20. Rhinoplasty in the Latino Nose.pdf

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Home Articles Rhinoplasty in the Latino Nose

Rhinoplasty in the Latino NosePosted by Roxana Cobo on April 29th, 2011

Abstract

Latino patients are also known as hispanic or mestizo and are a combination of different ethnic groups that originate fromSpanish speaking countries from around the world. When performing surgery on this group of ethnic patients, the goals areto achieve a natural looking appearance preserving patient's ethnic features and hopefully fulfilling the patients' desires. Agradual approach to the nose is presented where support structures are reinforced; techniques are used to increaserotation and definition without necessarily making the nose look bigger. A judicious selection of suturing techniques andplacement of grafts is presented. The final surgical result should be a nose that blends in with the patients face withoutlooking operated or overdone.

Introduction

Civilizations over time have always had a genuine interest in beauty and ethnic groups around the world are not theexception. Migration patterns of different ethnic populations looking for better working opportunities and improvement intheir quality of life have changed the racial composition in many countries and regions. Today pure races tend to be lessprevalent and facial plastic surgeons worldwide are faced with patients of many different cultural and ethnic groups wantingto improve their looks.

The most important migrations from Latin American countries have been to United States and Spain and to a lesser degreeto other European countries and to Canada. Most of the population have established themselves in these new countriesand with time have become part of the society that has received them.

Definition of Latino

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Latino can be defined as "a person of Latin-American origin living in the United States. 1 Latino is a term that in the UnitedStates can often be used interchangeably with hispanic or mestizo without any offense meant. It refers to people comingfrom Spanish speaking countries mainly Latin American countries. The terms latino and hispanic are related to where theperson is coming from. In United States the terms are used interchangeably and refer mainly to people coming fromMexico, Central and South American countries.

Mestizo is a term used to define racial features. It is defined as a mixture of races mainly Indian, Caucasian and Negro. Thepredominant features will vary depending on where the patient comes from and what specific migration patterns haveoccurred in that geographical area. A strong influence of Caucasian features (European countries) can be found in patients

coming from countries like Argentina and Chile. Indian features are predominant in countries like Per, Bolivia, Mexico,Guatemala and other Central American Countries. A stronger African influence is seen in countries like the CaribbeanIslands, Cuba, Brazil, and the coasts of Venezuela and Colombia. In spite of all this, mestizos are defined as being a mixtureof racial features.2-5 It will be the surgeon's responsibility to adequately define the patients characteristics and underlyinganatomical problems.

Anatomical Characteristics of the Latino, Hispanic or Mestizo Nose

As we mentioned before, mestizo is defined as a mixture of racial features. Anthropologically, three big groups are used todefine nasal features: platyrrhine, mesorrhine and leptorrhine.6,7 The platyrrhine nose is usually flat and wide and is usuallyseen in patients with predominant negroid racial features. The leptorrhine nose tends to be tall and narrow and is more

related with Caucasian or northern European patients. The mesorrhine nose is that seen in the mestizos of Latin Americaand is considered an "in between" stage between the platyrrhine and the leptorrhine nose.

Characteristics in these patients tend to be more modest than those found in leptorrhine noses. The underlying bony andcartilaginous support structures of the nose tend to be weak. Nasal bones have a tendency to be small and slightly widealthough it is not uncommon to find a deep radix accompanied by a small dorsal hump. Tip support mechanisms tend to bedeficient. The nasolabial angle tends to be more acute, the nasal spine is smaller, the columella can be shorter and theshape of the nostrils will be more rounded or horizontal looking. Alar cartilages although wide, tend to be weak and flimsyresulting resulting in poor projection and rotation of the nasal tip.5 (Table 1, Figure 1)


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Table 1. Nasal Characteristics of Mestizo Patients

NASAL CHARACTERISTICS MESTIZO PATIENTS

Skin Type Normal/ Thick/ Sebaceous

S-STE Thick/ tendency towardsinflammation

Nasal Bones Small

Bony Dorsum Normal to low radixWide nasal bridge

Cartilaginous Nasal Vault Normal to Weak , wide

Nasal Tip/ Alar cartilages Flimsy/ unsupportive/ wide/undefined

Columella Normal to short

Nasolabial angle Normal to acute

Nasal spine Normal to short

Tip Recoil poor

Nostril shape Horizontal shape

Alar Base Normal to wide

Preoperative Evaluation

a. Consultation

Having the time and being able to communicate with the patient in an adequate manner is fundamental if the surgeonwants to establish an appropriate relationship with the patient. Several issues must be covered during the consultation:

