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348 Part VII&Facial Surgery
Table 47.3 Specific Ethnic Characteristic s
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
REFERENCE
1. Daniel RK. Hispanic rhinoplasty in the UnitedStates,with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244; discussion 257
ETHNIC ANATOMIC PRINCIPLES
7. Which of the following is characteristic of a type II (Mexican American) nose?
D. Low radix height, near-normal bridge, dependent tip.
Hispanic nose, type II Mexican American nose is characterized by low radix height, near-normal bridge,
dependent tip (Table 47.4).
1
Table 47.4 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 colu-
mella, transversely oriented nostrils, flaring alae
Chapter 47&Ethnic Rhinoplasty 349
REFERENCE
1. Daniel RK. Hispanic rhinoplasty in the UnitedStates,with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244; discussion 257
ANATOMIC PRINCIPLES/PREOPERATIVE PLANNING
8. Which of the following is an advantage to using costal cartilage as grafting material?
E. Lower vascular demand making it less likely to resorb.
The overall infection rate is less than 1% (not 5%). Also, costal cartilage is stronger therefore can be cut
thinner with less bulk in the nose, has lower vascular demand making it less likely to resorb (not higher),
and surgeons are able to harvest a larger amount of cartilage. Septal grafts tend to be straighter when
compared to costal cartilage grafts. The disadvantages to costal cartilage harvest include increased
operative time, warping, and donor site morbidity.
1,2,3,4,5,6
REFERENCES
1. Ozaki W, Buchman SR. Volume maintenance of onlay grafts in the craniofacial skeleton: microarchitecture versus
embryologic origin. Plast Reconstr Surg 1998;102:291
2. Lin KY, Bartlett SP, Yaremchuck MJ, et al. The effect of rigid fixation on the survival of onlay bone grafts: an experimental study. Plast Reconstr Surg 1990;86:449
3. Vuyk HD, Adamson PA. Biomaterials in rhinoplasty. Clin Otolaryngol 1998;23:209
350 Part VII&Facial Surgery
4. Peer LA. Diced cartilage grafts. Arch Otolaryngol 1943;38:156
5. Peer LA. Cartilage grafting. Br J Plast Surg 1954;7:250
6. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. New York: Thieme Publishers; 2015
PREOPERATIVE PLANNING
9. Which of the following is an advantage of using allografts such as silicone, ePTFE, and porous polyethylene?
B. No additional surgical site, and minimal change in operative time.
Advantages of using allografts include ease of use, no additional surgical site, and minimal change in
operative time. Disadvantages include increased lifetime risk of infection, displacement/extrusion, thinning
of skin over implant site, and implant translucency and pain. Often times, allografts, particularly porous
polyethylene, are associated with significant postoperative edema. Additionally, structural grafting can lead
to nasal stiffness which should be addressed with the patient during the initial consultation.
1
REFERENCE
1. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. New York: Thieme Publishers; 2015
PERIOPERATIVE CONSIDERATIONS
10. Which of the following is correct regarding injecting local anesthetic before prepping and draping?
B. Injection can create hydrostatic dissection for ease of elevation of mucoperichondrial flaps.
Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is injected before prepping and draping, which
allows ample time for vasoconstriction. Injection also creates hydrostatic dissection for ease of elevation of
mucoperichondrial flaps.
1
REFERENCE
1. Decker JR, Dutton JM. Local anesthesia for nasal and sinus surgery. Ear Nose Throat J 2013;92(3):107–108
ANATOMIC PRINCIPLES/PREOPERATIVE PLANNING
11. Which of the following is true when harvesting auricular cartilage?
C. Infection prophylaxis is required if auricular cartilage is to be harvested.
Infection prophylaxis with first-g eneration cephalosporin and fluoroquinolone is required if costal or
auricular cartilage is to be harvested. The entire face and intranasal area are prepared with dilute
povidone-iodine, and the patient is draped to maintain sterility throughout the procedure. If cartilage is to
be harvested, then surgeons must change gloves to prevent contamination. Auricular cartilage actually has
a higher vascular demand when compared to costal cartilage making it more likely to resorb.
