Multiracial Rhinoplasty 

Updated: Oct 26, 2018
Author: Manoj T Abraham, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Distinctive anatomic differences exist between the nonwhite nose (platyrrhine, mesorrhine) and the white nose (leptorrhine). Surgeons who perform rhinoplasty in multiracial patients must recognize these differences and must implement specific surgical strategies to achieve the desired aesthetic and functional outcome.

An image depicting rhinoplasty on a nonwhite nose can be seen below.

Preoperative (left) and postoperative (right) view Preoperative (left) and postoperative (right) views of the African American multiracial nose. Rhinoplasty was performed as described in this article.

History of the Procedure

The concept of rhinoplasty in nonwhite has evolved over time.[1] In 1913, Schultz characterized the typical black nose as broad and flattened, frequently lacking dorsal projection.[2] The tip was described as flat and round, with flared alae and an obtuse alar dome angle. A number of authors, including Matory and Falces, have commented on the predilection for nonwhites to have thick nasal skin with a large amount of subcutaneous tissue.[3]

Despite such stereotypic features, authors have more recently pointed out the difficulty in categorizing individual patients. In 1976, Stucker noted that few African American patients possessed all the aforementioned racial characteristics.[4] Ofodile and James performed an anatomic study on 24 alar cartilages in 12 African American male cadavers and documented considerable variability in morphology.[5] They were able to divide subjects into 3 distinct groups and hypothesized that the considerable miscegenation among African Americans, whites, and Native Americans in the United States could account for differences among these groups. Baker and Krause analyzed 8 external nasal surface measurements in 196 nonwhite patients and could divide their study population into 5 statistically significant groups.[6] Interestingly, the so-called typical black nose did not typify the most common nasal configuration in African Americans.

Similarly, Aung et al used a laser surface scanner to perform anthropometric measurements in 90 subjects of Asian descent.[6] The authors concluded that the Asian nose is generally broader in relation to height and has less tip projection, but they also noted 3 different subtypes. In a study of 206 Chinese adults, of Han ancestry, compared with 103 North American whites, Wang et al pointed out that the Chinese nose fit the dimensions of the nasofacial canon (the nose width is one fifth of the face width) significantly more frequently (51.5%) than did the white nose (36.9%).[7, 8]

The conceptualization of the ideal nonwhite nose has changed dramatically in the literature. In the past, many authors assumed that multiracial patients sought rhinoplasty to gain a more white appearance. Martin reported that both black and white men in the United States ranked black women with white facial features as more beautiful, while men in Nigeria preferred women with black features.[9] Falces et al connected this perceived desire to appear more white to economic considerations.[10] Patients may feel it necessary to fit the white ideal of beauty to succeed in Western society. Given the limitations of rhinoplasty in this context, Snyder suggested the need for increased preoperative consultations for the achievement of realistic goals and the occasional need for psychiatric evaluation.[11]

In 1972, Pitanguy voiced the currently accepted perception that the nose must be in harmony with the rest of the face and the race of the individual.[12] Stucker stressed the importance of eliciting patients' desires and expectations, and he warned against imposing the aesthetic ideals of the surgeon on patients. This view was supported by Baker and Krause's survey of 196 nonwhite employees and outpatients at the University of Michigan.[6] This study revealed that the vast majority of African Americans considering rhinoplasty do not desire white-type noses. In view of the increased diversity of patients requesting rhinoplasty, Yellin commented that white normative standards of facial analysis are no longer sufficient in the new millennium, and he called for additional studies to define aesthetic ideals within the various racial groups.[1, 13, 14, 15, 16]

Problem

In general, multiracial patients requesting aesthetic rhinoplasty desire improvement and refinement of their noses with preservation of defining ethnic characteristics. However, certain anatomic features often found in the noses of multiracial individuals make rhinoplasty more challenging.

Epidemiology

Frequency

Facial plastic surgery has gained widespread acceptance and is growing in popularity because of the continued introduction of new and improved techniques and technology and to the continued exposure and advertisement of the media and entertainment industry. In the United States, the demand for cosmetic facial plastic surgery is increasing in all segments of society. With the influx of multiracial immigrant populations and the growth of minority communities, the number of multiracial patients requesting facial plastic surgery is rising steadily, especially in large urban centers. Internationally, on the basis of location, a surgeon's practice could potentially encompass only nonwhite patients.

