Middle Eastern rhinoplasty

What repeats

Five findings that hold across the literature.

The described anatomy is consistent across authors

One review lists a high radix, a wide overprojecting dorsum and an amorphous hanging nasal tip. A second lists an ill-defined droopy tip, a wide and high dorsum and a thick skin envelope. A third notes wide variation in skin tone, skin thickness and structural deformity within the same group. The features are described as reflecting the underlying bone, cartilage and soft tissue rather than as surface appearance. A retrospective chart review of 100 consecutive primary cases in patients of self-identified Middle Eastern heritage, each followed for at least a year, read the operative reports and standardised photographs to record the anatomy, the surgical goals and the techniques used.

Rests on: Azizzadeh and Mashkevich, Middle Eastern rhinoplasty · Rohrich and Ghavami, rhinoplasty for Middle Eastern noses · Deeb, surgical considerations · Rahimian and Sajjadian, 100 consecutive cases · and nasal anatomy.

Reduction has to be balanced by structure

The surgical planning paper states four critical techniques: reduce the specific component of the dorsal deformity, balance augmentation against reduction wherever possible, accept that the need for spreader grafts rises as reduction increases, and achieve tip shape through structural support rather than excision. A prospective series of 50 consecutive female primary patients emphasises the need for structure throughout the nose, using both spreader grafts and columellar struts.

Rests on: Daniel, anatomy, aesthetics and surgical planning · Daniel, Part I primary rhinoplasty · and open roof and spreader grafts.

The pollybeak is the deformity this literature watches for

Among 1160 revision patients, 720 had a pollybeak deformity, a share of 62%. The commonest contributing factors were an underprojected tip with poor support in 490 patients, excessive supratip scarring in 259, an overresected bony dorsum in 202 and a high anterior septal angle in 173. The described prevention is tip support and controlled dorsal reduction, with a steroid injection protocol used against recurrence.

Rests on: Hussein and Foda, pollybeak deformity · and the polly beak deformity.

Skin thickness was measured, and it varies down the nose

Radiological measurements were taken at the three vertical thirds of the nasal dorsum in 154 patients, 80 women and 74 men, scheduled for computed tomography of the paranasal sinuses. The reported male values were 6.13, 2.76 and 3.70 mm across those thirds, and the female values 5.34, 2.13 and 3.21 mm. Patients were then grouped as thick, medium and thin skinned and satisfaction was compared across the groups.

Rests on: Alharethy et al., skin thickness and satisfaction.

The revision problem is failure to correct, plus visible surgical marks

A prospective study of 40 consecutive female secondary patients found the principal reasons for secondary surgery were failure to correct the original deformity and the presence of visible surgical stigmata. Most of those patients were older than 25, half had undergone a single previous rhinoplasty, and the other half had between two and five.

Rests on: Daniel, Part II secondary rhinoplasty · and revision rhinoplasty.

By what is being planned

The reviews break the operation into the same decisions.

The dorsal profile

The dorsum is described as wide and high, and the instruction is to reduce the specific component that is deformed rather than to take the whole profile down. As reduction increases, the reviews say the need for spreader grafts increases with it.

Rests on: Daniel, surgical planning · Rohrich and Mohan, update · Apaydin, rhinoplasty in the Middle Eastern nose · and component dorsal hump reduction.

The tip and its support

Tip shape is to be achieved with structural support and not with excision. A prospective single institution study measured anterior nasal spine length and septal caudal extension with calipers and photographs, and tested how strongly each was associated with the Goode ratio for tip projection, the columellar-labial angle and the columellar-spinal angle.

Rests on: Daniel, surgical planning · Arden et al., nasal spine and caudal septum.

The angle at the base of the nose

A survey asked 1027 raters, 506 men and 521 women, to pick a preferred nasolabial angle from photographs altered to 85, 90, 95, 100, 105 and 110 degrees. Male raters chose 89.5 ± 3.5 degrees for male faces and 90.8 ± 5.6 degrees for female faces. Female raters chose 89.3 ± 3.8 and 90.5 ± 4.8 degrees. The difference between rater groups was not significant, at p 0.342.

Rests on: Alharethy, preferred nasolabial angle.

The dissection plane

A study of 38 primary patients, 23 women and 15 men, divided them into five groups by skin thickness and combined dissection planes within one operation, subcutaneous over the lower lateral cartilages then deeper above. The reason given is that each plane has different advantages in thick skin.

Rests on: Elshahat, triple plane dissection · and open versus closed rhinoplasty.

