Retaining the ethnic "flavor" of one's nose is a common goal among the vast majority of ethnic patients seeking rhinoplasty, according to surgeons who devote a significant portion of their practice to this procedure.

"There has been a fear among African-American, and, to a lesser degree, in Latino and even Asian patients, that if they wanted to change their features that this would signify that they weren't proud of who they were," says cosmetic surgeon Charles M. Boyd, M.D., who is in private practice in Birmingham, Mich., and New York. In ethnic patients who seek rhinoplasty, Dr. Boyd's goal is to de-emphasize the nose and draw attention to the eyes instead. "There are subtle things that we can do to make a change in the profile, in the definition of the nose, without changing their ethnicity, without intrinsically changing their appearance," Dr. Boyd says.

A black patient before (left) and after rhinoplasty. — (Photos credit: Steven Hopping, M.D.)

A Middle Eastern patient before (left) and after rhinoplasty. — (Photos credit: Steven Hopping, M.D.)

Dr. Boyd points out that some patients are really looking for a new nose, while others want subtle changes. "If the patient wants dramatic changes and the surgeon doesn't provide that, or similarly, if the patient wants subtle changes and the surgeon has completely changed the nose, the patient is not going to be happy," Dr. Boyd says. "So, you really need to communicate to share the same vision."

SURGICAL MANEUVERS As far as surgical strategy, skin thickness and cartilage stiffness are standard anatomic considerations of which surgeons should be cognizant with respect to ethnic rhinoplasty. "These are the two most important things to assess preoperatively, because if the patient has really thick skin and really poor cartilage support, then the surgeon has to pull out all the stops," Dr. Hopping says. "In cases like this, you have to de-fat the skin in order for the patient to be able to appreciate any of the changes or refinement that you introduce, and you're going to have to use some kind of graft — probably the patient's own cartilage in the tip to create some definition."

Thicker skin and poor cartilage support are common among African Americans, Middle Easterners and Asians, Dr. Hopping says. "Even though a lot of patients of these ethnic backgrounds want a smaller nose, they need to augment with their own cartilage," he says, adding that he believes using patients' own cartilage is much safer than using silicone or some other artificial material implant. "Even Asian patients — who tend to want to make their noses slightly larger — have generally poor cartilage support and have fairly thick skin. So we need to either put an implant in, or use the patient's own cartilage to provide some definition," he says.

WALKING A FINE LINE There's a fine line between de-fatting the skin enough to feature the refinements made, and thinning the skin too much. Dr. Boyd points out that one of the biggest mistakes that surgeons can make in performing rhinoplasty in thick-skinned patients is to overly thin the skin. "This is a concern in Southeast Asian, African-American and even some Latino noses. Surgeons feel a strong desire to thin the nose, and they do an open rhinoplasty and remove some of the tissue or the subcutaneous tissue below the skin. This can be done effectively in moderation, but the danger is in going to far," he says. "If it's an African-American patient who has relatively thick skin, I won't thin the skin so much. Instead, I'll use more cartilage to build up the tip, to build up the dorsum, and then the thinning will take care of itself," he says. "If you add enough structure to give the nose the proper projection, then you really don't need to thin the skin at all."

Middle Eastern patients' noses also have thick skin, but they have a distinct shape that includes a dorsum hump and a bit of tip ptosis as well. "Often, the tip needs to be augmented and the dorsum needs to be reduced," Dr. Boyd says.

Dr. Hopping, who often performs surgery in Dubai, United Arab Emirates, says, "In Dubai, they don't want an 'American nose.' There they like to keep the nose longer for a more natural look." He notes that this requires a pure reductive rhinoplasty. "We just have to be cognizant of not doing as much as we might typically do in the Western world because in Arab cultures, they often want to keep the nasal length," he says.

A distinction in black patients' noses, Dr. Hopping notes, is the width. "If you leave the nostrils alone, the result is more natural, but oftentimes, the width is part of the patient's complaint. In this case, we would perform some sort of nostril narrowing procedure," he says. However, this complicates the process — almost like adding an extra procedure, with the inherent risks. "There is some risk of nostril asymmetry, and there is the risk of a scar, but there has never in the history of medicine been keloid scarring in this area. So, fortunately, we can operate on this region with impunity," Dr. Hopping says.

