Shifting Goals in Aesthetic Rhinoplasty: Eurocentric Ideals, Ethnic Background, and Cultural Identity

Abstract

Background:

Westernization of nasal features has long been presented as an essential framework for enhanced beauty. Whether surgery is meant to align one’s appearance to Western ideals, or whether it should be considered a means of improvement within one’s own culture and ethnicity, deserves serious consideration.

Methods:

A systematic literature search of PubMed, Embase, and Web of Science databases was conducted to identify reports on aesthetic preferences for ethnic nasal shape as they apply to aesthetic rhinoplasty.

Results:

Identified reports confirmed that there is no universal ideal nasal morphology across cultures and ethnic groups. However, cognitive investigation of aesthetic preferences of non-White patients is very limited, and most reports provided a low level of evidence.

Conclusions:

Variations in nasal features are morphological adaptive transformations pressured by evolution and natural selection. Their perception as positive beauty cues is also determined by evolution. Nasal profile preferences of various ethnic patients and the objectives of “ethnic rhinoplasty” are still poorly appreciated. Rather than being intended to correct existing features that deviate from the White “norm,” for creating a racially congruent and aesthetically pleasing outcome, aesthetic rhinoplasty is better perceived as an improvement fitting within the specific cultural and ethnic background of each patient and within the context of mate preferences and cognitive averageness.

Takeaways

Question: Does aesthetic rhinoplasty align with Eurocentric beauty ideals, or should it focus on preserving cultural and ethnic identity while achieving an aesthetically pleasing outcome?

Findings: There is no universal standard of beauty in rhinoplasty. Despite the long-standing influence of Eurocentric beauty norms, patients increasingly seek results that respect their ethnic identity. The study highlighted the limitations of traditional classifications of “ethnic rhinoplasty” and emphasized the need for a patient-centered approach that balances cultural preservation with aesthetic enhancement.

Meaning: Aesthetic rhinoplasty should move beyond Eurocentric ideals and instead focus on achieving natural, culturally congruent results that enhance individual ethnic identity while maintaining facial harmony.

INTRODUCTION

The human face is the most distinctive feature for identification, interaction, and communication.^1–3 The nose, being a central facial feature, is an important feature defining humans into different “races” and “ethnic” groups.^4–6 Although Western features have long been presented as the ultimate canons of beauty,^2,3,7 they do not necessarily exemplify universal beauty applicable to all.^3,8,9 With wide variations in perception and preferences across races, ethnicities, and cultures, it is difficult to define a single universal standard of beauty and attractiveness.^3,8,10 Nevertheless, despite definite ethnic-dependent and cultural specificities, there are common denominators across ethnic groups, sexes, ages, and sexual orientations that still reflect proportions, symmetry, harmony, balance, regularity, and poise, and equate with cross-cultural principles of averageness.^{2,7,8,11–13}

Although patient satisfaction is the ultimate outcome of cosmetic surgery,^4,14 there is an unclear understanding of how race, ethnicity, and culture may influence patients’ aesthetic preferences and goals.⁶ It is becoming imperative to realize the interplay between patients’ ethnic identity and cosmetic surgery practice.¹⁵ Owing to increasing accessibility of facial plastic surgery and demand by non-White people, whether this surgery is meant to align one’s appearance to Western ideals or to improve features within one’s own culture deserves serious consideration.^2,3,7,16,17 From a psychosocial and cultural perspective, preservation of patients’ identity is critical.^9,18 The aim of this review was to determine, beyond individual preferences, how ethnic aesthetic norms impact individuals’ choices, as this will constitute a guide to clinical practice in an ever-increasing multiethnic and multicultural environment.

