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Original Article |

Rhinoplasty for African American Patients A Retrospective Review of 75 Cases FREE

Oleh Slupchynskyj, MD; Marzena Gieniusz, BA
[+] Author Affiliations

Author Affiliations: Aesthetic Facial Surgery Center of New York and New Jersey, New York, New York.


Arch Facial Plast Surg. 2008;10(4):232-236. doi:10.1001/archfaci.10.4.232.
Text Size: A A A
Published online

Objective  To determine satisfaction, change in self-esteem, and maintenance of ethnic characteristics in African American patients after rhinoplasty.

Patients  African American male (n = 21) and female (n = 54) patients aged 14 through 58 years (mean, 33.8 years) who underwent rhinoplasty.

Methods  Open structure rhinoplasty, using the 3-tiered approach, was performed on all 75 patients. An anonymous questionnaire addressed postoperative patient satisfaction, maintenance of ethnic characteristics, self-esteem, and nasofacial harmony. The rate of complications was determined by medical record review.

Results  On a scale of 1 to 5 (1, no change; 5, complete change), patients reported a significant degree of preservation of ethnic characteristics (mean, 2.3), high self-esteem (mean, 4.3), and very high satisfaction (mean, 4.6) and facial harmony (mean, 4.3) postoperatively (< .001 for all). The overall complication rate was 2.7%.

Conclusion  In African American patients, 3-tiered open structure rhinoplasty yields high patient satisfaction with a minimal rate of major complications.

Figures in this Article

The nose is the central feature of the face. Therefore, it can easily enhance or detract from overall beauty. In 2005, an American Academy of Facial Plastic and Reconstructive Surgery survey found that, when considering 4 popular cosmetic surgery procedures (rhinoplasty, blepharoplasty, facelift, and chin augmentation), African Americans are most likely getting rhinoplasty (65%).1 Rhinoplasty, which has been used to make an African American nose look more white, has evolved a great deal as societal understanding of ethnic beauty has increased and surgical techniques for ethnic features have improved.2,3

Various cultures and ethnic groups have different standards of beauty.4 In addition, people of African descent typically have noses unlike the typical noses of people of European descent. To achieve a greater degree of facial harmony, a common goal among patients undergoing rhinoplasty, the anatomical characteristics of an African American nose often require a different, more challenging treatment approach than the technique that is suitable for white patients. Anthropometric studies confirm the view that characteristic African American features are significantly different than white features.59 In their study, Ofodile and Bokhari6 conclude that the African American nose is, on average, wider and shorter than a typical European American nose and has an acute columella and nasolabial angle. In our experience, African Americans also tend to have thicker nasal skin with a thick fibro-fatty sublayer and a bulbous fatty nasal tip, weak lower lateral cartilage, and large nostrils in the vertical and horizontal dimensions.

In addition, skin pigment is an obvious difference between African American and white individuals.10 Any surgical procedure may put African American patients at a greater risk of developing keloids, which may be of concern to African American patients considering cosmetic procedures.11 However, we have seen no cases of keloid formation as a result of rhinoplasty, a conclusion echoed by Rohrich and Muzaffar12 as well as Patrocinio and Patrocinio.13 Therefore, we consider this concern to be unfounded.

Ofodile et al14 conclude that there is a considerable degree of variation among African American noses, which they divide into 3 groups: African, Afro-Caucasian, and Afro-Indian. Although this was not a focus in our study, their categorization draws attention to the importance of an individualized approach to rhinoplasty, such as the 3-tiered surgical technique used in this study.

In our study of 75 African American patients undergoing rhinoplasty, all sought (1) nasal dorsal augmentation to improve inadequate nasal dorsal height; (2) elevation of a depressed nasofrontal angle; (3) refinement of a poorly defined and bulbous nasal tip; and (4) reduction of nasal alar width in the horizontal and vertical dimensions. To address these common issues, we used the 3-tiered approach for all patients.