What the patient is asking for

One review reports that the ideal nasal shape varies widely between Middle Eastern countries and sometimes between regions of the same country. Another states that goals differ by age, with older patients requesting a more refined result and younger patients a smaller nose. Both treat the consultation as the place where the plan is set.

Rests on: Obeid, a case-based approach · Daniel, Part I.

What to ask about this operation

Questions the evidence supports asking.

How much are you taking off the bridge

Overresection of the bony dorsum was a contributing factor in 202 of the pollybeak cases in the 1160-patient revision series. Ask what is being reduced, and what is being added back to hold the middle of the nose open.

Rests on: Hussein and Foda · Daniel, surgical planning · and the inverted-V deformity.

What is holding my tip up afterwards

Structural tip support is the stated method in this literature, using spreader grafts and columellar struts. Ask which support is planned, and what happens to projection over the first year.

Rests on: Daniel, Part I · Arden et al. · Sajjadian, rhinoplasty in Middle Eastern patients.

How thick is my skin, and what does that change

Thickness was measured in three thirds down the dorsum in 154 patients and used to sort them into thick, medium and thin groups. Ask which group the surgeon puts you in, and what it changes about the plan and about how long swelling lasts.

Rests on: Alharethy et al. · Elshahat · and recovery.

What is your revision rate

In the 50-patient primary series, 40 patients were followed for 18 months and three had revisions, two minor and one moderate, with no functional complaints. Ask the surgeon for their own number and the follow-up period behind it.

Rests on: Daniel, Part I · and revision rhinoplasty.

How is satisfaction measured here

A retrospective study of 183 patients operated between 2010 and 2020 used the FACE-Q nose score before and after surgery, alongside sociodemographic data and respiratory symptoms. Ask which questionnaire is used and when it is filled in.

Rests on: Maassarani et al., FACE-Q survey.

The terms, defined

The words used about this operation.

• Radix: the root of the nose, where the bridge meets the forehead. [20206101]
• Overprojection: a nose or a tip that stands further out from the face than the plan calls for. [20206101]
• Pollybeak: fullness in the supratip that leaves the profile convex above the tip. [27494583]
• Supratip: the part of the dorsum just above the tip. [27494583]
• Spreader graft: a strip of cartilage set between septum and upper lateral cartilage to hold the middle vault open after reduction. [20446205]
• Columellar strut: a cartilage post between the medial crura that supports the tip. [20009849]
• Anterior nasal spine: the small bony projection at the base of the septum, measured against tip projection. [30480200]
• Goode ratio: a photographic measure of tip projection against nasal length. [30480200]
• Nasolabial angle: the angle between the columella and the upper lip. [28243784]
• Surgical stigmata: visible marks of previous surgery, named as a reason patients seek revision. [20009850]
• FACE-Q: a patient-completed questionnaire with a nose score, used before and after surgery. [37425578]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess and record before operating, and it applies whatever technique is chosen.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, runs an ethnic rhinoplasty category. Three of its chapters cover this operation, the hump it usually addresses and the screening that comes before it. They are written for surgeons and go further into technique than a patient page should.

• Middle East nose in Rhinoplasty
• The Dorsal Hump
• Psychiatric Screening of the Rhinoplasty Patient

The reference summary

StatPearls, on the National Library of Medicine's Bookshelf, carries two chapters in full text at no charge.

• Rhinoplasty, the anatomy, the approaches and the complication list.
• Rhinoplasty Tip-Shaping Surgery, the suture and graft techniques used on the tip.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.
• International Society of Aesthetic Plastic Surgery, which surveys its members every year and reports procedure counts by country.

The trials in progress

Hump reduction and septorhinoplasty outcomes are both under test in registered trials.

• Hybrid Osteoplasty Versus Osteotomy in Rhinoplasty, active and not recruiting, 200 participants.
• Outcome Analysis in Septorhinoplasty, recruiting, 750 participants.

What is not settled

• Most of this literature is single-surgeon series and narrative review. The largest prospective primary series is 50 consecutive patients, all female, from one practice. [20009849]
• The pollybeak figures come from one revision practice of 1160 patients, which selects for patients whose first operation did not work. They are not a rate for primary surgery. [27494583]
• Skin thickness was measured on scans taken for sinus disease, and the link to satisfaction is a cross-sectional comparison rather than a controlled one. [30520507]
• The preferred nasolabial angle comes from photographs altered in software and rated by 1027 laypeople, not from surgical outcomes. [28243784]
• Middle Eastern is a self-identified label covering many countries, and one review states that the ideal shape varies between them and within them. A systematic review makes the same point about clustering groups by geography. [39492208] [35725958]
• Whether a preservation approach to the dorsum changes the pollybeak rate in this anatomy is not measured. [30656100]