Etiology

The racial and ethnic features of each patient's nose are determined by the underlying bony and cartilaginous framework and by the covering skin and soft tissue envelope. These characteristics are determined at a genetic level but may be influenced to a certain extent by environmental factors, such as nutrition, aging, trauma, and surgery.

Pathophysiology

As expected, underlying anatomy dictates appearance and function of the multiracial nose. The platyrrhine nose often lacks bony and cartilaginous support, resulting in a wide flat dorsum and a poorly projected tip. Frequently, the alar base is wide, and the nostrils are flared. Differences in nasal anatomy are most likely responsible for the differences in nasal valve physiology observed by a number of authors.

In a recent study, Canbay and Bhatia used rhinomanometry to measure total nasal resistance following nasal decongestion in 42 white and 32 African American healthy adults.[17] The study demonstrated a statistically significant decrease in the mean total airway resistance in African Americans in comparison to whites (0.136 Pa/cm³/s to 0.179 Pa/cm³/s, respectively, by the anterior method and 0.134 Pa/cm³/s to 0.161 Pa/cm³/s, respectively, by the posterior method).

In a similar study, Burres used acoustic rhinometry to study nasal valve physiology in 28 Asian subjects.[18] The author found a statistically significant decrease in nostril asymmetry in the Asian group compared with a white control group (39% vs 59%). Burres also found the mesorrhine nose to be less likely to respond to the use of a Breathe Right strip dilator.

Presentation

The clinical presentation of multiracial patients requesting rhinoplasty is just as varied as the presentation of white patients and is influenced by the etiology of the perceived problem. Younger patients are more often interested in altering genetically inherited nasal traits. Older patients may desire a reversal of the effects of aging on nasal appearance. Patients who have had nasal trauma or have previously undergone unsatisfactory nasal surgery are seen in the context of the injury. Men and women are equally likely to have rhinoplasty; however, the rationale for undergoing surgery is often different because men are more likely to have had nasal trauma.

Indications

As in all patients, no absolute indications exist for rhinoplasty in multiracial individuals. Patients desire rhinoplasty for both functional and aesthetic reasons. Anatomic nasal obstruction is by far the most common functional nasal complaint amenable to correction with routine rhinoplasty techniques.

Other functional complaints (eg, rhinorrhea, crusting, epistaxis, pain, anosmia) may reflect other rhinologic disease, the diagnosis and treatment of which are beyond the scope of this chapter. Aesthetic motivation can be objective (eg, obvious asymmetry of the nose) or subjective (eg, the nose is not in balance with the face). Regardless of the rationale for seeking rhinoplasty, patients must have realistic expectations of the outcome of the procedure.

Relevant Anatomy

Each patient's nose is unique and may not possess all the characteristics typical of the platyrrhine nose, although certain features specific to these noses make rhinoplasty more challenging (see the image below). Bone and cartilage support is often lacking, resulting in a wide dorsum with poor anterior projection (nasofacial angle < 30°). The piriform aperture is wide. This lack of skeletal support, in addition to thick skin and a prominent subcutaneous fibrofatty pad, contributes to a poorly projected tip that is amorphous and lacks definition. The nasal alae tend to be wider than the intercanthal distance and flared, with more horizontally oriented nostrils. The premaxillary area is hypoplastic.

Lateral view (a) - Characteristics of the platyrrh Lateral view (a) - Characteristics of the platyrrhine multiracial nose (on the left) compared with the Caucasian nose (on the right) include reduced bony and cartilaginous dorsal support and lack of tip projection and definition. Base view (b) - The platyrrhine multiracial nose often has wide flared nasal alae, poor tip support, and a thick, subcutaneous, fibrofatty pad, resulting in blunted tip definition. The ideal equilateral triangle appearance of the nose on base view is not achieved.

 

Contraindications

No contraindications are specific to rhinoplasty in multiracial individuals.

 

Workup

Laboratory Studies

Perform routine preoperative laboratory studies as indicated.

Imaging Studies

As with all facial plastic surgery, preoperative and postoperative photographic documentation is essential.

Computer modeling of projected outcome may help ground patient expectation.

