Nasal Analysis: Considerations for Ethnic Variation

The Quadrangular Cartilage in Rhinoplasty: A Surgically Focused CT Dimensional Analysis of Black African and Caucasian Populations

The apparent lack of quadrangular cartilage in Black African noses is commonly observed both from a radiological and clinical point of view. To the best of our knowledge, only a few research papers have been conducted on the facial proportions and structural anatomy of black people of Southern and Eastern Africa. The aim of this retrospective comparative study is a radiological assessment of the total amount of septal quadrangular cartilage by measuring its area in sagittal CT views, in two selected Black South African and Caucasian (CA) samples and the comparison with the literature in our hands. Statistical analysis was conducted, categorical variables are shown as frequencies and percentages, while continuous variables as means and standard deviations. Normal distribution of variables was verified using the Shapiro-Wilk test or by means of skewness and kurtosis values. Differences among unpaired groups were evaluated using the independent Student's t-test for normally distributed data (complemented by the Cohen's d to show the effect size with the following cutoff: d = 0.2, "small" effect size; d = 0.5, "medium" effect size; d = 0.8, "large" effect size) and Mann-Whitney U test in case of non-normal distribution. Statistical significance was defined as p < 0.05 setting the α-error probability at 5%. This study shows that, on average, there is 30% more cartilage available in CA compared with Black African noses and confirms the apparent lack of quadrangular cartilage and in Black African noses which is commonly observed in surgery. The need for an adequate amount of autologous septal cartilage makes cartilage availability a major concern before surgery and being able to preoperative accurately measure the amount of septal cartilage that is available to be harvested for other grafts in the surgery is essential.

Ultrasonic Evaluation of the Asian Nasal Soft Tissue Envelope

OBJECTIVE

The thickness of the nasal soft tissue envelope (STE) plays a crucial role in the final rhinoplasty results. The Asian nasal contour is typically characterized by a thicker STE and broader nasal tip, but objective data are lacking. The purpose of this study was to objectively measure nasal dermal thickness and overall STE thickness and to determine any demographic differences.

METHODS

From July to September 2023, 110 patients presenting for consultation underwent ultrasound evaluation of their nasal STE. STE thickness was measured at predetermined subsites and compared with published data on white patients.

RESULTS

The thickness of the STE in Asian patients was greater than that in white patients. The STE was thickest at the supratip (mean [SD]), (4.88 [0.74] mm) rather than at the nasion and thinnest at the rhinion (2.25 [0.51] mm). The nasal tip (4.07 [0.72] mm) showed comparable STE thickness with the nasion (4.13 [0.72] mm) but had a significantly thicker dermis than the nasion (2.35 ± 0.49 mm vs. 1.35 ± 0.35 mm, P < 0.05). Male sex and higher BMI tended to be correlated with a thicker nasal STE, but age did not show any relationship. A thicker nasal tip STE showed significantly greater nasal tip width and nasal alar thickness.

CONCLUSION

STE thickness at different nasal subsites varies and affects external nasal contour and rhinoplasty outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Safety and Efficacy of Autologous Cartilage Graft in Augmentation Rhinoplasty

Augmentation rhinoplasty or commonly known as "nose jobs" is one of the most common plastic surgical procedures aimed to improve cosmetic appearance. This procedure is considerably safer, less time consuming with faster recovery and immediate cosmetic effect. This procedure needs of highly experienced and well-trained plastic surgeon. According to facial analysis you can select the type of rhinoplasty. Open discussion with the patient to select appropriate surgical technique and its possible risks with your plastic surgeon to ensure the highest level of safety and satisfaction. Autologous grafting materials are safe, efficient and also the first choice for rhinoplasty due to it can survive without a vascular supply, the resorption rate of cartilage is much lower than that of a bone graft. Autologous grafting materials are stable and resistant to infection and extrusion over time so, they are successfully used for dorsal augmentation. To perform successful augmentation rhinoplasty, surgeons should be highly experienced and well-trained and augmentation materials that are currently available and understand their risks, benefits and uses. Autologous cartilage graft regarded as the graft of choice in augmentation rhinoplasty because of their lower rate of infection, rejection, resorption, extrusion, donor site morbidity, easy reshaping.

Beyond Alar Base Resection: Contouring of the Alar Rim and Base

SUMMARY

Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Gender Considerations in Rhinoplasty

SUMMARY

Precise nasofacial analysis ahead of rhinoplasty is imperative. Features common to the White masculine nose are reviewed in a stepwise fashion and contrasted with those of the White feminine nose. A solid understanding of the cisgender male, masculine nose enables the plastic surgeon to determine the changes required for a successful facial feminizing rhinoplasty as a part of facial gender confirmation surgery.

Gender Facial Affirmation Surgery: Cheek Augmentation

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.

Three-dimensional Anthropometric Analysis of Racial and Ethnic Differences in Unilateral and Bilateral Cleft Nasal Deformity

This study used three-dimensional measurements to provide a nasolabial analysis of patients with unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and controls across different races and ethnicities.

A retrospective comparative study.

Tertiary care pediatric institution.

The study included 90 patients with UCLP, 43 patients with BCLP, and 90 matched controls. Patients are separated as self-identified Caucasian, Hispanic, or African American.

Nasal length, nasal protrusion, columellar height, columellar width, tip width, alar width, alar base width, nasolabial angle, upper lip length, philtrum length, nostril height, and nostril width.

All UCLP groups had significantly greater columella and tip widths and decreased nasolabial angles than controls. All BCLP groups had significantly greater columella width, tip width, nasolabial angle, and nostril widths. Upper lip length, philtrum length, and nostril height were significantly decreased in BCLP compared to controls. Across UCLP groups, African Americans had significantly decreased nasal protrusion and columella height and a significantly increased columella width compared to Caucasians and Hispanics. Alar and alar base widths were significantly different between all groups. Across BCLP groups, the Caucasian nostril width was significantly less than the African Americans.

These findings suggest that when correcting nasolabial characteristics in patients with cleft lip, it is important to consider racial and ethnic differences to achieve a normal appearance. Specifically, goals for alar width, alar base width, nasal tip, and projection should be tailored to the patient's race and ethnicity.

Modern Concepts in Nasal Deprojection

SUMMARY

The overprojected nose, also known as a long nose, is a consequence of several interrelated factors. Standardized nasofacial assessment typically is approached through the anterior, lateral, and basal views. The senior author (R.J.R.) has developed an algorithmic approach to deprojection. The algorithm, presented in this article, allows for less aggressive methods to be followed while permitting a cartilage excision modality combined with construct supporting techniques when needed.

The use of race-based terminology in the rhinoplasty literature

PURPOSE OF REVIEW

To provide an overview of the use of race-based terminology in the rhinoplasty literature.

RECENT FINDINGS

The rhinoplasty literature is often indexed by race, with common usage of the terms Ethnic/Non-Caucasian/Nonwhite; African American/of African descent; Hispanic/Latinx; and Asian to refer to certain patient populations. There are wide variations in facial features within these populations, but specific traits may be more prevalent in patients with certain backgrounds. More recently, in particular within the 'Asian rhinoplasty' literature, titles have pivoted to include specific anatomic characteristics of interest, which offers a more objective way of discussing this topic.

SUMMARY

The use of race and ethnicity to describe facial and nasal anatomy in the rhinoplasty literature introduces subjectivity and diminishes the validity of the rhinoplasty literature. We advocate the usage of specific physical and anatomic descriptions rather than race and ethnicity within the rhinoplasty literature.

The Ideal Nasion in Chinese: A Preference Analysis of the General Population

Augmentation rhinoplasty has gained popularity in China in the past decades and nasion profile is a key variable in aesthetic outcomes. The nasion is the deepest portion of the nasofrontal groove and its aesthetic preferences vary between different ethnic groups. At the time of this writing, there is limited research about ideal nasion measurements in the Chinese population. Therefore, we conducted an online survey of plastic surgeons and the public through social media. Participants were asked to rank nasion images according to their preferences. Images were created from a 3-dimensional scan of a Chinese Han female and modified to show various dimensions of nasion height, position, and forehead height. Nasion preferences were compared by age, sex, ethnicity, occupation, and whether had a history of plastic surgery. There were 777 respondents, including 461 (59.3%) women and 74 (9.5%) plastic surgeons. Nasion height of 8 and 10 mm ranked highest among all demographic groups. All respondents preferred nasion position to be level with the center of the pupil and forehead height of 4 mm above the nasion. Our study showed that the ideal Chinese nasion is in line with baseline ethnic characteristics. Therefore, plastic surgeons must be aware of these nasion preferences to guide preoperative discussions and achieve satisfactory outcomes.

Versatility of the Fixed-Mobile Septal Extension Graft for Nasal Tip Reshaping

SUMMARY

Key goals of nasal tip reshaping include precise control of tip shape and position, along with restoration of proper structural support. Unfortunately, traditional techniques attempting to address these goals have yielded unpredictable results. In this article, the authors detail their surgical technique and discuss the numerous aesthetic and functional benefits of this graft, along with its applicability to a wide variety of patient populations and nasal deformities. The authors' technique utilizing the fixed-mobile septal extension graft has demonstrated reliability in establishing proper tip positioning through precise adjustments to tip rotation and projection, while simultaneously providing a stable structure for maintaining tip support. While fixed at the anterior septal angle, this graft also proves beneficial in maintaining natural tip mobility because of its anterior extension past the septum. The fixed-mobile septal extension graft is versatile and reliable when used for tip reshaping and support.

Defining regional variation in nasal anatomy to guide ethnic rhinoplasty: A systematic review

BACKGROUND

Recently, there has been increasing focus on understanding nasal anatomy in ethnic populations and using it to guide rhinoplasty techniques in non-Caucasian patients. Many disparate groups have historically been inappropriately clustered based on geography. However, there has been little attention on describing regional differences within these populations.

METHODS

A systematic review was conducted according to PRISMA guidelines. The search terms "African", "Asian", "Indian", "Middle Eastern", "Hispanic OR Mestizo", "rhinoplasty", "nasal", "anatomy", and "ethnic" were used in combination with the Boolean operators "AND" or "OR" to identify the initial search results. Papers were included if they originated from the specific geographic region of interest, if they specifically discussed patients of one particular nationality or sub-ethnicity, or if they discussed multiple anatomical subtypes within a specific ethnicity of interest.

RESULTS

A total of 81 papers were identified overall. The search identified 40 articles discussing Asian nasal anatomy, 8 articles discussing Indian nasal anatomy, 6 articles discussing African nasal anatomy, 9 articles discussing Middle Eastern nasal anatomy, and 19 papers discussing Latin American nasal anatomy. Numerous regional variants were described within each historic geographic phenotype. The majority of descriptions of Asian nasal anatomy were consistent with the classical definition, whereas nasal anatomy among the other ethnicities was more variable. Very little has been written about the geographic variation of nasal anatomy across the African continent. Several established sub-classification schemes exist for the Latin American nose.

CONCLUSIONS

Awareness of the heterogeneity of ethnic nasal anatomy is critical for surgeons performing rhinoplasty on non-Caucasian patients.

Reproducibility of Novel Soft-Tissue Landmarks on Three-Dimensional Human Facial Scan Images in Caucasian and Asian

Background

Three-dimensional surface imaging is established in many disciplines for objective facial acquisition regarding anthropometry. Former studies addressed the validation of landmark-based measurements for single race. In order to distinguish racial difference, the reproducibility of the landmark measurements must first be validated.

Objectives

Our purpose is to validate the reproducibility of 46 facial soft-tissue landmarks on x, y, z axes to prove their reliability as 3D reference points.

Methods

The study included 80 European Caucasian and 80 Chinese volunteers. Standardized 3D surface imaging was performed using Vectra 3D system. Two raters identified and defined 46 landmarks (138 coordinates), then repeatedly 3D-imaged volunteers' facial region in separate sessions. Coordinates' reproducibility of landmarks is divided into three categories (< 0.5 mm, < 1 mm, and >1 mm) for intra- and inter-rater reproducibility assessments.

Results

Coordinates' reproducibility of 160 samples was distributed as follows: Intra-rater: < 0.5 mm (45%), < 1 mm (42%), >1 mm (13%); inter-rater: < 0.5 mm (31.2%), < 1 mm (42%), > 1 mm (26.8%). The reproducibility of landmarks in nasal tip region differs slightly between Caucasians and Asians. Compared to females, males typically have higher landmark reproducibility in lip and chin region. However, there were no differences in the reproducibility ranking of landmarks by gender.

Conclusion

The majority of the 46 landmarks in the 3D plane are reproducible to 1 mm, which is clinically acceptable. All selected landmarks showed strong consistency across race and gender, suggesting their potential use as reference points in prospective clinical practice.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02642-4.

Investigating the Reliability of Novel Nasal Anthropometry Using Advanced Three-Dimensional Digital Stereophotogrammetry

Three-dimensional surface imaging systems (3DSI) provide an effective and applicable approach for the quantification of facial morphology. Several researchers have implemented 3D techniques for nasal anthropometry; however, they only included limited classic nasal facial landmarks and parameters. In our clinical routines, we have identified a considerable number of novel facial landmarks and nasal anthropometric parameters, which could be of great benefit to personalized rhinoplasty. Our aim is to verify their reliability, thus laying the foundation for the comprehensive application of 3DSI in personalized rhinoplasty. We determined 46 facial landmarks and 57 anthropometric parameters. A total of 110 volunteers were recruited, and the intra-assessor, inter-assessor, and intra-method reliability of nasal anthropometry were assessed through 3DSI. Our results displayed the high intra-assessor reliability of MAD (0.012-0.29, 0.003-0.758 mm), REM (0.008-1.958%), TEM (0-0.06), rTEM (0.001-0.155%), and ICC (0.77-0.995); inter-assessor reliability of 0.216-1.476, 0.003-2.013 mm; 0.01-7.552%, 0-0.161, and 0.001-1.481%, 0.732-0.985, respectively; and intra-method reliability of 0.006-0.598°, 0-0.379 mm; 0 0.984%, 0-0.047, and 0-0.078%, 0.996-0.998, respectively. This study provides conclusive evidence for the high reliability of novel facial landmarks and anthropometric parameters for comprehensive nasal measurements using the 3DSI system. Considering this, the proposed landmarks and parameters could be widely used for digital planning and evaluation in personalized rhinoplasty, otorhinolaryngology, and oral and maxillofacial surgery.

Nasal Tip Shaping Finesse in Rhinoplasty

SUMMARY

Anatomic subtleties of the nasal tip have a dramatic impact on the overall appearance of the nose. Mastery of normal nasal aesthetics and anatomy is a critical prerequisite to adeptly performing nasal tip refinement during open rhinoplasty. This article and series of videos aim to provide a focused review of nasal tip analysis, anatomy, and surgical technique, with particular emphasis on pertinent tip sutures and cartilage grafts.

Approach for Rhinoplasty in African Descendants

The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

Photogrammetric Analysis of Nasal Dimensions in Indian Malaysian Adults

ABSTRACT

In cosmetic rhinoplasty, knowledge of average nasal dimensions is important to create an aesthetic nose compatible with gender, ethnicity, and other facial feature. This study aimed to establish gender-specific nasal anthropometric data for Indian Malaysians (IMs) and to determine the interracial difference by comparing it with published data of three studies. Evaluation of nasal morphology was done on the standardized frontal, lateral, and basal photographs of 200 male and 200 female IM noses, aged 18-27 years. The measured variables were evaluated by using an independent t-test. Significant sexual dimorphism was found in 20 of 21 measurements, 5 nasal indices and 2 ratios. Significant racial features between IA and Saudi Arabian population were found in all 18 measurements and 5 nasal indexes. Seven of the 8 measurements and including the 2 ratios were significantly different between IM and Whites, but between IM and Chinese, all the 8 measurements and 2 ratios were significantly different. Compared to Saudi Arabian and Whites, IM had wider intercaantal distance, the nose was relatively shorter and wider, less projected radix, and prominent glabella with an increased backward slope of the forehead. Compared to the Chinese, the IM intercaantal distance and nose was narrower and the nasal root was slightly wider in the male group. The IM nasal tip was less projected and underrotated compared to all the 3 groups. In conclusion, the anthropometric analysis of IM noses revealed several unique nasal features, understanding these variations could be useful for the rhinoplasty surgeon to deliver ethnically congruent results.

Photographic Nasal Soft Tissue Analysis From Preadolescence to Young Adulthood: Anthropometric Measurements

ABSTRACT

The nose has a tremendous effect on facial esthetics and overall facial harmony, accordingly it contributes to the physical appearance of individuals. The aim of this study is to establish sex-related nasal soft tissue norms for preadolescents, adolescents, and young adults in Anatolian population. A total of 300 volunteers (150 males and 150 females) with ages varying from 10 to 24 years were divided into 6 subgroups according to gender and educational status. The anthropometric measurements of the nose in preadolescent, adolescent, and young adult males and females were performed on digital photographs. A total of 16 nasal parameters, 13 linear and 3 angular measurements, were analyzed for sex-related variations. A significant sexual dimorphism was observed for nasofrontal and nasolabial angles in adolescent and young adult groups (P < 0.001, P = 0.011, and P = 0.007, respectively). All linear measurements of the nose were larger in males as compared to females, except for left alar thickness, which were similar between males and females in young adult group. Of the 16 nasal measurements, 13 were found to be sexually dimorphic in certain age groups (P < 0.05). In Anatolian population, the nasal shape and dimensions displayed significant sexual dimorphism in preadolescents, adolescents, and young adults. The average values of nasal soft tissue in this population could serve as a database for the planning of cosmetic and reconstructive rhinoplasty in the pediatric and adult population and obtaining the desired outcomes.

3D Virtual Planning for Rhinoplasty Using a Free Add-On for Open-Source Software

BACKGROUND

Rhinoplasty is one of the most frequent aesthetic surgeries; the procedure can be challenging for inexperienced surgeons, and positive outcomes depend on good communication with the patient, proper planning, and precise execution. Three-dimensional (3D) technology has emerged to address these issues, but specific software for 3D planning tends to be expensive.

OBJECTIVES

This study presents a simple, low-cost method for 3D simulation to plan rhinoplasty.

METHODS

This preliminary report describes 3D rhinoplasty planning in a series of 3 cases employing free software and an add-on especially developed for rhinoplasty (Blender and RhinOnBlender, respectively). The photogrammetry protocol, which can be performed easily with a smartphone, is described in detail along with all the steps in 3D planning.

RESULTS

The software and add-on automated the process, making the tool environment accessible to surgeons who are not familiar with graphic design software. The surgeries were uneventful in all cases, and the patients were satisfied with the outcomes.

CONCLUSIONS

3D graphic technology has provided significant advances in health research, improvement, and teaching for surgeons and communication between surgeons and patients. Free open-source software and add-ons are excellent options that offer proven utility, affordability, and ease of utilization to healthcare providers.

An Evaluation of Racial Diversity in Craniofacial Surgery Literature

ABSTRACT

Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Determination of Ethnic Variation in Infant Nasolabial Anthropometry Using 3D Photographs: Implications for Bilateral Cleft Lip Nasal Correction

OBJECTIVE

We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients.

METHODS

Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05.

RESULTS

Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures.

CONCLUSIONS

African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.

