author's personal copy rhinoplasty in the patient of african descent · 2015. 7. 1. · the...

Author's personal copy

Rhinoplasty in thePatient of AfricanDescentMonte O. Harris, MDa,b,c,*

We are in the midst of truly changing times, aspatients of African descent actively embrace facialcosmetic surgery. The Eurocentric aesthetic plat-form is slowly evolving to embrace a more globalstandard of beauty. This enlightened perspectivehas provided much-needed breathing room forpopulations with skin of color to seek facialenhancement without the accompanying claimsof ‘‘trying to look Caucasian.’’ As a result, stigmasurrounding cosmetic nose reshaping has notice-ably decreased in the African American commu-nity. Rhinoplasty is now more commonlyperceived as a means to achieve greater harmonyand balance in the face and not as a denial of ethnicheritage. In the 2006 American Academy of FacialPlastic and Reconstructive Surgery MemberSurvey, African Americans were more likely toseek rhinoplasty than any other facial plasticsurgery procedure.1 Modern rhinoplasty surgeonshave the unique opportunity to redefine surgicallogic and classification schemes to be moreanatomically sophisticated and culturally sensitive.

Gaining surgical consistency in patients ofAfrican descent has proven to be elusive, unpre-dictable, and challenging for many rhinoplastysurgeons. In general, rhinoplasty necessitatesa thorough appreciation for key surgical anatomyas well as a high degree of technical skill. Theseprerequisites are increasingly important even forthe skillful surgeon who is not accustomed to

operating on patients of African descent, asanatomic variables may often be misleading.2

The author would further assert that identifyingpertinent surgical anatomy and operative skill arenot the only hurdles to overcome in achievingconsistent favorable rhinoplasty outcomes in thispopulation of patients. Anatomy and operativetechniques can indeed be taught. Cultivating anaesthetic consciousness for Afrocentric nasalharmony, however, is a more nuanced endeavor.Here, surgical success relies on the surgeon’sability precisely to identify anatomic variablesand reconcile these anatomic realities with thepatient’s expectations for aesthetic improvementand ethnic identity. To do this successfully,surgeons need not only a clear understanding oftheir patient’s expressed aesthetic goals but, asimportantly, the knowledge and understanding ofthe often unexpressed cultural influences thatundergird these expectations. This knowledge isamongst the most challenging aspects of rhino-plasty surgery in patients of various cultures andethnic groups. Yet, a surgeon’s ability to ‘‘cultur-ally connect’’ with the patient is essential to estab-lishing a foundation for the creation of a sharedaesthetic vision.

Much of the interruption in the progression tofavorable rhinoplasty aesthetic outcomes occurspreoperatively during the consultation and nasalexamination. There are 3 major areas of

a Center for Aesthetic Modernism, 5530 Wisconsin Avenue, Suite 612, Chevy Chase, MD 20815, USAb Department of Otolaryngology–Head and Neck Surgery, Georgetown University Medical Center, 3800Reservoir Road, Washington, DC 20007, USAc Department of Dermatology, Howard University Hospital, 2041 Georgia Avenue, NW, Washington, DC 20060,USA* Corresponding author. Center for Aesthetic Modernism, 5530 Wisconsin Avenue, Suite 612, Chevy Chase, MD20815.E-mail address: [email protected]

KEYWORDS

� African American rhinoplasty � Ethnic rhinoplasty� African American � Black American � Culture � Ancestry

Facial Plast Surg Clin N Am 18 (2010) 189–199doi:10.1016/j.fsc.2009.11.0121064-7406/10/$ – see front matter ª 2010 Published by Elsevier Inc. fa

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breakdown that occur before the surgeon sets footin the operating room.

1. Patient not confident that the surgeon under-stands his or her aesthetic goals.

2. Flawed nasal analysis and surgical plan basedon Eurocentric nasal beauty standards.

3. Unrealistic expectations held by surgeon orpatient without consideration of pertinentanatomic variables and nasal skin envelopelimitations.