A well-performed history and physical examination obviates the need for radiologic imaging studies (eg, CT, MRI) in patients who do not have other concomitant rhinologic disease (eg, sinusitis).

Diagnostic Procedures

The following procedures may be useful in selected patients with nasal obstruction:

  • Rhinomanometry provides objective measurement of nasal airway resistance.

  • Acoustic rhinomanometry allows accurate determination of the cross-sectional area of the nasal cavity.

 

Treatment

Medical Therapy

Besides altering concepts of self-image and camouflaging nasal appearance with makeup, no nonsurgical means of obtaining a desired change in nasal appearance exist.

Surgical Therapy

For patients with reasonable expectations who are interested in tangibly altering the appearance of the nose, current rhinoplasty techniques provide an excellent means of achieving predictable aesthetic and functional results.

Preoperative Details

A comprehensive preoperative evaluation is imperative. Obtain a detailed history documenting the patient's perception of the problem, fully explore both functional and aesthetic concerns, and elicit any history of previous nasal trauma or surgery. A history of smoking, nasal substance abuse, and relevant systemic problems should be taken into consideration. Appropriately discontinue all anticoagulant medication before surgery.

Perform a thorough physical examination, with special attention to multiracial features that may affect the operative plan. Evaluate skin texture and quality and the nature of the subcutaneous fibrofatty pad by visual inspection and palpation. Determine bony and cartilaginous dorsal nasal support. Note size, strength, and pliability of the upper and lower lateral cartilages, and test patency of the nasal valves with the modified Cottle maneuver. Study tip projection, rotation, and definition. Note the width of the alae and any deficiency in the premaxillary area.

Anterior rhinoscopy and flexible nasal endoscopy are important for uncovering intranasal causes of nasal obstruction and sinonasal pathology. Evidence of other rhinologic disease may require attention prior to rhinoplasty. Meticulous photographic documentation helps in operative planning and is necessary for follow-up, medicolegal, and learning purposes. Occasionally, other facial plastic procedures (eg, mentoplasty, maxillary augmentation, cheiloplasty) in conjunction with rhinoplasty must be considered to achieve the optimal desired result.

The surgeon must have a complete understanding of the patient's concerns and expectations of rhinoplasty surgery. In light of the patient's request, discuss the goal of maintaining facial features congruent with the patient's ethnic identity, while improving nasal contour. Carefully review limitations imposed by the anatomic features of multiracial individuals and the slightly increased risk of complications. Computer modeling of projected outcome can help to ground patients' expectations, although the final result may not exactly duplicate the projection. Many patients do not have direct contact with others who have had the procedure and may base hopes and desires on inaccurate sources. Having patients meet with satisfied multiracial role models who have already undergone the procedure is often helpful. Dissuade patients who have unrealistic expectations of rhinoplasty from having the procedure, and encourage them to seek additional counseling.

Intraoperative Details

The authors practice the following technique for multiracial rhinoplasty. The procedure can be performed under local anesthesia with monitored sedation or under general anesthesia, depending on patient and surgeon preference. General anesthesia may be preferable, given the challenging nature of these cases. Achieve topical vasoconstriction of the nasal mucosa by placing a sponge (eg, Merocel) impregnated with 3-5 mL of 0.5% phenylephrine hydrochloride (Neo-Synephrine) in each nostril. Then, appropriately inject the nose with 0.5% lidocaine hydrochloride with 1:200,000 epinephrine bitartrate, taking care to avoid distortion of nasal anatomy.

Perform a septoplasty in standard fashion, using a transfixation incision. Harvest cartilage, conscientiously preserving adequate anterior and dorsal struts. Correct cartilaginous and bony spurs and deviations. Then, close the transfixation incisions using interrupted 4.0 chromic sutures. Reapproximate the septal mucoperichondrial flaps using a 3.0 chromic mattress suture. Exercise caution to ensure adequate drainage holes to minimize the chance of postoperative septal hematoma. Save harvested cartilage for use as graft material. If adequate septal cartilage is not present, as often is the case in multiracial rhinoplasty, cartilage can be harvested from other sites (ear, rib), or Medpor (porous high-density polyethylene [PHDPE]) may be an acceptable alloplastic alternative (see Future and Controversies).

