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Master Techniques in Facial Rejuvenation

Dr. Azizzadeh is the author of the preeminent facial plastic surgery textbook "Master Techniques in Facial Rejuvenation", which is currently in second print. Surgical techniques are described in detail through text, photos, illustrations, and two comprehensive DVD's.

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Facial Plastic & Reconstructive Surgery

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Non-Surgical Facial Rejuvenation

In Beverly Hills and serving the Los Angeles area

Babak Azizzadeh, MD, FACS- The Center for Facial & Nasal Plastic Surgery
Beverly Hills, California
Attending Surgeon – Facial Plastic & Reconstructive Surgery
Cedars-Sinai Medical Center
Assistant Clinical Professor of Surgery
Division of Head & Neck Surgery
David Geffen School of Medicine at UCLA
md@facialplastics.info

Grigoriy Mashkevich, MD
Assistant Professor
Division of Facial Plastic Surgery
New York Eye & Ear Infirmary
310 East 14th Street
New York, NY 10003
(212) 979-4545
gmashkevich@nyee.edu

Introduction

Aesthetic rhinoplasty in patients of Middle Eastern extraction poses a specific set of challenges for the rhinoplasty surgeon. As is true in other geo-ethnic groups, several unique anatomic features define the appearance of the “Middle Eastern nose” and require a tailored approach to achieve aesthetic refinement. Implicit in the surgical methodology for this group is the prevention of “Westernization rhinoplasty” and preservation of the native ethnic look (the word ‘ethnic’ is used loosely throughout text and refers to all ethnicities of the Middle East). Middle Eastern rhinoplasty also highlights the fundamental surgical tenets of cartilage sparing and structural grafting. These are particularly applicable to this group of patients, who consistently demonstrate inherent cartilaginous weakness as well as thick overlying nasal skin. This chapter explores the common nasal characteristics shared by people of the Middle Eastern origin and reviews the essential elements of a rhinoplasty consultation. Various surgical techniques that have been found effective by authors in the aesthetic refinement of the Middle Eastern nose are discussed in detail.

Background and Demographics

While the term “Middle East” refers to a geographic region, its precise borders have been poorly defined and blurred over the centuries by migration and intermixing of various populations. The phrase “Middle East” has its origins in the United Kingdom at the turn of the twentieth century and refers to regions of Western Asia and North Africa. Numerous modern nations presently comprise this subcontinent and are home to almost a billion people (Table I). Some historians argue that several large adjacent countries, such Armenia, Afghanistan, Pakistan, and India, also belong in the Middle Eastern category. While this discussion is beyond the scope of the present chapter, it is not surprising that people inhabiting these neighboring countries certainly share many of the nasal characteristics reviewed in detail below.

Middle East is also home to a wide range of ethnic and religious diversity. This may partially explain subtle variations in the aesthetic desires for rhinoplasty between various geographic areas within Middle East. For instance, it has been suggested that people living outside of the Arabian Peninsula and Gulf regions (nations of Saudi Arabia, Kuwait, Qatar, UAE, Oman, and Iran) desire more significant changes from rhinoplasty, such as greater dorsal reduction and tip projection.

In the United States, the estimated size of the Middle Eastern diaspora varies according to the source, but nevertheless provides a sense of its demographic impact. According to a recent population census, over 1.2 million people of strictly Middle Eastern origins reside in United States. This number expands to “at least 3.5 million” as per the Arab American Institute. While the residence of this ethnic group has been documented in all 50 states, an overwhelming 94% reside in large metropolitan areas (Los Angeles, Detroit, New York are the top three cities).

Visual and Anatomic Characteristics of the “Middle Eastern” Nose

Several unique features define the ethnic appearance of a Middle Eastern nose (Table II). These can be readily appreciated in some of the well-known political figures from the Middle East (Fig 1).

One of the chief distinguishing characteristics of a Middle Eastern nose is its relatively thick overlying skin-soft tissue envelope (SSTE). Numerous pilosebaceous units dotting its surface produce an oily texture and further contribute to skin thickness. These anatomic properties of SSTE significantly influence the appearance of the lower one third of the nose by effectively blunting the configuration of the underlying cartilaginous framework. Specific findings include an effacement of the supratip region and concealment of tip definition. This results in an overall amorphous appearance of the nasal tip. In the post-operative period, the above-mentioned features of SSTE promote scarring, which in turn predisposes to contracture forces and formation of a polybeak deformity. Both of these can be controlled with specific surgical maneuvers and steroid injections respectively, as outlined in sections that follow.

