Rhinoplasty: The African American Patient
Adeyiza O. Momoh, M.D.,1Daniel A. Hatef, M.D.,1Anthony Griffin, M.D.,2
and Anthony E. Brissett, M.D., F.A.C.S.3
Over the past three decades, an increasing number of African American patients
have undergone rhinoplasty, and many continue to present to surgeons for rhinoplasty
evaluation. The reality is that rhinoplasty is no longer an uncommon procedure in the
African American population. Most patients desire nasal refinement while preserving their
cultural identity. The African American nose has many unique features that have to be
appreciated and understood to provide the desired outcome. In this paper, we present an
overview of the unique anatomic features of the African American nose, rhinoplasty
techniques tailored to this patient population, and complications encountered postoper-
KEYWORDS: Rhinoplasty, African American rhinoplasty, ethnic rhinoplasty
Understanding the nuances of the nasal anatomy of the
African American patient is critical in the evaluation,
diagnosis, and selection of rhinoplasty interventions in
this specific patient population. Multiple studies and
reports in the literature document unique features of the
anatomic components of the African American nose.1–3
When compared with the leptorrhine nose, the platyr-
rhine nose has been described to have a flat, wide, and
depressed dorsum, less defined tip, alar flaring, short
columella with an acute columellar-labial angle, de-
creased nasal length/height, and low radix, with thick,
sebaceous skin2,3(Figs. 1 and 2).
There is, however, significant variation within the
African American population, and the description by
Ofodile et al4of ‘‘the black American nose’’ highlights
this fact, dividing patients into three groups based on a
historically diverse ethnic heritage. In his classification,
the African nose (group A) is short with a wide, low/
concave dorsum, less defined tip with decreased projec-
tion, has a short columella, with a wide and flared alae.
The Afro-Caucasian nose (group B), in contrast, as the
name implies, appears more leptorrhine with a longer
nose, high/narrow and straight dorsum, better tip defi-
nition, and less flared alae. The Afro-Indian nose (group
C) represents the third group and is longer and larger,
with a high, wide dorsum associated with a dorsal
irregularity. The alae in these patients are flared and
the tips are less defined, but with more projection than is
seen in the African nose.
Considering the structural components of the nose,
differences have been noted in the skeletal and cartila-
ginous framework of the nose in patients of African
American descent when compared with that of other
A study of the nasal bones and pyriform apertures
of cadaver skulls with anthropometric measurements
1Division of Plastic Surgery, Baylor College of Medicine, Houston,
California;3Department of Head and Neck Surgery, Baylor College
of Medicine, Houston, Texas.
Address for correspondence and reprint requests: Adeyiza O.
Momoh, M.D., Division of Plastic Surgery, Baylor College of
Medicine, 6701 Fannin, CC610.00, Houston, TX 77030 (e-mail:
2Beverly Hills Cosmetic Surgery Institute, Beverly Hills,
CosmeticSurgery intheEthnic Population: SpecialConsiderations
and Procedures; Guest Editor, Jamal M. Bullocks, M.D.
Semin Plast Surg 2009;23:223–231. Copyright # 2009 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-0029-1224802. ISSN 1535-2188.
reported by Ofodile5in 1994 again showed evidence of
the triethnic heritage of the African American patient.
Skulls from the West African Ashanti tribe studied had
nasal bones that were short, narrow, and thick when
compared with American Indian and Caucasian skulls.
Similar measurements in the African American skulls
were found to fall between the West African and
Caucasian/Indian American groups. The shape of the
pyriform aperture in the African American skulls varied
from oval to triangular, again falling between the
Ashanti and Caucasian/Indian American groups, which
had apertures that were oval and triangular In addition
to these findings, as has been reported by others,6,7the
nasal bones in the skulls of African origin had an obtuse
angular relationship to each other at the nasal dorsum.
The clinical significance of these findings is that at-
tempts to improve dorsal apex projection are better
achieved by dorsal augmentation as opposed to osteot-
omy and infracture.5,7
Alar cartilage in African American patients, ex-
trapolated from cadaver studies,3also appears to show
some variation along the previously mentioned triethnic
lines; variations were primarily seen in the range of
anteroposterior alar cartilage width. Cadavers with the
African type nose had narrower alar cartilage compared
with the Afro-Indian and Afro-Caucasian type noses.
