Most individuals have an interest in being perceived by others as attractive, regardless of their ethnic heritage, racial background, or country of origin. Over time, migratory movements have contributed to the ethnic and racial melting pot responsible for the diversity we have come to expect in major metropolitan areas. Industrialized countries in the world today constantly receive immigrants from developing countries seeking more freedom or better working opportunities than they experienced in their country of origin. Latin America has not been the exception to this phenomenon. The United States, Canada, and, to a lesser degree, Europe have seen significant migratory movements arising from Latin American countries. Today one of the fastest growing and largest minority groups among these recipient countries are the “Hispanics” or “mestizos.”
Among the number of available aesthetic facial plastic surgical procedures, rhinoplasty is one of the most popular procedures. Elective aesthetic procedures have become more accessible to people of different parts of the world and from different socioeconomic backgrounds. Even though paradigms of beauty have shifted throughout the years, some publications still hold the “Caucasian” or “Western” features as ideals for aesthetic standards of beauty. In many textbooks and medical articles, the ideal nose is still defined as moderately thin, angular, tapered, and slightly projected.
Facial plastic surgeons today contend with the fact that the established standards, and proportions once conceived with the Caucasian ideals of beauty in mind, do not necessarily hold true across different ethnic backgrounds, including Hispanic patients. It behooves us to accurately redefine the ethnically correct standard of beauty so that patients can be delivered a surgical result that is in line and closer to their aesthetic ideal.
“Hispanic” is a term derived from Hispania, a Greek word for the Iberian Peninsula (modern-day Spain, Portugal, Andorra, and Gibraltar) that is commonly used to describe Spanish-speaking people from Spain and Central and South America. Patients originating from territories once under the rule of the Spanish crown, especially countries from Latin America, are referred to as Hispanic patients. This population is also known as “Latinos” or “mestizos.” The U.S. Census Bureau does not consider Portuguese-speaking individuals as Hispanic.
The term “mestizo” is defined as a mixture of races. In Latin America, this meant the mixture of the local Indian tribes with the Caucasian European conquerors during the fifteenth and sixteenth centuries. The introduction of the African slave trade in the eighteenth century added a new ethnic and racial variation, and the term meant the mixture of three predominant races: Indian, Caucasian, and black. Today, the mestizo race is characterized by distinct phenotypical features without a predominant racial pattern in Latin America. Racial features vary depending on the geographic zone. Mexican patients typically have a stronger Indian influence; some parts of Central America typically have a stronger African influence; Argentina is predominantly European; other countries such as Colombia have a heterogeneous mix of all of these.
The Hispanic population in the United States is composed of mestizo patients who migrate mainly from Mexico, Central America, the Caribbean (including Cuba and the Dominican Republic), and South American countries. This mix of populations had initially established communities along the southwestern U.S. border, Florida, and New York City but have since transcended these territories, and they can be found throughout the nation and across international borders.
Mestizo Facial and Nasal Characteristics
Mestizo facial and nasal characteristics are different from the universally accepted ideal “Caucasian” proportions. Although phenotypical variations are as diverse as the origins of the racial backgrounds leading to them, the mestizo face tends to be broad with a relatively small underprojected, ptotic nose. The skin tends to be thicker and more sebaceous with a resulting skin–soft tissue envelope (SSTE) that is thicker and harder to redrape and for whom changes will be less noticeable. Malar eminences tend to be slightly more prominent and eyelids have a heavier look with more lid hooding. Heavy skin is a term that can commonly be used when describing these patients.
The noses of patients of Hispanic origin will tend to have an underlying cartilaginous architecture showing poor structural support. Nasal bones can be small, short, and slightly wide, with weak cartilaginous vaults. Tip support is poor due in part to a weak caudal septum, a small nasal spine, and soft alar cartilages. Externally, the Hispanic nose can exhibit a wide nasal bridge, a low nasion, a wide nasal base, a short columella, an acute nasolabial angle, and nostrils that tend to have a more flaring and horizontal shape ( Table 32-1 , Figure 32-1 ).
|Mestizo Noses||Caucasian Noses|
|Type of skin||Oily, thick SSTE||Normal to thin SSTE|
|Upper third of nose||Wide nasal bridge||Normal nasal bridge|
|Normal to low radix||Normal to high radix|
|Short nasal bones||Normal to long nasal bones|
|Middle third of nose||Weak upper lateral cartilages||Normal upper lateral cartilages|
|Lower third of nose||Weak, unsupportive alar cartilages||Normal to thick alar cartilages|
|Normal to acute nasolabial angle||Normal to obtuse nasolabial angle|
|Poor tip recoil||Normal tip recoil|
|Flaring, horizontally shaped nostrils||Oval-shaped nostrils|
It is important to be able to have the time and the ability to communicate with the patient in an adequate manner. The following points should be covered during the consultation:
Acknowledgment of the patient’s ethnic background with explanation of key issues
Understanding of the patients’ desires and expectations: a more balanced result preserving some of the patient’s nasal ethnic features or a more dramatic change resembling the “Caucasian” ideal
Complete history and physical exam (including disclosure of all previous nasal procedures as well as an internal and external nasal examination)
Discussion of a realistic surgical plan and discussion of potential complications and limitations
A complete external and internal nasal examination must be performed to evaluate the function of the nose. The examination is usually performed through palpation, as well as with a nasal speculum, and can be complemented with nasal endoscopy.
