People have different morphological features related to their ethnic differences, because of racial characteristics. The Middle East is rather a political than a geographical or ethnic division as it includes North African countries, Gulf countries, countries in Asia like Syria, Lebanon, Iraq, Jordan, Turkey, and Iran.1 , 2 The Egyptian nose is an example of the mixed ethnic nature as regards the anatomy and morphology of the nose.3 , 4 The predominant character in the Middle Eastern noses is the thick skin and weak cartilages if compared with the White noses. This fact undermines the aesthetic outcomes of rhinoplasty, especially when the common techniques are adopted without paying attention to inherent anatomic features. Many authors have made their contributions like defatting of the skin over the lower part of the nose, but this was followed by prolonged edema in the supra-tip area.5 Daniel6 stated that most secondary rhinoplasties are due to poor definition of the tip in addition to failure of correction of the original deformity and presence of visible surgical stigmata. Thick skin, weak cartilages, amorphous nasal structure, bulbous tip, and postoperative supra-tip swelling require technical endeavors to improve the outcomes of rhinoplasty in this category of patients. The author discusses some anatomical findings responsible for the stigmata of these noses and describe some technical modifications adopted to achieve better esthetic outcomes.
PATIENTS AND METHODS
This is a retrospective study from 2003 to March 2016, the author has done rhinoplasties in 624 patients of Middle Eastern origin (584 Egyptian, 20 Saudi, 12 Kuwaiti, 4 Palestinians, 2 Algerians, 1 Jordanian, and 1 Moroccan).
In these patients, the author has identified 4 main anatomical findings with varying degrees of severity, which are peculiar to these kinds of noses.
- 1- The skin is very thick and sebaceous.
- 2- The cartilages are thin and weak with lesser contribution to the shape of the nose.
- 3- The lateral crus of the lower lateral cartilage is broad and saucer-like with a lateral fibrous attachment replacing the minor sesamoid cartilages of the lateral crus described in literature (Fig. 1).
- 4- There is a thick fibro-fatty layer between the skin and the lower lateral cartilage, which during dissection can come out easily with the lateral crus of the lower lateral cartilage, the thinner the cartilage the thicker this fibro-fatty layer.
All these factors lead to failure of distinction of the different parts of the nose, as the thick skin drapes heavily over the weak cartilaginous structures, so the tip becomes amorphous and bulbous and the middle vault is not narrow enough to distinguish the radix from the lower nose. Surgical creation of the dorsal aesthetic lines (Sheen lines) is needed to improve this deformity. The lateral attachment of the lateral crura of the lower lateral cartilages blurs the distinction between the nasal sidewall subunit and the alar lobule subunit externally, so identification and cutting these attachments instantaneously improves this problem.
To overcome these anatomical variations, the author has used some surgical techniques in addition to the commonly used ones to achieve satisfactory aesthetic outcomes; these can be summarized as follows:
1- Open rhinoplasty without columellar incision (or Closed rhinoplasty with alar delivery): as described by Holmstrom.7
This is done to avoid severing of the lymphatics and venous drainage of the skin of the tip to diminish postoperative edema and swelling which is more in thick skin than in thin skin and sometimes causes persistent tip swelling.
2- Identification and release of the lateral attachment of the lateral crus of the lower lateral cartilage: ( Supplemental Digital Content 1, http://links.lww.com/PRSGO/A832).
This lateral fibrous band spans between the lateral part of the lower lateral cartilage and the subcutaneous tissues at the nasolabial line. Cutting this band releases lateral tension on the lower lateral cartilage and helps to narrow the tip after doing the interdomal sutures.
3- Reduction of broad lateral crus of the lower lateral cartilages by lateral, cephalic, and caudal resection:
This is done to reduce the size of the lateral crus contrary to White rhinoplasty where cephalic resection of the lateral crus is sufficient to refine and cephalically rotate the tip.
4- Cephalic rotation is achieved mainly by M-shaped excision of the inner lining of the vestibule and the caudal part of the septum: (Fig. 2):
This is usually done by incision of about 2–4 mm of the inner surface of he vestibules at the upper edge of the rim incision. Then by cephalic advancement of the lower edge and suturing the tip will be advanced cephalically and the nose will be shortened.
5- Creation of the the dorsal aesthetic lines of the nose (Sheen lines):
This is usually done by designing the dorsal and lateral osteotomy and subcutaneous tissue reduction and placement of dorsal graft to exaggerate the dorsal lines.
