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. 

Artefill is the first and only FDA approved wrinkle filler in the United States.  As cosmetic surgeons, we have waited a long time for a safe product such as Artefill to become available to our patients.  Although there have been other products on the market (such as silicone and Medpor, etc) none have been FDA approved and none have had the safety heritage of Artefill’s predecessor – Artecoll. 

Artefill is essentially a mixture of purified Bovine collagen as well as Polymethylmethacrylate (PMMA) microspheres in an 80:20 ratio.  There is also 0.3% Lidocaine (anesthetic solution) mixed with the collagen for added patient comfort.  The collagen portion resorbs over several weeks but the PMMA micro-spheres remain and become encapsulated by the body as a permanent “filler.”  Most patients will require two or three treatment sessions spread about four to eight weeks apart in order to achieve the final desired result without “over-filling.”

The treatment initially involves a simple skin test to ensure that the patient is not allergic to the Bovine collagen component of Artefill.  If after a month, no signs of allergic reaction are seen then the treatment can be performed safely.  The skin test involves placement of 0.1cc of Artefill test mixture under the skin of the forearm in the same manner as a PPD (T.B. test).

The FDA has approved Artefill for wrinkle reduction of the Nasolabial folds (deep lines extending from the sides of the nostrils to the corners of the mouth).  Although the FDA approval is for correction of the nasolabial folds, Artefill can also be used for the correction of other deep facial lines.  Artefill should not be used around the eyes, in the lips, or in superficial lines.  However, it can be used for permanent tissue augmentation such as for malar (cheek) augmentation in place of a malar or submalar implant or in place of fat injection or even a mid-face lift.  It can also be used to augment the chin or the pre-jowl area in place of implants. 

The cost is higher than traditional fillers such as Restylane or Collagen but given its permanent nature, Artefill is cost effective overall with a cost per syringe that is only slightly higher than that of Radiesse (another filler that lasts about 12-18 months). 

First, I want to clarify some terminology. The "prejowl" area is exactly as it sounds. It is the area lateral to the chin but medial to the "jowls", so basically it is an area between the chin and jowls. The most common aesthetic defect affecting this area is a lack of fullness making the chin look too pointy. The treatment includes "filling" the area with fillers such as Restylane or Radiesse, using pre-jowl implants such as the "Mittleman prejowl implant" or using fat grafting in the area. All are valid options. With Artefill, the new permanent filler recently approved  by the FDA, the options are even more abundant.

Now the other issue is "jowling" or "jowls." This refers to fullness or sagging in the area of the jowls. The gold-standard treatment is a "traditional" lower facelift and the reason I place the word "traditional" in quotes is that if you have done your homework you will appreciate and possibly be overwhelmed by the fact that there are numerous approaches, incisions, dissection techniques and extents and methods for carrying out a "traditional" facelift.   No two surgeons do a facelift the same way – almost.

Some patients, especially younger patients with very minimal jowls and good skin tone, can benefit from a "mini" type lift and delay undergoing a more extensive facelift for many years. Again, there are many variations of "mini lifts" as well.  

Liposuction of the jowls can be carried out very conservatively and it is somewhat effective. However, there are risks associated with it and, given the very slight benefits, it may not be the best option by itself.

As the appearance of the "aging face" is a result of tissue and volume loss, replenishment of this "volume" using fat grafting or fat transfer is a valid option. The same can be achieved with fillers or implants. As the area under the skin is "filled", it "pulls" on the more dependent lower areas and in effect "lifts" the skin and jowls.

If you decide to go with a min-lift, you can expect a 5 to 7 day recovery for the edema, bruising and "rippling" to substantially subside despite what the advertisers of “weekend facelifts” and other marketing hype today would make you believe. Unfortunately, men cannot use makeup for cover-up and camouflage but they generally heal faster due to the nature of male skin with an abundant presence of hair follicles and sebaceous units.  Women can easily use makeup to cover the slight bruises that may persist beyond the first few days and go about their daily routines after a mini-lift. There usually is not much pain or swelling associated with mini-lifts although each patient may have a different experience. A very important consideration is incision placement, especially in men since again men cannot cover scars with makeup.   The proper placement and location of incisions are much more important than the length of the incision in assuring that the scars are hidden and camouflaged well. 

Many patients today are on diets or have weight loss goals in mind as part of their overall “makeover.”  I usually recommend reaching your "target weight" before undergoing any kind of a "lifting" procedure.  If you are going to lose more than 15lbs, then the skin will loosen back up once the weight is gone and you may need another "tuck-up" procedure prematurely.

As far as the neck, a neck lift with or without a cheek lift (which would make it essentially a facelift) is the gold standard for the treatment of a heavy neck with loose skin and extra fat tissue commonly known as the "turkey gobbler neck".

However, neck liposuction in younger patients or combined with submentoplasty (where the platysma muscle is imbricated or sutured in the mid-line, creating a nice, tight "corset" with removal of a little bit of skin medially under the chin as opposed to laterally with a neck/facelift) is a valid alternative in someone with a moderate size neck. (In very large, heavy necks, a neck lift is still the preferred choice.)

Unfortunately, the highly-marketed modalities, such as Thermage and Contour lifts / thread lifts to name a few, do not properly or permanently address the aging neck and are often a disappointment.

Until now, the best and only proper way to address an aging neck was a neck lift.  It is a fantastic surgery but it is “over kill” in the majority of non-obese patients.  The ideal neck lift patient has a large neck or a neck with lots of extra fat or lots of extra skin.  A neck lift creates a beautiful jaw line and a nicely-sculpted and natural-looking neck with long-lasting results.

The ideal candidate for submentoplasty is a patient who is relatively within their ideal weight to height ratio with moderate loose skin and fat who wants a nicer neckline.  This 45-minute “mini neck lift” provides exactly the proper amount of “surgery” for such patients.  The results are significant yet natural.  There is almost no pain and the only downtime is associated with the post-op bruising which can readily be covered with make-up.  The results are real and long lasting and do not rely on sutures or wires and the procedure is relatively quick and safe.   What allows this procedure to stand apart from almost anything else out there today is the use of a very small hidden “T” incision under the chin which allows removal of excess skin and fat as well as muscle tightening through this one-inch incision that is well hidden and inconspicuous.   Patients often return to work within 5 days and the cost is about half of what a neck lift would be.  However, proper patient selection is key to achieving the best results.  This procedure is amazing but it is not for everyone.

With every new procedure there is a wave of followers creating a new “trend.”  The fact is, if there is abundance of loose skin and sagging tissue on the face and neck then these areas have to be "lifted" to a more youthful position and then the excess must be judiciously excised - hence a facelift of some sorts.

If there is decent of tissue with loss of volume then "filling" the areas will lift things and harmonize the face and replenish fullness.  Incidentally, implants or fillers will give a similar result in many instances.

Occasionally the best result is achieved with a combination of these modalities.  For example some patients look amazing and youthful a few weeks after a facelift but then notice some areas of "aging" again fairly soon after surgery as the swelling subsides. In such a patient, "filling" with a filler or fat at the time of surgery would have resulted in a better long-term aesthetic outcome. Each patient is different so each patient requires a somewhat unique approach - to some extent.

Many patients are interested in obtaining fuller more youthful cheeks.  Some have lost this fullness due to sagging tissue and loss of tissue volume as result of age.  Other have never had the ideal cheek or malar fullness as a result of genetic bony and soft tissue variations.

Options are numerous and depend on the patient’s age and anatomy.  Implants made in various shapes and sizes are great options.  Fat injection done in a series of 2 to 3 sessions will also result in naturally appearing fuller cheeks.  Fat can also be injected to the naso-labial folds at the same time if needed in older patients.  Filler injections although viable, were not cost effective until now.  Artefill, the first permanent “filler” approved by the FDA is a fantastic option for augmentation of the cheeks and effacement of the naso-labial folds.  Mid-face lift is also another option best used in older patients who have deep naso-labial folds and show inferiorly and medially descended cheeks.  This procedure may be combined with fat injection, filler injection or even cheek implants. 

The ultimate goal is achieving a triangular face (with the base located between the cheeks and the apex at the chin).  This “inverted triangle” is associated with youth rather than the “rectangular face” associated with aging.