The external decortication approach is highly recommended to achieve the exposure necessary for accurate placement of augmentation grafts and for adequate nasal contouring (see the image below). Make a gull-wing incision along the narrowest part of the columella or along a prominent columella-labial groove. Next, extend the incision laterally, in a marginal fashion, along the caudal edge of the medial crura, dome, and lower lateral cartilage.

Postoperative augmented platyrrhine multiracial no Postoperative augmented platyrrhine multiracial nose, achieved by using techniques described in this article. Lateral view (a) - Dorsal augmentation with tiered cartilage and fibrofatty graft, columella strut, tiered shield tip graft, dome binding stitch, and premaxillary augmentation graft. Base view (b) - Secured columella strut, shield tip graft, premaxillary augmentation graft, and alar base reduction.

Use blunt-tipped scissors to perform a superficial dissection of the nasal skin, taking care to avoid injuring the subdermal plexus. Begin dissection of the underlying thick subcutaneous tissue and fibrofatty pad at the middle columellar region. Elevate the soft tissue pad from the nasal tip cartilages and middle aspect of the dorsum, where it fades into surrounding connective tissue. Save the excised fibrofatty pad for later use with the dorsal augmentation graft. Separate the medial crura down to the anterior nasal spine and premaxilla using sharp-angled scissors. Construct a small precise pocket near the premaxilla to snugly accommodate a carved cartilaginous augmentation graft. If septal or autologous cartilage is unavailable, multiple, tiny, carved-particle Medpor implants may substitute as plumper grafts.

Next, fashion a straight thin strut from septal cartilage or from a 0.85-mm thick sheet of Medpor if autologous cartilage is unavailable. Position this columellar strut between the medial crural cartilages and stabilize with interrupted 4.0 nylon sutures, in a through-and-through manner. Place the stitches sequentially, starting at the nasolabial angle and progressing to the nasal tip, incorporating some lateral crural steal for additional tip projection.

Additional tip support and medialization of the dome and lower lateral cartilages can be achieved with a dome-binding stitch. Given the typically deficient alar cartilages, cephalic trim of the lower lateral cartilages is generally not necessary for tip definition. Placement of a tiered, carved, nasal-tip shield graft, secured in appropriate position with 6.0 nylon sutures, enhances nasal tip projection and rotation. Craft a tired dorsal augmentation graft from septal cartilage, incorporating the harvested fibrofatty pad as the most superficial layer to provide a natural dorsal nasal contour. Insert the graft into a tightly fitted nasal dorsal skin pocket. Alternatively, if autologous cartilage is unavailable, an appropriately carved Medpor nasal dorsal tip implant can be used.

Redrape the nasal skin over the newly contoured dorsum and nasal tip. Reapproximate the transverse columella incision with an interrupted 5.0 Vicryl deep layer, followed by interrupted 6.0 nylon sutures for skin closure. Close the marginal incisions with 5.0 chromic sutures. If necessary, resection of the anterior aspect of the inferior turbinate with turbinate out-fracture is useful in widening the nasal cavity and in increasing the size of the internal nasal valve.

Rohrich[19] categorized alar bases into 3 possible aesthetic configurations: (1) excess flaring of the alar rims, (2) increased interalar distance, or (3) a combination of the two. Care must be taken to diagnose the facial disharmony that is present and perform the appropriate intervention. In patients with wide nasal alae, narrow the alae using a pointed caliper to perform carefully measured curved excisions at the nasal base, just above the alar-facial junction, as described by McKinney et al.[20] Precision is key, and the alar curve must be preserved. Excision of vestibular skin reduces nostril size, while excision of skin along the cutaneous alar margin reduces nasal base width and flare.

When vestibular skin is resected, Sheen recommends preserving a medial skin flap to decrease the likelihood of nasal sill notching. Sheen warns against performing alar base reduction when the nostrils are wide but not flared because this causes an acute angulation of the ala to the nasal base and may lead to a pinched appearance of the nose. Accomplish lateral osteotomies through the nasal base incisions to further define the nasal dorsum. Then, exactingly reapproximate the alae using 5.0 polyglactin (Vicryl) deep sutures and interrupted 6.0 nylon sutures for the skin. Begin the skin closure at the most superior lateral edge of the incision to hide any irregularities of closure within the medial intranasal portion of the incision. If additional narrowing of the nasal base is required, vertical diamond-shaped skin ellipses can be excised inside the nasal sills. Close these incisions with interrupted 6.0 nylon sutures.

