Secondary Logo

Journal Logo

Recognizing Racial Heterogeneity in the Latino Nose: Aesthetic Concepts for an Individualized Approach

Perez, Justin L. M.D.; Mohan, Raja M.D.; Rohrich, Rod J. M.D.

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 857-867
doi: 10.1097/PRS.0000000000006092
Cosmetic: Special Topics
Free
SDC

Background: Latinos are one of the fastest growing ethnic groups in the United States, and there is a growing demand for aesthetic rhinoplasty in these patients. The authors provide an individualized, systematic approach for evaluation and improvement of surgical outcomes in Latino patients.

Methods: A retrospective review of patients identified as Latino who underwent primary rhinoplasty and those who did not but had documented nasal photographs was performed. Photographs and operative records were reviewed in detail. Specific aesthetic nasal characteristics, individualized surgical techniques, and aesthetic results were recorded.

Results: The Latino nose has some characteristic nasal traits, including thick soft-tissue envelope, bulbous and underrotated tips, fatty hanging alae with propensity for anterior notching, weak underlying cartilaginous structures, and a propensity for alar flare worsened by depressor septi hyperactivity. Case review, however, demonstrates that there is moderate variability, with some patients demonstrating features more consistent with a European Caucasian nose and others displaying features more congruent with the black nose.

Conclusions: Addressing the Latino nose requires a firm understanding of the racial heterogeneity that exists within this patient population, ranging from features more consistent with the black nose to features more congruent with a European Caucasian nose. A patient’s aesthetic goals should be thoroughly discussed to avoid racial incongruity. The authors provide an individualized, component approach to improving aesthetic outcomes in Latino rhinoplasty.

Dallas, Texas

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center; and the Dallas Plastic Surgery Institute.

Received for publication April 4, 2018; accepted September 14, 2018.

Disclosure:Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing. He is a clinical and research study expert for Allergan Inc., Galderma, and MTF Biologics, and the owner of Medical Seminars of Texas, LLC. No funding was received for this article. Drs. Perez and Mohan have no financial interest to disclose. No outside funding was received.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Rod J. Rohrich, M.D., Dallas Plastic Surgery Institute, 9101 North Central Expressway, Suite 600, Dallas, Texas 75231, rod.rohrich@dpsi.org, Twitter: @DrRodRohrich, Instagram: @Rod.Rohrich

Ethnic rhinoplasty remains one of the most difficult aesthetic operations to perform. Over time, rhinoplasty in Latino patients has evolved from imitating canonical, neoclassical ideals of beauty toward the preservation of ethnic characteristics. Given that one of the fastest growing ethnic groups in the United States consists of Latinos, we are seeing increased demand for aesthetic procedures in this group, many of whom hold high expectations. Although there has been significant attention in the literature to other ethnic groups, relatively little has been written regarding the nuances of Latino rhinoplasty.

Critical to understanding rhinoplasty in the Latino nose is understanding the racial heterogeneity and mixed heritage that exists in this population as a result of a colonial past. After the Spanish and Portuguese conquest of Mesoamerica, significant mixing of white and native races occurred.1,2 Commonly, the term “mestizo” is used to describe Latino populations, representing that diverse racial blend composed of Native American, Spanish, and/or Portuguese conquerors that occurred in the fifteenth and sixteenth centuries, with subsequent addition of African and Yoruba roots during the eighteenth century. Furthermore, the rich history of Arab influence in Spain cannot be ignored. Arab influence on the Iberian Peninsula dates back to 711, and has deeply shaped the Spanish language, architecture, and facial aesthetics of Iberian inhabitants.3–6 Thus, to typify the Latino nose into discrete categories by geographic location is inherently flawed. Although there may be some common characteristics, there is no such entity as “the Mexican nose” or the “Puerto Rican nose.” Pigeonholing a patient’s nasal aesthetics into one of these discrete Latino subtypes should be avoided. Instead, one can conceptualize the Latino nose as a spectrum—ranging from features more consistent with the black nose to ones consistent with European, Caucasian features. In between lies a vast gradient of mestizo features, and striking similarities to the Middle Eastern nose. Recognizing and respecting these features is key to developing a focused surgical plan and executing an aesthetically pleasing result.

Back to Top | Article Outline

PATIENTS AND METHODS

A 5-year retrospective review of nasal consultations seen by the senior author (R.J.R.) was performed. Latino patients were identified by the junior author (J.L.P.) based on surname recognition and by documented clinical history. Chart review was performed and consisted of systematic facial and nasal analyses (as part of systematic nasal analysis, tip projection was assessed by drawing a line from the alar-cheek junction to the nasal tip; 50 percent of the nasal tip should lie anterior to a vertical line tangent to the most projecting portion of the upper lip vermillion; those less than 50 percent were classified as underprojected) of preoperative and postoperative photographs of patients who underwent rhinoplasty (n = 18) and those who did not (n = 42). Operative notes were reviewed to assess for common surgical maneuvers performed in this patient population.

Systematic evaluation of Fitzpatrick skin type, skin thickness, fatty quality of soft-tissue envelope, dorsum/radix position, and contour was performed. Characteristics present in greater than 50 percent of patients were documented as common or frequent. Any characteristic that was seen in less than 20 percent of patients was noted to be “infrequent.”

Back to Top | Article Outline

RESULTS

Based on comprehensive nasofacial analyses of 60 Latino patients, nasal characteristics were stratified as either frequent (>50 percent) or infrequent (<20 percent). Number and percentage distribution of patients possessing these characteristics were tabulated (Tables 1 and 2). The five most frequently encountered features of the Latino nose included thick, fatty soft-tissue envelope; wide bony vault and concomitant prominent dorsal hump; wide and weak lower lateral cartilages; fatty hanging alae with propensity for alar notching or flare; and ubiquitous bulbous, poorly defined, underrotated nasal tips (Fig. 1).

Table 1. - Common Characteristics of the Latino Nose
Anatomical Feature Characteristic No. of Patients (%)
Skin-soft tissue envelope Thick, sebaceous, fatty 60 (100)
Skin type Fitzpatrick type IV+ 42 (70)
Quadrangular septal cartilage Weak, tendency toward recessive anterior septal angle 40 (67)
Radix Low 57 (95)
Dorsum Dorsal hump 46 (77)
Bony vault Wide 43 (72)
Supratip Full 58 (97)
Tip projection Underprojected 20 (33)
Normal projection 21 (35)
Overprojected 19 (32)
Nasolabial angle Acute, underrotated 40 (67)
Tip definition Poor 58 (97)
Lower lateral cartilages Wide, asymmetric, flimsy with tendency to collapse 58 (97)
Alae Fatty, tend to hang posteriorly
with propensity for notching anteriorly
47 (78)
Propensity to flare 36 (60)
Columella Length
Short 29
Normal 71
Position (neither retracted nor hanging) 44 (73)
Nostril shape Oval 30 (50)
Elongated/flattened 30 (50)
Depressor septi Hyperdynamic 46 (77)

Table 2. - Features Absent or Infrequently Encountered in the Latino Nose
Anatomical Feature Characteristic
Skin-soft tissue envelope Thin skin
Quadrangular septal cartilage Weak
Radix High, full
Dorsum Low
Supratip Break
Nasolabial angle Overrotated
Tip Bifid; boxy
Lower lateral cartilages Strong
Alae Retracted
Columella Retracted or hanging
Nostril shape Round

Fig. 1.

Fig. 1.

