Dr. Sam Rizk , a new york rhinoplasty surgeon with double board certification in facial plastic and Reconstructive surgery (abfprs.org) and Otolaryngology-Head and Neck Surgery (ABO), will share his extensive experience with the ethnic rhinoplasty. Dr. Rizk has a large number of patients of ethnic descent (non-white) who request rhinoplasty (nose job) surgery in New York, the melting pot of the United States and the world. As Dr. Rizk practice is on Park Avenue in the heart of Manhattan, he sees patients of ethnic descent from all over the world who come to New York City for many personal reasons, one of which is usually to undergo rhinoplasty surgery by Dr. Sam Rizk.
The ethnic nose can have a variety of characteristics, and variabilities but what distinguishes it from the white nose is typically a low radix, a flat dorsum, a broad base, round nostrils, and short and thin alar (lower lateral) cartilages. These characteristics results in limited nasal tip projection and an acute nasolabial angle. The ethnic nose can refer to the Latino/Hispanic nose, the Middle Eastern nose, the African American nose (which is flatter with a more concave dorsum) or the Asian nose (also usually flatter and wider).
According to Dr. Sam Rizk, although there is a large spectrum of variabilities in these noses, there are some common characteristics which allow them to be grouped as ethnic, which is thick skin and weak tip cartilages.
The nose is probably the most important element of the facial features presenting very well-defined racial characteristics. Anatomic variations typical of each ethnic group are also present in the facial skeleton, contributing to facial harmony. This is particularly true for the maxillary area which is the support platform of the nose. Ideally, a beautiful nose should have a straight dorsum separated from the forehead by a shallow groove located at the level of the upper border of the tarsal cartilage of the upper lid. The dorsum should be narrow and divided by two parallel lines (or slightly concave) that extend from the brows to the nasal tip. The tip should be slightly more prominent than the dorsum, and covered by thin skin that enhances the projection of the alar domes. The columella should be visible and should project caudally to the alar rim on the profile view, forming an n angle of 90-100 degrees with the upper lip.
The dimensions, the shape, and the projection of the nose are determined by the structural support of the osteocartilaginous nasal framework and also by the skeletal support of the midface. The Proportions of the nose are related to the rest of the facial structures, mainly the maxilla, the mandible, the dental arches, and the lips. Dr. Sam Rizk, a New York rhinoplasty surgeon and specialist in the nose, pays particular attention to the soft-tissue cover of the nose which he feels is also basic for nasal beauty. Although color and texture are important, skin thickness produced by a layer of subcutaneous fat or by a large number of sebaceous glands. Excessive thickness produced by a layer of sebaceous glands or by a combination of the two eliminates angularity and nasal definition. This excessive soft tissue thickness also increases the size and volume of the nose.
The non-indo-European nose can be divided into African American or Asian noses, presenting physical differences with the Indo-European not only in the color of the skin but also in facial features. These differences are related to the shape of the facial skeleton, the configuration of facial muscles, and the thickness of the skin and its subcutaneous fat layer. Dr. Sam Rizk, a NYC rhinoplasty surgeon, discusses surgery of the non-Indo-European nose which can be a mixture of the Native Americans (of Asiatic origin) and the Europeans. This type of nose is different from the African nose but the techniques used for its correction are also applicable to other African or Asian groups.
The Mestizo nose (mixture of Spanish and Amerindian) is small. The radix is low and the dorsum is slightly convex, resulting from the low nasion and limited tip projection. The alar cartilages are thin and short, especially the medial crura, which is the central column of the tripod responsible for the projection of the tip. Dr. Sam Rizk, a New York rhinoplasty surgeon, uses various techniques to build the middle portion of the tripod to strengthen it and project it including columellar struts as well as various tip grafts. This lengthens the short columella and rotates the tip cephalically. This also changes the nasolabial angle from 70-80 degrees to over 95 degrees.
The nasal base is broad and the nostrils are round rather than elliptical because of the width of the nostril sill and the relatively short columella, which is also responsible for the limited tip projection.
In the lateral radiographic cephalogram the nasal spine is located in the prominent position. The convexity angle of the face is larger in this group than in the indo-european group. The upper and lower alveolar ridges protrude well in front of the nasal spine. This skeletal biprotrusion projects the lips anteriorly, which contributes to producing an acute nasolabial angle.
Objectives of the surgery - The main objective of the surgical procedures in non-Indo-Europeans, according to Dr. Sam Rizk, one of the best rhinoplasty surgeons in the world based in New York, is to modifty the nose and other facial features so that the final results preserves their ethnic preservation while sharpening and defining their features within their facial proportions, and not to create something based on the Indo-European ideal. To achieve this result, the following elements must be altered: dorsum, nasal pyramid, tip, nasolabial angle, alar base, pyriform area, tip definition and projection, and alveolar ridges.