High radix and a strong dorsum, with an associated dorsal hump commonly frame the upper two thirds of a Middle Eastern nose. This visual feature is almost always accentuated by the underprojected and hanging nasal tip, thereby enhancing an illusion of increased dorsal height. As such, elevating tip position goes a long way in visually reducing the dorsum. Moreover, establishing an improved nasal harmony by elevating the tip avoids an over-resection of the nasal dorsum.

Weak structural integrity of the lower lateral cartilages represents an additional defining property of the nasal tip. Medial crura are typically thin and contribute minimal support to the tip. The lateral crura are commonly rotated in a cephalic orientation and variably contribute to tip fullness. Overactive depressor septi nasi muscle and alar flaring are also frequently seen, especially in people from the West African regions of the Middle East.

Rhinoplasty Consultation

The initial consultation for a Middle Eastern rhinoplasty allows the surgeon to form a fertile ground for understanding patient concerns, goals, and motivations for surgery. The concept of maintaining ethnic identity should be clearly communicated on both sides of the table. A surgeon should be wary of patients requesting a drastic change in their appearance, which may cause an unnatural result (or “Westernization”) down the line and result in an unsatisfied patient.

It is generally a good idea to include a family member in the consultation process. Their opinion may represent an important feedback and help avert a potential misunderstanding within a family. Digital photography and morphing can greatly assist in conveying the proposed changes and help communicate more effectively. These should be used as a point of reference, without implicit guarantees as to the result. Various points discussed in the previous and later sections should be kept in mind when altering patient images (Table III). If requested, before and after photographs of previously operated patients can be utilized as well. This may also help in clarifying the differences in rhinoplasty goals for Caucasian and Middle Eastern noses.

Middle Eastern Rhinoplasty

The basic tenets of Middle Eastern rhinoplasty include the avoidance of over-resection and preservation of ethnic appearance. Westernization, through application of standards suitable for a Caucasian nose, should be avoided in this patient group. Not adhering to this concept carries a risk of establishing a disharmonious and unnatural nasal-facial relationship. General concepts, discussed in detail below, include a very conservative lowering of the radix and dorsum, providing adequate tip projection, and rotating the nasal tip while maintaining a hint of an acute nasolabial angle (less than 95o). These and other goals for the Middle Eastern rhinoplasty are summarized in Table III.

The authors prefer an external rhinoplasty approach in this patient group, as it affords superior visualization of internal structures and allows precise modification of the tip and osseo-cartilaginous framework. An endonasal approach is utilized only when patients have natural tip aesthetics with good tip support requiring only dorsal modification. In the authors’ experience, the columellar scar from an external approach heals exceptionally well in this patient group, making an open incision not an issue. This observation has been corroborated by Foda, who performed a columellar scar analysis on 600 patients of Arabic extraction. In his series, only 1.5% of patients found the columellar scar to be unacceptable (cited reasons were scar widening, hyperpigmentation, and columellar rim notching).

The philosophy of open structure rhinoplasty underlies the surgical approach to the Middle Eastern nose. It is imperative to add sufficient structure to the cartilaginous framework, in light of the weak inherent cartilage strength and thick overlying skin-soft tissue envelope (SSTE). The latter structure becomes a significant risk factor in the post-operative period for soft tissue contracture, which can easily overwhelm any unaltered native cartilage.

Following an open rhinoplasty exposure, the upper two thirds of the nose are addressed with a conservative dorsal hump and radix modification. Maintenance of sufficient dorsal height, in harmony with a high radix, is critical in preserving an ethnic appearance in a Middle Eastern nose. These structures must be conserved to a greater extent than in a Caucasian nose. In most cases where patients have dorsal hump reduction, the authors place spreader grafts in order to avoid internal valve narrowing and an inverted ‘V’ deformity.

As previously discussed, a dependent position of the nasal tip partially contributes to the appearance of excessive dorsal height. Tip projection, in turn, creates an illusion of a lowered dorsum. This maneuver, almost always necessary in a Middle Eastern rhinoplasty, allows for a more conservative reduction of the nasal dorsum.

Similar to a dependent nasal tip, low radix visually accentuates the dorsal height. Correction of the radix-dorsum disproportion, by augmenting the radix, improves nasal balance and reduces dorsal prominence in a Middle Eastern nose. A crushed cartilage graft is highly effective in elevating the radix bed. For assistance during placement, the graft can be guided into position with a 6-0 chromic suture on a Keith needle. A knot is then tied over the skin at the site of transcutaneous suture penetration, which serves to secure the graft in the immediate post-operative period. This suture is cut at the skin surface at the time of cast removal (typically in one week).

