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338 Part VII&Facial Surgery
Fig. 46.6 Intercartilaginous graft. Insertion of a septal graft into the gap between the upper lateral cartilage and
the lateral crus element. The cephalic end of it is sutured end-to-end to the upper lateral cartilage. The caudal
end slips under (deep to) the edge of the lateral crus element. (Source: Overresection. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002;109:2495; discussion 2506
2. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg
1992;90:821
3. Gruber RP, Kryger G, Chang D. The intercartilaginous graft for actual and potential alar retraction. Plast Reconstr
Surg 2008;121:288e
PROSTHETIC COMPLICATIONS
15. A dorsal prosthetic implant becomes palpable and visible beneath the skin. What is the most appropriate
corrective action?
D. Removal of the implant and replacement with a new prosthetic.
When prosthetic implants become extruded, palpable, or visible, there is increased risk of infection even if
the skin remains intact. For this reason, they must be removed and replaced with autologous tissue, which
carries a lower risk of infection. There is no indication in the case described above to start antibiotics.
1,2
REFERENCES
1. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of AlloDerm for the correction of nasal contour deformities. Plast
Reconstr Surg 2001;107:561; discussion 571
2. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of autogenous rib cartilage grafts. Clin Plast Surg
2010;37:371
RIB GRAFT
16. Injury to the parietal pleura is identified during rib graft extraction. What is the correct course of action by
the surgeon?
D. Place red rubber catheter into the cavity, close the incision in layers, and remove catheter with suc-
tion while providing positive pressure ventilation.
Collection of rib graft carries the risk of pneumothorax, as the parietal pleura lies just beneath the ribs and
is prone to injury when the overlying rib is extracted. In the case of injury to the parietal pleura, a red
Chapter 46&Secondary Rhinoplasty 339
rubber catheter should be placed into the pleural cavity, the incision should be closed in layers, and the
catheter should be removed with suction while positive pressure ventilation is provided. This should be
followed by a chest radiograph postoperatively to monitor for pneumothorax.
1
REFERENCE
1. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for secondary rhinoplasty. Plast Reconstr Surg
2008;121:1442
47. Ethnic Rhinoplasty
Anup Patel, Simon Moradian
See Essentials of Aesthetic Surger y, pp. 634–644
PREOPERATIVE PLANNING
1. To ensure patient satisfaction following ethnic cosmetic rhinoplasty, which of the following must be routinely
addressed during the preoperative evaluation?
A. Payment plans.
B. Skip over sensitive history such as previous facial trauma or prior nasal/sinus surgery.
C. CT of the head looking for any abnormalities.
D. Rhinometry results.
E. Determine whether the goal is for Westernization of features versus maintenance of natural characteristics.
PREOPERATIVE PLANNING
2. What tool should surgeons use to demonstrate potential changes preoperatively that can help patients com-
ment on desired modifications, and allow the surgeon to better understand the patient's goals and desires?
A. CT head.
B. Digital image-morphing software.
C. Pencil/paper sketches.
D. Clay carvings.
E. Rhinometry.
ETHNIC ANATOMIC PRINCIPLES
3. What are anatomic variations in ethnic patients when compared to Western patients?
A. Skin is usually thicker, more sebaceous, and relatively inelastic in ethnic patients.
B. The fibrofatty layer is thinner and less prominent over the lower lateral cart ilages and between the medial
crura.
C. Alar base usually has a decreased base width with insertion lateral to the medial canthal lines. There is min-
imal flaring where the alae extend less than 1 mm lateral to the alar facial grove.
D. The soft tissue facet between the medial crura and lower lateral cartilages is often acute and has minimal fat.
E. The fibrofatty layer does not contribute to the tip definition.
ETHNIC ANATOMIC PRINCIPLES
4. Which of the following is characteristic of a Black nose?
A. Short nasal bones, wide nose, low dorsum, wide bimalar distance, horizontally oriented nostrils, deficient
premaxilla, limited septal cartilage.
B. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, less septal cartilage, deficient premaxilla,
wide nasal base, and retracted columella.