The medical records of 21 male and 54 female African American patients, aged 14 through 58 years (mean, 33.8 years), who underwent open structure rhinoplasty performed by one of us (O.S.) in a private practice setting were examined retrospectively. All patients underwent dorsal augmentation with the custom-carved Silastic SLUPImplant (patent pending) (Figure 1), tip refinement using cartilage grafting and defatting of the tip, and vertical and horizontal alar base narrowing.

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Figure 1.

SLUPImplant (patent pending) for dorsal augmentation of the African American nose.

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An anonymous questionnaire was given to all 75 patients who agreed to participate in the retrospective study. The questionnaire addressed self-esteem, preservation of ethnic characteristics, degree of facial harmony, level of media or television influence on the individual's decision to seek rhinoplasty, and overall patient satisfaction postoperatively. The questionnaire's scoring system was based on a Likert scale (1, not at all; 2, below average; 3, average; 4, above average; and 5, very much/to the highest degree).

Of 75 questionnaires, 64 (85%) were completed. Results were analyzed using SPSS statistical software (SPSS Inc, Chicago, Illinois). A 2-tailed, 1-sample t test was conducted to establish statistical significance. Complication and revision rates were also recorded to evaluate and further assess the success of the procedure and patient satisfaction with the technique and results.

A total of 75 African American patients underwent rhinoplasty, including dorsal augmentation, tip refinement, and alar base narrowing.

Of 62 patients who completed the postoperative questionnaire, 35 said that their nose was in harmony with the rest of their face to the highest degree after rhinoplasty, 16 rated nasofacial harmony as above average, and 5 said average (mean [SD], 4.3 [1.1]; P < .001) (Table and Figure 2). Overall, 56 patients (90%) reported average or above average nasofacial harmony postoperatively.

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Figure 2.

Degree to which patients believe their nose fits their face after rhinoplasty: 1 indicates poor nasofacial equilibrium; 5, the highest degree of nasofacial equilibrium.

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Of 61 patients, 47 said their natural ethnic features had been changed by surgery an average amount or less; 26 (43%) reported no change in ethnic features postoperatively (mean [SD], 2.3 [1.4]) (Figure 3). Average or above average rating of self-esteem postoperatively was noted by 60 of 63 patients (95%) (mean [SD], 4.3 [0.9]) (Figure 4). When asked how well the results of the surgery met their expectations, 61 of 62 (98%) answered average or above average (mean [SD], 4.6 [0.7]; P < .001) (Figure 5).

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Figure 3.

Degree of change in ethnic characteristics after rhinoplasty: 1 indicates no change; 5, a high degree of change.

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Figure 4.

Postoperative increase in self-esteem after rhinoplasty: 1 indicates no increase in self-esteem; 5, the highest increase in self-esteem.

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Figure 5.

Patients' overall satisfaction with rhinoplasty; 1 indicates not at all satisfied; 5, the highest degree of satisfaction.

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One patient developed an infection postoperatively, and the infected implant was later removed. Two patients requested that the height of the custom-carved implant be further decreased because of overaugmentation. After a procedure to revise the implant height, both patients were satisfied with the results. Poor wound healing in the left alar incisions occurred in 4 patients and was corrected by re-excising and closing the incision after excision to attain narrowing of the nostrils. One patient developed right nostril hypertrophic scarring, which was treated with 20 mg of triamcinolone once a month for 3 months. This patient will also undergo composite auricular skin-cartilage grafting.

Many studies, including that of Rohrich and Muzaffar,12 have found that rhinoplasty is a challenging procedure, and attaining satisfactory results is difficult.1518 It becomes even more challenging when performing rhinoplasty for an African American patient. A surgeon performing rhinoplasty for an African American patient should be able to distinguish the various standards of beauty for different ethnic groups. Only then can the surgeon enhance ethnic features rather than changing them to fit inappropriate standards.12 When reporting on costmetic surgery for non-Caucasian noses in 1970, Falces et al stated, “[The] aim of the surgery is to produce a Caucasoid nose.”2(p317) This statement is not in agreement with current views on the aim of surgery in African American patients we studied. We agree with Dr Fuselier,19 who states in her article that the goal of rhinoplasty for African American patients is to enhance natural beauty that brings out ethnic traits.