After dorsal hump modification and middle nasal vault reconstruction, the lower lateral cartilages are examined for inherent weakness. Nasal tip reconstruction begins by placing a columellar strut and suturing it to both medial crura. A septal extension graft can be utilized instead. When projecting the tip, it should be kept in mind that the supratip break should never be as prominent as in the ideal Caucasian nose. In male patients, it is especially desirable to only have a minimally visible break in the supratip region. Cartilage suturing techniques (intradomal sutures, lateral crural steal dome sutures, etc) and additional grafting as necessary (shield or cap grafts) are utilized to improve tip projection and definition. Judicious nasal skin de-fatting may be performed at this point, in the subdermal plane (Fig 2).

Minimal resection of the cephalic margin of the lower lateral cartilages should be performed. Lower lateral cartilages are typically weak structures and minimally contribute to tip fullness. The authors prefer to reinforce lateral crura with strut grafts and place rim grafts along the alar margin. These maneuvers provide an additional layer of protection against post-operative collapse of the vestibule, as well as against alar rim notching and retraction. They key factor is to create a straight structurally sound lateral crura avoiding excessive convexity or concavity.

Tip rotation should be conservative and aim to create a nasolabial angle of approximately 95o or smaller. This can be achieved in most instances with a combination of strut placement, dome suturing, and a conservative triangular caudal septal excision with the base at the anterior septal angle. Vertically oriented lateral crura may prevent cephalic rotation of the tip tripod, necessitating an additional lateral crural overlay or caudal repositioning of the lateral crura. If either scenario is utilized, lateral crural strut grafts are used for reinforcement.

At the conclusion of the procedure, medial and lateral osteotomies are performed. Medial osteotomies are performed in a lateral fading fasion at the osteocartilagenous junction. If the patient has open roof deformity, medial osteotomy is avoided. Lateral osteotomies are performed in a high-low-high fashion.

If necessary, alar base modification is completed following osteotomies, keeping in mind that mild alar flaring is an important feature of the Middle Eastern nose. The type of alar base modification will depend on two key factors: alar flaring and interalar-intercanthal distance. If the patient has normal interalar-intercanthal relationship (usually should be 1:1), then “alar wedge resection” is performed (see figure). Alar wedge resection avoids sill incision. If the patient’s interalar distance is significantly wider than intercanthal distance, then a sill incision will also be necessary. Still incisions must be made medial to the nostril axis to avoid “?” (see figure). Middle Eastern patients can tolerate to keep the alar base slightly wider than the intercanthal distance. (put Kridel article as citation)

Complications and Pitfalls

Several undesirable outcomes may complicate the Middle Eastern rhinoplasty. These usually arise from a combination of factors, not the least of which is surgical execution.

In both men and women, an overly aggressive resection of the dorsum and / or excessive lowering of the radix can take away an important ethnic characteristic of a Middle Eastern nose. Re-establishing adequate tip projection should avoid the need to significantly lower the dorsum.

Polybeak deformity represents a real concern in this patient group due to excessive thickness and elevated glandular content of the skin-soft tissue envelope (SSTE). Avoiding over-resection of the dorsum in combination with de-fatting of the supratip region in the subdermal plane and vigilant observation in the immediate post-operative period can help avoid this dreaded complication. Of particular assistance is triamcinolone acetonide (Kenalog-10; Bristol-Myers Squibb Co, Princeton, NJ) . This steroid can be injected as soon as one week post-operatively. Injections can be repeated bi-weekly for several cycles until the desired effect is attained. A judicious use of smaller volumes and lighter concentrations of Kenalog should avoid pigmentary skin changes. We rarely utilize steroid injections but do reserve it for this purpose.

Tip descent may occur secondary to inadequate structural grafting of the columella and failure to preserve sufficient native cartilage. Placement of a strong columellar strut with concomitant medial crural binding sutures, or placement of a caudal extension graft, is essential to counteract forces of scarring and preserve tip projection post-operatively.

Aggressive rotation of the tip, resulting in an obtuse nasolabial angle can create an unnatural appearance for this patient population. While tenets of Caucasian rhinoplasty dictate an ideal nasolabial angle of 95-110 degrees in women, the same angle in a Middle Eastern nose risks overrotation and an incongruous appearance. A practical goal of less than 95 degrees of rotation should be followed to avoid this complication.