C. Long nasal bones, low radix, large hump, hanging columella, septal deviation.
D. Long nasal bones, low dorsum, narrow nose.
E. Low radix height, near-normal bridge, dependent tip.
Chapter 47&Ethnic Rhinoplasty 341
ETHNIC ANATOMIC PRINCIPLES
5. Which of the following is characteristic of an Asian nose?
A. Short nasal bones, wide nose, low dorsum, wide bimalar distance, horizontally oriented nostrils, deficient
premaxilla, limited septal cartilage.
B. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, less septal cartilage, deficient premaxilla,
wide nasal base, and retracted columella.
C. Long nasal bones, low radix, large hump, hanging columella, septal deviation.
D. Low radix height, near-normal bridge, dependent tip.
E. High radix, near-normal bridge, dependent tip.
ETHNIC ANATOMIC PRINCIPLES
6. Which of the following is characteristic of a Middle Eastern nose?
A. Short nasal bones, wide nose, low dorsum, wide bimalar distance, horizontally oriented nostrils, deficient
premaxilla, limited septal cartilage.
B. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, less septal cartilage, deficient premaxilla,
wide nasal base, and retracted columella.
C. Long nasal bones, low radix, large hump, hanging columella, septal deviation.
D. Low radix height, near-normal bridge, dependent tip.
E. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, wide nasal base.
ETHNIC ANATOMIC PRINCIPLES
7. Which of the following is characteristic of a type II (Mexican American) nose?
A. Short nasal bones, wide nose, low dorsum, wide bimalar distance, horizontally oriented nostrils, deficient
premaxilla, limited septal cartilage.
B. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, less septal cartilage, deficient premaxilla,
wide nasal base, retracted columella.
C. Long nasal bones, low radix, large hump, hanging columella, septal deviation.
D. Low radix height, near-normal bridge, dependent tip.
E. Long nasal bones, low dorsum, deficient premaxilla, septal deviation, horizontally oriented nostrils, wide
nasal base.
ANATOMIC PRINCIPLES/PREOPERATIVE PLANNING
8. Which of the following is an advantage to using costal cartilage as grafting material?
A. Overall infection risk of 5%.
B. Grafts tend to be straighter compared to septal grafts.
C. Higher vascular demand making it less likely to resorb.
D. Low donor site morbidity.
E. Lower vascular demand making it less likely to resorb.
PREOPERATIVE PLANNING
9. Which of the following is an advantage of using allografts such as silicone, ePTFE, and porous polyethylene?
A. Decreased lifetime risk of infection.
B. No additional surgical site, and minimal change in operative time.
C. Decreased lifetime risk of extrusion.
D. Less prolonged edema after implantation.
E. Less nasal stiffness after structural grafting.
PERIOPERATIVE CONSIDERATIONS
10. Which of the following is correct regarding injecting local anesthetic before prepping and draping?
A. It allows ample time for vasodilation.
B. Injection can create hydrostatic dissection for ease of elevation of mucoperichondrial flaps.
C. 2% lidocaine without epinephrine is preferred.
D. 2% Marcaine with epinephrine is preferred.
E. An infraorbital block (V2) is preferred.
342 Part VII&Facial Surgery
ANATOMIC PRINCIPLES/PREOPERATIVE PLANNING
11. Which of the following is true when harvesting auricular cartilage?
A. Infection prophylaxis is not required if auricular cartilage is to be harvested.
B. It takes longer to harvest than costal cartilage.
C. Infection prophylaxis is required if auricular cartilage is to be harvested.
D. If auricular cartilage is to be harvested, the surgeon does not have to change gloves to prevent
contamination.
E. Auricular cartilage has a lower vascular demand when compared to costal cartilage.
PREOPERATIVE PLANNING/PERIOPERATIVE CONSIDERATIONS
12. What is the benefit of sharp dissection while opening the nose?
A. A large, loose subperiosteal pocket is created in anticipation of a secure dorsal augmentation graft.
B. Helps preserve the subdermal plexus and prevent excessive swelling.
C. Helps preserve the columellar artery.
D. Minimizes destabilization of septal cartilage.
E. Minimizes intraoperative blood loss.
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
13. Why is it impor tant to avoid injury to soft tissue triangles during tip exposure?
A. They are likely to cause excessive intraoperative bleeding.
B. They contain the neurovascular bundle.
C. Injury can lead to destabilization of the junction between the upper and lower cartilages.
D. They are extremely difficult to repair.
E. They protect and support the lower lateral cartilages.
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
14. When harvesting septal cartilage after the upper third of the nose is addressed to prevent destabilization,
how much cartilaginous L-strut should be preserved to ensure adequate support?
A. 2.5 mm.
B. 5 mm.
C. 10 mm.
D. 15 mm.
E. 20 mm.
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
15. What is true when performing an osteotomy?
A. They are per formed from lateral to medial.
B. They should be performed if using a large dorsal graft greater than 3.5 mm in height.
C. They are used to narrow the dorsum or correct deviations or dorsal hump.
D. They should only be performed in revision rhinoplasty.
E. They should only be used in primary rhinoplasty.
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
16. Which of the following is a benefit of using spreader grafts?
A. They allow for retraction of the columella.
B. Unilateral placement of a spread graf t is used to add curvature to the nose.
C. They increase the area of the internal nasal valve and provide foundation to prevent saddling.
D. They are used to decrease the internal nasal valve angle.
E. They are primarily used to help correct septal deviation.
OPERATIVE TECHNIQUE
17. What technique is used to reset the caudal septum to midline?
A. With a swinging-door maneuver or by shifting the nasal spine.
B. By placing 4–0 Silk sutures in the columella, and using as a lever to shift the spine.
C. By placing a curved caudal septal extension graft.
D. Costal cartilage is preferred to septal cartilage for caudal septal extension grafts as it is straighter.
E. Placement of spreader grafts.
Chapter 47&Ethnic Rhinoplasty 343
OPERATIVE TECHNIQUE
18. Which of the following is an appropriate technique for tip contouring?
A. Tip onlay grafts are used when no change to the infratip is needed.
B. A shield graft is used to decrease tip projection in thin-skinned patients.
C. Lateral crural strut grafts are used to enhance convexity.
D. Tip bulbosity can be corrected through the use of alar batten grafts.
E. Malpositioned lateral crura and alar retraction are corrected through repositioning of asymmetrical or cau-
dally oriented lateral cr ura.
PREOPERATIVE PLANNING/ETHNIC ANATOMIC PRINCIPLES
19. Which of the following is a good example of why an individualized approach is crucial to tip management in
ethnic patients?
A. Repositioning of the lateral crus may be effective for f lared nostril s caused by the large convex lower lateral
cartilages common to Middle Eastern patients.
B. Repositioning of the lateral crus may be effective for flared nostrils caused by the large convex lower lateral
cartilages common to Asian patients.
C. Repositioning of the lateral cr us may worsen the appearance of flared nostrils caused by large convex lower
lateral cartilages seen in Middle Eastern patients that commonly have weak lower lateral cartilages and
hanging alar lobules.
D. Repositioning of the lateral crus may be effective for narrowed nostrils caused by the large convex lower
lateral cartilages common to African American patients.
E. Repositioning of the lateral crus may worsen the appearance of flared nostrils caused by large convex lower
lateral cartilages commonly seen in Mexican American patients.
PERIOPERATIVE CONSIDERATIONS/ETHNIC ANATOMIC PRINCIPLES
20. Which of the following is an important principle to keep in mind when closing darker-skinned patients?
A. Absorbable sutures are most appropriate as they will minimize swelling, erythema, and scarring.
B. Nonabsorbable sutures are not appropriate as they will result in prolonged swelling, erythema, and possible
suture tracking when compared to absorbable sutures.
C. The use of absorbable sutures will result in prolonged erythema and possible suture tracking.
D. Chromic gut sutures are the most appropriate sutures for closing dark-skinned patients as it minimizes
inflammation, erythema, and possible suture tracking.
E. Plain gut sutures will result in minimal inflammation, erythema, and possible suture tracking.
PERIOPERATIVE CONSIDERATIONS
21. Radiopaque 0.25-mm septal splints are placed if turbinate work is performed to prevent what potential post-
operative complication?
A. Hematoma.
B. Infection.
C. Empty nose syndrome.
D. Synechiae formation.
E. Suture breakdown.
PERIOPERATIVE CONSIDERATIONS
22. When are lateral wall splints appropriate?
A. If turbinate work is performed.
B. If lateral crural strut grafts were used.
C. If auricular grafts were exclusively used.
D. If a radix graft is placed.
E. If the patient has any previous history of facial trauma.
OPERATIVE TECHNIQUE
23. Which is a key to successful base reduction?
A. The use of cautery.
B. Injecting local anesthetic prior to base reduction.
C. Taping of nose postoperatively to guide remolding.
D. Perpendicular incision to discourage eversion of skin edges.
E. Plan incision slightly adjacent to alar/facial or alar/vestibular
344 Part VII&Facial Surgery
POSTOPERATIVE CARE
24. Which of the following is an effective strategy to avoid complications following rhinoplasty?
A. Infection is managed aggressively with the patients returning to OR for a washout and drain placement
along with broad spectrum antibiotic coverage.
B. Dermal sutures are not recommended for the columellar incision as they increase scar width.
C. Visible grafts and warping should not be managed during the initial procedure—they should be returned to
the OR in 3 to 4 months.
D. Local anesthetic reduces the incidence of keloid formation following rhinoplasty.
E. Any base reduction should be performed prior to complete closure.
Chapter 47&Ethnic Rhinoplasty 345
Answers
PREOPERATIVE PLANNING
1. To ensure patient satisfaction following ethnic cosmetic rhinoplasty, which of the following must be routinely
addressed during the preoperative evaluation?
E. Determine whether the goal is for Westernization of features versus maintenance of natural
characteristics.
Patient consultation should include discussion of aesthetic preferences and cultural concerns. Patient
expectations and preferences should be assessed, and the surgeon should determine whether the goal is
for Westernization of features versus maintenance of natural characteristics. Problem-specific surgical
history must be obtained as history may greatly alter surgical plan. Palpation of the cartilaginous and
bony structures should also be performed.
REFERENCES
1. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37:335
2. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg 2013;111:1322; discussion 1340
3. Kontis TC, Papel ID. Rhinoplasty on the African-American nose. Aesthetic Plast Surg 2002;26(Suppl1):S12
4. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg 2009;123:1343
5. Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin North Am 2002;10:381
PREOPERATIVE PLANNING
2. What tool should surgeons use to demonstrate potential changes preoperatively that can help patients com-
ment on desired modifications, and allow the surgeon to better understand the patient's goals and desires?
B. Digital image-morphing software.
Three-dimensional stereophotogrammetry facilitates objective comparison of preoperative and
postoperative results. Digital image-morphing software allows direct communication of proposed
changes to all parameters (dorsal height, nasal length, tip rotation/projection, and base width). Patients
may comment on desired modifications based on the morphed image. The use of a computer-imaging
program can demonstrate potential changes preoperatively and aid in communication between patients
and surgeons regarding expectations and possible outcomes.
1,2,3,4,5
1,2,3
REFERENCES
1. Afrooz PN, Amirlak B. Digital imaging and standardized photography. In: Rohrich RJ, Adams WP Jr, Gunter JP, eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. New York: Thieme Publishers; 2014
2. Dixon TK, Caughlin BP, Manaretto N, Toriumi DM. Three-dimensional evaluation of unilateral cleft rhinoplasty
results. Facial Plast Surg 2013;29:106
3. Toriumi DM, DixonTK. Assessmentof rhinoplasty techniquesbyoverlay of before-and-after3D images.FacialPlast
Surg Clin North Am 2011;19:711
ETHNIC ANATOMIC PRINCIPLES
3. What are anatomic variations in ethnic patients when compared to Western patients?
A. Skin is usually thicker, more sebaceous, and relatively inelastic in ethnic patients.
Ethnic patients generally have thicker skin that is more sebaceous and relatively inelastic when compared to
their Western counterparts. The fibrofatty layer is also thicker (2–4 mm) and more prominent over the lower
lateral cartilages and between the medial crura. It plays a significant role in lack of tip definition. Alar base
usually has an increased base width with insertion lateral to the medial canthal lines. There is excess flaring
where the alae extend more than 2 mm lateral to the alar facial groove. Additionally, the soft tissue facet
between the medial crura and the lower lateral cartilages is obtuse and filled with fat.