1. Define the patients ethnic, racial and cultural background.2. Define the patient's desires and expectations. Does he/she want to preserve ethnic features or is there a clear desire for a

more dramatic change in appearance.3. Complete previous medical history including previous surgical and non-surgical procedures on the nose and face including

procedures performed by aestheticicians.

b. Physical Examination

1.Functional EvaluationThe function of the nose should be evaluated with an internal and an external examination. This is done using a headlight,palpating external structures and progressing to an internal exam with a nasal speculum and if indicated a flexible or rigidnasal endoscopy.


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The following aspects should be properly documented:a. alar collapse.b.evaluation and/or compromise of internal or external nasal valve.c. septal deviations/ availability o f septal cartilage for harvesting.d. turbinate hypertrophy.e. sinus disease.

2.Aesthetic Evaluation

a. Facial characteristics/ presence of facial asymmetries/ deformities/ scarsb. Definition of skin type/ thickness of S-STEc. Definition of nasal characteristics1. Upper Third of Nose: Bony dorsum2. Middle Third of Nose: cartilaginous dorsum3. Lower third of nose: nasal tip

C. Photography

A set of standard rhinoplasty photographs should be obtained. These should include: frontal view, base view, Lateral views(left and right), left and right oblique views. The author routinely uses computer imaging to show possible surgical changes

and evaluate before and after images. This helps the patient evaluate if those are the surgical changes he wishes to haveand understand the limitations of the surgical procedure. When using computer imaging, the expertise of the surgeonbecomes crucial in defining how much of a realistic change will be obtained. This will help surgeon define what surgicaloptions can be offered and will help the patient understand the extent of the procedure that is going to be performed.Photography automatically becomes part of the medical record and is useful not only during the consultation with thepatient. The author uses printed copies of the pictures during surgery and the pre-surgical images are constantly used toevaluate the patients' evolution during follow-up visits after surgery. Post-surgical pictures should be taken ideally at 6months and 12 months after surgery. This helps evaluate aesthetic outcomes, surgical techniques and becomes a valuabletool when performing long term follow up on patients.

D. Discussion and Explanation of possible surgical options

Step-Wise Approach to the Latino or Mestizo NoseThe latino or Hispanic population comprises a big heterogeneous group. Anatomical findings will really depend on whichracial features are predominant. The big question we have to ask ourselves as surgeons is: "what do our patients want?" Ingeneral mestizo patients want smaller noses that look more defined. A step-wise approach is necessary to be able toestablish an accurate anatomical diagnosis, define what problems the patient has, what are the problems the patient wantscorrected and what are the possible surgical solutions.

Anatomical Diagnosis


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Definition of existing problems

Definition of what problems the patient wants to correct

Definition of surgical approaches and techniques

Problem-wise most of our patients tend to have a thick S-STE and a weak underlying structural framework (bony andcartilaginous). The surgical techniques used should all be oriented towards preservation and strengthening supportstructures of the nose, conservative tissue excision and use of sutures and grafts to help define the different anatomicstructures of the nose 8,9.

Surgical Techniques

All cases are performed under general anesthesia and the external approach is used in most patients. The functionalaspects of the nose are addressed first before doing any cosmetic procedures. Standard endoscopic sinus procedures caneasily be performed without any postsurgical complications. In patients with turbinate hypertrophy, these are routinelytreated with endoscopic turbinoplasty procedures. Septal deviations are corrected and cartilage is harvested for grafting.The amount of quadrangular cartilage present in mestizo patients is not very big and like in most mesorrhine patients itusually is not thicker than 2-3mm.10,11

There is no "standard" surgical technique for latino or mestizo patients. Several general "rules" should be followed to ensurepredictable long term results: 1. Support structures of the nose should be preserved or strengthened 2. Conservativetissue excision 3. Structural grafting to improve nasal tip support 4.Use of sutures or grafts to help define the nasal tip. 8,9With this philosophy in mind, the surgeon must choose how and where he is going to use his grafting material in a wisemanner. The amount of septal cartilage that is available can be insufficient for all the possible grafts that could be used insome of these patients. If an organized surgical plan has been defined, choices can be made more easily and mistakeswhich will translate into unsatisfactory results can be avoided.

