Dr. Alejandro Nogueira's Case #QGKQCAFM

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; 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 or septum were ruled out as donor sites; it was decided preoperatively to access rib cartilages via an incision under the right breast, harvesting the cartilaginous shafts, not the cortex, from the seventh and sixth rib arcs; out of the cartilaginous material harvested four 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 beveled shape at its upper end to fit into the frontonasal groove and at the lower end a rectangular prong was tailored so that it can act as dorsocolumellar graft by means of fitting into the second element that follows; an en bloc tip and columella extended graft which also acted as caudal septal extension graft, with a tailored slot at is rear side to let the original caudal septum fit into it and a rectangular frame scooped at its top to host the rectangular prong of the dorsal graft and thus achieve structural stability; finally the two other elements were brand new lateral cruras to provide the necessary alar support, firmly sutured and caudally oriented; a supratip break effect was requested by the patient and intentionally designed when matching the dorsal and tip columella grafts; the patient expressly requested a not very sharp nose, thus a somehow broad tip was built during its redefinition.

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 triple removal of skin was performed by means of a wedge excision of alar base and nostril sill plus an alar rim inner vertical resection.

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.

Another remarkable point is how a well chosen rib cartilage does not warp; it is well known that only the shaft or center of the rib cartilage stays straight, it is the cortex that warps and has to be discarded; this case is a good proof of it, as well as is a good example of how problematic and unwise are nasal prostheses and the neat superiority of own patient's tissues as reconstructive material which, however, are more demanding technically for the surgeons due to their extraction and tailoring, this explains why it is so uncommon finding well trained and state of the art compliant surgeons able to manage these difficult cases.

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.