Dr. Alejandro Nogueira's Case #FVJ69A2V

The most remarkable issues are the missing dorsum, the nasal pyramid is barely existent due the minimal development of the nasal bones and upper lateral or triangular cartilages, the dorsum or bridge is flat, parallel to the maxilla and requiring a massive grade of augmentation, if not total reconstruction, notwithstanding other cases have even less dorsum development and the bridge is even flatter,; however the nose is not actually broad as it seems but just a mere optical effect due to the flat, rounded, broad and undefined dorsum, which is another one of the main issues in this case; the remains of the nasal pyramid are short, thus the nose needs lengthening too; the nasal tip is collapsed, undefined and flattened due to the weak, unsupportive, underdeveloped and thin lower lateral cartilages; the tip has the so typical large fibrofatty pad present in African noses, leading to a bulbous hypertrophy; there is poor alar support as well, making the nose somehow functionally impaired at its nasal valve but not aesthetically due to the thick skin cover; last but not least the issues at the nostrils, which have at the same time large alar flares, this is large alae, and large sills or nostril bases, and in this particular case an excess of inner lining leading to visible creases.

Mixed blood cases may be subject to more or less conservative approaches, but fully featured African noses require from the surgeon not only awareness of the ordeal he is facing but also deep understanding of the anatomical peculiarities underlying their shape and the very high end technical skills in parallel with artistic resources required for a successful outcome, making these rhinoplasties totally a world apart from caucasian ones or other ethnicities; the only ethnicity sharing features with the African noses is the Asian one.

This complete African case was simply and literally rebuild adding a new layer of skeleton overlapped above the pre existent one, using the original nose as pillars or platform to stand by the new skeleton added on top; after an open access the huge fibrofatty pad covering the tip domes, the supratip and the alae was completely and meticulously removed; then the recipient beds for the new onlay nose grafting were prepared at dorsum, tip, alae and columella.

Considering the huge amount, size and thickness of cartilage grafting required the ears and the deep septum were barely sufficient as donor sites, however it was possible performing the techniques on the verge of using rib grafting although finally this was not necessary; out of the cartilaginous material harvested several freely designed elements were tailored, customized and exhaustively tested until perfect compliance was assessed; the first was an entire new dorsum, thick enough to raise the congenitally absent bridge and with great care to obtain a straight and smooth new profile and a perfectly matched concave undersurface aiming to fit the pre existent dorsum with stability, such element was given a triangular shape at its upper and lower ends to fit into the frontonasal groove and at the lower end so that it can act as full dorsal replacement graft; a septal lengthening was carried ahead by means of a pair septocolumelar grafts of double support, two on one design and L shaped, anchored to the upper lateral or triangular cartilages and to the end of the caudal septum; these septocolumelar grafts acted as key stand structure to provide tongue in groove support and strut to the medial cruras and tip projection support.

Then the lateral cruras were tailored and secured in place to the angle of the septocolumellar grafts; a shield graft to replace the tip and a columellar onlay graft, fully customized and handmade, were applied to reposition, reshape and rebuild the nasal tip and the columella on top of L shaped nasal lengthening structure.

Once structural stability was confirmed the last stage was closure of the cutaneous hood and assessment of the final excess of alar and nostril skin; a double removal of skin was performed by means of a wedge excision of alar base and nostril sill.

It is very important noting these African noses are in need of both a massive augmentation in some areas like the bridge or an increase in nasal tip projection, plus an aggressive reduction in others as can be tip size, alar flare and nostrils sills' width.

It is hard to believe the final outcome is even technically feasible, however this case is the perfect proof that when skills are high, patience is immense and creativity shakes hands with deep anatomical understanding it is possible to carry ahead successful ethnic African rhinoplasties still providing very natural results, customizations to meet patient's preferences, feminization and awesome facial balance with preservation of ethnicity, unlike minimally invasive, conservative and scared approaches which, in these extremely complex cases, lead to grotesque, artificial, ethnically incompatible, insufficient or excessive, always disappointing and normally unsightly results; African noses and alike ethnicities need a very challenging technical management only feasible by the most talented surgeons in top class structure rhinoplasty.

Note: patients with dark or black skin are genetically prone to develop hypertrophic or keloid scars, of poor quality in general and more visible than the average; in spite there are treatments to put this problem under control and palliate it, there is no way to foresee or prevent its occurrence, being sometimes a price or risk patients well aware take in order to achieve their dreams of anatomical modification.

It is remarkable how, in spite it was extracted the maximum available amount of cartilage from both ears, the postoperative look of the auricle is perfect and no signs of such extraction nor deformities are present, no anterior scars, no droopiness, all the natural ear creases are respected and no rupture of contour; harvesting ear cartilage in rhinoplasty is not a trivial maneuver and in case it is not properly executed may lead to additional deformities requiring repair or even complex reconstruction.