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    Ethnic patients seeking rhinoplasty may prefer to retain uniqueness of features

    Retaining the ethnic "flavor" of one's nose is a common goal among the vast majority of ethnic patients seeking rhinoplasty, according to surgeons who devote a significant portion of their practice to this procedure.

    "There has been a fear among African-American, and, to a lesser degree, in Latino and even Asian patients, that if they wanted to change their features that this would signify that they weren't proud of who they were," says cosmetic surgeon Charles M. Boyd, M.D., who is in private practice in Birmingham, Mich., and New York. In ethnic patients who seek rhinoplasty, Dr. Boyd's goal is to de-emphasize the nose and draw attention to the eyes instead. "There are subtle things that we can do to make a change in the profile, in the definition of the nose, without changing their ethnicity, without intrinsically changing their appearance," Dr. Boyd says.


    A black patient before (left) and after rhinoplasty. — (Photos credit: Steven Hopping, M.D.)
    Washington cosmetic surgeon Steven B. Hopping, M.D., who lectures on ethnic rhinoplasty, also stresses that most patients want to retain their ethnicity. "Oftentimes, the typical patient is a woman who has inherited her father's nose and doesn't want to be quite that ethnic. She'd prefer something like their mother's or sister's nose," says Dr. Hopping, clinical professor of surgery, George Washington University, Washington.


    A Middle Eastern patient before (left) and after rhinoplasty. — (Photos credit: Steven Hopping, M.D.)
    Both Drs. Boyd and Hopping stress that communicating with patients to get a clear picture of their goals is the most important aspect of the entire procedure. "I use computer imaging and this is very helpful in pinpointing what patients are trying to achieve, and it enables them to see what's in my mind as well," Dr. Hopping says.

    Dr. Boyd points out that some patients are really looking for a new nose, while others want subtle changes. "If the patient wants dramatic changes and the surgeon doesn't provide that, or similarly, if the patient wants subtle changes and the surgeon has completely changed the nose, the patient is not going to be happy," Dr. Boyd says. "So, you really need to communicate to share the same vision."

    SURGICAL MANEUVERS As far as surgical strategy, skin thickness and cartilage stiffness are standard anatomic considerations of which surgeons should be cognizant with respect to ethnic rhinoplasty. "These are the two most important things to assess preoperatively, because if the patient has really thick skin and really poor cartilage support, then the surgeon has to pull out all the stops," Dr. Hopping says. "In cases like this, you have to de-fat the skin in order for the patient to be able to appreciate any of the changes or refinement that you introduce, and you're going to have to use some kind of graft — probably the patient's own cartilage in the tip to create some definition."

    Thicker skin and poor cartilage support are common among African Americans, Middle Easterners and Asians, Dr. Hopping says. "Even though a lot of patients of these ethnic backgrounds want a smaller nose, they need to augment with their own cartilage," he says, adding that he believes using patients' own cartilage is much safer than using silicone or some other artificial material implant. "Even Asian patients — who tend to want to make their noses slightly larger — have generally poor cartilage support and have fairly thick skin. So we need to either put an implant in, or use the patient's own cartilage to provide some definition," he says.

    WALKING A FINE LINE There's a fine line between de-fatting the skin enough to feature the refinements made, and thinning the skin too much. Dr. Boyd points out that one of the biggest mistakes that surgeons can make in performing rhinoplasty in thick-skinned patients is to overly thin the skin. "This is a concern in Southeast Asian, African-American and even some Latino noses. Surgeons feel a strong desire to thin the nose, and they do an open rhinoplasty and remove some of the tissue or the subcutaneous tissue below the skin. This can be done effectively in moderation, but the danger is in going to far," he says. "If it's an African-American patient who has relatively thick skin, I won't thin the skin so much. Instead, I'll use more cartilage to build up the tip, to build up the dorsum, and then the thinning will take care of itself," he says. "If you add enough structure to give the nose the proper projection, then you really don't need to thin the skin at all."

    Middle Eastern patients' noses also have thick skin, but they have a distinct shape that includes a dorsum hump and a bit of tip ptosis as well. "Often, the tip needs to be augmented and the dorsum needs to be reduced," Dr. Boyd says.

    Dr. Hopping, who often performs surgery in Dubai, United Arab Emirates, says, "In Dubai, they don't want an 'American nose.' There they like to keep the nose longer for a more natural look." He notes that this requires a pure reductive rhinoplasty. "We just have to be cognizant of not doing as much as we might typically do in the Western world because in Arab cultures, they often want to keep the nasal length," he says.

    A distinction in black patients' noses, Dr. Hopping notes, is the width. "If you leave the nostrils alone, the result is more natural, but oftentimes, the width is part of the patient's complaint. In this case, we would perform some sort of nostril narrowing procedure," he says. However, this complicates the process — almost like adding an extra procedure, with the inherent risks. "There is some risk of nostril asymmetry, and there is the risk of a scar, but there has never in the history of medicine been keloid scarring in this area. So, fortunately, we can operate on this region with impunity," Dr. Hopping says.

    ETHNIC BLENDING Interestingly, as surgeons familiarize themselves with the unique anatomical distinctions inherent in various ethnic groups, and as cosmetic surgery becomes more acceptable, the culture is morphing in a way that de-emphasizes these distinctions. The ideal "look" is one that's becoming interchangeable among races and ethnicities, according to Dr. Hopping.

    "I see that things are changing. In the characters that we see on nightly television shows and elsewhere, ethnic blending is occurring," he says. "Everybody wants to de-emphasize their nose a little bit. The noses are getting more and more alike, and I believe this is a product of the overall ethnic blending occurring in our society."

    This, he adds, is a new concept that cosmetic surgeons should be aware of as they counsel their patients.