6- The tip transfixion stitch: (Fig. 3)
In extremely thick skin a transfixion stitch with a prolene 3/0 on straight needle is inserted in the caudal ends of sheen line to define the tip in patients with amorphous tip, this helps to overcome the strong skin memory at the tip and force the skin to redrape over the modified cartilages and prevent the dead space between the skin and the operated cartilaginous frame work of the tip, which allows edema to develop and later on replaced by fibrous tissue leading to the supra-tip postoperative swelling. This stich is usually removed within 2 weeks.
The predominant feature of thick skin and weak cartilage is loss of distinction of different nasal esthetic subunits. In minority of cases, we have found thick skin and thick cartilages (6 cases). From above, we can realize that the nasal shape is either dependent on the skin (skin barring) or the cartilages (cartilage Barring), if one is thick the other is thin, or uncommonly both are moderate in thickness (skin and cartilage sharing). The fibrous lateral attachment between the lateral crus of the lower lateral cartilage is present in almost all patients, where it replaces the minor sesamoid cartilages and causing failure of distinction of the lobule of the nose and the sidewalls. The lower lateral cartilages are extremely wide in these patients, with its width from 5 to 12 mm and concave (saucer – like).
The cosmetic outcomes were measured by assessment of photographs in the standard views of rhinopalsty (the front, lateral, oblique lateral, and the occlusal view) by 2 plastic surgeons other than the author. The follow-up period ranged from 2 years to 13 years, and those patients with longer follow-up were coming for revision surgery or for other cosmetic surgery or with a friend who was seeking medical advice from the main author. They were asked to address the improvement as regard to:
- 1- The distinction of different parts of the nose.
- 2- The degree of recognition of the dorsal nasal aesthetic (Sheen) lines.
- 3- The degree of tip refinement.
- 4- The cephalic rotation of the tip and nasal length.
- 5- The total impression on the cosmetic outcome.
Assessors were asked to give a score out of 3, where 1 is poor result, 2 is average, and 3 is excellent result; depending on their impression on the above-named criteria and the mean is recorded for each patient. From the 624 patients in the study, 365 were of excellent results, 223 were of average results, and 36 were of poor results. Complications in the form of revision of rhinoplasty for supra-tip swelling by debulking of subcutaneous tissues (3 cases), nasal deviation (2 cases), internal valve obstruction (1 case with previous rhinoplasty done before by other surgeon), alar asymmetry after alar resection (1 case). No other complications have been recorded.
The degree of stigmata of the middle eastern noses varies from mild, moderate, or severe, example of mild cases is, moderate cases is and severe cases is (Figs. 4–6).
The term “middle eastern nose” is not as descriptive as the White, mongoloid, or Negroid noses, because of the multiple ethnicities of this region and diversity of its land extending from Africa to Asia and due to the dynamic impact of migration, invasion, and proximity by these territories. Nevertheless, there are traceable patterns such as thick sebaceous skin and weak cartilages in the majority of patients coming for rhinoplasty resulting in equivocal outcomes. Many authors had addressed this problem with excellent technical solutions and good results (1:6). The author has encountered nasal patterns differ in their severity than most of the published photographs and searched for methods to improve the outcomes. Thick skin has greater memory than thin skin, so it does not redrape easily over the modified osteo-cartilagenous nasal framework, and it retains the edema fluid longer than the thin skin resulting in less improvement than what is expected. Also, the lower lateral cartilage is wider than what is classically described in literature ranging from 5 to 12 mm, and usually it is concave like a saucer causing the tip to be bulbous. In almost all cases a lateral fibrous band was seen attached to the lateral crus and replacing the sesamoid cartilages and looks like a rudimentary muscle, which upon identification and cutting improves the distinction of the alar subunit from the sidewall of the nose. Nasal tip improvement has been achieved satisfactorily by trimming of the lateral, caudal, and cephalic parts of the lateral crus with inter-domal sutures. Columellar struts are used to define the dropped and bulbous tips in about 30% of cases, and it might have greater role in middle eastern rhinoplasty than in White rhinoplasty.8 , 9 The transfixion stitch as described above, is needed in about 20% of cases to define the amorphous tip and forces the unyielding thick skin to collapse and obliterates the dead space preventing edema collection and later fibrosis.
Cephalic rotation of the tip and nasal shortening is achieved in extremely thick skin by M-shaped excision of a measurable strip of skin from the nasal vestibule in addition to common procedures known for this purpose.10 Most of the patients with poor outcomes are those with more severe forms of thicker skin and weaker cartilages and amorphous nose, they were told preoperatively about these inferior results and that surgery will be more nasal volume reduction rather than refinement surgery and they agreed about that. Thick skin has only 1 advantage in rhinoplasty, which is being permissible for fine irregularities in the dorsal framework.
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Supplemental Digital Content
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