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

• 1.
  

  Multiethnic descendants of the transatlantic slave trade born and raised in the United States

  
  
• 2.
  

  Immigrants of African countries now residing with citizenship in the United States

  
  
• 3.
  

  Children of an African immigrant parent or parents born in the United States ( 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.

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

• 1.
  

  Multiethnic descendants of the transatlantic slave trade born and raised in the United States

  
  
• 2.
  

  Immigrants of African countries now residing with citizenship in the United States

  
  
• 3.
  

  Children of an African immigrant parent or parents born in the United States ( 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.