1
REFERENCE
1. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. New York: Thieme Publishers; 2015
PREOPERATIVE PLANNING/PERIOPERATIVE CONSIDERATIONS
12. What is the benefit of sharp dissection while opening the nose?
B. Helps preserve the subdermal plexus and prevent excessive swelling.
Sharp dissection while opening the nose helps to preserve the subdermal plexus and prevent excessive
swelling that occurs with tearing of the tissue during blunt dissection. By limiting blunt dissection over
the nasal dorsum, a tight subperiosteal pocket is preserved in anticipation of a secure dorsal
augmentation graft.
1
REFERENCE
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:42
Chapter 47&Ethnic Rhinoplasty 351
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
13. Why is it impor tant to avoid injury to soft tissue triangles during tip exposure?
D. They are extremely difficult to repair.
The soft-tissue triangle is located between the dome of alar cartilage superiorly and the nostril margin
inferiorly. There is a lack of cartilage support in this area as it is formed only of skin and soft tissue. The
triangle is made of two juxtaposed layers of skin, the external nasal skin and the internal vestibular skin,
separated by loose areolar tissue and some terminal fibers of nasalis and depressor septi nasi muscles. It
does not contain any neurovascular structures. Any postoperative retraction, notching, or asymmetries of
soft triangles can seriously affect the rhinoplasty outcome. Tip exposure should be achieved with Converse
scissors, making every attempt to avoid injury to soft tissue triangles, as these are extremely difficult to
1,2,3
repair.
REFERENCES
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:42
2. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast
Reconstr Surg 1997;99:943; discussion 953
3. Losquardro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plast Surg 2012;28:218
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?
C. 10 mm.
In order to decrease the potential for loss of the tip and dorsal nasal support, it is imperative to
preserve at least a 1-cm (10 mm) width portion of the dorsal and caudal septal segment which is
deemed the L-strut. Deformities of the septal L-strut create functional and aesthetic problems such as a
twisted nose, malpositioned tip, saddle deformity, and internal valve insufficiency.
1,2
REFERENCES
1. Jeong JY. Obtaining maximal stability with a septal extension technique in East Asian rhinoplasty. Arch Plast Surg
2014;41(1):19–28
2. Lee J-S, Lee D, Ha D-H, Kim S. Redefining the septal L-strut in septal surgery. PloS one 2015;10:e0119996
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
15. What is true when performing an osteotomy?
C. They are used to narrow the dorsum or correct deviations or dorsal hump.
Osteotomies are used to narrow the dorsum or to correct deviations or dorsal hump. They are
performed medial to lateral and should be avoided if major dorsal augmentation (large dorsal graft >3
mm in height) is planned to prevent a tubular, narrowed appearance of the dorsum.
1
REFERENCE
1. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37:335
ANATOMIC PRINCIPLES/PERIOPERATIVE CONSIDERATIONS
16. Which of the following is a benefit of using spreader grafts?
C. They increase the area of the internal nasal valve and provide foundation to prevent saddling.
Spreader grafts increase the area of the internal nasal valve and provide foundation to prevent saddling
and postoperative rotation/shortening. They also work to lengthen a short nose or retracted columella.
Unilateral placement of a spreader graft is used to straighten the nose.
1,2
REFERENCES
1. SheenJH. Spreader graft: a method of reconstructing the roof of the middle nasal vault followingrhinoplasty. Plast
Reconstr Surg 1984;73:230
2. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg 1998;102:856
352 Part VII&Facial Surgery
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.
The caudal septum is reset to midline with swinging-door maneuver or by shifting the nasal spine. This
can be achieved with a 5-mm straight osteotome placed at a slight angle toward the desired position.