Back to Top | Article Outline

CASE REPORTS

Case 1

A healthy 24-year-old Latina underwent open septorhinoplasty with aesthetic goals of reducing her dorsal hump, improving definition of her large bulbous tip, and reducing the width of her nasal base (Fig. 2). A component dorsal reduction was performed, lowering it 4 mm. Significant caudal deviation was eliminated with caudal septal resection. [See Figure, Supplemental Digital Content 1, which shows underlying cartilaginous framework of the patient in case 1. (Left) Severe caudal septal deviation is demonstrated. (Second from left) Illustration of spreader flap in-folding. (Second from right) Straightened septal cartilage after caudal septal trim, midvault reconstruction with bilateral spreader flaps, and septal straightening after clocking suture. (Right) Butterfly graft placement depicted, http://links.lww.com/PRS/D702.] Right midvault collapse was addressed with placement of bilateral spreader flaps, along with clocking sutures. Refinement of her tip was achieved with an extended cephalic trim, interdomal sutures, and transdomal sutures to create symmetry of her tip-defining points. Once tip rotation and projection were set, the transition from the infratip lobule to the soft-tissue triangle was softened with a butterfly graft. Alar contour grafts were placed to prevent alar notching, and the terminal portion interdigitates with the soft-tissue triangle (Fig. 3). The transcolumellar incision was then closed with 6-0 nylon. The lateral two-thirds of the infracartilaginous incisions were closed with 5-0 chromic suture, leaving the medial one-third of the incision open. She displayed type II alar flare, as is common in wide ethnic noses with underprojected and bulbous tips. Thus, a 3-mm alar base resection was performed, requiring extension across the nasal sill to decrease her wide nostril base. (See Figure, Supplemental Digital Content 2, which shows alar base resection for type II alar flare, including intraoperative markings, http://links.lww.com/PRS/D703.) Postoperatively, all columellar sutures and half of her alar base sutures were removed 1 week postoperatively, and the remaining sutures were removed on postoperative day 10.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

Back to Top | Article Outline

Case 2

A healthy 36-year-old Latino underwent open septorhinoplasty with aesthetic goals of reducing his dorsal hump and tip bulbosity (Fig. 4). Open rhinoplasty was performed by means of stairstep transcolumellar incision. Component dorsal hump reduction was performed, lowering it 8 mm. Bony dorsum was rasped. The lower lateral cartilages were undermined and conservative cephalic trim was performed. The tip was reshaped with low and high medial intercrural sutures, and interdomal and two inferior transdomal sutures (5-0 polydioxanone). Upper lateral tension-spanning sutures were used to resuspend the midvault. Redundant upper lateral cartilages provided sufficient cartilage stock for bilateral spreader flaps. Bilateral internal osteotomies were performed. Bilateral alar contour grafts were placed (Fig. 5). Transcolumellar incision was closed with interrupted 6-0 nylon sutures and intranasal incisions were closed with 5-0 chromic as described in case 1; also, 5-mm alar base resections were performed and closed with 6-0 nylon. Postoperatively, sutures were removed sequentially as described previously.

Fig. 4.

Fig. 4.

Fig. 5.

Fig. 5.

Back to Top | Article Outline

Case 3

A systematic approach to open Latino rhinoplasty is reviewed. (See Figure, Supplemental Digital Content 3, which shows preoperative and postoperative photograph comparison and corresponding graphics, http://links.lww.com/PRS/D704.) See accompanying video clips for case 3. [See Video 1 (online), which demonstrates nasal analysis, opening the nose, and assessment of cartilaginous framework. See Video 2 (online), which demonstrates raising mucoperichondrial flaps, inferior turbinate microfracture, component dorsal hump reduction, and midvault reconstruction. See Video 3 (online), which demonstrates a tip suture technique. See Video 4 (online), which demonstrates osteotomies and butterfly graft placement. See Video 5 (online), which demonstrates alar contour grafts and management of the soft-tissue triangle.]

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video demonstrates nasal analysis, opening the nose, and assessment of cartilaginous framework.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"0_v6293tp8"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"This video demonstrates raising mucoperichondrial flaps, inferior turbinate microfracture, component dorsal hump reduction, and midvault reconstruction.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"0_z1wob9ay"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3.","caption":"This video demonstrates a tip suture technique.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"0_fnqfdrb6"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4.","caption":"This video demonstrates osteotomies and butterfly graft placement.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"0_pb7nuhuj"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 5.","caption":"This video demonstrates alar contour grafts and management of the soft-tissue triangle.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"0_mdyysuoj"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

Back to Top | Article Outline

DISCUSSION

Managing Patient Expectations and Racial Congruity

Understanding a patient’s desires and motivation for surgery is critical. Some patients may desire a nasal appearance more in line with neoclassical canon. However, the surgeon should not assume all ethnic patients desire a nose that resembles this ideal. Some patients may desire “ethnic preservation rhinoplasty.” In our practice, preoperative computer imaging has been effective for this discussion and should be used as an educational tool for more detailed conversation. As rhinoplasty gains popularity in Latino culture, it is not uncommon for patients to reference features of prominent Latino celebrities to communicate their aesthetic goals—this should not be frowned on or viewed as a red flag. Rather, we welcome these types of discussions as a key component of understanding patient goals. If the surgeon is unfamiliar with the public figure presented, reviewing photographs with the patient may not only prove educational but also build rapport. This presents an excellent opportunity to discuss anatomical limitations and dispel any unrealistic expectations.

