As the U.S. population continues to become increasingly multicultural, one of the increasing ethnic groups is that from the Middle Eastern region. This is a geographic term that does not have a true precise meaning as it can vary based on which countries one chooses to include in the region. Most commonly, many would include the countries that surround the Gulf Sea as well as that of Northern Africa.
While the Middle Eastern region is a blend of many cultures, there are certain nasal characteristics that are commonly seen. The overlying skin is almost always thick and heavy, a large dorsal hump is present, the nasal tip is ill-defined and bulbous, and the columella is frequently short. These characteristics give the appearance of a long and plunging nose with an acute nasolabial angle.
The Middle Eastern nose, like all ethnic rhinoplasties, poses challenges based its thick skin and cartilaginous make-up. But beyond the anatomy of the nose, it is important to have clear communication with the patient about their nasal goals. When the plastic surgeon and the patient have different ethnic and cultural backgrounds, it is easy to have objectives that are unintentionally different. Computer imaging and multiple consults can help to prevent this communication gap.
The open approach should almost always be used. To rework the cartilage framework in a way that will make a significant change in nasal appearance requires optimal visualization. Some plastic surgeons may be able to achieve a great rhinoplasty result in the Middle Eastern patient through a closed approach, but that has not been my experience in my Indianapolis plastic surgery practice. While there is always a concern about the columellar scar in patients with increased skin pigmentation, that has not been a problem. That is not a surprise given the known experience with other ethnicities.
Structural support to the tip and the middle vault is essential. The thick skin of the nasal tip can make it challenging to achieve definition and a more upright position with an increased nasolabial angle. Septal grafts to the columella are always needed to support the large and heavy skin sleeve. Tip grafts are usually beneficial to create more definition through tip skin which has been slightly defatted. The septum can provide more than enough graft material and almost always needs work anyway as it is frequently deviated and off midline.
The dorsal hump must be looked at and analyzed carefully during surgery. While it can appear to be high, it may not need to be as significantly reduced as one initially thinks. In some cases, this is an illusion due to the downturned tip and decreased nasolabial angle. Rasping and radix grafts may be all that is needed. In other cases, however, a large bony hump does exist and full osteotomies are needed to bring down the dorsal line.
Alar and nostril narrowing by excising skin at the sill or base is often needed. One should not hesitate to do so when indicated as adverse scarring is rarely seen.
Rhinoplasty in the Middle Eastern patient is challenging but successful results and a happy patient can usually be achieved. The use of well known structural support principles through an open approach are important intraoperative maneuvers. Preoperative planning with an understanding of the patients aesthetic objectives is just as important in any form of ethnic rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana