Ethnicity in Facial Plastic Surgery

Russell W.H. Kridel, M.D., F.A.C.S., Julian Rowe-Jones, F.R.C.S. (ORL)

According to Wikipedia online (http://en.wikipedia.org/wiki/Ethnic_group), an “ethnic group is a group of humans whose members identify with each other, through a common heritage that is real or assumed. This shared heritage may be based upon putative common ancestry, history, kinship, religion, language, shared territory, nationality or physical appearance. Members of an ethnic group are conscious of belonging to an ethnic group; moreover ethnic identity is further marked by the recognition from others of a group's distinctiveness.” And so the question presents itself quite clearly in the physician-patient relationship: Are patients from an ethnic group, in any of its definitions of similarity, seeking to preserve, modify, or change that similarity, and to what extent and for what purpose? These indeed are considerations that must be discussed before embarking on any quest to change facial features.

Years ago, it was not difficult to separate out ethnic groups and to categorize them by appearance, beliefs, habits, and geography. For those physicians studying and writing about rhinoplasty in Europe and the United States in the late 1800s and early 1900s, the ethnic patient was the non-Anglo. Rhinoplasty as an operation was then just being performed on patients who wanted to fit into the model of the Anglo–Northern European; there was definite prejudice against many ethnic groups then and for many decades later, and those with stand-out physical characteristics that labeled themselves as non-Anglo, the choice was to change those facial characteristics that ostracized them from society both socially and in the business world. At those times, there were distinct physical characteristics that differentiated these populations. A rhinoplasty on a Northern European was simply easier than on many other ethnic populations: the skin was thinner, the rotation usually adequate, the nose generally less wide, the projection strong. And, these noses fit into the proportions of beauty established by the great painters of the Renaissance. But the original rhinoplasty work was done mainly on the Northern Europeans, taking down a hump or something similarly easy, and the original techniques were not described for the diverse anatomy of other ethnic populations. And so, the whole concept of ethnic (or really non–Northern European) rhinoplasty came into being as ethnic groups came into contact with the European/American rhinoplasty schools and surgeons. Truly the word ethnic is misused today in rhinoplasty, as it is all a matter of perspective. If I am Chinese, then classical Northern European noses are ethnic.

Today, the world is indeed flat, what with unrecognizable borders, ubiquitous migration, inter-racial marriages, and economic mobility allowing for a blurring of ethnic identity. Pure cultures may only exist in remote geographic areas such as the jungles of Africa, the Amazon, or the Outback. The face of America, the world's melting pot, is changing rapidly, and with that change we are embracing new proportions, understandings, and appreciation of beauty. Gone are the pure Caucasian standards of aesthetic beauty, modified and replaced now by the mélange of races and ethnic groups with the recognition that various standards of beauty exit in the minds of our patients rather than in the pages in our textbooks. We see mixed-race faces daily as our newscasters and our runway and magazine models. And so, although we cling to describing surgical techniques that we say are for the “ethnic” face or nose, we truly should just be concentrating on techniques that more describe the clinical situation than the background of the patient. For example, a patient with thick skin could be from several ethnic groups. In the articles of this issue, however, we will go against that advice and discuss dominant characteristics of classical ethnic groups with the understanding that the surgeon must individualize each patient as to anatomy and patient desires, rather than to heritage, last name, or place of birth.

To achieve the best possible result for his or her patients in aesthetic facial surgery, a surgeon must first understand his or her patients' wishes and their concepts of ideal beauty. Secondarily, the surgeon must understand the limitations imposed by his or her patients' tissues and the surgical pitfalls their anatomies present. Understanding the latter difficulties serves to bring realism to the former's idealism. Expectations can be managed and the patient can be provided with informed choices based on what is possible.

Cultural influences will have a strong bearing on concepts of beauty, and genetic composition will be a major determinant on facial anatomy. Awareness of a patient's race and ethnicity might provide greater knowledge and understanding of the patient's cultural influences and anatomy and so help optimize outcome for the patient. Anatomic knowledge that helps predict how soft tissues will behave and helps predict the morphology of subcutaneous structural elements would be of great value. However, surmising that this knowledge can be assumed and concluded from recognition of current ethnic types is probably increasingly simplistic and naive.

Traditional ethnic population classifications based on geography are increasingly inaccurate particularly as modern travel facilitates migration. These classifications must not be used to obfuscate genotype and an implied, associated phenotype. In the United Kingdom and Europe, the description Asian generally refers to individuals from the Indian subcontinent, whereas this description in North America tends to refer to the Far East. In India alone there are more than 6000 ethnic groups, so drawing conclusions about common anatomy likely among U.K. Asian patients requesting rhinoplasty, for example, is erroneous. Furthermore, making assumptions about concepts of beauty in an ethnic group is probably inappropriate. Modern media and digital communication combined with the ease of intercontinental travel means cultural influences are global. However, the surgeon must still be aware that such influences may not affect all generations of a family equally. This might result in conflict between the patient requesting aesthetic change and his or her parents. The parents may believe that what their son or daughter wants is at odds with their cultural beliefs. Guilt may then influence satisfaction with outcome and lead to conflict that could involve the surgeon.

Perhaps the importance of discussing ethnicity in aesthetic facial surgery is to highlight the importance of not making assumptions. To optimize outcomes for patients, the surgeon must accurately analyze the face of every patient as an individual and must be aware of and identify all their surface anatomic characteristics. Furthermore, the surgeon must understand all the possible underlying anatomic arrangements that are commensurate with the surface anatomy. The surgeon must fully understand what the individual patient's wishes are so that expectations can be managed and a result as close to what the patient wishes for achieved.