Functionally, the following aspects should be noted:
Compromise of internal or external nasal valve
Septal deviations/availability of septal cartilage for harvesting
When evaluating a mestizo patient for aesthetic rhinoplasty, several criteria must be defined to delineate an adequate surgical plan ( Table 32-2 ):
General facial characteristics
Skin type/thickness of soft tissue envelope
Nasal characteristics: upper third, middle third, lower third of nose
Underlying structural framework
Diagnosis of deformities and asymmetries
Once the consultation and physical exam have been completed, it is important to obtain a set of standard rhinoplasty photographs. This set includes frontal view, basal view, right and left lateral views, and right and left oblique views. Computer imaging is indispensable to demonstrate the existing challenges and to demonstrate a plan of how to overcome them with surgery. It is critical to have the patient understand the limitations of the procedure and be able to define a surgical plan within the context of realistic expectations and clear lines of communication.
Photography is useful for both the presurgical consultation and an intraoperative reference. Postsurgical results are also evaluated photographically, and photographs should be obtained ideally at 6 months and 12 months after surgery. This serves to help critically analyze aesthetic outcomes as well as surgical techniques.
All documentation from patients, including photography, must be kept as part of the medical record and serve as future reference for both medical and legal matters, should the latter arise.
Approaches to the Mestizo Nose
When evaluating mestizo patients, there are great anatomic variations depending on the predominant race of the patient. This makes it difficult to categorize these patients into a specific group. When defining what possible approaches and surgical techniques could be used with these patients, it is easiest to do so by focusing on the different problems encountered. Pertaining to usual generalizations, these patients tend to have:
Short nasal bones
Bulbous undefined nasal tips
Weak alar cartilages
Weak bony and cartilaginous support structures of the nose
In general, mestizo patients seek noses that look smaller and more defined. This typically means a narrower dorsum, a more defined and projected nasal tip, and a narrower base. Our challenge as surgeons is to carry out surgical techniques that give defining structural support without making the nose look much bigger. The external rhinoplasty approach is used in most of these patients. Surgical techniques will be discussed focusing on the areas of the nose where the most important problems are encountered.
Upper Third of the Nose
Mestizo patients tend to prefer a smaller dorsum to a high profile nose with a prominent tip. The dorsum in these patients are frequently low and wide and can have small convexities.
Surgically, the dorsum can be managed in several ways: To narrow a wide dorsum without an existing hump, medial and lateral osteotomies are performed routinely. In cases where there is a shallow radix with a small dorsal convexity, instead of lowering the hump to the level of the radix, a radix cartilage graft is used with excellent postsurgical results. This helps give the appearance of a stronger dorsum without making the nose much larger ( Figure 32-2 ).
One of the problems with ethnic patients is that significant amounts of cartilage are usually needed for structural grafting of the nose and usually the septum does not have enough to address all the essential regions. When dorsal augmentation is needed and if there is enough cartilage, dorsal onlay grafts are used, preferably from septal cartilage. If an insufficient amount of cartilage is available and the required dorsal augmentation is significant, alloplastic material such as expanded polytetrafluoroethylene (ePTFE, Gore-Tex; Implantech Associates, Ventura, CA) or porous high-density polyethylene implants (Medpor; Porex Surgical, Newnan, GA), which have excellent long-term outcome with low complication rates, can be used as alternatives in patients who prefer not to undergo a costal cartilage graft harvest.
Middle Third of the Nose
Mestizo noses very frequently have short nasal bones and weak upper lateral cartilages. This is a real problem for the surgeon if the cartilages are not strengthened properly. Patients with small nasal bones, weak upper lateral cartilages, and dorsal septal deviations are at greater risk of resulting in inverted-V deformities, deviation of the middle vault, and collapse of the upper lateral cartilages with a resulting compromise of the internal nasal valve. The use of bilateral spreader grafts as a preventive surgical technique strengthens the middle nasal vault, maintains a normal contour of the middle third of the nose, and avoids the formation of a postsurgical inverted-V deformity ( Figure 32-3 and 32-4 ). In cases where dorsal hump removal is going to be performed, strengthening of the middle third of the nose becomes imperative to avoid late postsurgical deformities.