Preservation Rhinoplasty: A New Approach to Mestizo Noses

Background:

Preservation rhinoplasty is a widely used technique; however, its use on mestizo noses is poorly documented. Our objective was to assess the level of satisfaction of our mestizo patients 1 year after their preservation rhinoplasty.

Methods:

The Rhinoplasty Outcome Evaluation (ROE), a Likert-type questionnaire validated in Spanish, was used to assess the level of satisfaction of 14 mestizo patients who underwent preservation rhinoplasty from March to July 2021 at 1 year after their surgery at the Higuereta Clinic in Lima, Peru.

Results:

The study included 14 patients, three men and 11 women, who underwent preservation rhinoplasty. A presurgical ROE questionnaire was applied, presenting a minimum value of 6, a maximum value of 21, and a mean of 12. When applied 1 year after surgery, the same ROE questionnaire presented a minimum value of 28, a maximum value of 30, and a mean of 30. The variation had a minimum value of 9 and a maximum value of 23, with a mean of 17 (P < 0.001).

Conclusions:

Preservation rhinoplasty can be successfully implemented in mestizo noses with good aesthetic results.

Takeaways

Question: Does preservation rhinoplasty provide good levels of aesthetic satisfaction in mestizo patients 1 year after surgery according to the ROE scale?

Findings: A mean of 29.71 was obtained for the level of satisfaction of mestizo patients, with a variation of 17.36 (P < 0.0001) 1 year after surgery.

Meaning: Preservation rhinoplasty can be successfully implemented in mestizo noses, with good aesthetic results.

INTRODUCTION

Rhinoplasty is one of the most sought-after procedures among patients seeking plastic surgery and is the fourth most requested procedure worldwide.¹ When patients seek rhinoplasty, a natural look is usually considered the most relevant. Although the purpose is to correct the anatomical features that may cause discomfort, natural and harmonious aesthetic results matching the proportions of each patient are sought, without creating any striking details.

Rhinoplasty can be performed using different techniques, depending on the approach and objectives of each patient. Conventional rhinoplasty described by Joseph modifies the nasal hump by opening the roof of the nasal pyramid and affecting bone structures. The anatomy is damaged, disrupting the structures required for the correct breathing of the patient. Moreover, it is not uncommon for certain imperfections to develop over time, often visible and stigmatic, when the nose is poorly remodeled.^2–5

The concept of a mestizo nose introduced by Ortiz-Monasterio refers to a special type of nose with specific ethnic and anatomical features found in non-White patients in Latin America. These noses have thick skin, poor projection, poor definition of the nasal tip, and a high dorsum, with a strong osteocartilaginous nasal hump⁶ (Fig. 1).

Fig. 1.

Frontal view of a patient with mestizo nose.

Meningeaud et al published the Rhinoplasty Outcome Evaluation (ROE) instrument in 2008, a scale for assessing satisfaction with aesthetic results of patients who underwent rhinoplasty.⁷ Calderon validated the ROE in Spanish in 2013.⁸

The objective of this study was to assess the level of satisfaction of mestizo patients who underwent preservation rhinoplasty using the ROE questionnaire 1 year after their surgery.

MATERIAL AND METHODS

From March to July 2021, preservation rhinoplasty was performed on 14 patients in Lima, Peru who underwent medical evaluation for this surgery and whose main feature was an Andean mestizo nose. All procedures were performed by the same plastic surgeon (main author), who is trained in preservation rhinoplasty; additionally, the patients completed the Likert-type ROE questionnaire validated in Spanish before surgery and 1 year after the procedure. All patients underwent surgery for the first time and had no history of uncontrolled diseases; no conditions that could compromise the postoperative results, such as nasal trauma, severe septal deviations, and chronic inflammatory pulmonary disease; normal preoperative examinations; and Goldman surgical risks lower than II. (See figure, Supplemental Digital Content 1, which shows the ROE questionnaire applied before and 1 year after preservation rhinoplasty in patients with mestizo noses. http://links.lww.com/PRSGO/C540.)