Problem-wise and to help plan surgery in a proper fashion, the nose can be divided into thirds:

-UPPER THIRD OF THE NOSE (BONY DORSUM)-MIDDLE THIRD OF THE NOSE (CARTILAGINOUS DORSUM)-LOWER THIRD OF THE NOSE (NASL TIP)

The bony and cartilaginous dorsum is managed before any nasal tip procedures are performed.

Upper Third of the Nose (Bony Dorsum)

The nasal bones of our patients tend to be short. Even though humps can be found in some of our patients, it is morecommon to have dorsums that tend to be low and wide.


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Common Anatomical Findings:

1. wide dorsum without hump and normal radix2. low radix with bony dorsal hump3. low nasal dorsum

Surgical solutions:

1. medial and lateral ostoeomies: will help narrow a wide bony dorsum. Medial osteotomies are done in a curved fashionbefore the lateral osteotomies using a 3mm osteotome. It is important to curve osteotomes 15-20 degress off the midlineto avoid going all the way up to the nasofrontal bone. Lateral ostetomies are performed in a high-low-high fashion using a2.2 guarded osteotome. Medial osteotomies are performed when there is a wide dorsum without a hump or a crookednose. Lateral osteotomies are performed in most cases. In the cases where there is a very wide bulbous tip with thick skin,and a straight dorsum, no osteotomies are performed. (figure 2)

A B


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C D

2. Bony dorsal humps: can be reduced either with an osteotome in a very conservative fashion or with graded rasps. Thecartilaginous portion of the hump is removed with a #15 blade taking out thin slivers of cartilage until the desired height is

obtained. It is not infrequent to have to remove portions of the septum (dorsal portion) and the upper lateral cartilages. Ifpossible the nasal mucosa should not be disrupted. This will help prevent secondary collapse of the upper lateral cartilages.

3. Radix graft: in those cases where there is a low shallow radix with a small dorsal convexity and short nasal bones, a radixgraft can be placed using morcelized cartilage to fill in this space and avoid lowering the convexity of the dorsum. This helpsbuild up the dorsum without making the nose look much bigger and is an excellent alternative to the use of implants on thenasal dorsum. 9,12

4. Radix graft+ lowering of bony dorsal hump: Frequently a combination of both techniques can be used. Crushed cartilage isplaced as a radix graft and only conservative rasping of the dorsum is performed. In this fashion height of the dorsum ispreserved Figure 3 .


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Dorsal augmentation: Ideally should be performed with cartilage and in the authors experience, septal cartilage ispreferred over auricular cartilage. All edges should be well trimmed and beveled so they wont be noticeable over time. Ifmore dorsal augmentation is needed, alloplastic material like expanded polytetrafluoroethylene (Gore-Tex) sheeting can beused with a low complication rate. Material should ideally be placed in precise pockets and if possible fixed with sutures to

the middle third of the nose to avoid shifting. (figure 4).13,14


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A B

C D


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Middle Third of the Nose

Latino patients tend to have weak support structures in the nose. It is not uncommon to find patients with short nasalbones and weak upper lateral cartilages that have a tendency to collapse. Any dorsal work performed on the nose will tendto increase this inherent weakness especially if humps are going to be reduced or medial osteotomies are going to beperformed. Preventive measures like structural grafting with spreader grafts or placement of reinforcement sutures in themiddle third of the nose can help avoid postsurgical complications like inverted v deformities of the upper lateral cartilages(ULC), collapse of any of the lateral cartilaginous sidewalls of the nose or compromise of the internal nasal valve.

Anatomical Findings:

1. Weak upper lateral cartilages2. Flattened / wide middle third of nose

Surgical Solutions:

1. Spreader grafts: are rectangular pieces of cartilage that are carved from the nasal septum, auricular concha, and in specialcases from rib cartilage. The thickness of the graft will be given by the type of graft thats used but with the exception ofrib the dimensions will vary between 1-3mm. The height should not be more that 3-5mm and the length can be 15-20mmdepending on the individual patients needs.Spreader grafts are used to give additional structural support to the middle third of the nose when any dorsal work hasbeen performed, or to strengthen the middle third area in the cases where there is a natural weakness or collapse of any ofthe upper lateral cartilages.15 These grafts help maintain the anatomical trapezoidal contour preventing the postsurgicalappearance of an inverted "v" deformity. If there is a previous crooked nose with any dorsal septal deviations, uni orbilateral spreader grafts will help in this correction. The length of the grafts is tailored according to patients needs. They canextend from the nasal bones all the way down to the caudal edge of the septum or can be circumscribed in one small areaof the middle third of the nose (figure 5). It is important that the grafts are not too wide because this could produce nasalobstruction especially at the nasal valve area.


