We are in the midst of truly changing times, as patients of African descent actively embrace facial cosmetic surgery. Gaining surgical consistency in patients of African descent has proven to be elusive and unpredictable for many rhinoplasty surgeons. Surgical success relies on the surgeon’s ability precisely to identify anatomic variables and reconcile these anatomic realities with the patient’s expectations for aesthetic improvement and ethnic identity. An appreciation for underlying heritage provides a link culturally to connect with prospective patients and serves as a tool for establishing realistic aesthetic goals. This article highlights the significance of exploring ancestry in the rhinoplasty consultation; identifies key anatomic variables in the nasal tip, dorsum, and alar base; and reviews surgical logic that has facilitated the achievement of consistent, balanced aesthetic outcomes.
We are in the midst of truly changing times, as patients of African descent actively embrace facial cosmetic surgery. The Eurocentric aesthetic platform is slowly evolving to embrace a more global standard of beauty. This enlightened perspective has provided much-needed breathing room for populations with skin of color to seek facial enhancement without the accompanying claims of “trying to look Caucasian.” As a result, stigma surrounding cosmetic nose reshaping has noticeably decreased in the African American community. Rhinoplasty is now more commonly perceived as a means to achieve greater harmony and balance in the face and not as a denial of ethnic heritage. In the 2006 American Academy of Facial Plastic and Reconstructive Surgery Member Survey, African Americans were more likely to seek rhinoplasty than any other facial plastic surgery procedure. Modern rhinoplasty surgeons have the unique opportunity to redefine surgical logic and classification schemes to be more anatomically sophisticated and culturally sensitive.
Gaining surgical consistency in patients of African descent has proven to be elusive, unpredictable, and challenging for many rhinoplasty surgeons. In general, rhinoplasty necessitates a thorough appreciation for key surgical anatomy as well as a high degree of technical skill. These prerequisites are increasingly important even for the skillful surgeon who is not accustomed to operating on patients of African descent, as anatomic variables may often be misleading. The author would further assert that identifying pertinent surgical anatomy and operative skill are not the only hurdles to overcome in achieving consistent favorable rhinoplasty outcomes in this population of patients. Anatomy and operative techniques can indeed be taught. Cultivating an aesthetic consciousness for Afrocentric nasal harmony, however, is a more nuanced endeavor. Here, surgical success relies on the surgeon’s ability precisely to identify anatomic variables and reconcile these anatomic realities with the patient’s expectations for aesthetic improvement and ethnic identity. To do this successfully, surgeons need not only a clear understanding of their patient’s expressed aesthetic goals but, as importantly, the knowledge and understanding of the often unexpressed cultural influences that undergird these expectations. This knowledge is amongst the most challenging aspects of rhinoplasty surgery in patients of various cultures and ethnic groups. Yet, a surgeon’s ability to “culturally connect” with the patient is essential to establishing a foundation for the creation of a shared aesthetic vision.
Much of the interruption in the progression to favorable rhinoplasty aesthetic outcomes occurs preoperatively during the consultation and nasal examination. There are 3 major areas of breakdown that occur before the surgeon sets foot in the operating room.
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Patient not confident that the surgeon understands his or her aesthetic goals.
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Flawed nasal analysis and surgical plan based on Eurocentric nasal beauty standards.
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Unrealistic expectations held by surgeon or patient without consideration of pertinent anatomic variables and nasal skin envelope limitations.
This article aims to provide insight for and raise the comfort level of rhinoplasty surgeons operating on patients of African descent. The article highlights the significance of exploring ancestry in the rhinoplasty consultation; identifies key anatomic variables in the nasal tip, dorsum, and alar base; and reviews surgical logic that has facilitated achieving consistent balanced aesthetic outcomes in the author’s practice.
The culture connection: why explore ancestry?
An appreciation for underlying heritage provides a link to culturally connect with prospective patients and serves as a tool for establishing realistic aesthetic goals. This cultural journey can be initiated by simply inquiring about a patient’s family background. The author asks patients “where did your family originate?” This question opens a nonthreatening pathway to establish authentic dialog regarding ancestry and ethnicity. This cultural conversation can be the ultimate tool in surgical decision making as it may shed light on how much or how little change a patient desires, or in understanding what anatomic variables a patient associates with ethnic identity, or simply positioning the clinician in the patient’s mind as someone who cares about his or her individuality.
