The ethnic rhinoplasty

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CHAPTER 43 The ethnic rhinoplasty

Ashkan Ghavami, Rod J. Rohrich

History

Rhinoplasty, since its origins has been intimately tied to specific ethnicities. For example, John Roe ¹ used endonasal approaches to perform cosmetic rhinoplasty on the “pug nose” (referring to Irish patients who had excessive nostril show and a high nasolabial angle), while Jacques Joseph, modified tips and dorsal humps in Germany in the early 1900s.² More recently, there have been numerous articles, documentaries, and media exposure over the popularity of rhinoplasty in Tehran, Iran, which is referred to by popular media as “the capital of nose jobs”.

In the United States, “standards of beauty” propagated by the mass media, are mostly based on Northern European facial traits with well-defined aesthetic goals (straight, narrow bridge, narrow and sharply defined nasal tip, a nasolabial angle of 90 to 95 degrees in men and 95–105 degrees in women). However, refining the nose of ethnic patients does not adhere to these European-based characteristics, which can lead to “racial incongruity”.³

“Racial incongruity” refers to an imbalance between the physical traits of individual and their ethnic background.³ A marked disproportion between nasal and facial morphology can be very conspicuous and awkward. For example, a sharp supra-tip break and an overly narrowed alar base in an African-American patient with Fitzpatrick 6 skin type, large jaws, and thick sebaceous skin, appears unnatural and over-operated. Many of the principles of avoiding an “over-operated” looking nose, are inherent to rhinoplasty as a whole. These concepts are even more critical in ethnic patients and racial incongruity can be prevented through proper preoperative evaluation and precise technical execution.

We will focus on specific ethnic groups, African-American, Hispanic, Middle Eastern, and to a lesser extent Asian patients. (The next chapter has been dedicated to Asian patients.) A preoperative evaluation and treatment plan that recognizes and incorporates the ethnic naso-facial morphology is critical. While each ethnic group demonstrates a variable spectrum of nasal characteristics, certain classical features are commonly present and should be recognized.

Many of the rhinoplasty lessons that we have learned and continue to improve upon have been by way of our non-Caucasian patients.¹^–¹⁶ Ethnic patients generally fall into two categories, those who want a “dramatic” difference without close attention to retaining their “ethnic” nose, and those who want subtle, natural refinement, without any loss of ancestral traits. The authors advocate a more “natural” approach to ethnic rhinoplasty. Furthermore, we feel that an open approach rhinoplasty works best for the complex, multidimensional nasal features of ethnic patients.³^–⁹

African-American

Introduction

African-American rhinoplasty has become more popular and acceptable as a means of establishing refinement and harmony with other facial features. Most African-American patients desire a nose that is “racially congruous” and are, justifiably, concerned because of their exposure to media images of African-Americans celebrities who demonstrate clear signs of “racial incongruity”. It is critical to acknowledge this fear perhaps before mentioned by the patient. This will “break the ice” and initiate the processes of establishing trust and the realization that you, as the surgeon, already have similar concerns and appropriate goals for your ethnic rhinoplasty patients.

Physical evaluation and anatomy

As with all rhinoplasty patients, the objectives should be clearly emphasized and discussed preoperatively. Ofodile and Bokhari ⁵ have described a variable spectrum in anatomical traits of African-Americans depending on their origin. Rees ⁶ observed that West Indies origination may influence the presence of a dorsal hump, which is very rare in African-Americans living in the United States. The African-American nose can typically be characterized by: thick, sebaceous skin/soft tissue, a shorter columella with less tip projection (rarely drooping), wide and flat dorsum (wide or non-distinct dorsal aesthetic lines), retrusive septal angle, alar flaring, wide interalar distance, bulbous tip, round nostrils, short nasal length, wide pyriform aperture, and bimaxillary protrusion (Fig. 43.1). In contradistinction to many Hispanic and Middle Eastern noses, African-American and Asian noses have a retrusive septal angle which can be beneficial in creating a pleasing tip-dorsum differential. Figure 43.2 depicts typical preoperative tip–alar relationships that should be recognized to prevent postoperative aesthetic complications. The osseous pyramid is often retrusive and wide. The presence and magnitude of these morphological traits should be closely evaluated, in addition to standard naso-facial analysis. Rohrich and Muzaffar³ have a clearly outlined and detailed study on African-American patients.

Fig. 43.1 A–D, Classic African-American nasal traits. D, general operative goals.

Fig. 43.2 African-American alar tip relations. A, Excess infratip lobule. B, Alar flaring. C, Alar notching.