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Figure 5 A Figure 5 B

Figure 5 C Figure 5 D


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Figure 5 E

2. Sutures: Mattress sutures using 4-0 or 5-0 absorbable material can help align the upper lateral cartilages to the dorsal edgeof the nasal septum and are always used by the author if any conservative resection of the cartilaginous dorsum has been

performed to securely position the upper lateral cartilages to the dorsal edge of the nasal septum.3. Onlay Grafts: can be used to help camouflage persistent depressions over the upper lateral cartilages. Morcelized cartilage

can also be used to smooth out or fill in defects.

Lower Nasal Third of the Nose

From a practical standpoint, the nasal tip can be divided in two big areas: the pedestal and the tripod. The pedestal is amore rigid structure that is formed by the caudal end of the septum. The tripod is more flexible and is formed by theconjoined medial crura and both lateral crura and sits on top of the pedestal. These structures, as mentioned earlier arecovered by the S-STE giving the final shape to the nasal tip. The nasal pedestal is addressed before any final tip work isdone. In this way projection and rotation will not be lost after tip remodeling techniques are performed.

The lower third of the nose is also referred to as the nasal tip. It can be divided into two areas: the nasal base and thenasal tip. The nasal base or pedestal is a more rigid structure that is formed by the caudal end of the septum and the nasalspine. The tripod is formed by the conjo ined medial crura and both lateral crura. It is more flexible and sits on top of thepedestal. 16,17

Latino patients tend to have bulbous tips that sit on bases with poor support. Any work that is performed on the tip firstrequires a stable nasal base in order to be able to modify structures and place grafts. The techniques that are used morefrequently are the columellar strut or the septal extension graft. 9

Anatomical Findings:


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1. A caudal septum that tends to be short and weak resulting in an acute nasolabial angle2. Short columella3. horizontally shaped nostrils that are the result of a weak tripod and pedestal structure4. disproportion in the ala/columella relationship

Surgical Options:

1. columellar strut: The columellar strut is used in the surgical cases where an open approach is used to give additionalsupport to the pedestal. This will help avoid loss of tip projection. The strut should be carved from a straight piece of

cartilage. The first grafting option is septal cartilage although conchal cartilage or rib cartilage can also be used. The graft isplaced in a pocket dissected between the medial crura. It is sutured in place with absorbable 5-0 sutures taking care not toplace these near the domes or high in the intermediate crural area in order to preserve the natural double break of thecolumella. The graft should sit a few millimeters above the nasal spine and should be cut slightly below the domes.Posteriorly the edge of the strut should not overlap the anterior portion of the caudal septum or the nasal spine becausethis will produce an uncomfortable clicking sensation at the base of the nose. The strut is designed to give additionalsupport to the tripod and pedestal, helps maintain or increase tip projection and rotation, and corrects buckling orasymmetries that may be found in the medial crura. It also provides a stable base for the use of grafts in the nasal tip(Figure 6).



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2. Caudal septal extension graft: Many times, the columellar strut will not give the necessary support the pedestal needs andwill not correct big deformities in this area. The Caudal septal extension graft becomes very useful in these situations. Theindications for its use are: patients with acute nasolabial angles, under projected tips, caudal septums that can be normal or

short but with poor tip support or inadequate alar/collumelar relationships.18 The cartilage used in this type of graft shouldbe relatively straight. The ideal material is septal cartilage, when this is not available, conchal cartilage can also be usedalthough it is not as strong and the piece used should be straightened with sutures. The graft is placed overlapping for a fewmillimeters the caudal edge of the patients septum and sutured in place with 4-0 absorbable sutures. The graft must befixed inferiorly at the level of the nasal spine and superiorly at the level of the anterior septal angle. If the piece of cartilageused reaches the region of the internal nasal valve, it should be thinned out so there wont be a resulting nasal obstruction.Once the graft is fixed securely in place, the feet of the medial crura are sutured to the caudal edge of the graft. Where thefeet are fixed will be defined by how much rotation and projection is needed. This position will define the final position of thenasal tip (figure 7).