ETHNIC BLENDING Interestingly, as surgeons familiarize themselves with the unique anatomical distinctions inherent in various ethnic groups, and as cosmetic surgery becomes more acceptable, the culture is morphing in a way that de-emphasizes these distinctions. The ideal "look" is one that's becoming interchangeable among races and ethnicities, according to Dr. Hopping.

"I see that things are changing. In the characters that we see on nightly television shows and elsewhere, ethnic blending is occurring," he says. "Everybody wants to de-emphasize their nose a little bit. The noses are getting more and more alike, and I believe this is a product of the overall ethnic blending occurring in our society."

This, he adds, is a new concept that cosmetic surgeons should be aware of as they counsel their patients.

INTERNATIONAL REPORT — Innovative technological advances have given birth to Axis Three's Portrait Face Simulation Module, allowing patients to view a three-dimensional (3-D) simulation of what their aesthetic outcome will look like prior to the actual cosmetic procedure taking place. The technology benefits both physicians and patients, as realistic aesthetic goals can be discussed and agreed upon well before the first cut.

Using Axis Three's 3-D face simulation software, surgeons can improve the expectations and experiences of patients seeking surgical improvements to their nose, chin, cheeks and jaw.

The face simulation module is based on the same technology as Axis Three's Portrait 3D Surgical Simulation Platform, which shows patients who plan to undergo breast procedures a more accurate visualization of the surgical outcome prior to the surgery. Using a 3-D camera, the patient's image is captured, processed and displayed on a viewing screen. The captured images give a realistic representation of the body, and they can be rotated, altered and viewed from all angles.

Axis Three's technology differs from other, similar technologies in that its integrated physics engine can address and measure tissue characteristics such as tissue elasticity and density. In software terms, a mathematical model allows the skin elasticity and density to be profiled for each cosmetic patient individually.

RHINOPLASTY SIMULATION Compared to the breast module, the face module takes a softer approach, because there is more artistry involved in procedures such as rhinoplasty. Therefore, a "softer" software program was engineered, allowing the physician to more accurately control the fine nuances and sculpt the nose to the patient's specifications as they would in the operating room in real surgery time.

In the face simulation's rhinoplasty module, a series of landmark registration points are plotted in and around the nose. Within those points, the physician can move each of those regions to fit a nose that the patient would aesthetically desire post-procedure. The physician can profile backward and forward, widening or narrowing the nostrils and other physical aspects until the desired image is achieved.

Comparison screens such as these enable users to view all of a patient's case data together. Users can show pre-op images beside simulated views. (Photos credit: Axis Three)

CONSULTATION COUNTS Most surgeons would agree that the essence of the consultation is communication. This is where the patient communicates goals and desires and the surgeon communicates what he or she thinks can be realistically achieved. The Axis Three face module represents a language that both patient and physician speak — namely, visual imaging.

Screen shot of the user interface showing the rhinoplasty toolbar, which allows control over the projection of the nose. (Photo credit: Axis Three)

SCANNER ADDITION Recently, Axis Three introduced its XS-200 scanner, which captures anatomically accurate 3-D images of a patient's face in order to simulate surgery outcomes. This tool complements Axis Three's face simulation software module and allows surgeons to even more accurately showcase aesthetic surgical outcomes prior to the surgical procedure itself.

The XS-200 scanner is a mountable unit optimized to capture the face topology with a minimal hardware footprint and serves as a vehicle for delivering Axis Three's simulation software. The scanner attaches directly to the USB port of a surgeon's computer.

IMAGE PROCESSING Another advantage to the Axis Three simulation technology is the efficiency and speed at which images are processed. Virtual images can be altered and modified in only a few seconds.

"Many patients will see more than one doctor for consultation before they have a procedure done. My patients have commented explicitly on how tremendously helpful the 3-D imaging was in their decision process. Axis Three's technology has had a dramatic effect on my consultation and increased our patient flow for breast augmentation. I suspect that the 3-D imaging for face procedures will have a similar impact," Dr. Zwiebel says.

Of course, realizing the final cosmetic outcome close to the 3-D image pre-surgery has much to do with the skill and experience of the surgeon, the wound-healing quality of the patient's tissues and the type of procedure performed. However, according to Dr. Zwiebel, the surgeon's judgment in portraying an accurate image as opposed to getting creative and showing something that is impossible to do still remains the fundamental basis for the validity of the tool.