Back to Top | Article Outline

Gender Differences in the Latino Rhinoplasty

In our experience, Latinas prefer to have thinner and more defined noses with increased tip projection and a concave dorsum on profile view. In general, preoperative concern over racial incongruity is much less of a concern in Latino patients than in other ethnic groups such as Middle Eastern or black patients, where preservation of ethnic features may be of high priority. Latino men, perhaps derived from a cultural tradition of machismo, prioritize maintaining a “macho-appearing” nose with a higher, more convex dorsum. In fact, Latino men may even request preservation of some semblance of a dorsal hump, as this may be viewed as a feature of masculinity, virility, and attractiveness. This should be respected and explicitly documented in the clinical record.

Back to Top | Article Outline

Anatomical Considerations

Skin and Soft-Tissue Envelope

Similar to black and Middle Eastern noses, the skin of the Latino nose is notably thick, sebaceous, and inelastic.7–10 There is increased fibrofatty tissue within the tip and along the lower lateral cartilages. This “doughy” soft-tissue envelope can be up to 2 to 3 mm in thickness, making tip refinement particularly challenging. One should not hesitate to defat conservatively. As long as the subdermal plexus is respected, vascular compromise can be avoided. We have not seen any case of tip necrosis caused by aggressive defatting. In cases of biracial or triracial patients, or Latino patients with more Caucasian features, thinner skin may be present. Thus, less defatting should be considered to avoid vascular harm in this scenario.

Thick Latino skin also has a tendency for prolonged tip edema postoperatively, and patients should be informed about this. We have a low threshold to tape the soft-tissue envelope of ethnic patients for up to 2 to 3 weeks with Steri-Strips (3M, St. Paul, Minn.) to optimize tip aesthetics. Prolonged taping not only mitigates severe edema but also improves recontouring of the soft-tissue envelope to the newly shaped lower lateral cartilages.

Preoperative skin care is paramount in ethnic rhinoplasty given the predominance of sebaceous, oily skin types in this patient group. To reduce the sebaceousness of thick Latino skin, we commonly recommend isotretinoin preoperatively. (Isotretinoin prescriptions are supervised by a board-certified dermatologist. The iPLEDGE program is used and hepatic function monitored as appropriate. A typical isotretinoin starting dose is 0.5 mg/kg per day for the first month, up-titrated to 1 mg/kg per day as indicated by the dermatologist and tolerated by the patient. Decreased sebum production and improvement in oily character of skin can be expected and may take 4 to 6 months to achieve. For this reason, a dosing duration of 4 to 6 months may be required, stopping at least 1 month before surgery.) Postoperatively, a two-part antiacne prevention regimen is provided to patients, with explicit instructions for day and evening washes. [EraClea (Hylaco, Eraclea, Italy); daily 5% benzoyl peroxide cleanser, 2% salicylic acid lotion twice daily.]

On the first postoperative visit after Doyle splint removal, it is imperative to exfoliate the nasal dorsum and decompress sebaceous material with the passing of a blunt-tip instrument against the back-pressure of one’s finger. This is particularly important in the Latino nose, where prolonged taping to control tip edema may result in a high number of clogged pores and have comedogenic potential. Failure to decompress pores can result in acne breakouts and an embarrassed patient. Furthermore, pressure applied during this maneuver should be gentle; heavy-handed maneuvers risk displacing the nasal bones and disrupting symmetry of dorsal aesthetics lines. Techniques for optimizing aesthetics of the Latino tip are summarized in Table 3.

