The choice of open versus endonasal rhinoplasty techniques is largely surgeon dependent. Some of the recent literature on rhinoplasty in African American patients favors the use of the open technique,2,8
likely due to the advantage of direct visualization it affords the surgeon. Breaking the procedure into components based on the anatomic nasal components being addressed, multiple techniques have been shown to be effective.
Three subtypes of the alar base in African American patients have been described2,9
: (1) Increased base width with lateral positioning of the alar base relative to the medial canthus, (2) alar flare, and (3) a combination of the previous two variants. Alar flaring greater than 2 mm lateral to the medial canthi2
can be addressed by alar base resection (Fig. ). Interalar distance is improved by nostril sill resection and advancement2
(Fig. ). Narrowing the alar base should be tempered with preservation of the external nasal valve aperture.
Alar base resection for flaring greater than 2 mm lateral to the medial canthi.
Nostril sill resection and medial advancement for wide interalar distance.
Nasal Tip Definition
As previously described, the African American nose is characterized by a less defined tip with decreased projection. Tip bulbosity is likely secondary to soft, divergent middle crura and the thick overlying skin. The thick, sebaceous skin that drapes over the skeletal framework of the African American nose can be addressed with several techniques. In our hands, careful excision of excess fibro-fatty tissue in the nasal tip provides some improvement; this should be approached with caution given the risk for tip necrosis with excessive debulking.
Established maneuvers to increase tip definition in the non-ethnic patient can easily be translated into the African American nose with good results. Techniques to improve this appearance include excision and augmentation maneuvers that help accentuate the nasal tip. Cartilage excision, such as the cephalic trim, should be done in a very conservative manner. In the African American nose, these techniques are simply to facilitate rotation and shaping of the lower lateral cartilages; overly aggressive cartilage resection will lead to decreased tip support and ultimately a loss of projection.
Tip sutures and cartilage grafts are the mainstay of increasing tip definition and projection in these patients. Transdomal sutures
, a term coined by Tardy and Cheng,10
but in its current form described by Daniel,11
involves the placement of permanent horizontal mattress sutures through the two crura of each dome (Fig. ). The use of transdomal sutures helps improve tip definition by creating a more acute angle between the medial and lateral crura of the lower lateral cartilages. Additional strategic placement of alar sutures in the form of interdomal and intercrural sutures further aid in enhancing tip projection. The interdomal suture is placed from the anteromedial portion of one dome to the adjacent dome in a simple looped or figure-of-eight fashion (Fig. ). This ultimately results in approximation of the domes, narrowing of the tip, and lengthening of the lobule.12
Intercrural sutures broadly describes medial and middle crural sutures placed in specific segments of the medial crura. The medial crura suture is a looped suture placed in the middle third of the medial crura (Fig. ). This results in a narrowing and strengthening of the columella and augmentation of lobular volume and length.12
The middle crura suture is a simple looped suture placed through the most anterior portion of the medial crura (Fig. ). This suture compared with the medial crura suture produces greater reduction of the interdomal distance and increased lobule volume and protrusion.12
The medial and middle crura sutures are typically used in combination with columella struts to provide better tip support; given the limited availability of septal cartilage grafts, alternate graft options including costal cartilage and irradiated rib grafts should be considered.
Transdomal suture; narrows the nasal tip.
Medial crura suture, placed in middle third of medial crura.
Middle crura suture, placed in anterior third of medial crura.
Additional tip refinement can be achieved by augmentation, many recommending the use of autologous cartilage tip grafts.9,13,14,15
Grafts for tip refinement can be placed through the open approach as onlays sutured onto existing cartilage or into subcutaneous pockets through the endonasal approach. Tip onlay grafts (Fig. ), described by Peck13
in 1983, increase tip projection, lobule length, and enhance tip definition. In a similar fashion, infratip lobular grafts (Fig. ), described by Sheen14
in 1975, increase tip projection and volume. In a recent article, Guyuron and Jackowe15
describe a modification of the onlay and shield graft techniques with the use of a novel graft punch device that provides the advantage of precise, rapid sculpting of the cartilage used for augmentation.
A small nasal spine and short, rounded columella have been cited as reasons for the decreased nasal tip projection noted in African American patients. Techniques previously discussed for tip definition in the form of alar sutures and nasal tip cartilage grafts also improve tip projection to varying degrees.
A keystone to improving nasal projection are structural cartilage grafts that provide needed support to the nasal tip. With the septal extension graft (Fig. ) or the columellar strut graft (Fig. ), the rhinoplasty surgeon can adequately address tip projection in this patient population. The columellar strut graft is a popular method for increasing and maintaining tip projection. Placed between the footplates of the medial crurae, these grafts may be sutured in place with medial crural sutures, fixed to the nasal spine, or left free-floating.
Columella strut graft; improves tip projection and provides support.
Dorsal Projection/Nasal Bridge
A review of the literature shows a lack of consensus on the value of the lateral osteotomy in the face of a wide nasal bridge with decreased dorsal projection as is seen in many African American noses2,16,17
A significant concern is for the risk of excessively narrowing the dorsum relative to the nasal lobule, producing some racial incongruity.17
To avoid this incongruity, Rohrich and Muzaffar2
recommend making the infracture proportional to the lobule size, in addition to interalar width reduction and tip refinement. Dorsal augmentation alone without osteotomies has been advocated by others5,9,16,17
who have shown good, reproducible results with this technique. Augmenting the nasal dorsum gives an illusion of narrowing the nasal bridge18
(Figs. and ). Augmentation materials range from autologous tissue in the form of units of cartilage and bone to alloplastic materials such as Gore-Tex (ePTFE; W.L. Gore & Associates, Flagstaff, AZ), silicone, and AlloDerm (LifeCell Corp., Branchburg, NJ). Potential problems of warping, visibility, long-term survival, and the limited availability of cartilage grafts have been overcome by the increasing application of diced cartilage grafts in rhinoplasty. Optimizing the long-term viability of the diced cartilage by wrapping it in Surgicel19
(Johnson & Johnson, Somerville, NJ) or temporal fascia20
is still the subject of debate.
Intraoperative view of use of cartilage grafts for dorsal augmentation and tip projection with a columella strut.
Preoperative and postoperative photographs after dorsal augmentation, columella strut placement, and alar base resection.