NEXT PHASES Axis Three's next project will concentrate on the top layer of the skin, focusing on the removal of wrinkles and skin tightening. According to Mr. Moffett, this is a state-of-the-art technology that offers a high-tech angle to cosmetic procedures, while adding an element of assurance to the patient.

"As we're bombarded with new technologies targeting cosmetic surgery, we always have to be discriminating and diligent. In this particular instance, this technology clearly is an advance, easy to embrace and intuitive," Dr. Zwiebel says.

Disclosures:
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Cutaneous laser therapy can prove to be challenging in treating patients with skin of color, as this patient population has a higher risk of unwanted cosmetic side effects following treatment. A cautious and conservative approach and use of the right laser device can be instrumental in helping to avert unwanted side effects from laser therapy.

Dr. Chan

"The increased melanin can potentially pose a greater risk of complications when undergoing cutaneous laser treatments, because the pigment can absorb the laser energy, leading to undesirable side effects, the most common of which being postinflammatory hyperpigmentation," says Henry Chan, M.D., Ph.D., F.R.C.P., F.H.K.C.P., F.H.K.A.M., honorary professor, Li Ka Shing Faculty of Medicine, University of Hong Kong, HKSAR, and visiting scientist, Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston.

"Though an effective cooling is extremely important during and after the laser treatment, laser epilation treatments are less effective in patients with skin of color and are associated with a greater potential for complications," Dr. Chan says.

A similar problem is encountered when using lasers for the treatment of telangiectasias, as the melanin absorption of laser energy light sources has a very wide range. Therefore, lasers cannot only be less effective in the treatment of telangiectasias in patients with skin of color, but postinflammatory hyperpigmentation can also result, as well as interference by the superficial pigment in the epidermis, ultimately reducing the efficacy of the laser treatment.

POSSIBLE SOLUTIONS In order to avoid the unwanted side effects of laser treatments in patients with skin of color, it is very important to choose the proper parameters of the chosen laser device. It's also critical to apply adequate cooling during and after the laser procedure and to be less aggressive when performing therapy, particularly in higher-risk patients.

Devices such as Q-switched lasers are very effective in the removal of lentigines and freckles among Caucasians and Asians, but there is a 10 percent risk of postinflammatory hyperpigmentation in Asian skin. Therefore, these lasers can be less optimal for this indication in darker-skinned patients, and long-pulsed lasers may prove to be the better choice.

"Long-pulsed lasers are gentler than Q-switched lasers, because the Q-switched lasers induce not only a photothermal effect, but also the rapid change in the thermal gradient can lead to photomechanical damage, where the energy is delivered so rapidly that it literally causes the cells to rupture. Such damage can cause a greater risk of postinflammatory hyperpigmentation among skin of color," Dr. Chan explains.

Long-pulsed lasers are more effective mainly because they heat up the target more gradually and gently, reducing the excessive degree of inflammation and therefore decreasing the chance of adverse events. In order to maximize aesthetic outcomes and goals, more frequent treatment sessions would be required with this laser.

IPL AND FRACTIONAL DEVICES Intense pulsed light (IPL) is also effective for various cosmetic indications, even though the device is less selective in targeting specific lesions. According to Dr. Chan, IPL devices can work well depending on the contrast of the patient's skin in respect to the target lesions such as lentigines and freckles. IPL treatment is very effective and carries a low risk of adverse events if the patient's skin color is in great contrast with the color of targeted lesions. However, where the degree of contrast between the targeted lesions and the surrounding skin is much less, there will be a greater risk of injury.

"Either you use too low an energy not to negatively impact the surrounding skin, resulting in less-optimal treatment results, or too high an energy to effectively address the target lesions, with the increased risk of damaging the surrounding skin, leading to unwanted side effects. Therefore, one has to be extremely careful when treating patients with skin of color where the contrast between lesion and surrounding skin is low," Dr. Chan says.

Fractional resurfacing is frequently used for skin rejuvenation in Asian skin. However, given the fact that the degree and severity of photoaging tends to be much less in patients of skin of color, the role of these more aggressive ablative procedures (which carry a higher risk of complications) is much less justifiable, Dr. Chan says.

Noninvasive procedures such as radiofrequency and focus ultrasound for skin tightening are effective and very popular, as is nonablative skin rejuvenation using nonablative fractional resurfacing or nonablative laser devices.