Many authors agree that African American patients seeking rhinoplasty desire a nose that fits their face and enhances nasofacial equilibrium, rather than changing their ethnic characteristics.10,12,18 This view is consistent with the results of our study, which suggest that African American patients are not looking to change their ethnic features; rather, they want a nose that is in harmony with their other facial features.

Successful rhinoplasty starts with a thorough consultation, during which the patient's expectations and the surgeon's abilities are clearly defined. In our opinion, computer imaging is an indispensable tool in assuring realistic expectations, and more important, providing a better understanding of possible results, which leads to high patient satisfaction postoperatively.

The 3-tiered approach to rhinoplasty used in this study strives to enhance nasofacial equilibrium by increasing dorsal height, lessening alar flare, and increasing tip refinement and projection while maintaining ethnic characteristics (Figure 6A and B and Figure 7E and F). Most of our patients reported that there was a small amount of change or no change in ethnic characteristics postoperatively. In addition, nearly all patients indicated average or above average satisfaction with the results of rhinoplasty. The high satisfaction rate stems in part from the high degree of postoperative facial harmony and the significant preservation of ethnic characteristics perceived by patients, which in turn leads to high self-esteem postoperatively. We found a significant positive correlation between postoperative facial harmony and satisfaction rate (Pearson product moment correlation coefficient: r = 0.62; P < .001 [directional and non-directional]). We also found a negative correlation between perceived change in ethnic characteristics and satisfaction rate, although the linear correlation is too small to be considered statistically significant (Pearson product moment correlation coefficient: r = −0.05; < .35 [directional]; P = .70 [non-directional]). Therefore, we consider the level of facial harmony perceived postoperatively to be a major contributor to patient satisfaction. Considering the increase in self-esteem resulting from the 3-tiered approach, we believe this technique successfully addresses the concerns of African American patients seeking dorsal height augmentation, tip refinement, and correction of excessive alar flaring.

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Figure 6.

Preoperative (A) and postoperative (B) profile and three-quarter (C and D) views of an African American patient. Photos display postsurgical increase in tip definition, augmentation of the nasofrontal angle, and increased dorsal height.

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Figure 7.

Preoperative and postoperative frontal (A and B), three-quarter (C and D), and profile (E and F) views of an African American patient. Photos display decreased alar flare (nostril width and height), dorsal augmentation, and increased tip definition (decreased bulbousness of the tip).

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The question of whether patients were initially intending to change their ethnic features yielded unexpected results. Although patients recorded a significant maintenance of their ethnic features postoperatively and a very high degree of satisfaction, the mean response about the desire for rhinoplasty to alter ethnic characteristics was 3.2, or “average.” This result could be due to poor wording of the question, or perhaps some African American patients do initially want to change the ethnic characteristics of their nose. However, the resulting high satisfaction postoperatively, along with the significant degree of preservation of ethnic characteristics, is not consistent with the idea that a desire to alter ethnic characteristics motivated patients to elect the procedure. Further research is needed to gain more insight into this inconsistency.

Of 75 African American patients who underwent rhinoplasty, 2 experienced major complications: 1 developed an infection, which necessitated implant removal, and 1 developed hypertrophic scarring occurring in the right alar horizontal incision, which necessitated composite grafting. The other 6 complications were minor and included 2 requests for reduction of augmented dorsal height, both of which were revised successfully, and 4 scar revisions occurring in the left alar horizontal incision, all of which were later revised successfully under local anesthesia. The overall complication rate was 2.7%.

The 3-tiered approach to rhinoplasty for African American patients, which includes dorsal augmentation, tip refinement, and vertical and horizontal alar base narrowing, results in maintenance of racial congruity and yields high patient satisfaction with a minimal rate of major complications.

Correspondence: Marzena Gieniusz, BA, Aesthetic Facial Surgery Center of New York and New Jersey, 44 E 65th St, Ste 1A, New York, NY 10065 (marzena@facechange.org).

Accepted for Publication: December 19, 2007.