Patient follow-up was done by a trained nurse by telephone. The questionnaire was applied using Google Forms, and the information was stored in a Microsoft Excel 16.66.1 database for Mac. All patient information was coded and restricted by random numbering. The SPSS version 25 statistical program was used for the analysis, and the Wilcoxon test was used to validate the significance of the results.

SURGICAL TECHNIQUE

According to the literature, the ideal patients for this technique usually have a normal radix and a V-shaped hump. The other parameters are short nasal bones and a dorsal hump, which is mainly cartilaginous. These criteria do not exclude its use in mestizo patients.⁹ The surgery was performed with the patient under sedation and in the dorsal decubitus position, with the head elevated at 30 degrees. The vasoconstrictor anesthetic substance (lidocaine 2% without adrenaline plus 0.5 mL of epinephrine 1/1000) was then infiltrated in the supraorbital nerve, infraorbital nerve, nasal spine (nasal block), marginal incision, and septal mucosa. Some patients underwent surgery under general anesthesia (total intravenous) according to the anesthesiology evaluation. The volume of infiltration anesthesia with lidocaine and epinephrine never exceeded 14 mL. Surgery then started 10 minutes after infiltration in all cases. Closed rhinoplasty started with a right hemitransfixing incision with a scalpel blade No. 15 at the level of the anterior septal border, leaving 2 mm of septal cartilage (posterior septal strut), followed by subperichondral and subperiosteal wide septal dissection. The W-point is then located in the nasaldorsum to enter the subperichondral plane and reach the K-area. The subperiosteal plane is accessed at this level, and a wide dissection is performed for conventional or ultrasonic osteotomy as applicable. Open rhinoplasty started with marginal incisions and dissection of the alar cartilages. A stair-step incision is made in the columella, the skin is lifted, and the Pitanguy ligament is dissected and preserved, such that it can be repaired during closure. Subsequently, depending on the patient, a high or intermediate septal strip is resected, as described by Saban et al,¹⁰ Neves et al,¹¹ and Toriumi and Kovacevic.¹² This strip was cartilaginous in two cases and osteocartilaginous in the rest (12 cases). The strip height ranged from 2 to 4 mm, similar to the size of the nasal hump (Fig. 2). Internal osteotomy was performed with half-round chisels (push down) and lateral ostectomy (let down) with a piezotome or a rongeur, completing the transverse osteotomy at the end with a 3-mm percutaneous chisel for dorsal hump reduction with the push down or let down technique as applicable (Fig. 3). It follows posteroinferior septoplasty (for harvesting the columellar strut) with resection of bone spurs in cases of marked nasal septal deviations, marginal incision, and access to the alar cartilages preserving the Pitanguy ligament. The original domes were not preserved, but shifted 2 to 5 mm toward the lateral crura (lateral crura steal), and the new domes were formed with one or two Gruber stitches (hemitransdomal stitches) with 6/0 Prolene suture, as well as the polygons described by Cakir et al.¹³ A reinforced columellar strut was placed in most cases to strengthen the weak medial crura (Fig. 4). The posterior strut was reattached to the anterior septal border with 5/0 prolene suture. The incisions are closed with 5/0 absorbable polyglycolic acid suture, and the surgery is completed by placing nasal silicone splints (removed on the third to fifth postoperative day) and a thermoplastic nasal splint (removed on the seventh postoperative day). (See Video 1 [online], which displays development of preservation rhinoplasty in mestizo noses.)

Fig. 2.

Saban-type high septal strip resection.

Fig. 3.

Single (push down), double (let down), and transverse lateral osteotomy tracings.

Fig. 4.

Double columellar strut removed from the cahrtilaginous nasal septum, sutured with Prolene 6/0.

Video 1. This video displays development of preservation rhinoplasty in mestizo noses.