Technical steps

In general, African-American patients, like Asian patients, need augmentation in multiple dimensions. A common characteristic shared in varying degrees by each ethnic group in this chapter, is a thick, amorphous, and sebaceous skin/soft tissue nasal envelope and is best exemplified by the African-American nose. This weighs down the lower lateral, middle and medial crura, which can lead to prolonged swelling. Wide undermining is required for exposure, recruitment of nasal skin, and more even re-distribution of soft tissue healing forces (may aid in reduction of postop notching and buckling). The undersurface of the nasal skin, particularly in the supratip, domal, and paradomal region should be trimmed to, but not past the level of the subdermal plexus. Soft tissue debulking may improve the contractile ability of the skin to reveal the underlying framework established (Fig. 43.3). Taping and massage postoperatively plays an important role in limiting fibrous edema and thickened scarring between the skin and cartilage.

Fig. 43.3 Fibro-fatty tissue in ethnic noses. Infiltration of fibro-fatty tissue is present between and on top of the medial, middle and lower lateral crura. This obscures the cartilaginous shape. Trimming is recommended so that nasal shape can be realized long-term.

As with Asian patients, the nasal bones are commonly short and in certain cases, osteotomies should be avoided and dorsal aesthetic lines can be narrowed with onlay grafting alone. Osteotomies, when performed, should be performed in a low-to-low fashion, with a superior “hinge” greenstick segment, for a natural transition of nasal highlights between the maxilla and nasal side walls.

Dorsal aesthetic lines are just as important as tip shaping in African-Americans. The gold standard in dorsal augmentation is rib cartilage; however if the patient does not desire this, or does not require more than 6 mm of augmentation then the following methods can be employed: septal grafting with fascia or Alloderm (LifeCell Corp., Branchburg, NJ) overlay, Surgicel ¹⁷ or fascia-covered diced cartilage,¹⁸ or silicone dorsal implant. We do not advocate the “L-shaped,” combination dorsal-tip projection silicone implant which has a higher extrusion and complication rate.

Often, the main concern for African-American patients is a flat, poorly projecting nasal tip, wide alar base and large round nostrils. They may not recognize the significance of their dorsal deficiency. Dorsal reduction is almost never indicated. By addressing these other issues, dorsal augmentation is less critical and conservative osteotomies can provide the illusion of increased bridge projection through the narrowing achieved. However, the final assessment for dorsal augmentation should be made after osteotomies (when indicated) and tip enhancement. If less than 2–3 mm is needed, septal onlay (with or without alloderm or temporalis fascia coverage) is sufficient; 3–6 mm is achieved with a multi-layered septal construct, and thick multilayered Alloderm. More than 5–6 mm requires an anatomically-carved rib cartilage graft. Pocket dissection should be subperiosteal.

The new cartilaginous frame/shape must be established through maneuvers that increase tip support along with refinement. One benefit of the thick soft tissue coverage is that visible and more aggressive maneuvers can be used to improve tip shape and projection. A combination of tip suturing techniques are usually needed.¹⁹^–²² A systematic approach is advocated to serve as a guide (Fig. 43.4). This begins with establishing tip platform strength via a columellar strut, medial crural sutures (MCS) and medial crural–septal sutures (MCSS)(if necessary for tip positioning). Transdomal sutures (TDS), interdomal sutures (IDS), and lateral crural spanning sutures (LCSS) are placed next. A helpful technique to improve alar arch strength is to overturn and suture the cephalic portion of the LLC to the native caudal rim strip instead of simple excision, known as a “lateral crural turnover flap”. This is a beneficial maneuver in ethnic patients because irregularities in the lower lateral crura are corrected while simultaneously improving rim support. Alar contour grafts are often needed to prevent notching at the soft triangle which can readily occur in African-American and Asian patients due to round nostril shape, and wide interalar distance that is later reduced. The excess alar soft tissue, when bent and medialized during tip shaping tends to buckle and addition of a crushed soft triangle graft may be needed.

Fig. 43.4 Tip algorithm. This serves as a general guide in performing systematic nasal tip shaping.

Adapted from Janis JE, Ghavami A, Rohrich A. A predictable and algorithmic approach to tip refinement and projection. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas rhinoplasty: nasal surgery by the masters, 2nd edn. St Louis, MO: Quality Medical, 2007.