Postoperative Details

The authors find that placement of intranasal Silastic (silicone rubber sheets) septal splints helps promote healing if extensive lacerations of the mucoperichondrial septal flaps exist. Repair any opposing mucosal tears with 4.0 chromic sutures to minimize the chance of septal perforation. Reapproximate the septal flaps per routine with a 3.0 chromic mattress suture. Then, cut silastic sheets to the appropriate size. Slide these into place on either side of the septum and use 3.0 nylon to anchor anteriorly with a through-and-through stitch.

Use of a nonadherent intranasal dressing (eg, Telfa, Merocel sponge wrapped in Telfa) helps to decrease postoperative oozing. Lubricate the dressing in antibacterial ointment (eg, Bacitracin), position in the anterior aspect of the nasal cavity bilaterally, and secure loosely to each other with a stitch to prevent any chance of aspiration. Tape the nose externally to reduce postoperative edema and apply a cast (eg, Aquaplast). Use of cold compresses or soft ice packs postoperatively can help minimize bruising and swelling.

Follow-up

Remove the nasal packing 1-2 days postoperatively and encourage the patient to use saline irrigation. Remove the nasal cast, Silastic splints, and stitches 1 week after surgery. See the patient 2 weeks postoperatively to débride intranasal crusting and then at 1, 3, 6, and 12 months for postoperative photographic documentation. Occasionally, precise injection of steroid into the supratip may enhance tip definition. Final healing with resolution of edema and shrink wrapping of the skin and soft tissue envelope may not occur for as long as 1 year after the procedure.

Complications

As with any surgery, patients must be aware of the chance of complications following rhinoplasty. Potential short-term and long-term complications following any rhinoplasty include edema; bleeding; infection; septal hematoma and perforation; septal deviation or nasal valve collapse with nasal obstruction; poor skin draping or necrosis; underlying bony or cartilaginous irregularities; graft migration, extrusion, and resorption; altered sensation; and the need for revision surgery. However, these risks can be minimized in experienced hands, even in difficult cases of rhinoplasty in multiracial patients.

Multiracial patients are more prone to scarring and keloid formation. Risk of patient dissatisfaction is increased because of the inherent limitations imposed by the nasal anatomy in multiracial persons and by often-unachievable patient expectations.

In a study of 75 patients who underwent rhinoplasty with techniques described in this article, Romo and Shapiro noted no major complications and only occasional minor complications.[21] Four patients had notching of the transverse columella incision, 3 had observable suture marks along the alar closure, and 1 patient had an alar incision granuloma. Incorporation of a 2-layer tension-free closure (eg, 5.0 Vicryl deep layer, 6.0 nylon for skin approximation) eliminated all such minor complications. The authors report that critical evaluation of the nasal reconstruction revealed a moderate diminution of tip projection over time in 8 patients. All patients underwent reconstruction with autogenous cartilage grafts, and no significant absorption or extrusion of the grafts was noted.

Falces et al described problems with skin redraping and prolonged nasal tip edema in multiracial patients.[10] In a follow-up study, Matory and Falces reported implant displacement, infection, fracture, and extrusion in 4 of 134 rhinoplasties.[3] The authors believed that prolonged edema, scars, racial incongruity, or asymmetry were potential problems associated with rhinoplasty in multiracial patients.

Outcome and Prognosis

Using techniques described herein, the vast majority of multiracial patients undergoing rhinoplasty are happy with surgery outcome. Romo and Shapiro reported 100% satisfaction with cosmesis in 75 multiracial patients 2-7 years after they underwent rhinoplasty with autogenous cartilage grafts and techniques described in this chapter (see the images below).[21] In a follow-up study of 187 patients who received Medpor implants, 35.3% of whom were multiracial, only 1 patient requested revision of a dorsal implant. This favorable result is largely predicated on ensuring that patients understand the goals and limitations of ethnic rhinoplasty and have realistic expectations of surgery.

Preoperative (left) and postoperative (right) view Preoperative (left) and postoperative (right) views of the African American multiracial nose. Rhinoplasty was performed as described in this article.
Preoperative (left) and postoperative (right) view Preoperative (left) and postoperative (right) views of the Asian mesorrhine nose. Rhinoplasty was performed as described in this article.

