Rhinoplasty in patients of Middle Eastern origin requires complete understanding of nasal morphology and an individualized approach to create a racially congruent and aesthetically pleasing outcome. In this article, common anatomic features and characteristics and detailed steps, surgical techniques, and operative maneuvers that can lead to predictable outcome in rhinoplasty of Middle Eastern patients are discussed.
Key points
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Facial and racial congruity should be preserved by recognizing the features that are common in Middle Eastern rhinoplasty patients. Understanding of the maneuvers and techniques that lead to predictable result can prevent unnatural or an overoperated nose.
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For every Middle Eastern patient undergoing rhinoplasty, the measure of success is the ability to shape the nose into more pleasing proportions while maintaining the structure and improving nasal function.
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Detailed analysis and knowledge of structural differences among various ethnic groups within Middle Eastern patients are required to ensure predictable and harmonious results.
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Racial congruity and symmetry are achieved by conservative dorsal hump reduction, modest alar base and nasal tip narrowing, and avoiding overrotation of the nasolabial angle. In addition, the visible grafts should be reserved for patients with thicker skin.
Introduction
The recent upward socioeconomic movement of ethnic (nonwhite) minorities in the United States has provided many with the opportunity to seek elective plastic surgery, and many desire rhinoplasty. Mainstreaming has also helped erase the social stigma once associated with plastic surgery procedures.
Most ethnic patients have the aesthetic goal of preserving their ethnic heritage and cultural identity. However, most wish to improve their nasal features so that their nose is more harmonious with the rest of their face. Middle Eastern patients generally do not want to lose the important facial features that show their racial character and congruity.
Comprehensive knowledge of the nasal anatomy and familiarity with the nasal and facial features common in the Middle Eastern nose allow the surgeon to anticipate and prepare for the challenges. Properly choosing the surgical techniques, along with a realistic appreciation of the limits imposed by the particular ethnic skin quality and the underlying framework architecture, should allow the surgeon to achieve a predictably favorable outcome and a satisfied patient.
“Middle Eastern” often refers to individuals of Persian, Arabic, Turkish, and North African descent. One can consider broad categories to be (1) the Gulf countries (Iran, Saudi Arabia, Kuwait, Qatar, Bahrain, and United Arab Emirates), (2) the North African countries (Egypt, Libya, Algeria, and Morocco), (3) regional groups (Lebanon, Afghanistan, Syria, Turkey, Greece, and Armenia), and (4) the near Asia countries (India and Pakistan).
Rhinoplasty is the most difficult of all plastic surgery procedures, and there are particular challenges when treating the Middle Eastern or any “ethnic” nose, as opposed to the white nose. Although there is a large spectrum of variability in the Middle Eastern nose, there are some common characteristics and features, which are reviewed in detail. This article also specifically addresses the challenges presented by Middle Eastern noses and the treatment options that can lead to successful outcome.
Introduction
The recent upward socioeconomic movement of ethnic (nonwhite) minorities in the United States has provided many with the opportunity to seek elective plastic surgery, and many desire rhinoplasty. Mainstreaming has also helped erase the social stigma once associated with plastic surgery procedures.
Most ethnic patients have the aesthetic goal of preserving their ethnic heritage and cultural identity. However, most wish to improve their nasal features so that their nose is more harmonious with the rest of their face. Middle Eastern patients generally do not want to lose the important facial features that show their racial character and congruity.
Comprehensive knowledge of the nasal anatomy and familiarity with the nasal and facial features common in the Middle Eastern nose allow the surgeon to anticipate and prepare for the challenges. Properly choosing the surgical techniques, along with a realistic appreciation of the limits imposed by the particular ethnic skin quality and the underlying framework architecture, should allow the surgeon to achieve a predictably favorable outcome and a satisfied patient.
“Middle Eastern” often refers to individuals of Persian, Arabic, Turkish, and North African descent. One can consider broad categories to be (1) the Gulf countries (Iran, Saudi Arabia, Kuwait, Qatar, Bahrain, and United Arab Emirates), (2) the North African countries (Egypt, Libya, Algeria, and Morocco), (3) regional groups (Lebanon, Afghanistan, Syria, Turkey, Greece, and Armenia), and (4) the near Asia countries (India and Pakistan).
Rhinoplasty is the most difficult of all plastic surgery procedures, and there are particular challenges when treating the Middle Eastern or any “ethnic” nose, as opposed to the white nose. Although there is a large spectrum of variability in the Middle Eastern nose, there are some common characteristics and features, which are reviewed in detail. This article also specifically addresses the challenges presented by Middle Eastern noses and the treatment options that can lead to successful outcome.
Treatment goals and planned outcomes
In addition to extensive training in rhinoplasty, it is imperative that the plastic surgeon has additional training and experience in performing ethnic rhinoplasty to address the unique characteristics of the ethnic nasal anatomy. Rhinoplasty for Middle Eastern patients is a specialization. It requires great surgical skill, sensitivity, and proven results to achieve a cosmetic result that improves the nose and face while respecting and preserving the patient’s ethnicity.
Many plastic surgeons have experience operating primarily on white noses and may not have experience to perform “ethnic rhinoplasty.” Occasionally the standard has been for surgeons to perform rhinoplasty on all patients in exactly the same way regardless of their ethnicity. This is probably because communications media have popularized the Western look and thus it became the goal in rhinoplasty. However, this has produced noses for some ethnic patients that appear unnatural and unbalanced when compared with their other facial features and physical characteristics (racial incongruity).