This article aims to provide insight for and raisethe comfort level of rhinoplasty surgeons oper-ating on patients of African descent. The articlehighlights the significance of exploring ancestryin the rhinoplasty consultation; identifies keyanatomic variables in the nasal tip, dorsum, andalar base; and reviews surgical logic that has facil-itated achieving consistent balanced aestheticoutcomes in the author’s practice.

THE CULTURE CONNECTION: WHY EXPLOREANCESTRY?

An appreciation for underlying heritage providesa link to culturally connect with prospectivepatients and serves as a tool for establishing real-istic aesthetic goals. This cultural journey can beinitiated by simply inquiring about a patient’sfamily background. The author asks patients‘‘where did your family originate?’’ This questionopens a nonthreatening pathway to establishauthentic dialog regarding ancestry and ethnicity.This cultural conversation can be the ultimatetool in surgical decision making as it may shedlight on how much or how little change a patientdesires, or in understanding what anatomic vari-ables a patient associates with ethnic identity, orsimply positioning the clinician in the patient’smind as someone who cares about his or herindividuality.

WHO IS AN AFRICAN AMERICAN . ORBLACK AMERICAN

Previous rhinoplasty literature has often discussedrhinoplasty in patients of African descent under thegeneric headings of ‘‘non-Caucasian’’2–4 and‘‘ethnic.’’5,6 Whereas some reports have takena more focused and individualized approach usingthe terms ‘‘African American’’7,8 or ‘‘Black Amer-ican,’’9,10 active debate exists regarding the defini-tion and inclusiveness of the term AfricanAmerican that is beyond the scope of this article.11

Much of the debate focuses on who actually fallsunder the umbrella of African American termi-nology. Arguments have included diverse opinions

regarding the inclusion of ‘‘white-skinned Cauca-sian’’ Africans and distinctions between BlackAmericans and African Americans. Being awareof the nuances of this particular debate, however,serves to heighten a surgeon’s cultural sensitivity.From a pragmatic point of view, the most commoncategories of so-called African Americans whomay present to the office for rhinoplasty are

1. Multiethnic descendants of the transatlanticslave trade born and raised in the United States

2. Immigrants of African countries now residingwith citizenship in the United States

3. Children of an African immigrant parent orparents born in the United States (Fig. 1).

African American terminology has relevancefrom an anatomic, geographic, and culturalperspective. Racial admixture in the African Amer-ican population has resulted in a diverse array ofanatomic and morphologic nasal presentations.Psychosocial impressions of ethnic identity maybe quite different for a Nigerian patient who immi-grated by choice to the United States comparedwith the patient born and raised in America withremote African ancestry originating from the trans-atlantic slave trade. Ironically, many American-born descendants of slavery can more aptly identifyEuropean (such as Irish, Scottish) and Native Amer-ican (such as Cherokee, Powhatan) lineage, overthe nonspecific African heritage that defines theirethnic identity in American culture. A large segmentof the African American cultural story has beenmotivated by an underlying desire to reconnectthe links severed by slavery to a distinct Africanancestral past. The past 30 years have seena renaissance of sorts with respect to African Amer-ican economic empowerment and the influence ofuniquely African American culture on globalsociety. African American influenced music (jazz,blues, hip hop), dance (Alvin Ailey American DanceTheater), and fashion have been embraced world-wide. The author’s prospective rhinoplasty patientsof African descent (most commonly between 20and 40 years old) have nurtured their sense ofself-identity in this accepting, globally inclusiveenvironment. As a result, many of these patientshold preservation of ethnic identity in high regardas they seek to enhance facial attractiveness.These are cultural nuances of which ideally anaesthetic surgeon should be aware. Such aware-ness will not change the technical approach, but itmay facilitate an enlightened conversation withthe patient regarding ideal aesthetic outcomes,and allow surgeons to fine tune surgical logicregarding the amount of change the patient willfind acceptable and pleasing. The ‘‘cultural

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connection’’ is yet another universal means toformulate a shared vision between surgeon andpatient with regard to defining aesthetic ideals.Once the aesthetic vision is defined, it is up to thesurgeon to formulate a surgical plan whereby thevision can be made a reality.

