In the medical literature, the morphology classified as the Middle Eastern or Arab nose is a distinctive anatomical presentation defined by a prominent nasal hump, a wide base structure, a low nasal tip that lacks support, and a thick-skin characteristic that directly affects the surgical process. In this nose type—seen across a broad geography from Türkiye to North Africa—a successful rhinoplasty requires not only volumetric reduction but also reconstruction of a strong cartilaginous framework capable of carrying thick and heavy skin. Aesthetic planning is based on a holistic structural surgical approach that preserves the person’s ethnic identity, softens harsh facial expressions, restores profile balance, and improves functional breathing.
İçindekiler
What are the features of the Middle Eastern and Arab nose?
When we talk about this nose type, we are actually referring to a complex structure in which contradictory characteristics coexist. Although patients often see only a “big” nose when they look in the mirror, we surgeons analyze the underlying anatomical contrasts. On the one hand there is excess along the nasal dorsum, and on the other hand there is a serious lack of support at the nasal tip. Understanding this structure is the first step toward the right treatment.
The most prominent characteristic features of this nose type are as follows:
- Prominent nasal hump
- Wide nasal base
- Low nasal tip
- Thick skin structure
- Weak cartilage support
- Flared nostrils
- Oily skin texture
- Indistinct nasal tip contours
When these features come together, surgical planning goes beyond a simple “reduction” procedure. In fact, what we do is both reduce the nose and strengthen the framework that will carry it, using the existing materials. In particular, the nasal tip drooping further when smiling and the narrow angle between the lip and the nose can make the facial expression look more tired or harsher than it actually is. Any intervention performed without correctly reading this anatomical picture will, unfortunately, produce artificial results that are incompatible with the face.
How does the thick-skin factor affect the surgery and the outcome?
In Middle Eastern rhinoplasty, the factor that challenges both the surgeon and the patient the most is undoubtedly the “thick skin” structure. To explain this with an analogy: a small marble placed under a thin silk cover is clearly visible from the outside, whereas the same marble placed under a thick quilt is almost not noticeable at all. This is the fundamental situation we encounter in thick-skinned patients.
No matter how delicate and fine we shape the cartilages during surgery, if the overlying skin is very thick, it tends to camouflage that fine craftsmanship underneath. Skin thickness does not arise only from the skin itself; the fat layer and fibromuscular tissue immediately beneath the skin also contribute to this thickness. This makes it more difficult for the nasal tip to look “defined” and refined.
The disadvantages created by thick skin during the surgical process are as follows:
- Prolonged swelling
- Concealment of fine details
- Risk of healing tissue
- Bulky nasal tip
- Slow skin adaptation
- Wound-healing issues
To overcome this difficulty, we apply a special procedure called “Defatting.” This is the thinning of excess subcutaneous fat and connective tissue at a safe level that will not compromise the skin’s blood supply. However, this procedure does not offer unlimited freedom. We can thin the skin only up to a certain limit; beyond that, it disrupts skin nutrition. Therefore, in thick-skinned noses, our strategy is not only to thin the skin, but also to build a strong framework that will tension the skin by pushing it from underneath.
Why is cartilage support essential in a humped nose structure?
This is usually the topic our patients ask about most frequently and have difficulty understanding. “Doctor, my nose is already big and humped—why are you placing extra cartilage inside it? Won’t it become even bigger?” This question seems perfectly logical, but the answer is hidden in biomechanical principles. In Middle Eastern noses, the skin is heavy. When we remove the hump and reduce the nose, we also weaken the natural support that carries the skin.
If you demolish the columns (the cartilage framework) under a heavy roof (thick skin) and do not replace them with stronger columns, the roof will collapse over time. In rhinoplasty, this collapse manifests as nasal tip drooping and widening of the nose over time. That is why, while reducing the nose, we paradoxically need to make its internal structure stronger than before.
The main materials we use for structural support are as follows:
- Septal cartilage
- Rib cartilage
- Ear cartilage
- Cadaver cartilage
The “Strut” grafts we place at the nasal tip function like a tent pole. The heavier the tent fabric (skin), the stronger you must keep the pole. In addition, to break the ball-like appearance of the nasal tip (bulbosity) and achieve a sharper, more angular look, we prepare special “caps” from cartilage (Shield grafts). These cartilage pieces push the thick skin outward from the inside and make the nasal contours more visible. In other words, we are not enlarging the nose; we are building an architecture that can carry the weight of the skin and preserve its shape for years.
What is the relationship between the chin and the nose for profile balance?
The perception of an aesthetic face depends not on the individual beauty of each part, but on the harmony between these parts. When we look at the Middle Eastern profile, we often encounter not only nasal issues but also mismatches in the chin structure. The condition we call “micrognathia” or “retrognathia,” where the lower jaw is retruded and small, is quite common in this patient group.
A retruded lower jaw causes the nose to appear perceptually much larger and more projecting than it actually is. This is an optical illusion, but it deeply affects aesthetic perception. In such a case, reducing the nose alone may not be enough to correct the profile. In fact, sometimes, when the chin is retruded, making the nose too small can lead to a “bird face” appearance, which is an undesirable outcome.
The points we consider in profile analysis are as follows:
- Forehead convexity
- Nasal root depth
- Lip projection
- Chin tip position
- Neck angle
- Cheekbones
Because of this holistic approach, we perform preoperative simulations for our patients. If the chin is retruded, a fat injection, filler, or chin implant application (genioplasty) performed in the same session as rhinoplasty can dramatically improve the quality of the outcome. The nose, forehead, and chin are pieces of a puzzle that complete each other in the profile. When one piece is missing or positioned incorrectly, it becomes difficult to achieve that perfect balance in the overall picture, no matter how much you correct the other piece.
What is the aesthetic approach that preserves ethnic identity?
In the past, a “one-size-fits-all nose” understanding dominated aesthetic surgery. Everyone’s nose was made very small, extremely curved, and upturned. However, today this understanding has been replaced by the philosophy of “ethnic preservation” and “naturalness.” In individuals of Middle Eastern origin, facial features are often strong: the eyes are prominent, the lips are full, and the facial lines are characteristic. Creating an overly small and curved nose on such a face—one that looks as if it belongs to a Northern European person—not only looks artificial, but also disrupts the person’s characteristic facial expression.
Our goal is not to erase the person’s ethnic origin or make them resemble another ethnicity. The objective is to reveal the most beautiful, most refined, and most balanced version of the ethnic features the person already has. While carrying “Arab nose” characteristics, it is essential to modernize these features, soften the face, and bring a more open and refreshed expression.
The goals of the ethnic-preservation principle are as follows:
- Natural appearance
- Facial harmony
- Preservation of character
- Functional improvement
- Cultural self-acceptance
Months after surgery, when the patient enters a social environment, people should not ask, “Who did your nose?” Instead, they should say, “Something has brightened your face—you look more refreshed.” Successful surgery is not the kind that loudly announces itself, but the kind that whispers and highlights beauty. The hump should be reduced, the nasal tip should be brought to the ideal angle, but all of this must look like a “sibling” with the rest of the face.
How should the healing process and swelling management be?
In thick-skinned Middle Eastern noses, another issue that is perhaps as important as the surgical technique is postoperative patience and follow-up. While a thin-skinned patient’s nose finds 80–90% of its shape in 6 months, this process is much longer in thick-skinned patients. Thick skin and the tissues beneath it tend to retain fluid like a sponge. It takes time for the lymphatic circulation to clear this swelling and for the tissues to adhere to the new framework.
In this patient group, the nose can take 12 months, and sometimes even 18 months, to reach its final form. In the first months, the nasal tip may feel swollen, numb, or firm to the patient. Swelling on the face upon waking in the morning may decrease during the day with gravity. These fluctuations are a natural part of the process. The patient needs to be psychologically prepared for this long marathon.
What we recommend to accelerate the healing process is as follows:
- Salt restriction
- Sleeping with the head elevated
- Avoiding hot environments
- Lymphatic massage
- Night taping
- Drinking plenty of water
- Sun protection
There is a particular risk of swelling accumulating and the area appearing puffy just behind the nasal tip, in the region we call the “supratip.” This is called the “pollybeak” deformity. This risk is higher in thick-skinned patients. To prevent it, during postoperative follow-ups, we may administer very low-dose cortisone injections to that area when necessary, resolving swelling and suppressing healing tissue (scar). This is not a complication, but a routine part of managing the process.
Is intervention on the nasal alae necessary during surgery?
In the Middle Eastern nose structure, the nasal base is generally wide. However, it is not a correct approach to cut and narrow every nasal ala that appears wide. Rhinoplasty is a three-dimensional procedure. When we elevate the nasal tip (increase projection and carry it forward), the nasal alae tighten like the hem of a tent and narrow on their own.
If, despite lifting the nasal tip, the alae still look too wide relative to the overall facial proportions, then surgical intervention is considered. The aim here is not to make the nostrils so small that breathing is compromised, but to narrow them within aesthetic limits.
The criteria for nasal ala intervention are as follows:
- Inner canthus alignment
- Facial width
- Nasal tip projection
- Breathing capacity
- Presence of asymmetry
This is generally performed with the method we call “Alar Base Excision,” by removing millimetric tissue from the crease where the nasal alae meet the cheek. Because the scars are hidden within the natural crease, they usually become indistinct once healing is complete. However, since this step is irreversible, it is vital that the surgeon acts very conservatively and does not remove more tissue than necessary.
What are the risks that can be encountered after surgery?
As with any surgical procedure, there are some specific risks in thick-skinned Middle Eastern rhinoplasty. The most important of these is the persistence of swelling and the development of fibrosis (problematic scar/healing tissue), as mentioned earlier. Thick skin tends to fill empty spaces with scar tissue. If the cartilage vault is not built strong enough, or if the patient does not adhere to recommendations during the healing period, the nasal tip can lose its shape.
Another risk is expectation management. Expecting the “sharp” and “angular” contours achievable in a thin-skinned nose from a thick-skinned nose can lead to disappointment. It is the surgeon’s duty to honestly explain the limits of what can be achieved. Skin quality is the canvas of surgery; the painting can only be as clear as the canvas allows.
Possible risk factors are as follows:
- Persistent swelling
- Contour irregularities
- Asymmetry
- Breathing problems
- Sensory loss
- Infection
- Bleeding
Prof. Dr. Murat Songu – Burun Estetiği (Rinoplasti) Uzmanı
Prof. Dr. Murat Songu, 1976 yılında İzmir’de doğmuş, tıp eğitimini Ege Üniversitesi Tıp Fakültesi’nde tamamladıktan sonra Celal Bayar Üniversitesi Kulak Burun Boğaz Anabilim Dalı’nda uzmanlık eğitimini tamamlamıştır. 2005–2006 yıllarında Fransa’nın Bordeaux kentinde Prof. Vincent Darrouzet ve Dr. Guy Lacher gibi rinoloji alanının önde gelen cerrahlarıyla çalışarak rinoplasti, fonksiyonel burun cerrahisi ve kafa tabanı cerrahisi üzerine ileri eğitim almıştır.
Burun estetiğinde doğal görünüm, nefes fonksiyonunun korunması ve yüz estetiği dengesini ön planda tutan Prof. Dr. Songu, açık teknik rinoplasti, piezo (ultrasonik) rinoplasti, revizyon rinoplasti, burun ucu estetiği ve fonksiyonel septorinoplasti operasyonlarında ulusal ve uluslararası düzeyde tanınan bir cerrahtır. Yurt içi ve yurt dışında çok sayıda rinoplasti kongresinde eğitici ve konuşmacı olarak yer almış; yüz estetiği ve burun cerrahisinde modern tekniklerin yaygınlaşmasına öncülük etmiştir.
100’den fazla bilimsel yayını, kitap bölümü yazarlıkları ve 1700’ü aşkın uluslararası atfıyla rinoplasti alanında Türkiye’nin en saygın akademisyenlerinden biri olan Prof. Dr. Murat Songu, doğal, yüzle uyumlu ve fonksiyonel sonuçlar hedefleyen cerrahi yaklaşımıyla hem bilimsel hem estetik başarıları bir araya getirmektedir.