Any form of cephalic alar excision in these patients with
narrow alar cartilage should be approached with caution
given the risk for alar collapse. On average, though, the
height and width of the lower lateral crura in African
American patients were found to be similar to dimen-
sions found in Caucasian patients. The distance from the
lower margin of the alar cartilage to the nostril rim was
also found to be similar in both African American and
Caucasian patients. Differences between African Amer-
ican and Caucasian patients at the level of the alar
cartilage can be attributed to the angle of inclination of
the alar cartilage relative to the plane of the maxilla.
Morphologically, in African American patients with a
more acute cartilage angle of inclination, the nasal base
appears widened and the nose has less tip projection.
Flaring of the alae and the bulbous tip in addition
contribute to a distinctly different appearing nose
when compared with the Caucasian nose.
These anatomic differences, even within the Afri-
can American population, emphasize the importance of
an individualized approach to rhinoplasty using sound
PATIENT’S DESIRES AND GOALS OF
As a general rule, African American patients considering
rhinoplasty desire some form of nasal refinement without
and poor tip projection.
Preoperative photograph illustrating a wide, depressed nasal dorsum, wide alar base, short columella, bulbous tip,
Preoperative photograph illustrating a wide nasal dorsum, alar flaring, bulbous tip, and good tip projection.
SEMINARS IN PLASTIC SURGERY/VOLUME 23, NUMBER 32009
loss of their ethnic identity. The term nasal refinement is
preferred, as it refers to operative changes made to
approach appearances that are often seen in the leptor-
rhine nose. Patients may wish to address specific features
such as alar flare, tip definition, dorsal irregularities, and
decreased tip projection.
The surgeon has the challenge of formulating an
operative plan that optimally addresses these patient
desires. It cannot be overstated that the overarching
goal of rhinoplasty in the African American patient, as
it is in all non-Caucasian patients, is to make changes in
the nose that produce refinement while preserving ethnic
features and harmony with the rest of the face. Achiev-
ing this goal hinges upon an understanding of the nasal
anatomy of the African American patient as well as the
critical differences that affect the operative technique of
Rohrich and Muzaffar2succinctly summarize five
goals in African American rhinoplasty as follows: main-
taining nasal-facial harmony and balance; a narrower,
straight dorsum; enhanced tip projection and definition;
slight alar flaring; and narrower interalar distance.
The choice of open versus endonasal rhinoplasty techni-
ques is largely surgeon dependent. Some of the recent
literature on rhinoplasty in African American patients
favors the use of the open technique,2,8likely due to the
advantage of direct visualization it affords the surgeon.
Breaking the procedure into components based on the
anatomic nasal components being addressed, multiple
techniques have been shown to be effective.
Three subtypes of the alar base in African American
patients have been described2,9: (1) Increased base width
with lateral positioning of the alar base relative to the
medial canthus, (2) alar flare, and (3) a combination of
the previous two variants. Alar flaring greater than 2 mm
lateral to the medial canthi2can be addressed by alar base
resection (Fig. 3). Interalar distance is improved by
nostril sill resection and advancement2(Fig. 4). Narrow-
ing the alar base should be tempered with preservation of
the external nasal valve aperture.
Nasal Tip Definition
As previously described, the African American nose is
characterized by a less defined tip with decreased pro-
jection. Tip bulbosity is likely secondary to soft, diver-
gent middle crura and the thick overlying skin. The
thick, sebaceous skin that drapes over the skeletal frame-
work of the African American nose can be addressed
with several techniques. In our hands, careful excision of
lateral to the medial canthi.
Alar base resection for flaring greater than 2 mm
RHINOPLASTY IN THE AFRICAN AMERICAN PATIENT/MOMOH ET AL
excess fibro-fatty tissue in the nasal tip provides some
improvement; this should be approached with caution
given the risk for tip necrosis with excessive debulking.
Established maneuvers to increase tip definition
in the non-ethnic patient can easily be translated into
the African American nose with good results. Techni-
ques to improve this appearance include excision and
augmentation maneuvers that help accentuate the nasal
tip. Cartilage excision, such as the cephalic trim,
should be done in a very conservative manner. In the
African American nose, these techniques are simply to
facilitate rotation and shaping of the lower lateral
cartilages; overly aggressive cartilage resection will
lead to decreased tip support and ultimately a loss of
Tip sutures and cartilage grafts are the mainstay
of increasing tip definition and projection in these
patients. Transdomal sutures, a term coined by Tardy
and Cheng,10but in its current form described by
Daniel,11involves the placement of permanent horizon-
tal mattress sutures through the two crura of each dome
(Fig. 5). The use of transdomal sutures helps improve tip
definition by creating a more acute angle between the
medial and lateral crura of the lower lateral cartilages.
Additional strategic placement of alar sutures in the
form of interdomal and intercrural sutures further aid
in enhancing tip projection. The interdomal suture is
placed from the anteromedial portion of one dome to the
adjacent dome in a simple looped or figure-of-eight
fashion (Fig. 6). This ultimately results in approximation
of the domes, narrowing of the tip, and lengthening of
the lobule.12Intercrural sutures broadly describes medial
and middle crural sutures placed in specific segments of
the medial crura. The medial crura suture is a looped
suture placed in the middle third of the medial crura
(Fig. 7). This results in a narrowing and strengthening of
the columella and augmentation of lobular volume and
length.12The middle crura suture is a simple looped
suture placed through the most anterior portion of the
medial crura (Fig. 8). This suture compared with
the medial crura suture produces greater reduction of
the interdomal distance and increased lobule volume and
protrusion.12The medial and middle crura sutures are
typically used in combination with columella struts to
provide better tip support; given the limited availability
of septal cartilage grafts,alternate graft options including
costal cartilage and irradiated rib grafts should be
Additional tip refinement can be achieved by
augmentation, many recommending the use of autolo-
gous cartilage tip grafts.9,13–15Grafts for tip refinement
can be placed through the open approach as onlays
sutured onto existing cartilage or into subcutaneous
pockets through the endonasal approach. Tip onlay
grafts (Fig. 9), described by Peck13in 1983, increase
tip projection, lobule length, and enhance tip definition.
In a similar fashion, infratip lobular grafts (Fig. 10),
described by Sheen14in 1975, increase tip projection and
volume. In a recent article, Guyuron and Jackowe15
describe a modification of the onlay and shield graft
techniques with the use of a novel graft punch device
wide interalar distance.
Nostril sill resection and medial advancement for
SEMINARS IN PLASTIC SURGERY/VOLUME 23, NUMBER 32009
that provides the advantage of precise, rapid sculpting of
the cartilage used for augmentation.
A small nasal spine and short, rounded columella have
been cited as reasons for the decreased nasal tip projec-
tion noted in African American patients. Techniques
previously discussed for tip definition in the form of alar
sutures and nasal tip cartilage grafts also improve tip
projection to varying degrees.
A keystone to improving nasal projection are
structural cartilage grafts that provide needed support
to the nasal tip. With the septal extension graft (Fig. 11)
or the columellar strut graft (Fig. 12), the rhinoplasty
surgeon can adequately address tip projection in this
patient population. The columellar strut graft is a pop-
ular method for increasing and maintaining tip projec-
tion. Placed between the footplates of the medial crurae,
these grafts may be sutured in place with medial crural
sutures, fixed to the nasal spine, or left free-floating.
Dorsal Projection/Nasal Bridge
A review of the literature shows a lack of consensus on
the value of the lateral osteotomy in the face of a wide
nasal bridge with decreased dorsal projection as is seen in
manyAfrican Americannoses2,16,17Asignificant concern
is forthe riskof excessively narrowingthe dorsum relative
to the nasal lobule, producing some racial incongruity.17
Transdomal suture; narrows the nasal tip.
Medial crura suture, placed in middle third of
RHINOPLASTY IN THE AFRICAN AMERICAN PATIENT/MOMOH ET AL