LESS PHOTOAGING Compared to Caucasian skin, Asian skin tends to have much delay in terms of photoaging. Pigmentary issues such as lentigines, freckles and melasma are common problems after extensive ultraviolet (UV) light exposure, but, compared to Caucasian skin, deep wrinkles tend to present one to two decades later.

"The superficial epidermal melanin content in Asians is higher and therefore offers a greater UV protection — approximately 10 times that of Caucasian skin — and this protection increases with darker skin," Dr. Chan says. "As the degree and speed of skin aging is not as severe as that seen in Caucasian skin, we tend not to require extremely dramatic means to rejuvenate the skin."

For those physicians who do not regularly see patients with skin of color, Dr. Chan suggests that they treat a small test area of lesional skin with a given device first, and establish the correct parameters of the laser treatment in each patient before treating all lesions. Additionally, physicians with less experience with laser treatments in skin of color may want to begin with more forgiving devices, such as the long-pulsed laser.

"Remember to be conservative when performing laser procedures in skin of color. You do not want a patient to return because of potential issues and adverse events," Dr. Chan says.

DISCLOSURES:

Skin that produces a lot of melanin has an increased reaction to influences such as sun exposure and heat, as well as anything else that can potentially irritate the skin, such as a chemical peel. Chemical

Dr. Bucay

"Generally speaking, the darker skin types tend to have more of a tendency to react to anything that would irritate the skin — anywhere from a mosquito bite to a topical numbing agent to a burn on the stove to a chemical peel," says Dr. Bucay. When a dark-skinned patient presents and either requests or is a candidate for a chemical peel, she analyzes the patient's goals and carefully reviews the medical history. "We need to know if this is somebody who is getting a chemical peel for acne or for melasma or for something else, and I also look to see if they have any history of sensitivity to irritants or a history of eczema or rosacea," Dr. Bucay says.

Dr. Downie

SUPERFICIAL TREATMENT New Jersey dermatologist Jeanine Downie, M.D., also stresses the importance of choosing a more superficial peel. "In a situation like this, you should definitely go with a lighter, more superficial peel in the 20 percent, 25 percent or 30 percent range," she says, adding that it's a good idea to "avoid medium-depth peels (in this patient population) until you have significant experience and really know what you're doing."

A patient burned with a curling iron and suffering from melasma is shown before treatment (left) and two months later, after two salicylic acid peels, 20 percent, and one Fraxel re:store treatment. (Photos credit: Jeanine Downie, M.D.)

Regarding hyperpigmentation, "People with skin of color are often coming into the office to get help with their hyperpigmentation problems, so you certainly don't want to add to that," Dr. Downie says. Post-peel hyperpigmentation does not happen frequently, she notes, but when it does, it can be troublesome for the patient and the physician. "If the patient's skin is overly sensitive, if you leave the peel on too long or it doesn't get rinsed off (thoroughly), the result can be the induction or worsening of hyperpigmentation," she says.

Post-peel hyperpigmentation is possible in anyone, but is more obvious in skin of color. "If a physician does not have a lot of experience performing chemical peels in patients of color, they should feel comfortable referring the patient elsewhere," Dr. Downie says.

PRETREATMENT OPTIONS Dr. Bucay suggests that inhibiting pigment production before the procedure can reduce a possible inflammatory response to the chemical peel. Starting patients on hydroquinone and/or topical vitamin C six weeks before the chemical peel would be ideal, she says, stressing that even if the patient pre-loads for two weeks prior to the peel, there could be benefits.

Of course, the most important factor in the process is consistent sunblock use. "The patient must wear sunblock from the moment they leave the office, because all it takes is one sun exposure, especially after a peel, and they will pigment quickly," Dr. Downie says. Dr. Bucay says she prefers a physical as opposed to chemical sunblock, such as a micronized preparation of transparent zinc oxide or titanium dioxide. "A physical sunblock reflects the light and is less likely to cause irritation of the skin afterward," she says.

Poor candidates for chemical peels, especially in darker-skinned patients, are those who are not consistent in their use of sunblock and those who have a tendency to pick their skin. "They're going to tell you their skin isn't any better, but it's not because of your treatment plan, it's because they're not committed to the post-peel instructions," Dr. Downie says. "The bottom line is that most people are good peel candidates if they need a deeper level of exfoliation and if they follow our instructions."

