Cosmetic surgery for the Asian nose stands in marked contradistinction to that for the Western nose in that its objectives can be the opposite in many cases (i.e., augmentation rather than reductive rhinoplasty). However, an Occidental ideal for rhinoplasty has often been used for the Asian patient, leaving an individual with too high a nasal dorsum and too narrow a tip for his or her ethnicity. This monograph will introduce modified standards for the ethnic nose so that a surgeon who is unfamiliar with the Asian patient can create an aesthetically pleasing result that is ethnically sensitive but, even more important, that appears natural. A dimension that should not be ignored during the preoperative evaluation is the unusual cultural motivations that may drive an Asian patient’s decision to undergo aesthetic rhinoplasty among other facial enhancement procedures. For example, a higher dorsum may signify wealth and fortune for an individual and a distinctly visible nostril show from a frontal view has been thought to indicate the potential for monetary loss. Although a Western surgeon may regard these ideas as unfounded, failure to explore this perception explicitly before surgery may lead to dissatisfaction postoperatively. Finally, a strategy will be developed for both primary and revision rhinoplasty for the Asian nose, taking into consideration the widespread popularity of solid silicone implants in Asia and the need to understand the role and results of this alloplast even if the surgeon does not desire to use this material (as I myself no longer do).
Cultural Issues
The first priority for surgeons should be to understand the patient before trying to understand the operation. What has emerged as a frequent comment from my colleagues is the failure to comprehend the enigmatic nature of the Asian patient and that miscommunication has led to surgical failure even when the surgical result may have been deemed a technical success. This lack of clear communication may only be partly blamed on the language barrier of some first-generation immigrants. There are two glaring failures that may in fact underscore the miscommunication: a lack of cultural sensitivity and a lack of understanding ethnic identity. This section will cover the former aspect of the purported problem.
Some of the folkloric cultural beliefs that inform Asians—who either live abroad, who have recently immigrated to the West, and even for those who are several generations later born and reared in the West—should be explored herein. As alluded to in the introduction, some Asian patients may desire undergoing aesthetic rhinoplasty solely for nonaesthetic reasons. For instance, the larger nose has been regarded as a sign of wealth and fortune for the bearer of this feature, or by turns offers the individual who acquires this attribute even via surgery to attain that level of monetary gain. I clearly recall a Chinese chef who ascribed his job promotion to his higher nose bridge and was more elated with his enhanced fortune in life brought on, in his view, by his higher nasal dorsum, than with the aesthetic outcome of his rhinoplasty surgery. However, with regard to the height of the nasal dorsum, the surgeon should always respect the parameters that would preserve a natural result. This topic will be discussed in the following section. The second most common request or desire that may have cultural underpinnings is to have less visible nostril show from a frontal view. Accordingly, anything that would lead to greater nostril show (no matter how narrow the nostrils are to begin with) could lead to patient dissatisfaction. That is why a dome-binding suture that leads to nasal tip refinement may not be a wise surgical option in many Asian patients. Besides the unaesthetic feature of widely visible nostrils, the motivating factor for the Asian patient may be the folkloric belief that visible nostrils may engender monetary loss. I recall a Vietnamese patient of mine who was born and raised in the United States but who wanted to have a higher bridge and less visible nostrils because a fortuneteller had informed him of the importance of doing so to change his fortune in life. He also desired nasal enhancement for aesthetic reasons and with preoperative imaging appeared to have realistic goals. However, the surgeon who is contemplating proceeding with surgery in the patient who is profoundly motivated by cultural beliefs risks the uncontrollable outcome that a patient has not attained the desired station in life perhaps due to a surgeon’s failure to accomplish sufficient structural change to the nose. These cultural elements should almost always be explored to determine the candidacy for undertaking rhinoplasty based on mutually aligned and attainable goals.
Other examples of folkloric beliefs related to the face may be illustrative and impart further insight for the Western surgeon who desires to work on the Asian patient. Freckles may be considered an endearing feature in the West, but any skin blemishes for the Asian patient may be remarked as unattractive and further thought to affect adversely one’s good fortune. Like a large nose, large ears are also believed to designate the bearer as an individual who holds great wealth and wisdom. Consequently, reductive otoplasty is less commonly undertaken in the Far East. Dimples are thought to impart fertility and increase one’s marriage prospect. Exploring these complex and multilayered motivations may help establish and align realistic objectives with the patient.
Preserving Ethnicity in the Asian Patient
Many patients select me as a surgeon simply because of my own ethnicity. They believe that as a fellow Asian (I am Chinese), I will be more sensitive to their own cultural motivations and ethnic features. Perhaps this may be true. However, through this chapter, every surgeon attempting Asian rhinoplasty can attain this level of sensitivity. This section will focus primarily on what constitutes an ethnically sensitive rhinoplasty that preserves rather than effaces ethnicity. Following the trend of Asian eyelid enhancement over the past two decades, the creation of a supratarsal crease has moved away from the unnatural “Westernized” look that dominated in the 1980s where the crease was made very high and significant postseptal fat was removed. Today, the crease is much lower and the fullness is preserved. The same trend can be spotted in most ethnic surgeries with the current goal to be ethnic preservation rather than effacement. In the same way the Middle Eastern nose should not be overly reduced, the Asian nose should not be overly elevated in height.