Future and Controversies

Open approach

The art and science of rhinoplasty is continually evolving. In recent years, a shift toward open-rhinoplasty techniques has occurred, especially in challenging cases such as multiracial rhinoplasty. The authors believe that the open decortication approach offers the best visualization, allowing for accurate graft placement when needed. Achievement of adequate aesthetic reconstruction may be more limited with classic intranasal techniques, which were used more extensively in the past.

Osteotomies

The need for osteotomies during multiracial rhinoplasty has been debated in the literature. Hubbard, Stucker, Larrabee, Nishioka, and others contend that the illusion of a wide nasal dorsum is created by lack of dorsal height in multiracial persons. These authors advocate placement of a dorsal augmentation graft without nasal osteotomies. Matory and Falces suggested that osteotomies actually might overnarrow the dorsum with respect to the lobule, creating a racially incongruous appearance.[3] However, the authors agree with Rohrich, who recommends osteotomy if the nasal bony width is more than 80% of the intercanthic distance. Narrowing of the upper third of the nose must be performed in proportion with alar base reduction and with increased tip projection and sculpting to ensure a balanced appearance to the nose.

Autografts versus alloplasts

The quest continues for the ideal autologous or alloplastic implant material when adequate nasal septal cartilage is not available. This topic is particularly relevant to multiracial rhinoplasty because septal cartilage is often deficient in these individuals. Other autologous and homologous graft materials have been considered. Auricular cartilage may be harvested, but use is often restricted because of the innate curvature of the cartilage. Monasterio and Michelena described the use of rib cartilage for correction of the nonwhite nose, but warping of the graft is a problem. Use of split calvaria, iliac, olecranon, and other bony graft material has also been proposed. Almost all homologous graft materials (eg, irradiated cartilage) and many autologous grafts are prone to resorption or fracture. All autologous graft materials, excluding nasal septal cartilage, are saddled with the inherent and potentially significant morbidity of a second operative donor site and additional operative time.

On the other hand, autologous grafts are less likely to become infected or extrude. Toriumi points out that, unlike alloplastic material, autologous grafts are unlikely to permanently harm the overlying soft tissue envelope of the nose.[22]

Because of availability and carving ease, many synthetic materials have been introduced for use in nasal reconstruction. These materials include silicone rubber (Silastic), polyamide mesh (Supramid), polytetrafluoroethylene carbon (Proplast, Teflon), polypropylene mesh (Prolene), polyethylene terephthalate (Mersilene mesh), and expanded polytetrafluoroethylene (e-PTFE, Gore-Tex). However, high rates of infection, extrusion, and resorption, along with excessive fibrosis and contracture due to chronic foreign body response, have left most surgeons dissatisfied with alloplasts.

Most of these implant materials are not rigid enough to provide structural support and have been used primarily for augmentation purposes. L-shaped silicone struts provide some structural support and have been used in multiracial rhinoplasty because the thick overlying skin better protects the implant. Deva et al reviewed their experience with silicone nasal implants in 422 patients, the majority (98%) of whom were women from Southeast Asia.[23] The study highlighted a 9.7% complication rate due to hemorrhage, displacement, extrusion, overprominence, supratip deformity, or excessive pressure, requiring removal of the graft. The study reported a 15.8% patient dissatisfaction rate.

In the authors' opinion, Medpor alloplastic implants offer the greatest promise. Medpor implants are rigid and allow fibrovascular ingrowth, thus promoting stability and resistance to infection. In 1998, Romo et al published a retrospective review of 187 patients who had undergone nasal reconstruction with Medpor implants (66 patients for multiracial rhinoplasty, 121 patients for revision surgery).[24] Postoperative follow-up ranged from 6 months to 3.5 years, with an average of 26 months. Complications were limited to 5 patients (2.6%), all of whom had impaired healing secondary to heavy smoking, cocaine abuse, collagen vascular disease, or multiple previous surgeries. Of these, 3 patients had early infection and 2 patients had delayed infection necessitating implant removal. Implants were removed easily, without damage to the overlying soft tissue and skin envelope. Additional favorable long-term results have been published.