Explore This IssueAugust 2013
While Caucasian females still make up the majority of patients seeking cosmetic surgery procedures, the proportion of racial and ethnic minorities—including patients of both genders—has been on the rise in recent years.
A 2011 study found that the number of black patients undergoing cosmetic surgery increased by 7.5 percent, Hispanics by 4.7 percent, Asians by 14.5 percent and Native Americans by 105.5 percent over the decade from 1998 through 2007 (Am Surg. 2011;77:1081-1085).
These increases have been attributed to the growing numbers of minorities and their increasing spending power, trends that are expected to continue in coming decades. Non-Hispanic whites are predicted to lose their majority status in the United States in the 2040s, according to an Associated Press analysis of 2010 U.S. census data. Immigration to the U.S. from Latin America and Asia in recent decades rivals that of the Irish, German and Italian waves of the 19th century.
What do these changes mean for otolaryngologists who perform facial plastic surgery? Whether they specialize in elective or reconstructive procedures, surgeons must learn to be culturally sensitive in talking to their patients. In addition, they may benefit from having a larger number of facial plastic procedures at the ready to accommodate a wider variety of facial structures.
With increasing socioeconomic status, many racial and ethnic minorities have the disposable income to spend on cosmetic procedures, said Anthony Brissett, MD, director of the Baylor Facial Plastic Surgery Center in Houston. There is more global appeal in plastic surgery and less taboo attached these days as well, he added. Factor in the higher numbers of people seeking facial plastic surgery and higher proportions of minority patients, and it’s easy to see why ethnic facial plastics is an ongoing trend in U.S. practices.
“Five or 10 years ago, there was maybe one session on this topic at a meeting,” said Dr. Brissett. “Now there are entire afternoons, entire days devoted to this.”
In addition, Dr. Brissett said facial plastic surgeons see a shift in expectations. “Twenty to 30 years ago, it was normal for beauty to be based on a Western ideal: small thin nose, chiseled features, small lips,” he said. These days, he said, fewer racially and ethnically diverse patients seek such cultural transformation.
Dr. Brissett reported on racial and ethnic trends in a paper published in Facial Plastic Surgery (2010;26:69-74). This survey of cosmetic procedures performed in 2008 found that rhinoplasty is one of the top three surgical procedures performed in African Americans, Asian Americans and Hispanics. Eyelid surgery, Botox and injectable fillers were also high on the list of procedures sought by this patient population.
The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) reports that 10 percent of its members have seen an increase among Hispanic, Asian American and African American patients in their practices from 2011 to 2012. Further, the AAFPRS reports that African Americans and Hispanics were most predisposed to undergo rhinoplasty, Asian Americans were most likely to undergo blepharoplasty or rhinoplasty, and Caucasians were most likely to have facelifts or rhinoplasty (See “Most Common Facial Cosmetic Surgical Procedure, by Racial Group, next page).
Kofi Boahene, MD, a facial plastic surgeon in the department of otolaryngology-head and neck surgery at the Johns Hopkins University School of Medicine in Baltimore, has seen the trends in his own practice, which includes elective and reconstructive surgery in equal measure. “I see a lot of people of African descent from Europe, the U.S. and the Caribbean islands,” he says, noting that the numbers of minorities he’s treated has gone up every year.
Talking to Patients
While otolaryngologists are trained in facial plastic surgery, they receive no instruction in ethnically sensitive esthetic standards, said Dr. Boahene. “It means making the result more ethnically congruent—refining features without losing ethnic identity,” he said. And elective plastic surgery isn’t the only area in which ethnic sensitivity is important. Patients undergoing removal of head and neck cancers are equally concerned about how they’re going to look after their surgeries.
Crucial to a successful result is taking the time to talk to patients, and really understanding what they want. Dr. Boahene described a common observation in patients of African descent seeking nose-shaping surgery: A woman comes in and says her nose is too flat. The surgeon in-terprets that as the need for a high bridge and nasal projection and puts in an implant to raise the bridge, and raises the tip. But, then, the nose looks Caucasian. In actuality, what the patient may mean by a “flat” nose is that her nose lacks definition, that her nose seemed to disappear when she was photographed. Dr. Boahene said that creating a subtle contrast of highlights and shadows, areas that strategically reflect and absorb light, can address the problem without the high and sharp Caucasian appearance.
Or perhaps the patient’s complaint is that her nostrils flare when she smiles, making her nose look even wider. “Facial plastic surgeons should learn how to correct that feature,” he said.
“I like patients to tell me specifically what they like and or dislike about their nose. At first thought, most patients say they like nothing about their nose, but with proving they actually see things differently. This is key,” Dr. Boahene said. For instance, a patient may say he likes the hump on his nose because it’s a family feature. He may want it preserved or only slighty modified. “Let them talk,” he said. “Then I can tell them what I achieve, or what’s not reasonable.”
“I do think there’s a general awareness that it’s not one size fits all,” said Jennifer Parker Porter, MD, FACS, director of Chevy Chase Facial Plastic Surgery in Maryland, who added that minority patients seek her out because she is African American. Like many facial plastic surgeons, Dr. Porter uses imaging technology and photos of previous patients to discuss with her patients what can be accomplished. “There are differing ideals of the African American nose, but you want to have an ideal more fitting for you.”
An otolaryngologist, Dr. Porter started out in reconstructive surgery but now practices mostly cosmetic procedures. “It’s a little bit of tweaking,” she said of her methods. “Typically, I’m doing slightly different things in ethnic patients,” she said. “You have to take into account the thickness of the skin and the differing bone structure. With experience, you develop techniques that work for you and give the result you want.”
Jeffrey Epstein, MD, FACS, founder and director of the Foundation for Hair Restoration and Plastic Surgery, with offices in Miami and New York City, has been in practice for 20 years and has witnessed the increase in Hispanic, African American and Asian patients. He said there are some features that no one likes—a wide bridge, a crooked nose, droopy eyelids—and that there are ways to reduce these features while maintaining ethnic appearance.
“As a doctor, I can show patients what’s possible,” Dr. Epstein said. “Then the patient can tell me: I like this. Not that.” He also warned, “Don’t make assumptions based on standards of beauty.” As an example, he said, if a young Asian woman with an underprojected chin comes in for a consult, don’t automatically suggest a chin implant.
Many ethnic patients seeking rhinoplasty need augmentation to increase the height of their nasal dorsum or to increase their nasal tip projection, said Dean Toriumi, MD, professor in the department of otolaryngology-head and neck surgery at the University of Illinois at Chicago, and ENTtoday editorial bord member. Unfortunately many patients are undergoing augmentation using different filler materials, he said. These materials do not provide the same degree of definition provided by cartilage grafts and most resorb over time. More importantly if the patient decides to go forward with an augmentation rhinoplasty the procedure may be greatly complicated by the presence of the filler, which can leave scar tissue and add a major variable to healing. “This type of ‘non surgical’ rhinoplasty is very popular amongst Asian patients,” he added.
Dr. Brissett said cultural and family values may add layers of complexity—what makes an individual feel like himself or herself. Using himself as an example, he said, “My race is Black, but my culture is Canadian.” Biracial patients may identify more strongly with one culture than another.
The bottom line is to be aware of the trends, learn the techniques, listen to your patients and don’t make assumptions based on Western standards of beauty, or even within ethnic standards.