Further tip refinement is established with a combined infratip lobular/onlay tip graft (Fig. 43.5). This will augment the deficient infratip lobule, improve tip projection and provide for necessary breakpoints. Septal cartilage is best and suture stabilization of the graft to the columellar construct and domes is recommended. Increased tip augmentation can be achieved by allowing the cephalad portion of the Gunter-type graft to project anterior to the domes. More cartilage grafts can be placed under this cephalad portion or as onlays. Additional crushed graft remnants can be placed after columellar closure, using a Bayonet forcep. Skin redraping throughout the process of tip shaping helps determine the influence of each maneuver on the external surface, which is the ultimate aesthetic goal.

Fig. 43.5 “Gunter type” infratip and tip-lobule onlay graft.

Lastly, enhancement of nostril shape and alar base reduction is almost always needed. Degree of alar flaring should be assessed according to how lateral to the medial canthus the flare is. Alar base resection is required when this is >2 mm (Fig. 43.6). Excision should not extend beyond the supra-alar groove where the lateral nasal artery travels. Closure using the “halving principle” is required. Excision amount should be measured with a caliper, and may be different on each side. Typically this measures between 6–12 mm. Extension into the nostril sill is needed when interalar distance is wide. Postoperative care will be discussed after all the ethnic nasal types have been addressed.

Fig. 43.6 Alar base resections involve either base only, or a combination of base and sill reduction if the interalar distance is wide.

Case 1

African-American

The patient demonstrates a wide dorsal hump and flat, poorly defined nasal tip (Fig. 43.C1). Alar base is wide. She also presents with a hanging ala and weak columella. There is a high dorsal hump and columellar-lobule disproportion. Internal exam was normal.

Fig. 43.C1 A, (i) Preoperative; (ii) postoperative. B, (i) Preoperative; (ii) postoperative. C, (i) Preoperative; (ii) postoperative. D, (i) Preoperative; (ii) postoperative. E, (i) Preoperative; (ii) postoperative. F, Intraoperative technique. G, Intraoperative technique. Red, resection/excision; Green, augmentation/grafts.

Hispanic

Introduction

Hispanics make up the largest proportion of ethnic minority groups in the United States. In areas such as Los Angeles and Miami, Hispanic patients are one of the largest groups seeking cosmetic surgery. Aside from post-partum modifications such as body and breast contouring, rhinoplasty is becoming a more acceptable way to achieve a refined elegance and balance to the face. Similar to Middle Eastern patients, this ethnic group requires detailed preoperative planning to delineate the significant characteristics that warrant alteration. An over-operated appearance is commonly seen by surgeons that perform similar maneuvers in every ethnic type, without regard for the anatomical distinctions. As a whole, Hispanic patients are very appreciative, and realistic about the postoperative expectations.

Although many of the noses of Hispanic television celebrities appear over-operated (large supratip slope, over-resected dorsum, pinched/over-rotated tip), a large proportion of Hispanic patients in the United States want a “natural” improvement. Interestingly, while this has not been studied, the authors believe that many Hispanic patients seek to have a more Spanish-European nasal appearance approaching the Castilian side of the spectrum (less Mestizo appearing). Angularity is important to them.

Physical evaluation and anatomy

A classic Hispanic rhinoplasty study is that of Fernando Ortiz-Monasterio on the Mestizo nose.¹¹ Ortiz-Monasterio¹¹ lists five characteristics that differ from Caucasian noses: (1) thick, sebaceous soft tissue envelope; (2) small osseocartilaginous vault; (3) weak tip support due to short medial crura and weak caudal septum; (4) short, hidden columella; and (5) broad alar base and round nostrils. He advocates an intracartilaginous approach with supportive grafts, struts, minimal dorsal augmentation, and nostril/sill correction. Since that seminal manuscript, further ethnic and morphological delineations have been made by Sanchez²³ (“Chata”-Caribbean nose, predominant “Black” or “Asian” features) and Milgrim.²⁴ Milgrim²⁴ divides the Hispanic female nose into three subtypes based on geographical origin: Caribbean, Central American, and South American.

Daniel ¹⁵ reported on his experience with primarily Mexican-American patients and classified them into three types: Type 1 – (Castilian) high arched osseocartilaginous dorsum and normal tip projection; Type 2 – (Mexican-American) low radix and underprojecting tip with the illusion of a large dorsal hump; Type 3 – (Mestizo) thick skin envelope, dorsal-tip disproportion, amorphous, wide base. While classifications are less relevant, an analysis-based treatment plan is imperative in this ethnic group. In addition, those with more African-American (Caribbean-Creole) features tend to be more wary of significant nasal modification, sometimes citing noses of notable African-American celebrities that display extreme “racial incongruity”.