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Figure 7 C

The shape of the caudal septal extension graft may vary. It usually has a rectangular shape, but in the patients where thenasolabial angle is very acute and rotation very poor, leaving the graft wider in the inferior portion will help push out thisarea and will help rotate the nasal tip superiorly (Figure 8, 9).


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Figure 8


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Gradual Approach to the Latino or Mestizo Nasal Tip

Once the nasal base has been strengthened and stabilized, the nasal tip can be approached. There are no standardprocedures when working with mestizo noses. A gradual approach is used starting with conservative and predictabletechniques leaving the more aggressive ones for prominent deformities. The tripod structure in Latino patients is moreflimsy and unsupportive. Alar cartilages tend to be wide, with undefined domes, the feet of the medial crura are short,

resulting in nasal tip lobules that are bulbous and lack projection and rotation.

The philosophy used in these patients is: minimal tissue resection, reinforcement of support structures of the nose,structural grafting, and use of sutures and grafts to help define and contour cartilaginous structures. As surgeons, we mustbe careful not to overuse grafts in these patients. We want nasal tips that look more defined without necessarily lookingbigger. All sutures are performed with 5-0 non absorbable sutures being careful of burying knots so they will not extrudeover time. 8

Problems encountered:


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1. Wide, flimsy alar cartilages2. Domes without definition3. Weak medial crura4. Rounded looking nostrils/ wide nasal base

Surgical techniques can be divided into intact strip procedures, incomplete strip procedures and use of grafts.

1. Intact Strip Procedures: These are procedures where the strip of alar cartilage is left intact and any changes performed aredone with suturing techniques or with cephalic resection of the alar margin.

a. Cephalic resection of alar cartilages: In patients where alar cartilages are excessively wide in the vertical dimension (caudalto cephalic), a conservative cephalic trim leaving 9-10mm at the lateral crus and 5-7mm at the dome area can beperformed. Resection should not be extended into the lateral portion of the lateral crus. This can result in supralar pinchingor collapse of the lateral nasal wall that with time will tend to get worse. Cephaic trim is not performed routinely by theauthor. Tip bulbosity is usually dealt with suturing techniques to define the dome area and flatten any convexities that canbe present in the cartilages.

1.a. Lateral crural turn-in-flap of cephalic portion of alar cartilage: In patients where the alar cartilages are very wide butadditionally very flimsy and weak, instead of performing a cephalic resection of the alar cartilage, the portion that is goingto be resected is folded under the cephalic edge and sutured in place. In this way the cephalic portion is strengthened andpostsurgical pinching can be avoided (figure 10).



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1.a. Suturing techniques: They are the first step in managing the bulbous undefined tip and are usually performed with 5-0 non-absorbable sutures. The big advantage of using suturing techniques is that if the result obtained is not satisfactory, thingscan be undone easily without major problems. Most suturing techniques are used to refine, project and rotate the nasal tip.

1.1.1. Lateral Crural Steal: This is one of the most useful techniques in mestizo noses because it increases rotation and projectionwithout compromising support. The rotation is done by lateralizing the position of the domes by lengthening the medialcrura. The vestibular skin of the alar cartilage is dissected from the undersurface of the dome area and the "new" dome ismarked 3-5mm lateral to the existing dome depending on how much tip rotation is needed. This rotation is done bylenthening the medial crura at the expense of the lateral crura. Besides rotating and projecting the tip, this techniquecreates a more triangular base, and a tip with more definition (figure 11, 12)


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Figure 11 E


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Figure 12

2. Dome defining sutures: In the cases where the dome is in an adequate position but is not properly defined, mattresssutures are placed narrowing the domal angle. The suture must be tied trying to narrow the domal angle without pinchingthe domal area or producing buckling of the lateral crus of the alar cartilage. In the cases where the alar cartilage is veryweak or a concavity forms after tying the sutures, the lateral portion of the cartilage can be straightened with a lateralcrural strut graft (figure 13).


