If there is one plastic surgery trend you can count on, it’s that rhinoplasty (a.k.a. nose job) will always be one of the most popular procedures. According to the American Society of Plastic Surgery (ASPS), some 350,000 ‘nose reshaping’ surgeries were performed in 2020 — making it number one on the list of top cosmetic surgical procedures.
Even so, the ever-present rhinoplasty is said to be one of the most challenging procedures to perform simply because of the complexity and individuality of each person’s nose. Not a one-size-fits-all procedure, various factors play into a successful rhinoplasty, including a patient’s ethnicity. The concept of ‘ethnic rhinoplasty’ refers to the need to take differences in nasal anatomy (e.g. skin thickness) and perceptions of beauty between cultures into account when considering if the feature is harmonious to the rest of the face.
Here, we’re speaking to top plastic surgeons about the nuances of rhinoplasty.
The History of Rhinoplasty
Since its inception, rhinoplasty has always been a multinational, multicultural, and multi-ethnic procedure. The history of rhinoplasty stems from Egyptian manuscripts dating back to around 3000 BC, followed by reconstructive rhinoplasty treatises from India around 1550 BC, says Corey Maas, MD, a double board certified facial plastic and reconstructive surgeon in San Francisco and president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). “Modern rhinoplasty was described by otorhinolaryngologist John Orlando Roe, who went on to develop elective rhinoplasty surgery,” he explains. “Many early cultures and ethnicities had described versions of this procedure, which, in the modern era, were largely performed by surgeons — later known as facial plastic surgeons — in the treatment mainly of disproportionately large noses.”
Rhinoplasty has always been one of the most ‘mainstream’ cosmetic surgeries, yet, thanks to social media exposure and a trend toward transparency, more people are opting for the surgery and deeming it socially acceptable than ever before. “By definition, everyone has some type of ‘ethnic’ nose,” Dr. Maas notes. But, technically speaking, the term ‘ethnic rhinoplasty’ describes a procedure performed on an individual of non-Caucasian descent, including religious and cultural identities. “The discussion of ethnic rhinoplasty and its differences thus becomes one of generalizing the differences in nasal anatomy between cultures and where these differences become disproportionate enough from the average ‘attractive nose’ in various cultural groups to have individuals seeking balance in facial features,” he explains.
In all cases, rhinoplasty surgically and permanently modifies the nose's internal structure to enhance its outer shape and appearance. As a result, the patient and everyone else sees the external nasal shape and contour, says Jonathan Sykes, MD, a board certified plastic and reconstructive surgeon in Beverly Hills, CA.
What’s Different About Ethnic Rhinoplasty
In Caucasian patients, Dr. Maas says that modern rhinoplasty generally balances facial features by creating a straighter bridge (a.k.a. dorsum) by reducing a hump. “During surgery, assuring that the width is defined between vertical lines dropped from the inside corner of each eye is also important,” he adds.
However, suppose the techniques used in a Caucasian nose job are also used on a non-Caucasian patient. In that case, the person will complain that they don't see a difference, warns Michael Somenek, MD, a double board certified facial plastic and reconstructive surgeon in Washington, DC. “I frequently encounter this issue with ethnic patients seeking a revision with me,” he explains. “The way ethnic rhinoplasties vary is that often the cartilage or infrastructure of the nose is relatively weak and the skin is thick.”
In these situations, “cartilage and support via grafts from the nose, ear, or ribs, are added to address the external contour and shape,” Dr. Somenek says. As a result, there are additional sites to heal (besides the nose) with cartilage grafting, though the recovery is relatively minimal.
Not every ethnic rhinoplasty surgery is the same, yet the fundamentals of the procedure remain steadfast. Certain ethnicities — mainly those of Hispanic, African American, and Middle Eastern descent — are addressed somewhat similarly since the chief goal is usually an overall reduction in the size of the nose. As Dr. Somenek explains, this often involves:
- Narrowing the nostrils
- Refining the nasal tip
- Narrowing the nasal bones
- Removing a dorsal hump
Even so, he adds that it’s imperative to respect the ethnicity of the person being operated on and understand that the nose still needs to balance with the other facial features. “Some proportions, particularly the nostril width, are typically a little wider than a Caucasian nose,” Dr. Somenek notes. “Because of this, even though I may narrow the nostrils in ethnic rhinoplasty, I am conservative to maintain some relative proportions to the rest of the nose.”
The nasal structure is inherently different between Caucasian patients and non-Caucasian patients. Due to disparities in bone, cartilage, tissue, and skin thickness, the surgical approach is of a different viewpoint; otherwise, adverse effects, like breathing issues and poor healing, may be the procedure's outcome.
Furthermore, Black, Asian, and Middle Eastern noses have variations in the nasal skeleton and skin soft tissue envelope (SSTE) that separate their anatomy from the Caucasian anatomy, explains Jennifer Levine, MD, a double board certified facial plastic and reconstructive surgeon in New York City. “Often, Caucasian rhinoplasty is a reduction rhinoplasty (taking down a hump or making the tip smaller),” she says. “With a Black or Asian nose, it may require an augmentation rhinoplasty to build the dorsum and the tip while narrowing the base of the nose and tip.”
As far as the Middle Eastern nose goes, there may be a dorsal hump, but there may also be the need for augmentation to the tip. “These changes are most often suited to an open approach, as multiple grafts are often necessary,” Dr. Levine adds. Open rhinoplasty makes incisions across the thin skin and tissue between the nostrils, whereas a closed approach hides the incision within the nose.
The primary reason why almost any patient seeks surgery is to correct a bulbous or too wide tip, a wide or humped bridge, a droopy tip, or a deviated septum. Most ethnic rhinoplasty procedures consider the different anatomical variations and aesthetic goals of each ethnicity, yet there is no denying that some faces call for a more prominent nose, while others can support a more upturned, petite one.