Table 3. - Maneuvers for Optimizing Tip Aesthetics in the Latino Patient
Meticulous preoperative skin care
Aggressive intraoperative defatting
Exfoliation at the time of Doyle splint removal
Postoperative topical treatments with antibacterial, keratolytic, comedolytic, and anti-inflammatory properties (i.e., benzoyl peroxide)
Avoidance of comedogenic triggers
Maintenance of low-salt diet

The surgeon should note that Fitzpatrick skin type is not universal across all Latino patients. Latinos of more indigenous, Indian, and/or African genetic profile will reside higher on the Fitzpatrick scale (i.e., IV or V). Families with more European genetic influence may be of lighter skin types (i.e., Fitzpatrick skin type II to III). Surgeons should be careful about assuming a patient’s race by means of skin color or surname; it is not uncommon for Latino patients to possess blond or red hair or light eyes. It is important to ask a patient’s ethnicity and document it in the medical record as a part of one’s nasofacial workup to understand their expectations and aesthetic goals.

Although we have not encountered any cases of hypertrophic or keloid scars after transcolumellar incision or alar base resections in our Latino patients, a history of pathologic scarring should be reviewed. In addition, sun avoidance and use of sunscreen postoperatively should be reviewed to optimize the appearance of postoperative scars, particularly along the alar-cheek junction in cases of alar base resection.

Back to Top | Article Outline

Bony Pyramid and the Nasal Dorsum

Management of the wide nasal dorsum is a pillar of Latino rhinoplasty. Some patients may complain of an appearance of increased interalar distance as a result. In contrast to the black nose, the Latino dorsum is more often prominent rather than depressed or concave. Nasal bone prominence is addressed during component dorsal reduction and nasal width is reduced with percutaneous osteotomies. However, some Latino patients may possess features more consistent with the black nose, with a widened, low, and broad dorsum. Should this be the case, osteotomies and subtle in-fracture may be carried out judiciously with or without dorsal augmentation.

A patient’s view regarding his or her dorsal hump should be discussed explicitly, particularly in men. Machismo is pervasive within Latino culture, and for many Latinos, a dorsal hump can be viewed as a highly masculine trait. A patient’s goals may include a conservatively reduced but preserved appearance of the dorsal hump, rather than complete elimination and a straight-line dorsum.

Spreader grafts should be used judiciously in the Latino rhinoplasty, as excessive or unnecessary use may overemphasize an already wide dorsum. If there is concern about overwidening the dorsal aesthetic lines, the surgeon can consider unilateral spreader or spreader flaps.

Although a radix position between the level of the supratarsal crease and lash line is ideal in Caucasian noses, a low radix position is a consistently ethnic feature. In the Latino nose, the radix should sit at or below the lash line. Altering the position of the radix is largely unnecessary and may result in racial incongruity. Alternatively, subtle radix augmentation and a less aggressive dorsal hump reduction can produce an aesthetically acceptable, masculine profile. This technique may be less suitable for female patients who potentially desire an overall “smaller” nose on lateral view.

Back to Top | Article Outline

Cartilaginous Framework

Septum.

One should consider that septal cartilage in ethnic noses, particularly the Latino nose, may be weak and recessive in nature, very similar to the black nose. Septal cartilage harvest should be conservative, as the already weakened quadrangular cartilage places the dorsocaudal support at risk of saddle deformity with overresection. In our practice, aseptically processed cadaveric costal cartilage (MTF Biologics, Edison, N.J.) has largely replaced the need for distant sites of autogenous cartilage (such as ear or rib cartilage) in cases of insufficient septum for cartilage grafts in both primary and secondary rhinoplasty. The high quality of aseptic processing and the variety of dimensions and thicknesses available make this medium highly customizable and convenient to use. Our preferred substrates for various graft types are detailed in Table 4.

Table 4. - Preferred Substrate for Various Graft Types
Septal cartilage
 Columellar strut graft
 Spreader graft (if needed at all)
 Extended alar contour graft
Cephalic trim
 Butterfly infratip graft
Costal cartilage (allograft)
 Dorsal only graft
 Spreader graft
 Columellar strut graft

Back to Top | Article Outline
Lower Lateral Cartilages.