Author Contributions: Dr Slupchynskyj and Ms Gieniusz had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Slupchynskyj and Gieniusz. Acquisition of data: Slupchynskyj and Gieniusz. Analysis and interpretation of data: Slupchynskyj and Gieniusz. Drafting of the manuscript: Gieniusz. Critical revision of the manuscript for important intellectual content: Slupchynskyj and Gieniusz. Statistical analysis: Gieniusz. Administrative, technical, and material support: Slupchynskyj and Gieniusz. Study supervision: Slupchynskyj.

Financial Disclosure: Dr Slupchynskyj is developing the SLUPImplant nasal implant with Implantech Associates, Ventura, California.

Previous Presentation: This study was presented at the annual meeting of the American Academy of Facial, Plastic, and Reconstructive Surgeons; September 20, 2007; Washington, DC.

 American Academy of Facial Plastic and Reconstructive Surgery 2005 Membership Survey: Trends in Facial Plastic Surgery, Feb 2006. http://www.aafprs.org/media/stats_polls/aafprsMedia2006.pdf. Accessed March 3, 2008
Falces  EWesser  OGorney  M Cosmetic surgery of the non-Caucasian nose. Plast Reconstr Surg 1970;45 (4) 317- 325
PubMed Link to Article
Snyder  GB Rhinoplasty in the Negro. Plast Reconstr Surg 1971;47 (6) 572- 575
PubMed Link to Article
Etcoff  NLSurvival of the Prettiest. New York, NY Doubleday1999;
Porter  JPOlson  KL Analysis of the African American female nose. Plast Reconstr Surg 2003;111 (2) 620- 628
PubMed Link to Article
Ofodile  FABokhari  F The African American nose: part II. Ann Plast Surg 1995;34 (2) 123- 129
PubMed Link to Article
Porter  JP The average African American male face. Arch Facial Plast Surg 2004;6 (2) 78- 81
PubMed Link to Article
Sushner  NI A photographic study of the soft-tissue profile of the Negro population. Am J Orthod 1977;72 (4) 373- 385
PubMed Link to Article
Romo  T  IIIAbraham  MT The ethnic nose. Facial Plast Surg 2003;19 (3) 269- 278
PubMed Link to Article
Grimes  PEStockton  T Pigmentary disorders in blacks. Dermatol Clin 1988;6 (2) 271- 280
PubMed
Grimes  PEHunt  SG Considerations for cosmetic surgery in the black population. Clin Plast Surg 1993;20 (1) 27- 34
PubMed
Rohrich  RJMuzaffar  AR Rhinoplasty in the African-American patient. Plast Reconstr Surg 2003;111 (3) 1322- 1341
PubMed Link to Article
Patrocinio  LGPatrocinio  JA Open rhinoplasty for African-American noses. Br J Oral Maxillofac Surg 2007;45 (7) 561- 566
PubMed Link to Article
Ofodile  FABokhari  FJEllis  C The black American nose. Ann Plast Surg 1993;31 (3) 209- 219
PubMed Link to Article
Davis  PKJones  SM The complications of Silastic implant: experience with 137 consecutive cases. Br J Plast Surg 1971;24 (4) 405- 411
PubMed Link to Article
Klabunde  EHFalces  E Incidence of complications in cosmetic rhinoplasties. Plast Reconstr Surg 1964;34192- 196
PubMed Link to Article
Oura  T Reconstructive surgery of the nose in non-Caucasians. Clin Plast Surg 1974;1 (1) 93- 120
PubMed
Romo  T  IIIShapiro  AL Aesthetic reconstruction of the platyrrhine nose. Arch Otolaryngol Head Neck Surg 1992;118 (8) 837- 841
PubMed Link to Article
Fuselier  M What the black woman should know about plastic surgery. http://www.audipartscatalog.com/content/healthcolumn/healthcolumnpdf/wbwskaps02.pdf. March 3, 2008

Figures

Place holder to copy figure label and caption
Figure 1.