THE RHINOPLASTY CONSULTATION: ANEDUCATIONAL OPPORTUNITY (A TEACHINGMOMENT)

The rhinoplasty consultation is an opportunity forboth surgeon and patient to share and learn fromeach other. A major complaint that the authorreceives from patients of African descent whohave visited other surgeons for consultation isa lack of confidence with the surgeon’s ability tointernalize their desired cosmetic goals withcultural sensitivity. As discussed previously,exploring ancestry is a means to set the stagewhereby surgeons can learn from their patients.In the same regard, the nasal examination is anopportunity for the surgeon to take the lead andteach, creating an educational atmosphere forpatients to learn from the surgeon. This educa-tional platform between patient and surgeoncreates an environment for the ‘‘sharing of knowl-edge,’’ which will ultimately facilitate the creationof a shared aesthetic vision for rhinoplasty.

In the consultation, the author asks each patientwhat concerns he or she has with the appearanceof their nose. To be more specific, each patient isgiven a cotton-tip applicator, is told it is a magic

wand, and is asked what he or she would changeif it were that simple. The rhinoplasty consultationfor patients of African descent sometimes comeswith a bit of psycho-social baggage. African Amer-icans have often rejected facial cosmetic surgeryseeing it as a way of conforming to European idealsof beauty. In many instances the patients are ontheir own, without the benefit of family support orclose associates who have already undergone theprocedure with whom they can relay concerns.The magic wand exercise works to alleviateanxiety. The exercise also encourages patients tobe more specific in identifying desired changeswith a focus on key anatomic variables. The authorthen reviews the anatomy of the nose with thepatient. In this teaching moment, the nose is sepa-rated into 3 major areas: upper, comprising thenasal bones; middle, comprising the upper lateralcartilages; and lower, comprising the paired tiplower lateral cartilages and the fibro-fatty frame-work of the nostrils. In a simplistic manner, theprospective rhinoplasty patients are informed thataesthetic complaints typically fall into 3 boxes.For some individuals a check can be placed in all3 boxes, for some, 2 boxes, and others, only one.The first box includes complaints related to theoverall contour of the bridge (shape, projection).The second box contains complaints associatedwith the width of the nose. The third box relates toconcerns regarding the shape of the nasal tip andnostrils. The consultation then proceeds withsurgeon and patient symbolically placing checksin the appropriate box or boxes, and together

Fig. 1. Who is an African American? These photographs illustrate common categories of African Americans. (A)American-born citizen (African ancestry as a descendant of slavery). (B) Multiethnic (Sierra Leone/Russia) Africanimmigrant now residing in the United States. (C) American-born citizen with African (Nigerian) parents.

Rhinoplasty in the Patient of African Descent 191


outlining a shared aesthetic plan incorporatingspecific techniques to modify their particularanatomy.

KEY TECHNIQUES RELATED TO SURGICALANATOMY

Given the vast morphologic diversity of patients ofAfrican descent, surgical approaches and tech-niques must be directed toward modifying specificanatomic variables. Previous reports have offeredgeneralized descriptions regarding surgicalanatomy in the African American patient withoutregard for geographic differences and ethnicmakeup of the study population. For instance,Stucker notes that the lower lateral cartilages arethinner and more flaccid than those found in theCaucasian race.12 Rohrich comments that ‘‘TheAfrican American nose typically has a short colu-mella, broad flat dorsum, slightly flaring alae, anda rounded tip with ovoid nares.’’7 Ofodile and Bo-khari reviewed harmonious anthropometricindices and normal baseline measurements forthe African American patient.13 This article nowcomments on a few surgical concepts and tech-nical pearls that have facilitated achieving consis-tent and natural results in patients of Africandescent.