Who is an African American … or Black American
Previous rhinoplasty literature has often discussed rhinoplasty in patients of African descent under the generic headings of “non-Caucasian” and “ethnic.” Whereas some reports have taken a more focused and individualized approach using the terms “African American” or “Black American,” active debate exists regarding the definition and inclusiveness of the term African American that is beyond the scope of this article. Much of the debate focuses on who actually falls under the umbrella of African American terminology. Arguments have included diverse opinions regarding the inclusion of “white-skinned Caucasian” Africans and distinctions between Black Americans and African Americans. Being aware of the nuances of this particular debate, however, serves to heighten a surgeon’s cultural sensitivity. From a pragmatic point of view, the most common categories of so-called African Americans who may present to the office for rhinoplasty are
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Multiethnic descendants of the transatlantic slave trade born and raised in the United States
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Immigrants of African countries now residing with citizenship in the United States
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Children of an African immigrant parent or parents born in the United States ( Fig. 1 ).
Fig. 1
Who is an African American? These photographs illustrate common categories of African Americans. ( A ) American-born citizen (African ancestry as a descendant of slavery). ( B ) Multiethnic (Sierra Leone/Russia) African immigrant now residing in the United States. ( C ) American-born citizen with African (Nigerian) parents.
African American terminology has relevance from an anatomic, geographic, and cultural perspective. Racial admixture in the African American population has resulted in a diverse array of anatomic and morphologic nasal presentations. Psychosocial impressions of ethnic identity may be quite different for a Nigerian patient who immigrated by choice to the United States compared with the patient born and raised in America with remote African ancestry originating from the transatlantic slave trade. Ironically, many American-born descendants of slavery can more aptly identify European (such as Irish, Scottish) and Native American (such as Cherokee, Powhatan) lineage, over the nonspecific African heritage that defines their ethnic identity in American culture. A large segment of the African American cultural story has been motivated by an underlying desire to reconnect the links severed by slavery to a distinct African ancestral past. The past 30 years have seen a renaissance of sorts with respect to African American economic empowerment and the influence of uniquely African American culture on global society. African American influenced music (jazz, blues, hip hop), dance (Alvin Ailey American Dance Theater), and fashion have been embraced worldwide. The author’s prospective rhinoplasty patients of African descent (most commonly between 20 and 40 years old) have nurtured their sense of self-identity in this accepting, globally inclusive environment. As a result, many of these patients hold preservation of ethnic identity in high regard as they seek to enhance facial attractiveness. These are cultural nuances of which ideally an aesthetic surgeon should be aware. Such awareness will not change the technical approach, but it may facilitate an enlightened conversation with the patient regarding ideal aesthetic outcomes, and allow surgeons to fine tune surgical logic regarding the amount of change the patient will find acceptable and pleasing. The “cultural connection” is yet another universal means to formulate a shared vision between surgeon and patient with regard to defining aesthetic ideals. Once the aesthetic vision is defined, it is up to the surgeon to formulate a surgical plan whereby the vision can be made a reality.
The rhinoplasty consultation: an educational opportunity (a teaching moment)
The rhinoplasty consultation is an opportunity for both surgeon and patient to share and learn from each other. A major complaint that the author receives from patients of African descent who have visited other surgeons for consultation is a lack of confidence with the surgeon’s ability to internalize their desired cosmetic goals with cultural sensitivity. As discussed previously, exploring ancestry is a means to set the stage whereby surgeons can learn from their patients. In the same regard, the nasal examination is an opportunity for the surgeon to take the lead and teach, creating an educational atmosphere for patients to learn from the surgeon. This educational platform between patient and surgeon creates an environment for the “sharing of knowledge,” which will ultimately facilitate the creation of a shared aesthetic vision for rhinoplasty.
In the consultation, the author asks each patient what concerns he or she has with the appearance of their nose. To be more specific, each patient is given a cotton-tip applicator, is told it is a magic wand, and is asked what he or she would change if it were that simple. The rhinoplasty consultation for patients of African descent sometimes comes with a bit of psycho-social baggage. African Americans have often rejected facial cosmetic surgery seeing it as a way of conforming to European ideals of beauty. In many instances the patients are on their own, without the benefit of family support or close associates who have already undergone the procedure with whom they can relay concerns. The magic wand exercise works to alleviate anxiety. The exercise also encourages patients to be more specific in identifying desired changes with a focus on key anatomic variables. The author then reviews the anatomy of the nose with the patient. In this teaching moment, the nose is separated into 3 major areas: upper, comprising the nasal bones; middle, comprising the upper lateral cartilages; and lower, comprising the paired tip lower lateral cartilages and the fibro-fatty framework of the nostrils. In a simplistic manner, the prospective rhinoplasty patients are informed that aesthetic complaints typically fall into 3 boxes. For some individuals a check can be placed in all 3 boxes, for some, 2 boxes, and others, only one. The first box includes complaints related to the overall contour of the bridge (shape, projection). The second box contains complaints associated with the width of the nose. The third box relates to concerns regarding the shape of the nasal tip and nostrils. The consultation then proceeds with surgeon and patient symbolically placing checks in the appropriate box or boxes, and together outlining a shared aesthetic plan incorporating specific techniques to modify their particular anatomy.
Key techniques related to surgical anatomy
Given the vast morphologic diversity of patients of African descent, surgical approaches and techniques must be directed toward modifying specific anatomic variables. Previous reports have offered generalized descriptions regarding surgical anatomy in the African American patient without regard for geographic differences and ethnic makeup of the study population. For instance, Stucker notes that the lower lateral cartilages are thinner and more flaccid than those found in the Caucasian race. Rohrich comments that “The African American nose typically has a short columella, broad flat dorsum, slightly flaring alae, and a rounded tip with ovoid nares.” Ofodile and Bokhari reviewed harmonious anthropometric indices and normal baseline measurements for the African American patient. This article now comments on a few surgical concepts and technical pearls that have facilitated achieving consistent and natural results in patients of African descent.
Modifying the nasal tip
Patients of African descent frequently present with concerns regarding the appearance of the nasal tip. Common complaints include bulbous shape, lack of tip projection, and poor tip definition. The lack of tip definition and broad, bulbous lobule appearance are often multifactorial, resulting from a combination of a thickened skin envelope, increased subcutaneous fibro-fatty tissue overlying the lower lateral cartilages, and a rounded/convex contour of the lower lateral cartilages.
Improving the appearance of the nasal tip should be approached from the perspective of contour modification and not simply narrowing. To do this reliably, it is important to comprehend the relationship between the external nasal contour and shape of the underlying tip structures. This exercise can be exceedingly difficult in the subset of patients of African descent who possess a thick skin envelope, excessive fibro-fatty subcutaneous tissue, and fragile lower lateral cartilages. By understanding the correlation between the external tip morphology and the underlying structure, the surgeon can simplify nasal tip surgery to preserve the favorable contours of the lower lateral cartilages and modify those that are unfavorable. With this goal in mind, developing a cultural sensitivity for a broad range of aesthetically pleasing anatomic contour relationships becomes important. The author wholeheartedly concurs with Toriumi’s position that “even broad tips that possess favorable shadowing can look very good.” Rhinoplasty surgeons are strongly urged to peruse the pages of ESSENCE magazine, a monthly women’s health and beauty publication, on a regular basis to familiarize themselves with the range of aesthetically pleasing nasal tip contours in women of African descent.
Ofodile and James have reported that the alar cartilages in African American patients are similar in size to those of Caucasian patients. Given the inherent morphologic diversity in African American patients, it should be further added that the full spectrum of cartilage shape, size, and thickness can be present, depending on the underlying multiethnic racial ancestry. A critical point of distinction is that in patients of African descent, it can be quite difficult to predict the shape of the cartilage framework without actual visualization. Digital palpation to assess cartilage strength is not as helpful as in individuals of European descent, due to the masking effect of the thickened skin and subcutaneous fibro-fatty tissue. In Ofodile’s study of the Black American nose, the presence of a heavy layer of fibro-fatty tissue was a consistent finding in all the subjects. The author has been surprised to find extremely weak and fragile lower lateral cartilages in patients despite a firm tip with digital palpation. Improved visualization with an external rhinoplasty approach has consequently proven to be a more reliable means to assess the anatomic contributions to external tip morphology in patients of African descent.
For external rhinoplasty, the skin envelope elevation is often performed just under the subcutaneous tissue, allowing for controlled tip debulking. A particular effort is made to preserve the fibro-fatty subcutaneous material overlying the lower lateral cartilages so that it can be used later for soft-tissue graft material, usually to soften the appearance of cartilaginous shield grafts ( Fig. 2 ). Although patients and surgeons may harbor reservations with the transcolumellar incision of the external approach, it has been found to heal in an imperceptible manner when executed proficiently and closed with meticulous surgical technique. The author use a 6-0 polypropylene suture in a vertical mattress fashion to reapproximate the columellar skin at the peaks of the inverted-V columella incision. The marginal incisions are closed with 5-0 fast-absorbing gut. The prolene sutures are removed at postoperative day 6. Two-layer closure with a single deep 5-0 monocryl is recommended if significant tension is present as a result of increased tip projection from cartilaginous tip grafts.