Download video file ^{(97.4MB, mp4)}

RESULTS

The study recruited 14 patients, 11 women (78.6%) and three men (21.4%). The minimum age of the patients was 18 years, whereas the maximum age was 42 years (mean: 29.9 years). All patients had a Goldman surgical risk index lower than II, with no adverse events reported by any participant. The minimum and maximum operative times were 80 and 180 minutes, respectively, with a mean of 140 minutes. General anesthesia was used in two patients (14.28%), and sedation with local anesthesia was used in 12 patients (85.71%). All the patients were Peruvian with noses with features corresponding to the description of mestizo nose as evaluated by a trained plastic surgeon (lead author) (Fig. 1; Tables 1 and 2).

Table 1.

General Patient Data

Variables	Categories	n	%
Sex	Feminine	11	78.6%
	Masculine	3	21.4%
Approach	Open	2	14.3%
	Closed	12	85.7%
Origin	Lima	14	100.0%
Anesthesia	General	3	21.5%
	Sedation + local analgesia	11	78.5%
Surgical risk	I	14	100.0%

Table 2.

Descriptive Data of the Numerical Variables

Variables	n	Minimum	Maximum	Mean	Deviation
Age	14	18	45	29.9	8.7
Operative time	14	80	180	140.0	27.9
Preoperative satisfaction	14	6	21	12.4	4.7
Postoperative satisfaction	14	28	30	29.8	0.6

QUESTIONNAIRE RESULTS

The ROE questionnaire was applied to the 14 patients before and after their surgery. The scores obtained before the preservation rhinoplasty had a minimum value of 6 and a maximum value of 21, with a mean of 12 after regular patient follow-up. The same ROE questionnaire was applied 1 year after surgery, presenting a minimum value of 28 and a maximum of 30, with a mean of 30. The variation had a mean of 17 (P < 0.001) (Table 3 and Fig. 5).

Table 3.

Level of Satisfaction before and after Surgery

Variable P		Timepoint	Mean	N	Deviation	Z
		Preoperative	12	14	4.702
Level of satisfaction
−3.31	0.001
		Postoperative	30	14	0.59

Fig. 5.

Variation of the level of satisfaction 1 year after surgery in mestizo patients who underwent preservation rhinoplasty.

DISCUSSION

Preservation rhinoplasty has become a good option for the management of the nasal dorsum in the recent years. There is a trend toward the preservation of the structure to obtain natural and long-lasting results with a lower risk of complications, such as an inverted V deformity and internal nasal valve collapse). The main goal of dorsal preservation is avoiding the open roof deformity that can occur with classic hump reduction, thereby preserving the aesthetic lines of the nasal dorsum.⁹ Modern rhinoplasty of the nasal tip has the aim of forming the polygons described by Cakir et al and preserving the Pitanguy ligament.¹³

The nose is a fundamental part of facial aesthetics. Therefore, an adequate approach for its modification can improve the anatomical features of the patient and avoid deformities or stigmas associated with conventional techniques. The success of a rhinoplasty can be assessed using other methods, such as anthropometric measurements, facial anatomical measurements, and functional scales. However, the patient’s level of aesthetic satisfaction is not always considered, which relates to their expectations and improvement of respiratory function after surgery.¹⁴

The term mestizo nose was originally described by Ortiz Monasterio in 1977, with thick skin and subcutaneous tissue and minimal support of the nasal tip as the main features of this type of nose.⁶ Although these features are frequently observed in our patients, the term could be insufficient to describe all the anatomical variations arising from the extensive mestization. Thus, the original description by Ortiz Monasterio did not include a classification of the mestizo nose. However, very conveniently, especially for its surgical approach, Rollin proposed a classification that divides the nose of the Hispanic mestizo population into three groups: type I or Castilian (high or normal radix, prominent nasal hump, variable skin, and normal tip), type II or Mexican-American (low radix, predominantly cartilaginous nasal hump, hypoprojected nasal tip, and variable skin), and type III or mestizo (low radix, no nasal hump, thick skin, and hypoprojected nasal tip). From our experience, all three types can be found in Peru, predominantly types I and II. In addition, we propose a type IV or Andean mestizo, with a low or normal radix, prominent osteocartilaginous nasal hump, sparse cartilaginous nasal septum, and thick-skinned nasal tip with poor support¹⁵ (Fig. 1).