What exactly are the standards for ethnically sensitive surgery then? For the nose, the dorsal height should not in most cases exceed the mid-pupil as the starting point for the radix. In many cases, the Occidental surgeon uses the Occidental standard of the supratarsal crease as the proposed radix height. This often can be too high for the Asian individual. Of course, facial features, like the depth of the nasofrontal angle, etc. will dictate aesthetic goals, which can be modified based on artistic judgment and communication with the prospective patient. The nasal tip can also be made too sharply defined and could appear unnatural for the Asian patient. Strategies of varying degrees of nasal tip definition from slightly rounder to slightly sharper will be elaborated upon later in this chapter. Finally, the alar base has often been considered a very important area to narrow in order to achieve the optimal aesthetic results. In reality, I rarely perform an alar base reduction, as I find it unnecessary unless the alar base is extremely broad.
Using photographs of Asian models and reviewing a surgeon’s “before and after” results can be helpful to any prospective Asian patient seeking to align aesthetic goals with a surgeon. There are two caveats that should be expressed: at times a patient can be more enamored with the overall composite of a model’s face and not necessarily just the nose itself and the same pitfall may arise when reviewing a surgeon’s results if the patient likes the face more than the nose. Assuming that an individual is wholly embracive of maintaining ethnicity can also be erroneous. Today’s globalized marketplace has placed an emphasis on models of mixed racial heritage. Also, with increased interracial marriage rates, offspring can strike a more ethnically blended aesthetic. I have also observed anecdotally that Asians who are partnered with Caucasians may seek to blunt their ethnic features to appeal more to their significant other. However, many Caucasians are drawn to Asians who exhibit more ethnic features and may not want those attributes significantly softened. At times, an open conversation including the prospective patient’s significant other may be a wise decision when electing aesthetic rhinoplasty or any facial enhancement procedure in the Asian patient.
When I perform Asian rhinoplasty (or almost any aesthetic endeavor for that matter), I rarely make great accommodations to a patient’s wishes if those desires do not align well with my own aesthetic judgment. It is not out of fear of betraying my own sense of ethnicity but more out of reticence to make a result that would compromise my own aesthetic philosophy.
Use of Silicone for Augmentation Rhinoplasty
Augmentation rhinoplasty with a single solid silicone implant has remained the most popular choice throughout Asia. When I started my career in Asian rhinoplasty, I was heavily influenced by this technique that appeared to be so pervasively the choice in the Far East where I had spent 5 months of apprenticeship. However, after a couple of years of using solid silicone implants, even very soft and tapered versions, I found multiple problems with them which have encouraged me to abandon this technique entirely. Nevertheless, any surgeon contemplating undertaking Asian rhinoplasty must understand the nature of a silicone implant since he or she will encounter a patient for revision rhinoplasty who already has a silicone implant that must be addressed.
Many of my senior colleagues in Asia have had remarkable success with solid silicone so I am not here to cast a shadow on their accomplishments. I only want to express the limitations that I have personally encountered which have compelled me to abandon use of the material. I will take ownership for any technical errors that I may have committed that may have contributed to my failure. Here are the problems that I witnessed with solid silicone. Because the implant tends to undergo encapsulation under very thin nasal skin, the edges can become visible over time and make the implant more visible-imparting an almost “shrink-wrapped” appearance. The thickness of the implant even when shaved paper thin with the added encapsulation that occurs over time made most of my efforts appear too high for my aesthetic taste. I am much more conservative with dorsal augmentation, as discussed previously. The major problem I encountered was distal migration of the implant downward over the nasal tip after a year or two (or sometimes sooner) that could occur spontaneously for no apparent reason (i.e., no history of inciting trauma could be elicited in many cases). The weight of silicone as compared with expanded polytetrafluoroethylene (ePTFE), which will be discussed, can predispose to eventual descent of the implant. I was taught to scrape the periosteum of the nasal bone vigorously immediately before implant insertion to minimize this consequence. Despite diligent attention to this surgical maneuver, I still found many instances when the implant shifted downward over the nasal tip.
Because of my prior use of silicone implants, I have become more experienced with handling the complications that can arise, which the reader should be familiar with. Often, the first instinct with an overly augmented silicone implant (which I find most of them are) is to remove it and simultaneously replace it with a smaller dorsal implant. If the bridge is only slightly too high or of appropriate nasal height, a simultaneous revision rhinoplasty may be warranted ( Figure 29-1 ). However, what I have found is that removal of the implant can often be all that is needed to restore a patient to a more pleasing nasal configuration without need for a revision rhinoplasty ( Figure 29-2 ). Many individuals worry that implant removal alone will lead to a return to their former nose shape. This is rarely the case. The scar tissue and remaining encapsulation lead to a result that lies somewhere halfway between the original nose and the overaugmented nose with a silicone implant.
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