In the case of a chemical peel gone wrong, Dr. Downie recommends several options for repairing the post-peel hyperpigmentation: Re-peel the patient with a lighter peel, advise the patient to wear sunscreen and reapply it more frequently, or suggest a gentle fade cream. Among the available prescription fade creams, Dr. Downie says she likes EpiQuin Micro (hydroquinone USP 4 percent, SkinMedica) and Tri-Luma (fluocinolone acetonide 0.01 percent, hydroquinone 4 percent, tretinoin 0.05 percent, Galderma).

DISCLOSURES:

Dr. Chan

The study identified 40 Chinese patients with Fitzpatrick skin types III or IV who were treated with either a 595 nm long-pulsed dye laser (LPDL; Vbeam Perfecta, Candela), a 755 nm LP alexandrite laser (GentleLASE, Candela), a 532 nm Q-switched (QS) Nd:YAG laser (MedLite C3, HOYA ConBio) or a 532 nm LP KTP laser (Gemini, Iridex). The patients were randomly selected from a large cohort of patients treated by Henry Chan, M.D., Ph.D., F.R.C.P., F.H.K.C.P., F.H.K.A.M., honorary professor, Li Ka Shing Faculty of Medicine, University of Hong Kong, HKSAR, and visiting scientist, Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston.

Patients received between one and four treatments at intervals of four to six weeks. The number of treatments depended on lesion response, and the mean for the entire study population was 1.8. An independent dermatologist assessed pigmentation clearance and postinflammatory hyperpigmentation (PIH) through visual analogue scale grading of pre- and post-treatment photographs.

"As a retrospective review, this study has methodological limitations, the most important of which is potential selection bias, as patients with a poorer clinical response or who developed a complication may be more likely to return for follow-up care than those who had an excellent outcome," Dr. Chan says.

Dr. Ho

Stephanie G.Y. Ho, M.D., honorary clinical research associate, University of Hong Kong, presented the research at the meeting. She says, "There has been little research comparing different pigment-specific lasers for darker skin types. Our study highlights the importance of using long-pulsed lasers, smaller spot sizes and cooling strategies in order to minimize the risk of PIH during laser treatment for skin of color. In addition, the 595 nm LPDL and 532 nm LP KTP, which appeared to be safe and effective for lentigines in darker skin types, may also be used to treat other conditions, and therefore may be good cost- and space-saving solutions for clinicians."

PIH RISKS FOR EACH LASER Dr. Chan explains that while all of the lasers used are effective for treating lentigines and freckles, complications are a particular concern in Asian patients because of the higher epidermal melanin content of their darker skin. The risk of PIH in skin of color is higher when using a QS versus LP laser because the QS device, with its relatively short pulse duration (nanoseconds), causes photomechanical injury in addition to a therapeutic photothermal effect.

"With the nanosecond pulse duration, there is a rapid change in the thermal gradient of the target that generates an ultrasonic wave and subsequently photomechanical injury leading to inflammation," Dr. Chan says. "The millisecond pulse duration of the LP lasers more closely matches the thermal relaxation time of the epidermal basal layer. It is more gentle because it produces only a photothermal effect, without inducing rapid thermal expansion that can lead to an ultrasonic wave."

Despite its long pulse duration, the LP alexandrite had the highest risk of PIH among the four lasers included in the study. This association may be explained by the large, 10 mm spot size of the device used.

"Spot size is not a major issue if there is significant contrast in pigmentation between the target lesion and surrounding normal skin," Dr. Chan says. "However, in darker Asian skin, the difference in pigmentation is less. Therefore, laser energy is also absorbed by the surrounding normal skin, which can lead to injury and an increased risk of complications."

Both the 532 nm QS Nd:YAG and the 532 nm LP KTP lasers have only a 2 mm spot size so that they selectively target smaller freckles and lentigines. In addition, the 532 nm LP KTP laser has a cooling device that helps protect normal surrounding skin.

Although the 595 nm LPDL has a relatively large, 7 mm spot size, the device used also features a compression handpiece that empties blood from vessels in the underlying skin, reducing the risk of purpura and therefore PIH, as well.

"Even with its larger spot size, the 595 nm LPDL will only affect the target lesion if it is used to treat larger lentigos. However, hyperpigmentation can also develop through induction of purpura secondary to mechanical injury to blood vessels. If bruising occurs, there can be some hemosiderin deposition that appears as PIH," Dr. Chan says.

DISCLOSURES: