Ethnic Rhinoplasty vs. Non Ethnic Rhinoplasty
Posted March 04, 2008 10:52 AM
Is there a difference in technique between ethnic and non-ethnic rhinoplasty?
The answer is double fold. Yes and No!
Lets clarify the "yes" answer first. When you look at African American, Asian, Hispanic and Middle Eastern noses, there are some important anatomic differences compared to Caucasian or northern European noses. These differences in skin thickness, cartilage size and strength, bone versus cartilage proportion on the bridge, nostril width, and septal cartilage size or abundance are important to recognize in order to plan the proper technique during rhinoplasty for the best outcome. Furthermore, the relationship between the nose, lips, chin and other facial structures must be recognized.
For example many Asian, Black, or Latino patients have thicker skin and weaker cartilages. This combination is not ideal for support and definition. However, if properly recognized pre-op and properly planned for, great aesthetic results are readily achievable in such patients. This often includes using more structural cartilage grafting and more suture techniques.
The mistake that I often see is surgeons who fail to recognize or plan for this anatomic situation and take the dangerous opposite approach by removing too much cartilage which results in further lack of definition and further lack of support. This results in a nose that is amorphous due to thick skin and scar tissue.
Now lets clarify the "no" answer. So with everything that I mentioned above, you may be wandering how could I possibly say that ethnic rhinoplasty is no different than non-ethnic rhinoplasty! Simply said, a successful rhinoplasty is impossible without proper initial diagnosis!
The most important skill any rhinoplasty surgeon has is the skill of diagnosis. The problem at hand must first be diagnosed before the solution can be reached. Diagnosis, diagnosis, diagnosis! I cannot emphasize this enough. No two noses are exactly the same. Each is different. Each needs its own individualized plan. A plan is impossible without initial diagnosis of the aesthetic issues needing correction. Furthermore, the nose is a three-dimensional structure and as such, any changes in one area or view will result in changes in other areas or views. Furthermore, correction of one problem surgically can result in creation of a whole new problem. These issues must be clearly planned out prior to the surgery. However, during the surgery, the skilled rhinoplasty surgeons must possess the knowledge and expertise to be able to successfully recognize and deal with new potentially unforeseen issues that may come up as a result of variations in tissue dynamics.
In this respect the ethnic nose is no different than the non-ethnic nose. Each and every patient's nose must be examined thoroughly and an individualized proper plan devised. Rhinoplasty is an operation of fractions of millimeters. The surgeon must diagnose and recognize the nature and dynamics of the tissue (cartilage, bone, skin, scar, etc) with which he/she is working in order to be able to manage and predict these minute but significant changes.
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Choosing "Open Rhinoplasty" versus "Closed Rhinoplasty."
Posted March 04, 2008 10:52 AM
One of the most common questions I get asked is "will my rhinoplasty be done 'open' or 'closed'?" There seems to be much needless controversy about this topic on the internet chat rooms. Granted, for years even amongst rhinoplasty surgeons, the debate was heated and controversial but in recent years the controversy has given way to a practical decision making algorithm and approach.
There are two main methods of nose surgery or Rhinoplasty. The "open" technique more appropriately referred to as the "external rhinoplasty" versus the "closed" technique more appropriately referred to as the "endonasal rhinoplasty. " To make matters slightly more complex for patients (and some surgeons) the "closed" or "endonasal" method is further subdivided to a "delivery" and a "non-delivery" method. Therefore truly there are 3 ways of performing a rhinoplasty.
The fact is that some surgeons do all of their rhinoplasties through an open approach and there are others that solely choose a closed approach. That is how they learned it and that is how they perform "the nose job. "
More commonly these days, we see surgeons who have not learned the closed technique and so they perform all of their rhinoplasties with an open approach. The open or external rhinoplasty is arguably easier to learn and easier to teach and so the pendulum has swung to this side of the debate currently in favor of the external or open rhinoplasty. Not because this is the better operation but rather because this is how most surgeons today have learned to perform the nose job.
So what is the difference between these different techniques? What are the advantages and disadvantages? And what kind of surgeon should you look for to do your Rhinoplasty?
The open technique is characterized by a "columellar incision" which is a small incision on the bridge of skin at the base of the nose that divides the two nostrils. When this incision is made in an "inverted V" fashion and then closed meticulously with fine sutures, the scar is practically invisible. The incision should not be made straight across or even in a "stair-step" pattern, which some plastic surgeons choose.
The remainder of the incisions for the open rhinoplasty are very similar to the ones in a closed rhinoplasty which are essentially all hidden inside the nose. Many patients needlessly focus on the incision and scar and many surgeons who market their closed technique use the phrase "No Scar Rhinoplasty" to advertise their approach. However, as I mentioned, the scar is almost never an aesthetic issue when done properly.
The advantages of an open technique are that the surgeon will be able to clearly visualize the tip structures and cartilages of the nose as they lay in a natural position in order to be able to diagnose causes of asymmetry or twisting. With an open technique, the rhinoplasty surgeon can also place and secure, with fine sutures, more structural grafts such as tip grafts and spreader grafts. Finally as I have mentioned above, the open technique is easier to learn and perform by less experienced surgeons. Furthermore, this is the preferred method when total tip (lobular) reconstruction is necessary in complex revision rhinoplasty cases or in patients with a history of cleft lip disorder.
The disadvantage is that the operation does take longer to perform and there will be more swelling and numbness at the tip of the nose.
The bottom line is that the open rhinoplasty is a fantastic operation for the proper nose. However, it is too invasive in a nose that needs minor changes or no tip work at all. Opening the nose in such patients creates more risk and unnecessary trauma and prolongs the healing time.
As far as the closed rhinoplasty goes, there is nothing "closed" about the operation! Some patients are shocked and awe stricken when they hear about an endonasal or closed rhinoplasty. They cannot visualize how a surgeon can perform the surgery through the nostrils! The fact is that for an experienced and skilled rhinoplasty surgeon the closed technique allows excellent visualization of everything that needs to be seen and altered.
The "delivery" modification allows the tip cartilages to be "delivered" through each nostril for clear inspection and alteration. The "non-delivery" modification allows the extremely skilled rhinoplasty surgeon to alter the nasal anatomy and create an aesthetic and beautiful nose with the least amount of trauma, minimize unnecessary dissection thereby improving healing time and minimizing scarring.
Just as there are many surgeons who perform each and every one of their nose jobs through an open technique, there are some surgeons who perform each and every one of their surgeries through a closed technique. It is much less important which technique your surgeon chooses but rather it is critical to make sure your surgeon is skilled and vastly comfortable with the operation allowing him or her to obtain great and safe results consistently. Rhinoplasty is arguably the most artistic operation ever invented by man and it requires a dedicated surgeon with a true understanding of the nose, its anatomy, and its response to surgical maneuvers. A true "rhinoplasty surgeon" dedicates the vast majority of his or her surgical practice to the operation of the nose.
Ideally, a skilled "Rhinoplasty Surgeon" will be well versed in all of the above techniques and will diagnose the aesthetic and/or functional problem with each patient's nose and then choose the most appropriate method to obtain the best results with the least trauma for each and every patient.
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