The Dorsum – Dr. Sam Rizk states that the nasal dorsum in the Hispanic-Amerindian group is relatively low and slightly convex. The nasal pyramid may appear broad because of its limited projection; however, it is fairly narrow in most cases. The dorsal convexity frequently is not related to the presence of a hump. It is related mainly to the low nasion and the limited anterior projection of the tip. The dorsal hump, when present, is very small. Its resection should be done with extreme care to preserve the structural support. Dr. Sam Rizk may use a delicate rasp to remove the boney bump or use the dermabrading diamond powered tools to achieve a smooth result. The cartilaginous section of the nasal bump can be resected or lowered with a knife or the powered diamond dermabrading tool. Underresection of the hump is desirable in many patients. A straight dorsum is obtained by elevating the depressed area of the radix with a cartilage graft. For this the subperiosteal dissection is extended along the nasion to the desired level, taking care to produce a limited pocket. The lateral limits of the subperiosteal dissection should be equal on both sides to prevent asymmetry. The optimal material for the graft in the nasion in Dr. Sam Rizk’s experience is crushed cartilage, which may be obtained from the cartilaginous hump or from the septum. Using a right-angle retractor, the graft is introduced into the pocket. No fixation is necessary if a symmetrical and snug pocket is prepared; it is maintained in position by the external splinting.
Narrowing the pyramid - If necessary, the nasal pyramid may be narrowed by lateral osteotomies. Dr. Sam Rizk performs this maneuver with a 2-4mm osteotome introduced through the pyriform region intranasally. This creates a very precise osteotomy. Dr. Sam Rizk extends further into the nasal process of the maxilla and does a low-low osteotomy in ethnic rhinoplasty patients because their bone height is short and to achieve better narrowing entails this type of osteotomy. A greenstick infracture is produced by continued moderate manual pressure on both sides of the nose. This produces a very stable fracture, which avoids conminution and telescoping of the pyramid into the pyriform fossae. When the dorsum is low, a cartilage graft or an implant is indicated. The dorsal graft or implant, according to Dr. Sam Rizk, should be at least 5cm long and 6-8mm in width. It must be made of one piece to prevent secondary irregularities. Longitudinal partial-thickness cuts are made on the superficial side of the graft to release surface tension and to obtain a transverse curvature similar to that of the normal dorsum. In general, it is not necessary to fix the graft. When the pocket is too large, its position may be maintained by one pull-out suture at the radix area placed with a straight needle. When the dorsum is very low, a major augmentation may be necessary with an implant or a costal cartilage graft, in conjunction with temporalis fascia or Alloderm.
The Tip-The tripod formed by the two lateral crura and the medial crura is responsible for the projection of the tip. In the Mestizo nose, the alar cartilages are usually small and weak and provide limited support. The lateral crura are usually narrow, seldom requiring more than a minimal resection of the cephalic edge. This resection should include the fatty tissue located between the domes which can be more prevalent in ethnic rhinoplasty noses. Septal cartilage grafts are used to increase the anterior projection of the tip. A small rim incision is made, and a wide pocket is dissected between the dermis and the superficial fascia of the SMAS, cutting the trabeculae that fix the skin to the fascia. This undermining permits a better draping of the skin over the modified structural support. A shield type or triangular graft is introduced in the pocket and fixed with one or two nonabsorbable sutures that pass through the skin and the graft and emerge again through the skin. The sutures are fixed to the skin with tape. Dr. Sam Rizk, a NYC rhinoplasty surgeon, prefers the septum as the source of cartilage, followed by the ear and rib cartilage. Costal or rib cartilage is needed when a major increase in dorsal height or projection is required. If the skin is thin, which is rare in ethnic rhinoplasty, minor crushing of the cartilage may be necessary to obtain a natural effect.
The Nasolabial angle - The nasolabial angle is formed by the upper lip and the columella. As a result of the short medial crura in the ethnic rhinoplasty, the columella and tip has limited support and the tip droops caudally. Sometimes also, according to Dr. Sam Rizk, a New York rhinoplasty surgeon, the alveolar maxillary bone protrudes, along with the upper lip, which also closes the upper lip. Dr. Sam Rizk emphasizes that the cephalad rotation of the tip obtained by the resection of the upper edge of the lateral crura is insufficient. To correct the shortness of the medial crura, a pocket is created between the medial crura and the base of the columella is freed from the nasal spine and the caudal edge of the septum. A cartilage strut graft is then placed in this pocket to increase structural support. Septal, ear, or rib cartilage may be used as cartilage grafts. Rib tends to be a little stiff and its use should be in deeper areas rather than as tip grafts in order for the nose to feel natural. It is also important not to use large columellar struts as they may create too much stiffness and distortion in the upper lip area and if they extend into the domal region may distort the dome also. The length of the graft in the columella should be about 15mm at most, sometimes smaller, and the width is typically 6mm. If the columellar graft is too wide, it may cause a hanging columella. It is usually fixed with a PDS absorbable suture through the base of the columella.
The Alar Base - Flaring of the alae is a relatively common characteristic seen in the ethnic nose. It can be assessed by tracing a vertical line from the medial canthus. The alar base is considered wide when the ala extends laterally more than 2mm from this line. The nostrils may be round rather than elongated vertically. This particular feature may be corrected partially after the insertion of the cartilage graft in the columella, which increases tip projection. If the nostril base is wide, Dr. Sam Rizk a NYC rhinoplasty surgeon, recommends a wedge resection at the connection of the alae and the sill. A partial sill excision may also be incorporated with the alar wedge excision, depending on how wide the alae are. The resection is extended to the nasal floor. If a correction of the flaring alae is indicated without decreasing nostril diameter, a resection of the sill is done in a triangular fashion.
The pyriform fossae - The nasal alae are supported laterally by the maxilla at the level of the pyriform aperture. Increasing the projection of the pyriform area automatically projects the nasal tip anteriorly.