Washington, D.C.
Northern Virginia
plastic surgery

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. 

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. 

One of the most confusing and daunting tasks for patients is deciding which one of the newest Lasers or devices is the best treatment for facial wrinkles &/or age spots.  I have seen hundreds of patients who come in telling me that they have tried this laser and that laser with little benefit or that each dermatologist or plastic surgeon they have consulted has suggested a different Laser, cream, peel or the “latest device” in their office or spa.

In order to properly rejuvenate the aging face, the nature, texture and tone of skin has to be improved in addition to any lifting type of procedure.  For example a Facelift surgery will treat sagging jowls but will do very little to reduce fine and medium depth wrinkles and lines on the face.  Immediately after surgery the face looks very youthful and most fine and medium lines will be invisible due to swelling but as this swelling resolves, the lines reappear.  

Age spots and blotchy hyper-pigmentation is also a tell-tale signing of aging and treating these issues at the time of other aging face procedures will not only add “icing to the cake” by improving the general appearance of the skin, it will also ensure longer lasting results from the other co-procedures (such as a Facelift) by having improved the general condition of the skin. 

So what are the best options for treating wrinkles, lines and hyper-pigmentation?  Should you invest in multiple Fraxel, IPL or Plasma treatments or should you go for the “controversial” CO2 Laser, or possibly even consider the older methods of surgical Dermabrasion or Chemical peels?

The answer is complex.  There is no “best treatment.”  They all work to different extents and the  “best treatment” depends on the patient.  Factors such as skin color, location of lines or wrinkles (e.g.: crows feet vs. peri-oral lines), amount of “down-time” the patient can afford, patient’s lifestyle such as outdoor work or hobbies and the resultant sun-exposure, time of year, and finally cost, are all factors to consider. 

All such treatments fall under the category heading of “Resurfacing.” Resurfacing involves removal or stimulation of different layers of skin resulting in changes and improvement in skin color, texture and tone.  Stronger and deeper modalities will result in more significant improvement but also require more “down time” for recovery and in inexperienced hands can result in scarring or other complications.  Weaker or “lunch-time” type procedures require a series of treatments spaced at regular intervals but also require patience on the part of both doctor and patient in order to see meaningful results. 

As a final note, surgical Dermabrasion, as well as Chemical peeling have become lost arts replaced by machines and lasers.  There are very few devices that can equal or match the effectiveness of Dermabrasion for treatment of smokers’ lines, or a Phenol / Bakers Chemical Peel for the treatment of crows feet lines.  One such impressive device is the controversial CO2 laser.  The CO2 laser has received bad publicity recently due to horror stories of patients who have been scarred or “over treated” with this powerful laser.  When used by a skilled plastic surgeon or facial plastic surgeon, this laser can yield unparalleled results treating deep lines as well as age spots and hyperpigmentation.