SLUPImplant (patent pending) for dorsal augmentation of the African American nose.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Degree to which patients believe their nose fits their face after rhinoplasty: 1 indicates poor nasofacial equilibrium; 5, the highest degree of nasofacial equilibrium.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Degree of change in ethnic characteristics after rhinoplasty: 1 indicates no change; 5, a high degree of change.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Postoperative increase in self-esteem after rhinoplasty: 1 indicates no increase in self-esteem; 5, the highest increase in self-esteem.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Patients' overall satisfaction with rhinoplasty; 1 indicates not at all satisfied; 5, the highest degree of satisfaction.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Preoperative (A) and postoperative (B) profile and three-quarter (C and D) views of an African American patient. Photos display postsurgical increase in tip definition, augmentation of the nasofrontal angle, and increased dorsal height.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Preoperative and postoperative frontal (A and B), three-quarter (C and D), and profile (E and F) views of an African American patient. Photos display decreased alar flare (nostril width and height), dorsal augmentation, and increased tip definition (decreased bulbousness of the tip).

Graphic Jump Location

Tables

References

 American Academy of Facial Plastic and Reconstructive Surgery 2005 Membership Survey: Trends in Facial Plastic Surgery, Feb 2006. http://www.aafprs.org/media/stats_polls/aafprsMedia2006.pdf. Accessed March 3, 2008
Falces  EWesser  OGorney  M Cosmetic surgery of the non-Caucasian nose. Plast Reconstr Surg 1970;45 (4) 317- 325
PubMed Link to Article
Snyder  GB Rhinoplasty in the Negro. Plast Reconstr Surg 1971;47 (6) 572- 575
PubMed Link to Article
Etcoff  NLSurvival of the Prettiest. New York, NY Doubleday1999;
Porter  JPOlson  KL Analysis of the African American female nose. Plast Reconstr Surg 2003;111 (2) 620- 628
PubMed Link to Article
Ofodile  FABokhari  F The African American nose: part II. Ann Plast Surg 1995;34 (2) 123- 129
PubMed Link to Article
Porter  JP The average African American male face. Arch Facial Plast Surg 2004;6 (2) 78- 81
PubMed Link to Article
Sushner  NI A photographic study of the soft-tissue profile of the Negro population. Am J Orthod 1977;72 (4) 373- 385
PubMed Link to Article
Romo  T  IIIAbraham  MT The ethnic nose. Facial Plast Surg 2003;19 (3) 269- 278
PubMed Link to Article
Grimes  PEStockton  T Pigmentary disorders in blacks. Dermatol Clin 1988;6 (2) 271- 280
PubMed
Grimes  PEHunt  SG Considerations for cosmetic surgery in the black population. Clin Plast Surg 1993;20 (1) 27- 34
PubMed
Rohrich  RJMuzaffar  AR Rhinoplasty in the African-American patient. Plast Reconstr Surg 2003;111 (3) 1322- 1341
PubMed Link to Article
Patrocinio  LGPatrocinio  JA Open rhinoplasty for African-American noses. Br J Oral Maxillofac Surg 2007;45 (7) 561- 566
PubMed Link to Article
Ofodile  FABokhari  FJEllis  C The black American nose. Ann Plast Surg 1993;31 (3) 209- 219
PubMed Link to Article
Davis  PKJones  SM The complications of Silastic implant: experience with 137 consecutive cases. Br J Plast Surg 1971;24 (4) 405- 411
PubMed Link to Article
Klabunde  EHFalces  E Incidence of complications in cosmetic rhinoplasties. Plast Reconstr Surg 1964;34192- 196
PubMed Link to Article
Oura  T Reconstructive surgery of the nose in non-Caucasians. Clin Plast Surg 1974;1 (1) 93- 120
PubMed
Romo  T  IIIShapiro  AL Aesthetic reconstruction of the platyrrhine nose. Arch Otolaryngol Head Neck Surg 1992;118 (8) 837- 841
PubMed Link to Article
Fuselier  M What the black woman should know about plastic surgery. http://www.audipartscatalog.com/content/healthcolumn/healthcolumnpdf/wbwskaps02.pdf. March 3, 2008

Correspondence

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