No matter how Malaysian you are, there is no hiding your ethnicity. One look at your eyes and nose will tell. Chan Li Jin sniffs out the differences between the different rhinoplasty procedures for the three main races in Malaysia.

If the face were a target board, the nose would be the bull’s eye. Situated smack in the middle of the face, the nose determines the overall appearance of your face. Each racial group has features that are specific to its ethnicity and background, which are easily recognisable, especially the eyes and nose.

Despite that, almost everyone will agree on one thing – a beautiful nose is defined as one that is sharp, well-shaped and well-proportioned to the rest of the face. But here’s another often overlooked aspect – the nose also plays an important function for survival.

"Cosmetic rhinoplasty addresses two main issues – the functional and cosmetic aspects of the nose which could be due to trauma or non-trauma. Due to trauma, the patient could have sustained a saddled, crooked or twisted nose. Non-trauma causes can be due to congenital causes or due to chronic rhinitis/sinusitis associated with an obvious deviated septum that is not responding to optimal medical therapy," says Professor Dato’ Dr. Balwant Singh Gendeh, the Head of the Nose & Sinus Unit, Hospital Universiti Kebangsaan Malaysia (HUKM).

Rhinoplasty is a common surgical procedure involving the nose. It is able to achieve good functional results for those with severe deviated septums (which can cause problems such as breathing difficulty) and establish aesthetic beauty for those with crooked noses.

The procedure can achieve the following: increase or decrease nose size (using autologous grafts and implants where indicated), narrow nostril span, remove humps, correct septal deviation, reshape nose tips or change the angle between the nose and upper lip.

While rhinoplasty can achieve aesthetically pleasing results, it is quite often, a necessary procedure for those who need to address their nasal function concerns.

Know Your Nose

Anatomically, the nose is divided into four main sections – the dividi septum or bridge, the tip, the alar or the flared sides, and the cartilage and nasal dorsum, which cover the sloping areas on both sides of your nose.

But that’s just what lies on the surface. Under the nasal pyramid lies a complex mish-mash of cartilage, fibrous attachments and nerves that make up the interior parts of the nose. A nose surgeon who conducts rhinoplasty would need to be fully familiar with the ins and outs of the nose before he can perform a procedure, as a wrong move could result in deformity and functional problems.

According to Professor Gendeh, Asia still has a lot of ground to cover where nose surgeries are concerned. He explains, "In the Western countries, only certified Ear, Nose & Throat (ENT) specialists are allowed to perform nose surgeries. In our part of the world where beauty procedures are less regulated, many cosmetic rhinoplasties can be performed in facioplastic clinics."

Even if no functional damage to the nose occurs, there is always the threat of ending up with a really hideous nose, which can be devastating for a person. In fact, many of Professor Gendeh’s patients consist of people who have had botched nose surgeries performed elsewhere.

Know Your Nose Surgery

So what can go wrong? Interestingly, one of Professor Gendeh’s main principles is never to operate on a 'psychotic' patient. "They are never satisfied no matter how good the outcome is. Everything seems wrong to the patient even though the new nose looks fine to others," says the ENT specialist who has been practicing cosmetic rhinoplasty since 1997.

A nasal procedure can take only 20 minutes in a facioplastic clinic performed under local anaesthesia where the surgeon snips a small hole at the caudal part of the nose and inserts an implant to create a higher or well-defined bridge. However, implants are associated with a higher rejection rate compared to using own body parts, leading to complications such as persistent infections and inflammation.

As such, Professor Gendeh prefers to use cartilage or a bone graft that is harvested from the patient’s own body, such as the nasal or dorsum cartilage, the ears and so on. "Natural grafts are very well-tolerated and never rejected," he says. But if implants are absolutely necessary, he chooses Gore-Tex® or medpor® instead of silicone implants, as they are medically known to have higher acceptance rates.

Professor Gendeh also points out the necessity of getting a full medical history of medications, allergies and medical conditions before proceeding. Other basic principles include adopting a policy of conservatism, knowing surgical limitations, providing full information of what to expect and not promising miracles.

"Most importantly, patients should remember that cosmetic rhinoplasty should improve their nasal looks within the configuration of their racial ethnicity. Anything else would look totally unnatural," he emphasizes.

Before The Surgery

Before the surgery, the surgeon performs a systemic analysis, which includes evaluating the lateral nasal profile, frontal, top and basal views. Photographs are usually taken for a clearer picture of how the nose looks from these angles, which are later shown to the patient in order to facilitate doctor-patient communication. They are also vital evidence in the event of a lawsuit!

"Through follow-through consultations, the surgeon will be able to better understand the patient’s needs and wants and will be better positioned to give sound advice prior to the surgery," says Professor Gendeh.

With the advances in information and innovative surgical technology, more people are opting for cosmetic nose surgery. Coupled with rising income levels, amongst youngsters especially, many are not hesitant about improving their appearance for better career or social prospects.

The cost depends on the extent of functional and cosmetic correction involved. A simple rhinoplasty can cost around RM6,000 and a difficult or revision rhinoplasty can cost up to RM10,000. It may seem like a lot of money for such a small part of the body, but it can open a brand new world for some people from the view of functional and cosmetic improvement.