Nasal Analysis of Classic Animated Movie Villains versus Hero Counterparts

Opposing facial features between animated villains and heroes have historically been used to demonstrate contrasting morality between characters, and this could have an impact on how humans view someone as good or evil in everyday life. Studies have been done investigating classic dermatologic features of villainous characters. This principle can be applied to nasal features as well. A search for "top animated characters" was performed. Characters were chosen from American Film Institute's "The Top Tens," Rolling Stone's "25 Best Pixar Movie Characters," and Screenrant's "The 30 Best Animated Movie Characters of All Time." Twenty villains and twenty hero counterparts from respective films were chosen. Classic nasal features were analyzed. Twenty villains (14 male, 6 female) and 20 heroes (12 male, 8 female) were analyzed. Sixteen villains (80%) had greater than normal nasal frontal angle versus 18 heroes (90%). Thirteen villains (65%) had an acute nasolabial angle versus two heroes (10%). Two villains (10%) had excess columellar show versus seven heroes (35%). Seven villains (35%) and one hero (5%) had a dorsal hump. Twelve villains (60%) had an overprojected chin versus three heroes (15%). Villains in pre-2000s films more frequently had a dorsal hump, overprojected chin, ptotic tip, pollybeak deformity, and bulbous tip. Heroes in pre-2000s films more frequently had an overrotated tip. Villains and heroes commonly have a greater than normal nasofrontal angle. Villains more commonly have an acute nasolabial angle, underrotated tip, overprojected chin, dorsal hump, and pollybeak deformity. Heroes more commonly have a large nasolabial angle and overrotated tip. Further research in conjunction with psychologists is required to obtain concrete data on how this affects whether an individual in real life is seen as good or evil, and the impact this has on interactions in society, including in the medical field.

Nasal Skin and Soft Tissue Thickness Variation Among Differing Races and Ethnicities: An Objective Radiographic Analysis

Importance: Nasal skin and soft tissue envelope (SSTE) thickness has considerable effects on procedural planning and postoperative outcomes in rhinoplasty surgery. Objective understanding of relative SSTE thickness in patients is essential to optimal outcomes in rhinoplasty, and knowledge of its variation by demographic group is of aid to surgeons. Objective: To measure and compare nasal SSTE thickness across different races and nasal subsites and to determine whether objective variability exists for these parameters. Design, Setting, Participants: Retrospective cross-sectional radiographic analysis was carried out on 200 adult patients, without nasal deformity, presenting to an academic otolaryngology clinic at a tertiary care academic referral center. Blinded evaluators measured nasal SSTE thickness at six sites on maxillofacial computed tomography (CT) scans and comparisons were made based on patient-reported race/ethnicity categories available in the electronic medical record. Intervention: N/A Main Outcomes and Measures: Nasal SSTE thickness was measured at six predefined anatomic sites using high-resolution CT imaging. Statistical comparisons between races/ethnicities were made based on these measurements. Results: Mean age of patients was 48.8 years, and 47% were male. Nasal SSTE showed thicker soft tissue at the sellion in Latin American (LA; mean (SD) 6.1 (1.8) mm) and white (5.8 (1.8) mm) patients vs. African American (AfA) and Asian American (AsA) patients. The supratip was thicker in AfA patients (5.2 (1.3) mm) vs. all other races. The tip SSTE was thinner in white patients (2.4 (0.7) mm) vs. all other races. Composite nasal SSTE thickness was thinner in AsA patients (3.22 (0.8) mm) relative to AfA and LA patients. Conclusions and Relevance: SSTE thickness influences surgical planning and postoperative outcomes in rhinoplasty patients. This study supports varied thickness of the nasal SSTE among patients of different races. These data are foundational in providing a framework for developing treatment strategies specific to the SSTE properties of a multicultural patient population.

Evidence-based Nasal Analysis for Rhinoplasty: The 10-7-5 Method

Rhinoplasty is one of the top 5 aesthetic surgical procedures performed in plastic surgery. A methodical evaluation based on solid and up-to-date scientific evidence in different key areas of nasal and facial analysis is presented, the 10-7-5 method. This represents the most important preoperative step for a successful rhinoplasty. The 10-7-5 method for nasal analysis is a useful instrument that provides the rhinoplasty surgeon a deep comprehension of nasal anatomy. Understanding the nasal structures’ main relationships and consequences of each surgical maneuver on nasal framework assists on establishing the appropriate surgical goals for each patient, both in primary and secondary rhinoplasty cases. This systematic analysis of patient’s frontal, lateral, and basal nasal views provides a background to identify changes to ideal aesthetic proportions and how to surgically restore them while maintaining gender and ethnic congruency.