Once engaged, the osteotome acts as a lever to shift the spine. Caudal septal extension/replacement
grafts are the only cart ilage grafts in structure rhinoplasty that must be straight. Septal cart ilage may be
preferred over costal cartilage in this case. Caudal septal extension grafts are preferred because they
minimize postoperative loss of tip projection and help to control rotation and length.
1,2,3
REFERENCES
1. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast
Reconstr Surg 1997;100:999
2. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape.
Plast Reconstr Surg 2003;112:1929
3. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. New York: Thieme Publishers; 2015
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.
Tip onlay grafts are used when no change to the infratip is needed. A shield graft is used to increase
projection in thick-skinned patients for appropriate tip definition. Lateral crural grafts prevent alar
collapse and control overrotation. They also prevent visibility of the shield graft. Lateral crural strut
grafts flatten the convexity. Tip bulbosity can be corrected through alteration of the dome and use of
lateral crural strut grafts. Malposit ioned lateral crura and alar retraction are corrected through
repositioning of asymmetrical or cephalically oriented (not caudally oriented) lateral crura.
1,2
REFERENCES
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:42
2. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast
Reconstr Surg 1997;99:943; discussion 953
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 flared nostrils caused by the large convex lower
lateral cartilages common to Middle Eastern patients.
An individualized approach is crucial to tip management in ethnic patients. Repositioning of the lateral
crus may be effective for flared nostrils caused by large convex lower lateral cartilages in Middle
Eastern patients but may worsen the appearance in Asian patients with weak lower lateral cartilages
and hanging alar lobules.
1,2
REFERENCES
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:42
2. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast
Reconstr Surg 1997;99:943; discussion 953
PERIOPERATIVE CONSIDERATIONS/ETHNIC ANATOMIC PRINCIPLES
20. Which of the following is an important principle to keep in mind when closing darker-skinned patients?
C. The use of absorbable sutures will result in prolonged erythema and possible suture tracking.
In darker-skinned patients, the use of absorbable sutures will result in prolonged erythema and possible
suture tracking. In the early healing period, the inflammatory response in conjunction with the
inflammation related to the gradual breakdown of the absorbable suture material can lead to abnormal
Chapter 47&Ethnic Rhinoplasty 353
hypertrophic scarring, hypo- or hyperpigmentation, stitch abscess, and granulomas particularly in darkskinned patients. In regard to dyspigmentation, these differences in healing between white and darker
skin types is likely related to melanocyte regulation. Although black skin and white skin contain almost
equal numbers of melanocytes and melanosomes, the cells do differ in terms of structure and function.
As melanosomes mature, stage I and II lightly pigmented melanosomes are found in higher ratios in
people with paler skin types and more densely laden, pigmented stage III and IV melanosomes in higher
ratios in people with darker skin types. Melanocytes withinblackskin are also larger and more dendritic
than those of white skin which may contribute to these differences in scarring and
dyspigmentation.
1,2,3,4
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
4. Chadwick S, Heath R, Shah M. Abnormal pigmentation within cutaneous scars: A complication of wound healing.
Indian J Plast Surg 2012;45(2):403-411
PERIOPERATIVE CONSIDERATIONS
21. Radiopaque 0.25-mm septal splints are placed if turbinate work is performed to prevent what potential post-
operative complication?
D. Synechiae formation.
Synechiae is an adherence with subsequent scar ring between the two mucosal surfaces in the nasal cavity
which may cause nasal obstruction which may lead to rhinitis and rhinosinusitis that can occur after any
turbinate manipulation or trauma. In the setting of functional rhinoplasty with turbinate work, radiopaque
0.25-mm septal splints are placed to prevent synechiae formation.
1
REFERENCE
1. Losquardro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plast Surg 2012;28:218
PERIOPERATIVE CONSIDERATIONS
22. When are lateral wall splints appropriate?
B. If lateral crural strut graf ts were used.
Lateral wall splints are placed if lateral crural strut grafts were used to ensure redraping of vestibular
mucosa. They are fashioned from 0.25 bivalve splints.
1
REFERENCE
1. Losquardro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plast Surg 2012;28:218
OPERATIVE TECHNIQUE
23. Which is a key to successful base reduction?
D. Perpendicular incision to discourage eversion of skin edges.
The key steps to successful base reduction are as follows: Plan incision slightly adjacent to alar/facial or alar/
vestibular junction. Forego injecting local anesthetic because it may deform anatomy. Avoid all cautery.
Slightly beveled incisions to promote eversion of skin edges. Close incisions meticulously.
1
REFERENCE
1. Losquardro WD, Bared A, Toriumi DM. Correction of the retracted alar base. Facial Plast Surg 2012;28:218
354 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 the OR for a washout and drain
placement along with broad spectrum antibiotic coverage.
Infection is managed aggressively to prevent graft resorption. These patients usually return to the
operating room for washout and placement of drains. Broad spectrum antibiotic coverage is crucial.
Dermal sutures at the columellar incision reduce the probability of widened scars if significant
augmentation and stretch were required. History of keloid should be determined. They are less likely to
form on the face and are managed with massage and steroids—local anesthetic does not reduce the
incidence of keloid. Base reductions should be performed after closure is complete (not before). This
provides the greatest potential to leave irreversible deformity if not done correctly. If performing a base
reduction is questionable, the surgeon should defer this irreversible technique. The decision to forgo
base reduction and possibly return at a later date should not be faulted.
1,2
REFERENCES
1. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. New York: Thieme Publishers; 2015
2. Amici JM. Hypertrophie cicatricielle précoce post-chirurgicale de la région nasale: intérêt des injections de
corticoïde retard [Early hypertrophic scar after surgery on the nasal region: value of long-acting corticosteroid
injections]. Ann Dermatol Venereol 2014;141(1):7–13
48. Lip Augmentation
David A. Sterling, Christopher C. Surek
See Essentials of Aesthetic Surger y, pp. 645–675
PREOPERATIVE EVALUATION
1. When evaluating a patient for lip augmentation, what is true regarding the ideal lip dimensions?
A. The length of the lips should equal the distance between the midpupillary lines.
B. The length of the lips should be equal to the double the size of the alar-to-alar base width.
C. The ratio of the upper/lower vermillion show should be 1:1.6.
D. With the lips slightly parted, the ideal incisor show should be 4 mm.
E. The subnasale to stomion and stomion to menton distances should be approximately equal.
AUGMENTATION USING INJECTABLE FILLERS
2. A patient comes to your office looking for lip augmentation with injectable filler. Which product requires skin
testing for hypersensitivity reactions?
A. Zyderm (Allergan).
B. Restylane (Galderma).
C. Juvéderm (Allergan).
D. Radiesse (Merz).
E. Poly-L-lactic acid (Sculptra).
AUGMENTATION USING INJECTABLE FILLERS
3. You injected a patient's lips with a hyaluronic acid–based filler on the first appointment of the day. She calls
your office in the early afternoon complaining of worsening pain and bruising. She has been injected with fillers on several occasions and has never experienced this. What is the most appropriate response?
A. Inform her that this is expected after injecting fillers and to keep her normal appointment in 2 weeks.
B. Instruct her to apply ice intermittently to the area.
C. Instruct her to apply intermittent warm compresses and to call the following day.
D. Ask her to come to your office immediately for evaluation.
E. Instruct her to immediately proceed to the nearest emergency department.
AUGMENTATION WITH GRAFTS
4. You are injecting a patient with autologous fat for augmentation of her lips. What technique is used in an
attempt to improve graft survival and overall result?