MODIFYING THE NASAL TIP

Patients of African descent frequently present withconcerns regarding the appearance of the nasaltip. Common complaints include bulbous shape,lack of tip projection, and poor tip definition. Thelack of tip definition and broad, bulbous lobuleappearance are often multifactorial, resultingfrom a combination of a thickened skin envelope,increased subcutaneous fibro-fatty tissue over-lying the lower lateral cartilages, and a rounded/convex contour of the lower lateral cartilages.

Improving the appearance of the nasal tipshould be approached from the perspective ofcontour modification and not simply narrowing.To do this reliably, it is important to comprehendthe relationship between the external nasalcontour and shape of the underlying tip struc-tures.14 This exercise can be exceedingly difficultin the subset of patients of African descent whopossess a thick skin envelope, excessive fibro-fatty subcutaneous tissue, and fragile lower lateralcartilages. By understanding the correlationbetween the external tip morphology and theunderlying structure, the surgeon can simplifynasal tip surgery to preserve the favorablecontours of the lower lateral cartilages and modifythose that are unfavorable.14 With this goal in

mind, developing a cultural sensitivity for a broadrange of aesthetically pleasing anatomic contourrelationships becomes important. The authorwholeheartedly concurs with Toriumi’s positionthat ‘‘even broad tips that possess favorable shad-owing can look very good.’’14 Rhinoplastysurgeons are strongly urged to peruse the pagesof ESSENCE magazine, a monthly women’s healthand beauty publication, on a regular basis to famil-iarize themselves with the range of aestheticallypleasing nasal tip contours in women of Africandescent.

Ofodile and James have reported that the alarcartilages in African American patients are similarin size to those of Caucasian patients.15 Giventhe inherent morphologic diversity in African Amer-ican patients, it should be further added that thefull spectrum of cartilage shape, size, and thick-ness can be present, depending on the underlyingmultiethnic racial ancestry. A critical point ofdistinction is that in patients of African descent, itcan be quite difficult to predict the shape of thecartilage framework without actual visualization.Digital palpation to assess cartilage strength isnot as helpful as in individuals of Europeandescent, due to the masking effect of the thick-ened skin and subcutaneous fibro-fatty tissue. InOfodile’s study of the Black American nose, thepresence of a heavy layer of fibro-fatty tissuewas a consistent finding in all the subjects.13 Theauthor has been surprised to find extremely weakand fragile lower lateral cartilages in patientsdespite a firm tip with digital palpation. Improvedvisualization with an external rhinoplasty approachhas consequently proven to be a more reliablemeans to assess the anatomic contributions toexternal tip morphology in patients of Africandescent.

For external rhinoplasty, the skin envelopeelevation is often performed just under thesubcutaneous tissue, allowing for controlled tipdebulking. A particular effort is made topreserve the fibro-fatty subcutaneous materialoverlying the lower lateral cartilages so that itcan be used later for soft-tissue graft material,usually to soften the appearance of cartilaginousshield grafts (Fig. 2). Although patients andsurgeons may harbor reservations with thetranscolumellar incision of the externalapproach, it has been found to heal in an imper-ceptible manner when executed proficiently andclosed with meticulous surgical technique. Theauthor use a 6-0 polypropylene suture ina vertical mattress fashion to reapproximatethe columellar skin at the peaks of the in-verted-V columella incision. The marginal inci-sions are closed with 5-0 fast-absorbing gut.

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The prolene sutures are removed at postopera-tive day 6. Two-layer closure with a singledeep 5-0 monocryl is recommended if signifi-cant tension is present as a result of increasedtip projection from cartilaginous tip grafts.