The lower lateral cartilages are typically wide and weak, with a tendency to buckle. In addition, the fibrofatty attachments suspending the lower lateral cartilages to the upper lateral cartilage and septum are inherently weak. This can be appreciated on physical examination with the doughy consistency and weak recoil of the Latino tip with palpation. Because of the inherently weak nature of the lower lateral cartilages in this ethnic group, lower lateral crural turnover flaps may need to be considered. In addition, when performing maneuvers to refine the Latino tip, note that it is nearly impossible to remove all bulbosity from the Latino tip. The goal is to improve on its definition and decrease its bulk. To aspire to achieve a perfectly sculpted tip in patients with such thick soft tissue is unrealistic and may provide the patient with an “operated” appearance.

In our hands, cartilaginous base support is most commonly used with a columellar strut, with systematic analysis of appropriate strut design and placement as described by the senior author (R.J.R.).11,12 In particular, the columellar strut is valuable in the Latino patient when the lower lateral cartilages are found to be weak with significant collapse on palpation. In these instances, a long, floating columellar strut is used. Select patients can be managed without stabilizing cartilage grafts (i.e., columellar strut) if the lower lateral cartilages are found to be strong. Features in these patients may favor more European characteristics where underprojection is less of a problem. Alternatively, the septal extension graft is a powerful technique to support the tip and is used by the senior author (R.J.R.) selectively.13 The benefits include dual modification of both tip projection and rotation, particularly when constraints of thick sebaceous skin and soft-tissue memory need to be overcome.

In those patients with less weak lower lateral cartilage frameworks, an extended-type cephalic trim may be required to allow better medialization of the tip-defining points and debulking of the supratip. Overaggressive cephalic trim should be avoided, as this can convert one’s moderately strong lower lateral cartilage framework into a weak one, and predispose to alar collapse. In our practice, cephalic trim remnants are routinely preserved for potential use as an infratip butterfly graft, which serves to soften the infratip and smooth the transition to the soft-tissue triangles.14 (The butterfly graft used is a lenticular graft fashioned from cephalic trim of lower lateral cartilages, measuring approximately 15 × 5 mm. On the frontal view, the graft is placed over the infratip lobule, just over the middle crura, with lateral portions just caudal to the domes. The lateral parts of the graft are not fixated, and exert a spring-like effect in a caudal direction to volumize the soft-tissue triangle and balance the transition from tip lobule to alar lobule.)

Back to Top | Article Outline

Alar Bases and the Nostril Sill

Alar base resections are the rule, rather than the exception in Latino rhinoplasty. In our practice, it is customary to err on the side of not performing an alar base resection if the flaring is slight or borderline. In the Latino nose, alar base resection should be used liberally, particularly because of concomitant depressor septi hyperactivity, which tends to exacerbate preexisting flare. We have never seen any cases of scar hypertrophy or keloid formation along the alar-cheek junction because of an alar base resection.

A systematic approach to alar base reduction is key to Latino rhinoplasty. As described previously, alar flare can be categorized into three types according to the vertical level of the lateralmost point along the alar rim relative to the sill-base junction on basal view. The reader may consult the senior author’s recently published alar base resection technique, with full details regarding alar base morphologies and the appropriate corresponding excisional patterns.15 After alar base resection, half of the alar base sutures are removed on day 7 (first postoperative visit); the remaining sutures are removed on day 10.

Back to Top | Article Outline

Addressing Alar Contour and the Soft-Tissue Triangles

Given that the Latino nose has a propensity for posterior alar hang and anterior notching, precise surgical maneuvers to counteract this tendency are critical. Five key techniques are used to prevent further deformation of the anteriormost portion of the ala extending into the soft tissue triangle—high infracartilaginous incision placement, placement of extended alar contour grafts, adding morselized cartilage to minimize internal concavity within the soft-tissue triangle, limiting lateral lining closure to avoid undue tension, and closure of dead space with bacitracin-coated diced surgical gauze (Surgicel; Ethicon, Inc., Somerville, N.J.).16 Areas of meticulous suture placement and careful obliteration of dead space are reviewed. [See Figure, Supplemental Digital Content 4, which demonstrates areas of meticulous suture placement and dead space closure to avoid exacerbating alar notching in the Latino nose. (Reprinted from Campbell CF, Pezeshk RA, Basci DS, Scheuer JF, Sieber DA, Rohrich RJ. Preventing soft-tissue collapse in modern rhinoplasty. Plast Reconstr Surg. 2017;140:33e–42e), http://links.lww.com/PRS/D705.]

