Discussion: Middle Eastern rhinoplasty in the United States: Parts I and II

D Daniel is to be congratulated for providing us with two very important studies on Middle Eastern rhinoplasty. This ethnic group represents a large proportion of rhinoplasty patients worldwide, so much so that popular media have recently dubbed Iran as the “nose job capital of the world.” Middle Eastern rhinoplasty patients demonstrate a complex array of nasal traits, which demands a thorough preoperative evaluation, lengthy patient discussion(s), and precise surgical execution. Both of Dr. Daniel’s case studies have adhered to these requirements. In part I, Dr. Daniel examines 50 primary rhinoplasty patients (mostly of Persian descent) over a period of 18 months. Part II focuses on the more complicated secondary Middle Eastern rhinoplasty patients (75 percent of whom are of Persian descent). Part I effectively delineates the classic nasal characteristics of Middle Eastern rhinoplasty patients: complex soft-tissue interactions, large dorsal hump, plunging and bulbous nasal tip, excess nasal length, wide midvault, and nostril-tip disproportion. Middle Eastern rhinoplasty patients can be both very specific in their goals and dislikes, and hypercritical of their surgeon’s work. This observation, along with the common “bartering practices,” were subtly noted by Dr. Daniel and best exemplified by case 3, in which three preoperative visits were required to discuss the limitations of the patient’s thick nasal skin. Many Middle Eastern rhinoplasty patients are young and female, with the patient’s mother being a fixture throughout the consultation process. It is imperative that racial incongruity and an overoperated appearance is not created. This critical point is stressed by Dr. Daniel and in other Middle Eastern rhinoplasty writings.1–3 The bartering mentality of Middle Eastern rhinoplasty patients (and their parents) signifies the demand for nothing less than exceptional results, because “outcomes should be worth all the expense.” Fortunately, many older Middle Eastern rhinoplasty patients who have had subpar or “overly done” noses have helped educate younger patients on the complex nature of Middle Eastern rhinoplasty. Expectations are high but realistic. Importantly, limitations in skin envelope contractility can reduce the surgeon’s control over the future surface visibility of underlying cartilage shape. Cartilage edges and osseocartilaginous relationships may reveal themselves where undesirable, and become hidden where visible framework shape would have been aesthetically desirable. To master this and to optimize control over these variables is perhaps the holy grail of Middle Eastern rhinoplasty and rhinoplasty as a whole. Dr. Daniel’s first article uses a numerical skin thickness scale, which may prove useful for documentation purposes. However, some contradictions are present throughout the article with regard to skin thickness. For example, references are made to the “often heavy skin sleeve” though the “majority” of patients are listed as “thin-skinned” (N, !1, or –1). This is in stark contrast to Asian or African American rhinoplasty.3 Optimal primary nasal tip shaping and improved control over framework-skin interactions requires multiple nondestructive (cartilage-preserving) techniques in addition to skin envelope manipulation and selective onlay grafting. Algorithms can serve as a basic guide on which to build.4,5 Typically, a combination of component dorsal reduction, soft-tissue thinning, tip-suturing techniques, “softened” cartilage grafts, structural grafts, and depressor septi nasi muscle treatment is indicated. Visible yet “subtle” grafts are frequently necessary to exploit pleasing nasal tip highlights and shadows.