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Figure 13 C

3. Intradomal Suture: This suture of 5-0 nonabsorbable material is performed to decrease the interdomal distance of thenewly defined or existing domes narrowing a very wide nasal tip. Care must be taken not to suture the domes too closetogether as this can result in a "pinched" look or a unitip deformity. (figure 14)


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Figure 14 E

4. Lateral Crural Spanning Suture: This is a mattress suture of 5-0 non absorbable material that is placed in the cephalicmargin of the lateral crus of the alar cartilages and is tied in the midline. It helps improve and refine an extremely bulbous tipand helps correct an ala with marked hooding. It is important to try and avoid vertical tip malpositioning of the cartilages inan attempt to define and narrow the nasal tip (Figure 15).


5. The transdomal refinement suture: With this technique a 5-0 non absorbable mattress suture is passed through the existingdomes and knotted in the midline. This suture changes the tip shape to a more triangular one (figure16). It is important not


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to tie the suture too tightly or to place the domes too close together. An adequate interdomal distance must be maintainedto preserve the double light at the dome area.19

Figure 16

6. Septoco lumellar suture: It is a loop suture that is introduced from a point low at the foot of the medial crura on one side,passed thru a point high in the caudal septum near the anterior septal angle, taken out at a point low at the foot of themedial crura of the contralateral side and then tied in the midline over the feet of the medial crura. This suture fixes themedial crura/columellar strut complex to the caudal septum and it helps preserve or slightly increase the rotation that hasbeen achieved with other techniques. The nasal base must be stable and fixed in the midline so the whole complex will notbe shifted to one side of the nose when the suture is tied in place (figure 17).


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Figure 17

1.a. Division of alar cartilages: Long plunging tips with a very thick S-STE are not rare in latino or mestizo patients. Thesepatients will have acute nasolabial angles with small and sometimes retrussive nasal spines accompanied by weak and shortcaudal nasal septums and long lateral and/or medial crura. In these patients a columellar strut combined with rotatingtechniques on the nasal tip will usually not be enough and the results wont be long lasting because the pedestal will nothave enough structural support. The surgical option that works well on these patients is the lateral crural overlay techniqueand the medial crural overlay. 20,21

b. Lateral Crural Overlay: Is very useful in long noses where the lateral crura is much longer than the medial crura. An incisionon the alar cartilage is placed 10mm lateral to the dome. The segments are elevated and freed from the underlying mucosaand the medial segment is superimposed over the lateral segment several millimeters and sutured in placed with a 5-0 nonabsorbable suture. This technique shortens the length of the lateral crura, reinforces the lateral crus of the alar cartilage androtates the tip upwards shortening the nose (figure 18).


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Figure 18 E Figure 18 F

c. Medial Crural Overlay: when the medial crura is overly long or very asymmetric a medial crural overlay is very useful. Anincision is placed a few mm below the existing domes, and the fragments are superimposed and sutured in place with a 5-0non absorbable suture. This creates counter-rotation of the nasal tip and lowers the height of the domes. In the caseswhere the overprojection is due to an overly long lateral and medial crura, an overlay technique in both areas of the alarcartilages will deproject the tip without changing the rotation (Figure 19



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Figure 19 G

1. Grafts: Grafts in the nasal tip can be grafts that give support and structure (structural grafts), they can be used to helpdefine structures, or they can be used as camouflage . Mestizo or latino patients in general want noses that look smallerand have more definition. Additionally, these are noses that have poor osteocartilaginous support structures and a thick S-STE. It becomes very important to reinforce and build up structures to be able to create support and definition but withoutmaking them a lot bigger. Since the amount of cartilage available is limited, grafts should be chosen and used wisely. On thenasal tip, grafts should be placed carefully and when possible sutured in place to avoid post-surgical shifting.

a. Shield Graft: It is very useful in patients with thick skin that have bulbous, flimsy, undefined tips. Shield grafts can be shapedfrom septal, conchal or rib cartilage and should be carved according to patients needs. The graft is fixed in place to thecaudal margins of the medial/intermediate crural strut complex with 6-0 non absorbable sutures. The leading edge of thegraft should be positioned at the level of the existing domes or slightly above and covered with morcelized cartilage orperichondrium to prevent visibility of the leading edge of the graft over time. These grafts help improve definition andprojection in the nasal tip. (figure 20)