Back to Top | Article Outline

Depressor Septi Nasi Muscle Hyperactivity

Similar to the Middle Eastern nose, a hyperdynamic depressor septi muscle is ubiquitous in the Latino nose. The Latino nose is already prone to underrotation and alar flare, and hyperdynamic depressor septi muscles will exaggerate these features. Thus, we have a very low threshold for depressor septi release in the Latino patient. One can consider botulinum toxin injection to assess the dynamic influence of the depressor septi on overall nasal harmony preoperatively. Note that depressor septi injections are exquisitely painful; injecting without topical analgesia is not recommended.

Back to Top | Article Outline

CONCLUSIONS

Addressing the Latino nose requires a firm understanding of the racial heterogeneity that exists within this population, ranging from features more consistent with the black nose to features more congruent with a European Caucasian nose. A patient’s aesthetic goals should be thoroughly discussed to avoid racial incongruity. We provide an individualized, component approach to improving aesthetic outcomes in Latino rhinoplasty.

Back to Top | Article Outline

PATIENT CONSENT

Patients provided written consent for the use of their images.

Back to Top | Article Outline

REFERENCES

1. Leach J. Aesthetics and the Hispanic rhinoplasty. Laryngoscope 2002;112:1903–1916.
2. Cobo R. Rhinoplasty in Latino patients. Clin Plast Surg. 2016;43:237–254.
3. Patel AD, Kridel RW. Hispanic-American rhinoplasty. Facial Plast Surg. 2010;26:142–153.
4. Cobo R. Rhinoplasty in the Mestizo nose. Facial Plast Surg Clin North Am. 2014;22:395–415.
5. Cobo R. Nuances with the mestizo tip. Facial Plast Surg. 2012;28:202–212.
6. Daniel R. Rohrich RJ, Adams WP, Ahmad J, Gunter JP. The Hispanic nose. In: Dallas Rhinoplasty: Nasal Surgery by the Masters. 2014:3rd ed. St. Louis: Quality Medical; 1171–1194.
7. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343–1354.
8. Rohrich R, Ghavami A. Rohrich RJ, Adams WP, Ahmad J, Gunter JP. The Middle Eastern nose. In: Dallas Rhinoplasty: Nasal Surgery by the Masters. 2014:3rd ed. St. Louis: Quality Medical; 1195–1224.
9. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg. 2001;111:1322–1339.
10. Rohrich R, Muzaffar A, Ghavami A. Rohrich RJ, Adams WP, Ahmad J, Gunter JP. The black nose. In: Dallas Rhinoplasty: Nasal Surgery by the Masters. 2014:3rd ed. St. Louis: Quality Medical; 1139–1170.
11. Rohrich R, Hoxworth R, Kurkjian T. The role of the columellar strut in rhinoplasty: Indications and rationale. Plast Reconstr Surg. 2012;129:118e–125e.
12. Rohrich R, Kurkjian T, Hoxworth R, Stephan P, Mojallal A. The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plast Reconstr Surg. 2012;130:926–932.
13. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape. Plast Reconstr Surg. 2003;112:1929–1935.
14. Rohrich R, Afrooz P. The infratip lobule butterfly graft: Balancing the transition from the tip lobule to the alar lobule. Plast Reconstr Surg. 2018;141:651–654.
15. Rohrich R, Malafa M, Ahmad J, Basci D. Managing alar flare in rhinoplasty. Plast Reconstr Surg. 2017;140:910–919.
16. Campbell CF, Pezeshk RA, Basci DS, Scheuer JF, Sieber DA, Rohrich RJ. Preventing soft-tissue triangle collapse in modern rhinoplasty. Plast Reconstr Surg. 2017;140:33e–42e.

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2019 by the American Society of Plastic Surgeons