Evaluation of soft tissue/skin thickness dictates the extent and plane of undermining. While only a minority of Middle Eastern patients demonstrate a thin skin envelope, Hispanic patients more commonly present with thin and non-forgiving nasal skin. We find soft tissue dissection directly on the perichondrium to be safe and predictable. This allows the soft tissue to be removed directly from the skin flap in the tip, supratip, and paradomal region. Most importantly, a combination of soft tissue debulking and filling of the soft tissue envelope with cartilage shaping sutures, supportive struts, and onlay grafts are necessary to improve the final translation from the new cartilage frame to the final visible nasal contour.

The bony vault, when wide and excessive, is treated with low-to-low osteotomies (sometimes with a cephalad medially directed J-component),²⁵ while short nasal bones in the “Chata” or Mestizo type nose can be treated with illusory and augmentative grafts. Daniel finds this to be a strong indication for his diced cartilage-temporalis fascia construct.¹⁸ However, the nasal bones, even when short are stronger than those of African-American and Asian noses.

We find there to be significant heterogeneity in the cartilaginous-bony relationship in Mexican-American noses. Nevertheless, two general morphologies present: (1) those towards the African-American spectrum with weak, wide, flat cartilage, wide alar base (usually combined with round nostrils), and low/flat dorsum; and (2) and those that present more as Mediterranean/Middle Eastern nasal types with dorsal hump, long nasal bones, poor tip projection and moderate tip bulbosity. When dorsal reduction is indicated, it should be performed in a graduate, component fashion.²⁶ Tip position in both groups usually is not plunging and if so, minimal tip rotation is required. Therefore, the mechanical disadvantage of low tip complex position relative to a high septal angle, (which predominates in the Middle Eastern nose) is not a major issue.

Often the dynamic effects of cephalic trim, tip suturing and a columellar strut is all that is necessary to maintain tip position long term. Suturing the tip complex to the caudal septum, significant caudal septal resection, and anterior nasal spine modification are sometimes required to enhance the columellar–labial relation. However, tip shape is of great importance to Hispanic patients and can proceed in the usual stepwise fashion (Fig. 43.4).

Nostril and alar base refinement is carried out in the standard fashion, when indicated (see African-American section of this chapter). It is, however, critical to mention nostril and alar base shaping maneuvers to patients preoperatively because a wide alar base is almost universally disliked by Hispanic patients. Sill resection is less indicated compared to the African-American nasal base.

Case 2

Hispanic

This patient demonstrates a Castilian type nose. She has a flat, poorly projecting nasal tip with a small degree of droop (Fig. 43.C2). Nasal skin is thin. There is a dorsal hump and marked alar–columellar disproportion. Caudal deviation and tip asymmetry are also present. The tip is poorly defined. This patient desired a dramatic improvement.

Fig. 43.C2 A, (i) Preoperative; (ii) postoperative. B, (i) Preoperative; (ii) postoperative. C, (i) Preoperative; (ii) postoperative. D, (i) Preoperative; (ii) postoperative. E, F Intraoperative technique.

Middle Eastern

Introduction

Middle Eastern patients make a up a large proportion of rhinoplasties performed throughout the world. In Iran, it is even fashionable to walk the streets with a nasal splint and it has become almost a sort of “rite of passage” for both males and females. Middle Eastern patients request rhinoplasty in numerous countries, including the United States. However, one explanation for the dramatic numbers seen in countries such as Iran, may be that the face is often the only visible part of the body in everyday public life (due to religious laws). Middle Eastern nasal characteristics present on a gradient between the African-American nose ³^–⁷ and the Caucasian nose.

“Middle Eastern” commonly refers to people of Arabic, Turkish, North African, Semitic (i.e. Assyrian, Judean, Babylonian descent), Armenian, and Persian descent. Further ethnic and geographical delineations are beyond the scope of this chapter. In a review on Middle Eastern rhinoplasty techniques, Bizrah ⁸ simplifies the division of the “Middle Eastern” population into the Middle East, North African, and Gulf regions. He makes a particular distinction as to the aesthetic preferences and social distinctions of specific groups, namely Gulf (Saudi Arabia, UAE, Kuwait, Iran, and Oman) and non-Gulf groups (Syria, Turkey, Lebanon, Turkey, Egypt and Morocco), with non-Gulf patients desiring more tip projection and less dorsal height. A large proportion of Middle Eastern patients are young females who often arrive at their consultation with their mother or mother and father. It is important to include the parents in the consultation and detailed discussion as they are very proactive and involved. It is not uncommon that the mother initiates the entire process.