The columellar strut is the primary workhorse fornasal tip modification in patients of Africandescent. As an essential support graft, the colu-mellar strut is placed to offset intrinsic alar carti-lage weakness. A particular effort is made toharvest a strong resilient cartilage graft from themaxillary crest to be used for the columellar strut(Fig. 3). The vestibular skin adjacent to the inter-mediate and medial crura is elevated in a limitedfashion to create a space for burying the fixationstitches. Multiple 5-0 PDS stitches in a horizontalmattress fashion are used to secure and stabilizethe columellar strut. Fixation of the columellar strutbetween the medial crura provides a stable foun-dation for a ‘‘ground up’’ approach to improvingtip contour and projection.

Much attention has been placed on the pres-ence of a supratip break point as a marker fora balanced elegant relationship between tip and

dorsum. It should be stressed that preservationof the infratip breakpoint has equal relevance inachieving a natural unoperated-appearingoutcome. Care should be taken to place shieldgrafts in a manner that does not obliterate the in-fratip break point. The author recommendspreserving the fibro-fatty tissue of the interdomalspace when present and leaving it attached inferi-orly (Fig. 4A). This tissue can be repositioned asa pedicled overlay soft tissue graft to improvethe contour of the infratip region (Fig. 4B).

MODIFYING THE NASAL DORSUM

The majority of complaints in patients of Africandescent with regard to the nasal dorsum centeron the presence of wide nasal bones, dorsalunderprojection, and lack of aesthetic continuity

Fig. 2. Subcutaneous fibro-fatty soft tissue overlyinglower lateral cartilages.

Fig. 3. Strong columellar strut positioned betweenmedial crura.

Fig. 4. (A) Inferiorly based medial crura soft tissuegraft. This graft material can be helpful to softenthe infratip breakpoint. (B) Infratip graft complexwith pedicled soft tissue graft in place over surfaceof shield graft.



between the brow and tip. In occasional cases,there is a dorsal convexity that may benefit fromreduction (Fig. 5A, B). Patients of African descentcommonly present with unfavorable nasal bonearchitecture for osteotomy induced narrowing.9

Although there is significant diversity in the thick-ness and shape of the nasal bones, very fewapproach a classic leptorrhine configuration evenin cases where there is recognized Europeanancestry. The pyriform aperture is often oval inshape with short, thickened nasal bones. Asa result, lateral osteotomy tends to have little visualimpact on narrowing the bony vault.15

The author spends a fair amount of time with thepatient, reviewing the shape of the dorsum and itsrelationship with a continuous brow-tip aestheticline. Female patients of African descent are usuallyaware of the impact of contour shadowing andhighlighting, as a result of their familiarity withmakeup techniques, to give the illusion of a morerefined bridge. A high dorsum is not essential fora continuous brow-tip aesthetic line. The authorhas several patients with a low, flat bridge whohave a pleasing, elegant brow-tip aesthetic line.In this subset of patients, dorsal augmentation isindicated only as a measure to maintain a harmo-nious profile line in situations when tip projection

has been surgically increased. Ideal dorsal heightis ultimately dependent on tip projection. It iswidely appreciated that nasal harmony featurestip projection being slightly higher than the dorsumalong with the presence of a slight supratip break.As Stucker states, ‘‘a nasal dorsum that isaugmented beyond what the tip projection canaccommodate loses its aesthetic harmony.’’12

Conservative dorsal augmentation has the dualbenefit of creating the appearance of a more con-toured bridge while establishing continuity of thebrow-tip aesthetic line. Onlay grafts are fashionedwith an aesthetic goal of maintaining a harmoniousprofile line. Excessive dorsal elevation in patientsof African descent disrupts nasal harmony, asthe high bridge typically falls outside of the normalrange of ethnic variation in patients with otherwisebroad facial features.

For primary rhinoplasty in patients of Africandescent, the dorsum is rarely elevated greaterthan 3 mm beyond the preoperative baseline.Although autologous material is considered safer,the amount that can be normally harvested withoutusing autologous rib cartilage is often inadequatefor the extent of dorsal augmentation required.Expanded polytetrafluoroethylene (ePTFE) is the al-loplastic material of choice for dorsal augmentation.

Fig. 5. (A) Preoperative profile view of patient of African descent with dorsal convexity. (B) Postoperative profileview following reduction rhinoplasty.

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The author has found it to be an aesthetically excep-tional material, with ease of sculpting, excellentblending with the dorsal contour, and a low compli-cation rate. Conrad and colleagues16 recently re-ported a 1.9% incidence of biologic complicationssuch as soft tissue reaction, infection, and extrusionin a 17-year retrospective review. The author mostoften uses ePTFE sheeting (ePTFE-SHEET-061 [Im-plantech Associates, Inc, Ventura, CA]) to elevatethe bridge and autologous septal cartilage for tipcartilage grafting. The ePTFE sheeting is carved ina manner to create an onlay implant encompassingthe full length of the dorsum from the nasion to theregion cephalad of the supratip breakpoint. Osteot-omy is reserved for those situations where the nasalbones are long and more vertically oriented or insituations, as Rohrich defines, where the width ofthe bony vault is greater than 80% of the intercan-thal width.17

MODIFYING THE NOSTRILS (ALAR FLARE)AND NASAL BASE

The majority of patients of African descent pre-senting for rhinoplasty will complain that their nos-trils are too wide or that ‘‘my nose spreads when Ismile.’’ There needs to be renewed thinking forboth the patient and the surgeon with regard tosurgical modification of the nostrils and nasalbase. Professional and popular culture has pro-grammed patients and many surgeons to believethat an aesthetically pleasing rhinoplasty outcomeshould include reduction of alar flare. TraditionalEurocentric nasal aesthetics has promoted thatthe lateral attachment of the ala to the cheekshould lie within the vertical line drawn throughthe medial canthus. As a surgical goal, Rohrichstates that by bringing the elements of the noseto lie closer to this boundary, nasal features canbe enhanced without altering ethnic appearance.7

The author disagrees with this surgical logic,particularly for patients of African descent. Investi-gators have demonstrated that the normal indexfor African American patients is actually a nostrilattachment to the face lateral to the medialcanthus.13 Surgeons must be sensitive to thisAfrocentric anatomic variable and avoid attempt-ing to surgically modify African American nasalmorphology to fit into a Caucasian aesthetic stan-dard. It is also important to be sensitive to theaesthetically harmonious relationship betweenthe tip lobule and alar rims to avoid creation ofunnatural shapes as a result of surgery. Forinstance, McCurdy stresses that extreme cautionis indicated in noses exhibiting a wide lobule inassociation with a wide alar base.18 In such cases,alar reduction often results in a rectangular or

square configuration of the lobule that is aestheti-cally less desirable than the original lobularshape.18

Excessive nostril narrowing in patients of Africandescent is the most easily recognized tell-tale signof nasal disharmony (Fig. 6). The efficacy of alarbase modification is also debatable becausesignificant tissue removal does not necessarilyguarantee a long-term improvement in flare.19 In

Fig. 6. (A) Excessive narrowing of the nasal ala. (B)Triangular ‘‘tent pole’’ configuration resulting fromreduction of alar flare in association with increasedtip projection.



Fig. 7. This patient underwent external approach rhinoplasty with suture tip contouring, and ePTFE dorsalaugmentation without direct modification of the nostrils. (A, C, E, G) Preoperative views; (B, D, F, H) 6-monthpostoperative views. Note preoperative horizontal nostril orientation.

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most cases with appropriate modification of the tipand dorsum, Weir excision type alar narrowingbecomes unnecessary.

To broaden the aesthetic perspective ofprospective rhinoplasty patients in reference toalar modification, a series of ‘‘before and after’’results for cases in which the nostrils were notmanipulated in a direct manner is reviewed,(-Fig. 7) thus allowing illustration of the pleasingeffects of modifying tip projection and itssecondary beneficial impact on nostril shape/width (Fig. 8). The author asserts that directalar rim and base modification is overused inpatients of African descent and contributes onlyin a limited capacity, if at all, to an improvedlong-term aesthetic outcome.

When indicated, successful reduction of thewide nasal base and alar flare is primarily depen-dent on sound clinical judgment and a culturallysensitive aesthetic sensibility. The author hasfound Porter’s simplified nostril orientation classi-fication system to be a clinically useful tool fordetermining which patients of African descentare more likely to have a favorable outcome withalar wedge resection narrowing.20 In the study, 3categories of nostril orientation were described:inverted, vertical, and horizontal (Fig. 9). In theauthor’s experience, those patients with a hori-zontal nostril orientation benefit from alar wedgeresection and nasal base reduction in a substantiveway. The horizontal orientation lends itself to morepredictable surgical reduction. Lateral alar wedgeexcisions in patients with an inverted nostril orien-tation tend to accentuate the inverted configura-tion in an unnatural way. In patients of Africandescent with a vertical nostril orientation, addi-tional narrowing is not necessary. In patients witha horizontal nasal base without alar flare, resectionof the nostril sill with medialization of the ala is aneffective technique, as described by Stucker andcolleagues.12 In patients with horizontal basewith alar flare, resection of the sill along withwedge excision of alar flare can be achieved asdescribed by Foda.21 Caution is necessary innoses lacking a well-defined nostril sill, because

scarring and notching are potentially moreproblematic.18

AN AVOIDABLE COMPLICATION: NASALDISHARMONY

An abundance of scientific rigor has been placed onthe integral aspect of nasal analysis as a key tosuccessful rhinoplasty. In rhinoplasty surgical plan-ning, nasal analysis has primarily focused on linearsurface measurements, photographic review, andclinical nasal examination. As we move furtherinto the 21st century, a modern approach to rhino-plasty should feature a more sophisticated appre-ciation for nasal contour aesthetics beyondanthropometric linear measurements.

In patients of African descent, the author seesiatrogenic nasal disharmony as the most commoncomplication of rhinoplasty. A review of theprevious rhinoplasty literature focusing on patientsof African descent illustrates many examples ofless than optimal aesthetic outcomes. In manyinstances, the preoperative photograph is morebalanced aesthetically than the postoperativeresult. This nasal disharmony is most frequentlyseen as an overly narrowed dorsum packagedwith a wide tip; overly narrowed nostrils associ-ated with a wide tip lobule; or an excessively nar-rowed tip, dorsum, and nostrils in a patient withotherwise broad/full ethnic features. Most of thesepoor aesthetic outcomes could easily be avoidedby adopting less of a surgical emphasis on narrow-ing. The author’s gut feeling is that poor outcomesare more often a result of poor aesthetic judgmentrather than failures in surgical technique. Surgeonsmust undergo a mental paradigm shift in rhino-plasty logic for patients of African descent. Low,flat, and broad can indeed be beautiful. Surgeonsmust keep in mind that a wide nose is notinherently unattractive. However, one can veryeffectively make it unattractive by artificially pack-aging wide features with overly narrow modifica-tions, thus creating nasal disharmony andimbalance. Modern rhinoplasty should be

Fig. 9. Nostril Axis of Orientation classification. (A) inverted, (B) horizontal, (C) vertical.

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undertaken from a mindset of maintaining or es-tablishing pleasing surface contour relationships.

SUMMARY

Rhinoplasty surgeons have a unique opportunityto adopt a modern approach to rhinoplastythrough redefining surgical logic to be moreanatomically sophisticated and culturally sensi-tive. Technical expertise is not the most significanthurdle to overcome in achieving favorable rhino-plasty outcomes in patients of African descent.Cultivating a renewed aesthetic consciousnessfor Afrocentric beauty aligned with technicalcompetence is paramount. Exploring ancestryprovides a pathway to ‘‘culturally connect’’ withprospective patients, and serves as a tool for es-tablishing a shared aesthetic vision betweenpatient and surgeon.

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