Conclusion

Aesthetic rhinoplasty in patients of the Middle Eastern extraction epitomizes primary goals of ethnic nasal surgery, which include avoidance of aggressive maneuvers, preservation and modification of native structures, and addition of supporting grafts capable of withstanding post-operative forces of contracture. These same guidelines, in the framework of a conservative and methodical surgical approach, underlie the basic tenets of Middle Eastern rhinoplasty. Preservation of native racial features through approaches described in this chapter should help achieve a natural aesthetic refinement in patients undergoing the “Middle Eastern” rhinoplasty.

Table I. Present Middle Eastern nations and their respective population estimates. Table and current data adopted from http://www.mideastweb.org and http://www.cia.gov.

Country	Population	Country	Population
Algeria	32,930,091	Oman	31,022,294
Bahrain	698,585	Palestine	3,889,248
Egypt	78,887,007	Qatar	885,359
Iran	68,688,433	Saudi Arabia	270,197,315
Iraq	26,783,383	Sudan	41,236,378
Israel	70,260,002	Syria	18,881,361
Jordan	5,153,378	Tunisia	10,175,014
Kuwait	24,183,933	Turkey	70,413,958
Lebanon	3,874,050	UAE	2,602,713
Libya	5,900,754	Yemen	2,602,713
Morocco	33,241,259	TOTAL	805,507,228

Table II. Common visual features associated with a Middle Eastern nose.

Skin-Soft Tissue Envelope	Thick skin with numerous pilosebaceous units, contributing to an amorphous appearance of the nasal tip and supratip fullness.
Upper Third	Overprojecting bony dorsum and high radix; excessive dorsal width resulting in straightening of the brow-tip aesthetic line.
Middle Third	Widening of the osseous and cartilaginous vaults.
Nasal Tip	Amorphous and hanging nasal tip, cephalic orientation of the lower lateral crura, weak medial crura, acute nasolabial angle.
Nostrils	Variable degree of alar flaring.

Table III. Surgical concepts and techniques commonly utilized for aesthetic refinement of the Middle Eastern nose.

Skin-Soft Tissue Envelope	De-fatting into the subdermal plane, especially in the supratip region; post-operative observation and conservative Kenalog (triamcinolone acetonide) injections to prevent polybeak formation.
Upper Third	Maintenance of high radix during dorsal hump reduction; elevation of the tip to create a harmonious dorsum-tip relationship, rather than aggressive reduction of the dorsum.
Middle Third	Medial and lateral osteotomies; placement of spreader grafts to avoid internal valve narrowing and an inverted 'V' deformity.
Nasal Tip	Cartilage sparing maneuvers with preferential use of suture techniques for the dome region; placement of strong supporting grafts (columellar strut or septal extension graft, shield or cap grafts); possible placement of lateral crural batten grafts and alar rim grafts.
Nostrils	Alar base modification as needed

References

The World Factbook, United States Central Intelligence Agency, http://www.cia.gov and http://www.mideastweb.org
Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin North Am 2002;10(4):381-96.
US Census Bureau, Census 2000 http://www.census.gov/prod/2003pubs/c2kbr-23.pdf
The Arab American Institute http://www.aaiusa.org/arab-americans/22/demographics
Rohrich RJ, Ghavami A. The Middle Eastern Nose. In: Gunter JP, Rohrich RJ, Adams WP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical Publishing, 2007; 1139-65.
Romo T 3rd, Abraham MT. The ethnic nose. Facial Plast Surg 2003;19(3):269-78.
Foda HM. External rhinoplasty for the Arabian nose: a columellar scar analysis. Aesthetic Plast Surg 2004;28(5):312-6.
Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg 1997;100(4):999-1010.
Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg 2000;2:34-42.
Rohrich RJ, Adams WP. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg 2001;107(7):1849-63.
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8(3):156-85.
Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg 1997;99(4):943-52.
Rohrich RJ, Raniere J, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002;109(7):2495-2505.
Foda HMT, Kridel RWH. Lateral crural steal and lateral crural overlay. An objective evaluation. Arch Otolaryngol Head Neck Surg 1999;125:1365-70.
Kridel RW, Castellano RD. A simplified approach to alar base reduction: a review of 124 patients over 20 years. Arch Facial Plast Surg 2005;7(2):81-93.
Hanasono MM, Kridel RW, Pastorek NJ, et al. Correction of the soft tissue pollybeak using triamcinolone injection. Arch Facial Plast Surg 2002;4(1):26-30.