Rohrich and Ghavami ⁹ present a component-driven approach based on specific classic nasal traits (Fig. 43.7 and Table 43.1). The goals in Middle Eastern rhinoplasty are shown in Table 43.2.

Fig. 43.7 Classic Middle Eastern nasal features and preoperative nasal measurements.

Table 43.1 Common characteristics of the Middle Eastern nose *

^* Percentage frequencies are listed in parenthesis. The total number of patients is 71.

^† Crural morphology was observed intraoperatively and was not quantified.

Adapted from: Rohrich RJ, Ghavami A. Rhinoplasty for the Middle Eastern nose. Plast Reconstr Surg 2009;123(4):in press.

Table 43.2 Common goals in Middle Eastern rhinoplasty

Adapted from: Rohrich RJ, Ghavami A. Rhinoplasty for the Middle Eastern nose. Plast Reconstr Surg 2009;123(4):in press.

Physical evaluation and anatomy

Middle Eastern patients commonly have Fitzpatrick skin types III–V. Skin is frequently thick and sebaceous throughout, particularly at the tip-supratip. One of the most common pitfalls and long-term aesthetic problems in Middle Eastern patients is a non-contractile and amorphous soft tissue envelope that does not improve as desired, over time. Prolonged edema and internal scarring is not uncommon and patients may need to wait more than a year and a half to see their “final” tip shape. Skin debulking maneuvers are necessary. Furthermore, the mechanically unfavorable combination of the high soft tissue : cartilage support ratio, and a plunging tip complex make for the greatest challenge in the Middle Eastern nose.

Commonly, the nasal dorsum is wide with a significant hump. The width begins very low at the ascending process of the maxilla. The nasal bones are almost always long which allows for the creation of dorsal aesthetic lines in a more predictable and precise manner. Osteotomies, if done, are performed using a low-to-low percutaneous technique or, if desired, a low-to-low internal continuous technique. A graduated dorsal hump reduction is important in order to directly visualize the magnitude of dorsal reduction attained in an incremental fashion.²⁶ This prevents excessive dorsal reduction, and subsequent problems such as inverted V-deformities which are all too common in Middle Eastern patients presenting for revision. Use of Byrd’s “autospreader flap” is beneficial to preserve more septal cartilage for other uses.²⁷ This is an extremely versatile, easy and useful technique and obviates the requirements for traditional spreader grafts in most cases. It is an important tool in large dorsal reduction.

Middle Eastern patients commonly have a combination of poor tip projection and a droopy tip. This creates a mechanically unfavorable tip shaping platform which is critical in maintaining tip shape/position long-term. The strength of the nasal tip platform is assessed by placing direct pressure on the domes and pressing posteriorly toward the nasal spine. There is frequently a lack of resistance as the tip/lobule complex collapses and plunges below the anterior septal angle. A strong columellar strut is mandatory along with appropriate caudal septal resection, and redundant lining excision to establish proper tip position.

The nasal tip is often ill-defined, bulbous or boxy. Standard invisible/non-palpable suturing and grafting techniques are required. Unlike African-American and Asian patients, Middle Eastern patients have dorsal over projection and optimal tip–dorsum relation is critical and is closely scrutinized by these patients as a primary goal. They readily complain of their nasal tip position in pictures. Excess domal width and angle of divergence usually present concomitantly, indicating the need for numerous tip suturing techniques.

The lower lateral and medial crural cartilages are frequently weak relative to the heavy skin and soft tissue overlying them. Furthermore they are frequently malpositioned (Fig. 43.8), which complicates the balance between the tip shape and alar arch. The lateral crura may be wide, but commonly do not contribute substantially to overall alar arch strength when they are malpositioned in a cephalad direction. When lateral crural malposition cannot be camouflaged with cephalic trim alone, then transection at the accessory chain region along with caudal repositioning using a lateral crural strut²⁸ or alar contour graft is performed. Toriumi²⁹ places importance on the position of the cephalic lateral crural margin relative to the caudal margin and advocates stabilization of inherent lateral crural instability prior to tip shaping techniques. If these issues are not addressed, tip–alar aesthetics may not be maintained long-term and postoperatively a shadow line that descends from the dorsal aesthetic lines and wraps around the paradomes, infratip and to the other side can ensue (an amorphous “sausage-like” appearance).

Fig. 43.8 Severely malpositioned lower lateral crura should be corrected. Failure to recognize and treat this morphology can lead to aesthetic and functional compromises.