There are infinite variations of rhinoplasty that can be accomplished to best present the nose's appearance while bringing balance to the face. For this reason, Dr. Sykes doesn't like to think of techniques as being Caucasian or ethnic. Instead, he looks at the interplay between the SSTE and the infrastructure to achieve an elegant result. “Some noses require removal or subtraction of infrastructure, and others require grafting or augmentation of the infrastructure,” he explains. “In many cases, the perfect combination is some augmentation and some reduction.” This is never determined by a set formula but rather an “individual sculpting of that particular nose,” he adds.
As you’ve likely gleaned, all rhinoplasty surgeries are complicated and detail-oriented. This is why it’s vital to seek out a board certified facial plastic or plastic surgeon who specializes in the procedure. Those with an emphasis on performing ethnic rhinoplasty, specifically, are an even better choice.
To confirm expertise, review a surgeon’s before and after images to judge that the results they achieve are on par with what you want to accomplish. This also allows you to see if they have operated on patients who have similar features to your own. Dr. Maas’ advice? Find a surgeon who has performed at least 1,000 nose surgeries in a multicultural city to help ensure a positive outcome.
Keep What You Like, Get Rid of What You Don’t
The most challenging aspect of ethnic rhinoplasty is retaining the features of the face or nose the patient doesn't want to alter. Many feel that certain cultural distinctions are what make them unique, which means the goal of the procedure is to eliminate what they don't like about the nose without disrupting other facial features or even aspects of the nose that they feel positively contribute to their look. “There’s an art to understanding how to achieve this and which features are best kept and refined as opposed to removed,” says Kevin Tehrani, MD, a board certified plastic and reconstructive surgeon in NYC.
Needless to say, it is crucial not to try to make an ethnic nose look like a Caucasian one, which is why your surgeon must preserve certain features. With that in mind, these are some of the most common requests:
The African American Nose
- Areas of Concern: A wide bridge and a flat tip due to thick skin.
- The Request: A bit more projection, a thinner bridge, and less prominent nostrils. “These patients (as well as Asian patients, too) often desire to build up a relatively flat or poorly defined bridge of the nose and reduce the thick appearance of the tip of the nose caused by skin and cartilage thickness," Dr. Maas explains.
The Asian Nose
- Areas of Concern: Typically, a flat, broad nose and an under-projected tip and bridge.
- The Request: More tip and dorsal projection. Dr. Maas explains that much of Asian rhinoplasty involves techniques of augmenting and/or building up disproportionately small noses or loss of part or all of the nose.
The Mexican & Latin Nose
- Areas of Concern: The most common are a bulbous or broad tip coupled with a wide bridge and poor projection.
- The Request: A refined and more elevated tip and a reduction of any humps.
The Middle Eastern Nose
- Areas of Concern: A thick, bulbous tip and a wide bridge; a deviated septum is also common.
- The Request: More definition in the tip of the nose and a reduction of the hump, which often requires reducing or removing excess cartilage and bone.
The Native American Nose
- Areas of Concern: A too-narrow bridge with poor projection.
- The Request: A soft, natural slope from the bridge to the tip.
While this can serve as a guide, the variation in what noses look like and what patients want is not always quite so predictable. “Some patients desire a small and very stylized nose whereas others want a more natural appearance,” Dr. Sykes explains. “I feel that it’s important to have a lengthy consultation with the patient to understand what they want to achieve.” During the consultation process, any good plastic surgeon should always be upfront and honest about what is achievable while considering the patient’s desires. “The consultation varies by individual and cannot be generalized to a given ethnicity,” he says.
The Importance of Skin Type
The skin on the nose, known as the nasal skin envelope, influences how surgeons perform rhinoplasty and what the result will look like in the end. Those with darker skin tend to have a thicker nasal skin envelope. That skin thickness can limit the overall nasal tip definition that’s achievable. “That is why it is so important to create a strong, supportive foundation in the nasal tip so that when the skin redrapes over the new underlying cartilage, it can have more definition,” Dr. Somenek explains. It's also imperative to know that, postoperatively, there is an increased risk of prolonged swelling in the tip.
Despite the longer healing time, the benefit of thicker skin is that it can help minimize contour irregularities overlying the cartilage. In addition, due to the thicker support and structure, the skin can provide a definition and shape that lasts. At the same time, it can create a more bulbous tip, Dr. Tehrani says.
While changing the SSTE is (relatively) easy to do, getting the skin to blanket down and assume its new structure is more complicated. “As a general rule, the thinner the skin, the easier to see the underlying change made; the thicker the skin, the more difficult it is to see underlying cartilaginous changes,” Dr. Sykes shares. For this reason, in thicker-skinned patients, structure and cartilage is often added via grafts to address the outer nasal contour. This can make it more challenging — though not impossible — to achieve a ‘small’ nose.
To improve the nose yet not disrupt the facial features, it's vital for the nose, which is at the center of facial appearance, to live in and even create harmony amongst the other features. Generally speaking, the onus is on the surgeon to understand the patient's desires, offer complete transparency on what’s possible, practice the appropriate technique, and retain proportion. “If a nose looks over-operated upon, it draws too much attention from other features and detracts from overall facial attractiveness,” Dr. Sykes cautions.
No two noses are the same, and that is especially the case when you consider ethnic differences in nasal anatomy. The goal of any rhinoplasty is to preserve the appropriate features. “Using the incorrect technique will lead to a suboptimal or unharmonious result,” Dr. Levine says. “The anatomy dictates a different approach.” Therefore, it’s essential to choose a board certified plastic surgeon with a deep understanding of the nose and a well-documented history of operating on them.
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