The important fact to be aware of for ethnic rhinoplasty is that there is no universal standard of beauty. It is best to avoid “westernizing” the ethnic nose; one should not try to create something based on the European ideal. Every attempt should be made to create a nose that is harmonious with the individual’s face and honor the cultural differences in the concept of beauty (also known as “ethnically consistent improvement”).
Ideally the surgeon should fully appreciate ethnic preservation and use an ethnosensitive approach, because it is no longer a foregone conclusion that ethnic nasal features must be eliminated. Rhinoplasty in ethnic patients often requires a different approach than in white patients.
The nasal and facial proportion guidelines that plastic surgeons in North America are taught have not, traditionally, taken different ethnicities into account. When altering a white nose, rhinoplasty often removes cartilage and bone because the nose is too long, too big, or too overprojected and refinement of the nasal bridge, the tip, and possibly modification of the alar base may be needed. Although similar procedures may be used in Middle Eastern rhinoplasty, the surgeon should cultivate deep understanding of the ethnic nasal structure to provide the best possible result.
As with all groups, patients with an ethnic background have specific characteristics typical of their nasal structure and architecture. However, each patient may also require a highly individualized approach because each nose can vary dramatically. Because of the variability of soft tissue thickness and cartilage resiliency, rhinoplasty in a Middle Eastern patient may require significant alteration of the nasal framework to change the external appearance. These factors make Middle Eastern rhinoplasty challenging because they must be addressed to achieve an optimal result.
The task is to artistically sculpt the Middle Eastern nose (ideally with subtle changes when possible) to achieve facial balance and enhance each patient’s natural beauty. The “triangle of beauty” around the patient’s nose should blend seamlessly into the rest of the patient’s facial structure. The desired result is a refined and aesthetically balanced nose, overall facial harmony, and a patient that feels more confident in their appearance. A successful surgery draws attention to a person’s eyes, not nose.
The internal and nasal framework changes to the Middle Eastern nose have an impact on the function of the nose. The surgeon must take great care in maintaining open nasal airways for optimal postsurgical breathing. Nasal function should never be compromised in the interest of beauty and should always be a primary goal.
Common aesthetic deformities and areas of concern of the Middle Eastern rhinoplasty patient include the following: prominent arching dorsum; wide bony vault; long and drooping tip with narrow nasolabial angle; bulbous, large, and ill-defined tip; and nostril asymmetry.
Preoperative planning and preparation
The most important part of preoperative planning and preparation for successful Middle Eastern rhinoplasty is effective communication with the patient.
Race is the genetic heritage one is born with, regardless of location; ethnicity is the learned cultural behavior of a particular group (behavior, beliefs, and values). How a person perceives their place within each of these groups affects his or her self-image and approach to cosmetic surgery. Even within the same race and culture, facial characteristics are appreciated differently. For example, a recent immigrant may have different cosmetic surgery goals than a third-generation transplant or foreign national (typically, a Middle Eastern patient born in the United States wishes to have more drastic change to the appearance of their nose). The surgeon must determine the patient’s wishes before surgery and never make assumptions; it is inappropriate to assume that all of any racial/ethnic group would want a “standard” nose. It has been the author’s experience that the younger Middle Eastern patients usually desire a more significant change to the appearance of their nose following rhinoplasty.
When interacting with patients of Middle Eastern origin, surgeons should provide culturally competent care, communicating without letting cultural differences hinder the conversation, but rather enhance it. This sometimes can pose a challenge because patient and surgeon bring individual patterns of language and culture to the meeting and both must be transcended to communicate effectively. The surgeon should learn about the particular ethnic culture and its approach to health care. Also, English may be a second language for these patients and an interpreter may be needed to ensure that patient-surgeon communication is accurate.
Surgeons are additionally cautioned not to impose their own aesthetic ideals, perceptions, or expectations on the patient. These conflicts with patient desires may not become apparent until after the surgery is completed, hence making the preoperative understanding of the patient’s goals and desires extremely important.
Patient satisfaction is the primary goal; however, that goal must also be aesthetically and surgically realistic. In addition, the patient’s desires should not result in an “operated” look. Computer imaging is useful for communicating this information and for educating the patient; it can provide examples for the patient to choose from, and a digital picture can be morphed from before to after showing the patient what is realistically possible. Computer imaging can also promote discussion of the specifics (eg, “I want a nose like this picture”), rather than generalities (eg, “I want a narrower nose”), and may prevent misunderstandings.
Some of the most challenging rhinoplasty cases are found among individuals of Middle Eastern origin. Common nasal anatomic features of the Middle Eastern nose include thick or regionally variable skin/soft tissue envelope, overprojecting osseocartilaginous vault, facial and nasal asymmetry and deviation, airway compromise, weak and asymmetric alar cartilages, and short medial crura. These can result in the following facial malformations and clinical findings: deviated, asymmetric nose; large bulbous nose; high arching dorsum; elongated nose; poorly defined drooping tip; broad bony middle vault; obtuse nasolabial and columellar-labial angle; and overall nasal asymmetry ( Figs. 1 and 2 ). Schematic diagram of the typical and ideal aesthetic proportions and ratios for Middle Eastern patients is found in Figs. 3 and 4 .