Looking back 70 years, nasal dorsum surgery was divided into two main categories. The first was the nasal hump removal technique, popularized by Joseph. However, Cottle demonstrated that this technique resulted in an open roof deformity and proposed closed roof techniques, advocating the push down technique.^5,16 Therefore, nasal dorsum surgery is historically presented in two main categories: open roof or closed roof.

The dorsal roof is preserved in all cases of the present study, with the advantage of preserving the dorsal aesthetic lines, retaining the function of the internal nasal valve, and avoiding inverted V deformities. Such alterations can occur with the Joseph technique if the nasal dorsum is not reconstructed with cartilage grafts, such as spreader grafts or spreader flaps. Ybes Saban is known for promoting the concept of preservation rhinoplasty in the recent years, using a high septal strip combined with push down. Based on our experience, it was decided to use this technique in our patients, as well as the Tetris concept described by Neves (Fig. 6) and the Kovacevic-Toriumi subdorsal Z-flap with good reproducibility in this Andean mestizo population.^10–12 (See figure, Supplemental Digital Content 2, which shows Kovacevic-Toriumi septal resection and push down osteotomy in the nasal dorsum. http://links.lww.com/PRSGO/C541).

Fig. 6.

Tetris-Neves-type intermediate septal strip, dorsal let down osteotomy. Nasal tip with polygon technique, closed approach. A-B, Preoperative. C-D, Results at 1 year postoperative.

The septal strip had a mestizo component (cartilage and bone) in most cases. Drooping tips are frequently found in our population, for which we have mostly used the polygon technique of Cakir et al consisting of a lateral crural steal, hemitransdomal suture to construct new domes, placement of intercrural strut, and X suture of new domes and strut with 5/0 polypropylene without fixing the lower two-thirds of the new domes to construct the interdomal polygon,¹³ considering the concept of ellipse that consists of modifying the original position of the dome toward the lateral crura by 2–5 mm. This procedure can improve the nasolabial angle that is usually acute in mestizo noses. In addition, placing an intercrural strut is very important to increase the resistance of the weak medial crura and, depending on the length of the strut, gain additional or lesser projection depending on the patient.

A special feature applied in our patients is the reinforcement of the strut (two rectangular sheets of 2–3 cm sutured together with Prolene 6/0) because the mestizo nose has very droopy and heavy tips due to the thick skin and hypoplastic medial crura, unlike the European population. The Pitanguy ligament was also preserved, as it decreases the incidence of supratip after surgery and, in our experience, prevents tip drooping in the long term to some extent, thereby confirming the importance of its preservation mentioned by Cakir et al.¹³

A tool to assess the patient’s level of satisfaction with surgery is becoming increasingly important.¹⁴ The Spanish version of the ROE is a valid, reliable, and reproducible instrument for assessing rhinoplasty outcomes from the perspective of Latino patients. The ROE questionnaire was translated and validated in Chilean Spanish for regional application; however, the neutrality of the translation allows for its application to any group of Spanish-speaking patients.⁸ The results of our study before the surgery clearly indicate patient dissatisfaction, with values ranging from 6 to 21 (mean of 12.43). Subsequently, 1 year after surgery, after applying the same questionnaire, a significant improvement was observed, with scores of 28–30 (mean of 29.79), thus demonstrating statistically significantly higher levels of satisfaction (P < 0.001). No significant adverse events were reported during patient follow-up.

CONCLUSIONS

Preservation rhinoplasty can be successfully used in Andean mestizo patients whose unique anatomical features had not previously been addressed and described with this technique. This study shows that it is possible to implement some adjustments in the surgical technique (reinforced columellar strut) with equally good results.

The results obtained in our patients in the present study were accepted with a good level of satisfaction 1 year after surgery and with a good statistical confidence level.

DISCLOSURE

The authors have no financial interests to declare in relation to the content of this article.

PATIENT CONSENT

The patients provided written consent for the use of their images.

Supplementary Material

gox-11-e4972-s002.pdf ^{(55.9KB, pdf)}

gox-11-e4972-s003.pdf ^{(2.5MB, pdf)}