1,2,3,4,5
REFERENCES
1. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg 2013;111:1322; discussion 1340
346 Part VII&Facial Surgery
2. Kontis TC, Papel ID. Rhinoplasty on the African-American nose. Aesthetic Plast Surg 2002;26(Suppl1):S12
3. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg 2009;123:1343
4. Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin North Am 2002;10:381
5. Beheri GE. Rhinoplasty in Egyptians. Aesthetic Plast Surg 1984;8:145
ETHNIC ANATOMIC PRINCIPLES
4. Which of the following is characteristic of a Black nose?
A. Short nasal bones, wide nose, low dorsum, wide bimalar distance, horizontally oriented nostrils, defi-
cient premaxilla, limited septal cartilage.
The Black nose is characterized by short nasal bones, wide nose, low dorsum, wide bimalar distance,
horizontally oriented nostrils, deficient premaxilla, limited septal cartilage (Table 47.1).
Table 47.1 Specific Ethnic Characteristics
Ethnicity Characteristics
Black nose Short nasal bones
Wide nose
Low dorsum
Wide bimalar distance
Horizontally oriented nostrils, wide base
Deficient premaxilla
Limited septal cartilage
Asian nose Thick sebaceous skin
Low dorsum
Weak lower lateral cartilage
Less septal cartilage
Deficient premaxilla
Wide nasal base
Retracted columella
Middle Eastern nose Long nasal bones
Low radix
Large hump
Hanging columella
Septal deviation
Hispanic nose (types
described by Daniel
1
)
Type I (Castilian): Normal radix height, high bridge, normal tip projection
Type II (Mexican American)—most common: Low radix height, near-normal bridge, depen-
dent tip
Type III (Mestizo): Broad base, thick skin, wide tip
Type IV (Creole)—predominantly black features: Broad, flat lower third, short columella,
transversely oriented nostrils, f laring alae
1
REFERENCE
1. Daniel RK. Hispanic rhinoplasty in the UnitedStates,with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244; discussion 257
Chapter 47&Ethnic Rhinoplasty 347
ETHNIC ANATOMIC PRINCIPLES
5. Which of the following is characteristic of an Asian nose?
B. Thick sebaceous skin, low dorsum, weak lower lateral cartilage, less septal cartilage, deficient pre-
maxilla, wide nasal base, and retracted columella.
The Asian nose is characterized by thick sebaceous skin, low dorsum, weak lower lateral cartilage, less
septal cartilage, deficient premaxilla, wide nasal base, and retracted columella (Table 47.2).
Table 47.2 Specific Ethnic Characteristics
Ethnicity Characteristics
Black nose Short nasal bones
Wide nose
Low dorsum
Wide bimalar distance
Horizontally oriented nostrils, wide base
Deficient premaxilla
Limited septal cartilage
Asian nose Thick sebaceous skin
Low dorsum
Weak lower lateral cartilage
Less septal cartilage
Deficient premaxilla
Wide nasal base
Retracted columella
Middle Eastern nose Long nasal bones
Low radix
Large hump
Hanging columella
Septal deviation
Hispanic nose (types
described by Daniel
1
)
Type I (Castilian): Normal radix height, high bridge, normal tip projection
Type II (Mexican American)—most common: Low radix height, near-normal bridge,
dependent tip
Type III (Mestizo): Broad base, thick skin, wide tip
Type IV (Creole)—predominantly black features: Broad, flat lower third, short
columella, transversely oriented nostrils, flaring alae
1,2,3
REFERENCES
1. Daniel RK. Hispanic rhinoplasty in the UnitedStates,with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244; discussion 257
2. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg 2013;111:1322; discussion 1340
3. Kontis TC, Papel ID. Rhinoplasty on the African-American nose. Aesthetic Plast Surg 2002;26(Suppl 1):S12
ETHNIC ANATOMIC PRINCIPLES
6. Which of the following is characteristic of a Middle Eastern nose?
C. Long nasal bones, low radix, large hump, hanging columella, septal deviation.
The Middle Eastern nose is characterized by long nasal bones, low radix, large hump, hanging columella,
septal deviation (Table 47.3).
1