the incisions used for alar base reduction (Figs 27 and 28). This basal bunching suture not only narrows the alar base, but it also blunts the nasolabial angle, making it less acute. If this suture is tied too tight, it will result in deformity. If the stitch is unsatisfactory, it can be easily removed through a small stab incision in the office. Actual incisions in the sill or base of the nostril tend to leave scars, and therefore should only be performed in selected cases .
POSTOPERATIVE CARE The columellar sutures should be removed at 4 to 5 days, keeping this incision taped for at least 6 weeks to keep tension off of the scar. The cast is removed at 7 days, using adhesive remover to loosen the adhesive tape and prevent skin elevation away from the nasal structure as the cast is removed. Postoperatively, these patients should be seen every 3 to 4 weeks for the first 6 months to monitor healing. In many cases, Kenalog (triamcinolone acetonide, 10 mg/dL) will need to be injected sub-
'" FIGURE 26. Selective alar base excisions. (A) Decreases alar flare and narrows the alar base. (8) Primarily narrows alar base. (C) Primarily decreases alar flare. (Reprinted with permission. © Calvin M. Johnson, Jr, MD, 1990.) A
FIGURE 27. (A) Alar base excisions in combination with a basal bunching suture. This suture (3-0 prolene) acts to narrow the alar base and will also help correct an acute nasolabial angle. (8) Note the narrowing of the alar base.
FIGURE 28. (A) Wide alar base with flared ala. Surgical marking pen used to outline extent of alar base excisions. (8) Note the decreased alar flare and narrowing of the alar base after performing alar base excisions with a basal bunching suture. TORIUMI, SYKES, AND JOHNSON
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FIGURE 29. Non-Caucasian rhinoplasty. (A, C, E, G) Preoperative, (6, 0, F, H) postoperative.
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FIGURE 30. Non-Ca ucasian rhinoplasty. (A, C, E, G) Preoperative, (8, 0, F, H) postoperative. OPEN STRUCTURE RHINOPLASTY
dermally in the supratip region to decrease edema and prevent scar tissue formation. The initial injection can be given 1 week after the cast comes off and can be repeated every 4 to 6 weeks. A 3D-gauge needle is used to reduce patient discomfort. The Kenalog must be injected below the dermis using less than 0.2 mL per treatment to prevent skin atrophy. Close postoperative follow-up is critical to attaining a good result.
FINAL COMMENTS Non-Caucasian rhinoplasty is extremely challenging, requiring aggressive surgical management to attain aesthetic goals. Open structure rhinoplasty techniques pro vide a means of dramatically changing the contour of the non -Caucasian nose without significantly decreasing the stability of the overall nasal structure (Figs 29 to 31). Successful non-Caucasian rhinoplasty requires a good understanding of the limitations of this surgery and the preservation of the patient's ethnicity.
REFERENCES 1. Johnson CM, [r, Toriumi DM: Op en Structure Rhinoplasty. Philadelphia, PA, \V.B. Saunders Co, 1990 2. Bernstein L: Rhinoplasty for the Negroid nose. Otolaryngol Clin North Am 8:783-795, 1973 3. Stucker FJ ir: Non -Caucasian rhinoplasty and adjunctive reduction cheiloplasty. Otolaryngol Clin North Am 20:877-894, 1987 4. Kamer FM, Parkes ML: The conservative management of the Negro nose. Laryngoscope 85:551-558, 1975
FIGURE 31.
Non-Caucasian rhinoplasty. (A, C, E, G) Preoperative, (B, D, F, H) pas toperative. TORIUMI, SYKES . AND JOHNSON
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