A. Injection of large aliquots followed by massage.
B. Injecting with a small cannula under high pressure.
C. Processing of the fat via gravity separation or high-speed centrifugation to produce small aliquot grafts.
D. Undercorrection of the deformity in anticipation of swelling of the graft.
E. Long-term splint and subsequent taping of the fat-grafted area.
AUGMENTATION WITH GRAFTS
5. What are some important considerations when using dermal fats grafts for augmentation of the lips?
A. Deepithilializing prior to harvesting the graft.
B. Harvesting precisely as much tissue as needed.
C. Remove 50% of the hair follicles.
D. Preserve as much fat as possible on the underside of the dermis.
E. Has more absorption than just using fat alone.
356 Part VII&Facial Surgery
AUGMENTATION WITH V-Y ADVANCEMENT
6. A 72-year-old female presents for lip rejuvenation. On examination she has a long, thin upper lip with an
inverted vermillion. She is interested in shortening her upper cutaneous lip and would prefer a permanent
option with no visible scars. What augmentation option is best for this patient?
A. V-Y advancement.
B. Direct lift lip.
C. Indirect lift lip.
D. Subnasal lip lift.
E. Anguloplasty.
INDIRECT LIP LIFT (ILL), SUBNASAL LIFT, “BULLHORN LIP LIFT”
7. When performing an indirect lip lift, how much skin should be left from the nasal base to Cupid's bow?
A. 7 mm.
B. 10 mm.
C. 12 mm.
D. 15 mm.
E. 17 mm.
DIRECT LIP LIFT, GULL-WING LIP LIFT, VERMILLION LIP LIFT
8. You are performing a direct lip lift on a 68-year-old female. What modification can be performed to reduce
the risk of perioral stricture?
A. Excising only skin and minimal subcutaneous tissue.
B. Limit the medial extent of the corner mouth lift to Cupid's bow.
C. Using interrupted rather than a running suture for closure.
D. Dermabrasion of the scar postoperatively.
E. Avoiding the use of nonabsorbable sutures for anchoring.
CORNER MOUTHLIFT, ANGULOPLASTY
9. A 70-year-old female presents to discuss lip augmentation. She has significantly downturned corners of her
mouths, which distresses her. She seeks the most permanent option for correction. What technique is best for
this patient?
A. Injectable hyaluronic acid filler to the corners of the mouth.
B. Indirect lip lift.
C. V-Y advancement.
D. Placement of a dermal fat graft at the commissures.
E. Anguloplasty.
Chapter 48&Lip Augmentation 357
Answers
PREOPERATIVE EVALUATION
1. When evaluating a patient for lip augmentation, what is true regarding the ideal lip dimensions?
C. The ratio of the upper/lower vermillion show should be 1:1.6.
Like in other areas of aesthetic surgery, it is imperative to know the ideal lip dimensions. There are
several important structures in the lower third of the face, as well as important relationships between
the middle and lower thirds that contribute to the ideal lip. The length of the lip should equal the
distance between the medial corneal limbi. The ratio of the upper/lower vermillion show should be 1:1.6
(golden ratio). The upper cutaneous lip/upper vermillion ratio should be 1.1 to 2.3. The interpupillary
line and commissural line should be parallel and horizontal. The subnasale–stomion distance should be
half the stomion–menton distance. With the lips slightly parted the incisor show should be about 2 mm.
Cupids bow should form a “gentle M,” the stomion should form a “lazy M,” and the lower lip vermillion
should form a “gentle W.” There are three thickenings of the upper lip: a central tubercle and lateral
thickenings. There are two paramedian thickenings ofthelower lip. The nasolabial angle should be 85 to
105 degrees and there should be a gentle “ski jump” transition at the vermillion border. The upper lip
should overly the lower lip by about 2 mm (Fig. 48.1, Fig. 48.2).
1
1.6
1,2
Subnasale
1x
Stomion
2x
Menton
Fig. 48.1 Frontal lip view. (Source: Ideal Lip Dimensions. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition.
New York: Thieme; 2018.)
Fig. 48.2 Profile view of the lips. The line depicts the Riedel line, connecting upper lip, lower lip, and chin.
(Source: Ideal Lip Dimensions. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)