Professor Gendeh relates a story about a young Sarawakian man who came to him with a bossy forehead and a flat nasal dorsum. The flaw in his appearance was so glaring that his parents disowned him, thinking he was cursed. He also had trouble making friends and keeping a job due to his low self-esteem.

"The rhinoplasty transformed him into a confident, cheerful person who no longer hates looking in the mirror," says Professor Gendeh. For some people, it’s a small price to pay for a whole new life.

Other factors that the surgeon will take into consideration before the surgery are:

Kind of surgery: Rhinoplasty can be performed under local or preferably general anaesthesia, taking over an hour. It can be performed either with the closed or open technique. "The closed technique is limited to minor dorsal defects but for obvious dorsal and tip defects, the open technique is advisable," says Professor Gendeh.

Gender: Having a nasal hump would lend masculinity to a nose, which would augur well for men but not for women. Women would prefer a slightly curved nasal dorsum to tip projection, which adds to feminine looks.
Expectations: Patients will be informed that there will be a minimum 60 percent improvement on functional aspects and 30 percent improvement on the cosmetic aspects of the procedure. Establishing the symmetry of the nasal tip depends on the surgeon’s skills. Factors affecting outcome of surgery depend on the structure of nasal bones, cartilage and on the facial harmony.

Age: The younger the better. Patients above 60 are usually not suitable candidates for cosmetic rhinoplasty as they are more likely to have medical conditions and the skin is more lax and tends to droop. On the other hand, patients below 18 are also not good candidates as they are still growing and rhinoplasty may interfere with the development of the nose.

Skin: Thicker skin takes longer to heal especially in regards to swelling on the tip of the nose.
Health conditions: The patient must be mentally and physically fit.

Facial features: The new nose should blend harmoniously with the rest of the face.

Medications: Patients who are planning to undergo rhinoplasty (or any surgery for that matter) will have to be completely off blood thinning drugs namely aspirin, garlic and ginger pills, health supplements containing ginseng and ginkgo biloba and so on.

No Nosey Parker
Due to genetic differences, each racial group is endowed with specific nose shapes. Professor Gendeh gives us insight into the different nose shapes of each race, and the recommended rhinoplasty procedures:

The CHINESE

General description: Augmentation rhinoplasty is quite common amongst the Chinese due to high spending power and an increased awareness of the cosmetic options to correct an unsightly nose. The Chinese, Koreans and Japanese have Oriental nasal features with low nasal dorsum and tip projection with a prominent alar flare.

Effects: The nose looks flat and poorly defined, contributing to an overall appearance of crudeness and clumsiness.

Corrective measures: Majority of the Chinese need a total augmentation of the nasal dorsum and nasal tip. Both need to be raised (augmentation rhinoplasty), while the alar flare is reduced to create a trimmer outlook.

Skin: Generally, Chinese skin is relatively thin compared to the Malays, making recovery a bit quicker.
Surgical considerations: The Chinese genetically have thin natural cartilage or bone available for grafts, which may not be adequate for augmentation and implants may be necessary.

The MALAYS

General description: The Malays, like the Chinese, have Oriental nasal features with low nasal dorsum and tip projection with prominent alar flare and a thicker skin fold.

Effects: A nasal tip that is round, flat and oversized gives the impression of a less firm and incompetent character.

Corrective measures: Nasal augmentation can be performed to raise the dorsum and project a more dignified and assertive look, whereas nasal tip remodeling can be done to sculpt the nostrils. These procedures can be done at one go or separately in more difficult cases.

Skin: Skin conditions are relatively thick compared to the other races, making recovery relatively slow, especially the nasal tip swelling.

Surgical considerations: Implants may be used if the nasal cartilage or bone availability is insufficient.

The INDIANS

General description: The Indians have Caucasian nasal features with high nasal dorsum and tip projection. Thus, Indian and Caucasian noses are very similar in their outlooks and surgical corrections.

Effects: Tendency for nasal humps and hooked nasal tips are common – which gives an impression of dominance.

Corrective measures: Reduction rhinoplasty is conducted to reduce the nasal hump and elevate the nasal tip.

Skin: Skin conditions are relatively thinner compared to the Malays, making recovery a bit faster.

Surgical considerations: The Indians are usually blessed with ample bone or cartilage available from the nose itself for nasal reconstruction.

After The Surgery

Post surgery care is equally, if not more, important for patients who have undergone rhinoplasty. These usually include:

• Oral antibiotic and steroid coverage for 10 days.
• Frequent nasal irrigation for 10 days.
• Allowing sufficient recovery time for the nasal tip swelling to settle.
  Nasal tip swelling recedes faster in thinner skinned people compared to thicker skinned people.
• Reduce swelling by minimising exertion and avoiding hot or cold drinks or food.
• Avoid long, hot showers.
• Avoid dusty and chilly places that might make you sneeze.
• Avoid foods that may cause allergic reactions such as seafood, dairy products, peanuts and seafood-based products.
• Sleep on your back at night to avoid crushing the nose by accident.
• Avoid looking down or shaking the head vigorously.