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Figure 20 G Figure 20 H


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Figure 20 I

b. Alar Strut Grafts: These are flat thin pieces of cartilage that are placed in the undersurface of the lateral crura. They willstiffen flimsy lateral crura, will help flatten the lateral crus when there is marked bulbosity or they can also correct anyconvexities created in the lateral crus when dome sutures are used. (figure 21)


c. Alar rim grafts: These grafts help correct alar contour irregularities, alar flare, and give the ala enough support to preventcollapse. They are thin, long pieces of cartilage that are placed in a non-anatomic position immediately above the alar rim.The graft should not extend all the way up to the soft triangle as this can create irregularities and asymmetries in this area.When using the external approach, the graft is placed thru the marginal incision and its superior edge sutured in place with a5 or 6-0 absorbable suture. The leading edge of the graft is crushed with a forceps or morcelized to prevent visibility over

time In Latino patients it is not unusual to find that there is a small convexity in the lateral crus of the alar cartilage after


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time. In Latino patients it is not unusual to find that there is a small convexity in the lateral crus of the alar cartilage afterdome binding sutures have been performed. These grafts will help hide this irregularity and will give the nasal tip lobule amore symmetrical appearance.(figure 22)



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Figure 22 G

d. Morcelized or Crushed Cartilage: Is cartilage used to hide and smooth out irregularities, fill in concavities and soften


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d. Morcelized or Crushed Cartilage: Is cartilage used to hide and smooth out irregularities, fill in concavities and softencontours. Any cartilage can be used (septum, ear or rib) but septal cartilage is the ideal material for crushing. Acartilage/bone crusher is used trying to have as a result a piece of cartilage that is pliable, has the texture of a mat and willnot break when manipulated. This cartilage is frequently placed over the supratip area to fill in any marked supratip breaks,over the alar cartilages covering the dome area, covering the leading edge of a shield graft or covering the nasal tip whentip suturing techniques have been used. Whenever possible it should be sutured in place with 6-0 sutures so it wont shiftover time. This type of graft is used frequently as a finishing touch in nasal tip surgery in latino patients even if they have athick S-STE. This helps give a smooth round look to the nasal tip and helps hide any irregularities that could becomenoticeable over time (Figure 23). 8


Figure 23 C


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Alar Base Reduction

Alar base reduction is not performed on a routine basis. If the nasal base is stabilized and the tip has increased its rotationand rotation, it is not infrequent to see that the orientation of the nostrils change acquiring a more normal and symmetricshape. This procedure is defined at the end of the procedure when all incisions have been closed. Incisions should be placedcarefully to avoid unnecessary scarring. The medial incision usually is placed in the natural crease that is created betweenthe nasal sill and ala. Laterally the incision should be kept within the alar facial groove if possible. Closure is performed using5-0 or 6-0 non absorbable sutures taking care to evert edges. Sutures are removed after 8-10 days.

Skin Soft Tissue Envelope

Latino or mestizo patients tend to have a thicker S-STE . In spite of this, no defatting or thinning of the subcutaneous flap isperformed. Cautery is used only when absolutely necessary as this can compromise the viability of the skin flap.

Postsurgical Follow-Up

Adequate follow-up on latino patients is a must. Columellar stitches and cast are removed after 1 week and nose is tapedfor an additional week. Excessive taping of the nose should be prevented as this will increase the inflammatory reaction onthe skin.

Skin care is a priority in latino patients. Inflammation is more prominent and the skin covering the nasal dorsum and tip willbe oilier and shinier several months after surgery. Sun exposure should be avoided for several months as this will increaseedema. It is not uncommon to find dark circles under the eyes in mestizo patients. After surgery, these can become moreprominent and it is imperative for patients to avoid sun exposure as this will definitely worsen pigmentation under the eyes.If the patient uses glasses or sunglasses, these should be avoided at least for 6 weeks after surgery. If glasses are needed,they should be taped on the forehead.

In the extreme cases where there is prominent acne that we know will worsen the postsurgical inflammation, it isimportant for them to follow a facial cleaning regime. In some cases these patients should be jointly treated with adermatologist. When there is persistent edema in the tip or supratip region, this can be treated with 1-2mg injections oftriamcinolone acetonide subdermically. Injections can be started as early as 2-3 weeks after surgery and can be repeated

every 6 weeks, taping the tip area inmediatly after injection. Injections performed too frequently can result in permanentcutaneous atrophy, and it is important to reassure patients that inflammation will subside and skin will slowly regain itsnormal texture.