Middle Eastern patients almost always lack supratip definition and racial incongruity will result if a sharp supratip break is produced. Males should have a neutral supratip region while females should have a supratip that is not as sharp as would be in Caucasian females. Proper grafting, liberal use of support struts, and proper tip positioning all serve to improve the biomechanical stability of the shaped tip complex and help prevent loss of tip refinement, projection, and position.

Alar flaring is frequent. Conservative alar base resections are often required due to nostril flaring, and should be performed at the end of the operation, after the columellar incision is closed. Excessive narrowing of the alar base should be avoided. Further resection can be performed during a simple office procedure.

The alar base can also be displaced cephalad. This exaggerates the appearance of a dependent, plunging tip. Upon animation, this imbalance between the caudally rotated nasal tip and cephalically positioned alar base is increased. However, the magnitude by which the alar base is re-positioned caudally is lessened after final nasal tip maneuvers have been made.

Correction of alar–columellar disharmony ³⁰ is mandatory and often manifests as a “hanging columella” deformity. Alar retraction in primary rhinoplasty is rarely seen in the Middle Eastern population. Correction of excess columellar show may require medial crural septal sutures for proper tip rotation, but the nasolabial angle should not be overcorrected which will lead to racial incongruity. There may be a tendency to overcorrect due to the presence of severe caudal tip position. Over-rotation is a common indication for revision.

A nostril-to-tip ratio of approximately 60 : 40 should be present.³¹ After proper correction of tip rotation/projection, alar–columellar discrepancy, and alar base positioning, any residual nostril abnormalities will become apparent. This will often be due to flaring medial crural footplates, short nostril deformity³¹ (soft triangle excess), or enlarged nostril size. Footplate excision or suturing (mattress “cinching suture across columellar base) along with intercrural space soft tissue excision adds further refinement to the alar base–nostril relationship.¹⁴

Case 3

Middle Eastern

This 41-year-old female with Fitzpatrick type III skin who did not like her dorsal hump and unrefined tip, which appeared “flat” to her (Fig. 43.C3). She had a large dorsal hump, poorly shaped nasal tip that lacks projection, is plunging, as well as hyperdynamic. This patient demonstrates the classic Middle Eastern nasal morphology. She requested a more dramatic change in her tip and this required a secondary soft tissue debulking operation.

Fig. 43.C3 A, (i) Preoperative; (ii) postoperative. B, (i) Preoperative; (ii) postoperative. C, (i) Preoperative; (ii) postoperative. D, Intraoperative technique. E, Interaoperative technique. Rorich RJ, Ghavami A. Rhinoplasty for Middle Eastern Noses. Plast Reconst Surg. In press.

Postoperative assessment

Two-year postoperative photos (from her primary operation) show a balanced nose that is aesthetically pleasing. The nasal envelope has been debulked, dorsum appropriately reduced, nasal tip refined, raised and projected. Note the drastic improvement in overall nasal envelope reduction and creation of conservatively defined supratip and infratip breakpoints. This required an intermittent revisional operation (Gunter diagrams not shown) with more soft tissue debulking (particularly at the supratip), as well as visible onlay tip graft replacement secondary to early resorption. The necessity for secondary tip refinement is not uncommon in the Middle Eastern population and should be fully discussed as part of the initial informed consent.

Asian

We will include only a short discussion of Asian noses as this topic is covered in the following chapter. Flowers ¹⁰ elegantly lists the salient points. It should be stated that, unlike the ethnicities above, this ethnic group is harder to convince regarding the benefits of autogenous grafts. Most Asian patients know of someone who has had an Asian rhinoplasty quickly and effectively by way of a silicone implant. We find this ethnic group to most frequently desire and require significant dorsal augmentation (>4 mm). We advocate the following criteria for dorsal implant placement: (1) patient does not want rib graft under any circumstance; (2) has thick dorsal soft tissue; (3) dissection plane for implant placement is sub-periosteal; (4) implant is fixated with non-braided sutures superiorly and inferiorly; (5) L-shaped, combination dorsal-tip implant is not used due to high extrusion rate; and (6) a thorough discussion of the potential short and long-term complications are discussed preoperatively with discussion that future removal may require replacement with autogenous material.

Toriumi ¹³ has had excellent results and a vast experience with autogenous rib which serve as both struts and nasal contouring grafts in both primary and secondary rhinoplasty. However, his patient population may be unique in that most present at consultation knowing that they will likely receive a rib graft.