Rhinoplasty patients usually want to see immediate results in spite of the fact you have made them aware that realpostsurgical results will not be completely appreciated until after 6 months to a year post op. It is important to have a goodpatient relationship established. This will help optimize final results and will definitely help during the initial postsurgicalmonths.

Conclusions

L ti ti t f th f t t i th i i U it d St t t d Rhi l t i f th ti


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Latino patients are one of the fastest growing ethnic group in United States today. Rhinoplasty is one of the cosmeticoperations that is constantly asked for in this group of patients. Being able to establish a proper diagnosis and understandwhat our patients want is very important to be able to obtain consistent results. The most common problem found in thesepatients is a relatively weak structural bony and cartilaginous framework and a thick S-STE. These are noses that haveproblems with projection and rotation. Surgical techniques are focused on minimal tissue excision, strengthening ofunderlying support structures of nose and reorienting and increasing rotation and projection of the nose with sutures andgrafts. The final result should be a nose that blends in with the patients face, does not change their ethnic featuresdramatically and can withstand the pass of time without resulting in important postsurgical deformities. The final goal of oursurgery is to bring our patients closer to their aesthetic ideal but in a realistic fashion.

BIBLIOGRAPHY

1. The American Heritage Dictionary of the English Language, Fourth Edition Copyright 2006 by Houghton Mifflin Company.Published by Houghton Mifflin Company.

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1996;122:1079865. Cobo R. Mestizo rhinoplasty. Facial Plast Surg 2003;19(3):257686. Lawson, Hoefflin S. Ethnic Rhinoplasty. In: Hoefflin S. Ethnic Rhinoplasty. New York: Springer Verlag; 1-15.

7. Farkas L. Anthropometry of the Head and Face. 2nd ed.New York: Raven Press; 1994:2863018. Cobo R. Hispanic/Mestizo Rhinoplasty. Facial Plast Surg Clin N Am 18 (2010) 173-188.9. Cobo R. Facial Aesthetic surgery with emphasis on rhinoplasty in the Hispanic patient. Curr Opin Otolaryngol Head Neck

Surg 2008:16 (4):369-37510. Kim DW, Hwang HS. Traumatic rhinoplasty in the non-caucasian nose. Facial Plast Surg Clin N Am. 2010; 18: 141-15111. Toriumi D, Johnson C. Open rhinoplastyfeatured technical points and long-term follow-up. Facial Plastic Surgery Clinics of

North America 1993:(1)122)12. Becker D, Pastorek NJ. The Radix Graft in Cosmetic Rhinoplasty. Arch Facial Plast Surg 2001 3(2) 115-11913. Romo T. III, Abraham MT. The Ethnic Nose. Facial Plastic Surgery 2003: Vol 19, # 3: 269-277.14. Godin MS, Waldman SR, Johnson CM Nasal Augmentation using Gore-tex: a 10 year experience. Arch Facial Plast Surg

1999: 1(2) 118-21

15. Toriumi D, Management of the Middle Nasal Vault in Rhinoplasty. 1995: Op Tech Plast Reconstr Surg. 2(1) 16-3016. Anderson JR: The dynamics of rhinoplasty. In Proceedings of the Ninth International Congress of Otolaryngology.Exerpta

Medica International Congress Series, No. 206. Amsterdam, Exerpta Medica, 1969,pp 708710.17. Johnson CM, To WC, The tripod-pedestal concept. In: A case approach to open structure rhinoplasty. 1rst Edition

Philadelphia, Pennsylvania, Elsevier Saunders; 2005. P.9-2018. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006: 8 (3)15618519. Tardy ME, Cheng E. Transdomal suture refinement of the nasal tip. Facial Plast Surg 1987: (4) 317-32620. Konior RJ, Kridel R. Controlled nasal tip positioning via the open rhinoplasty approach. Facial Plastic Surg Clin of North

America 1993: 1 53-62

21. Perkins S, Patel A. Endonasal Suture Techniques in Tip Rhinoplasty. Facial Plast Surg Clin N Am 17(2009) 41-54.


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, q p p y g ( )Tags:bulbous tips, ethnic, latino rhinoplasty, mestizo, Rhinoplasty, structural grafting, structural support, suturingtechniques

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