MATERIALS AND METHODS

A systematic population intervention control outcome literature search of PubMed, Embase, and Web of Science databases was conducted to identify clinical studies about aesthetic preferences for ethnic nasal shape (Fig. 1). The following Medical Subject Headings terms and keywords were used: ([“cultural characteristics” OR “ethnic groups” OR “ethnic identity” OR “cultural identity” OR “racial identity” OR “multiculturalism” OR “social perception”] OR [“beauty” OR “sociocultural factors” OR “beauty ideals” OR “aesthetic standards” OR “Western beauty” OR “facial aesthetics” OR “beauty perception”]) AND ([“rhinoplasty” OR “nose surgery” OR “nose reshaping” OR “aesthetic rhinoplasty”] OR [“nasal bone” OR “nasal anatomy” OR “nasal shape” OR “nose morphology” OR “nasal tip projection” OR “nasal dorsum”]). Results were further refined by limiting the search to studies published in English from 2000 to the present and focusing on the adult population. Additional unstructured searches were performed using various combinations of these terms. Inclusion and exclusion criteria are summarized in Table 1.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the systematic review of databases and registers to identify clinical studies on aesthetic preferences for ethnic nasal shape.

Table 1.

Inclusion and Exclusion Criteria

Criteria	Inclusion	Exclusion
Study design	• Peer-reviewed clinical cohort studies about ethnic preferences for primary aesthetic rhinoplasty and/or nasal shape aesthetic preferences	• Reviews, case reports, comments, and letters to the editors
Population	• Individuals of various racial and ethnic backgrounds expressing nasal shape aesthetic preferences	• Cohort studies not clearly reporting patients’ nasal shape preferences by ethnic groups
Outcome	• Aesthetic preferences for nasal shape	• Cohort report not reporting aesthetic preferences
Methodological quality	• Detailed description of nasal aesthetic preferences and outcome measurement	• Reports with incomplete description of aesthetic preferences and/or outcome measurement
Publication date	• Studies published since 2000	• Studies published before this time frame
Language	• Studies published in English	• Non-English publications

Two investigators reviewed the identified studies for relevance. Initial screening involved titles and abstracts. In case abstracts lacked sufficient detail, the methods section was reviewed. Disagreements in study selection were resolved by consensus or by consulting a third independent reviewer. Full texts of eligible studies were retrieved, and relevant data were extracted using a standardized form.

RESULTS

In all, 19 studies satisfied the inclusion criteria and were selected for review (Table 2). (See table, Supplemental Digital Content 1, in which details of the identified studies are summarized, https://links.lww.com/PRSGO/E277.) They all provide a low level of evidence about specific preferences; nevertheless, some general trends can be determined. It seems that there is no universal ideal nasal profile across cultures and ethnicities.³³ In 1 study about 7 different ethnic groups rating modified face photographs of 2 Asian and 2 White women, neither ethnicity of the models nor that of the raters played a significant role in determining the ideal nasolabial angle or tip width.³⁶ On the other hand, another study demonstrated that race is a statistically significant predictor of the ideal male nasolabial angle. Native Americans and African Americans prefer more acute male nasolabial angles.³²

Table 2.

Identified Reports and Summary of Varying Nasal Aesthetic Preferences by Ethnicity

Authors and Year	Conclusion
Kaewsomnuk et al19	• Study identified distinct ideal nasal profiles between the Thai general population and those considering rhinoplasty, different from the neoclassical orbitonasal proportion
Liu et al20	• Dorsal augmentation is the main treatment method • Chinese people value exquisite nasal tips and prefer delicate “natural” noses that match their facial features
Torbey et al21	• Syrians have unique anthropometric measurements and aesthetic preferences • The majority of participants who had not undergone rhinoplasty expressed a desire to modify various aspects of their nasal measurements, with the exception of nasal tip projection
Alshawaf et al22	• No significant differences in choices of ideal male or female nasolabial angle between sexes, and North American versus Middle Eastern nationalities
Tavakoli et al23	• Iranians prefer thinner female noses with wider nasofrontal angles for both sexes • Ideal nasolabial angles, dorsal heights, and tip projections were consistent with neoclassical cannons
Liang et al24	• The preferred ideal Chinese nasion aligns with baseline ethnic characteristics
Sun et al25	• Chinese patients prefer a more subtle projection compared with White patients • Chinese share same preferences of NLA as other ethnic populations
Corduff et al26	• In all East Asian countries, female and male patients mostly have low, mid-height, and short-length noses; prefer nose elongation and increased dorsal height • 60%–100% of Singaporean, Thai, Korean, and Malaysian female patients request higher dorsal height noses
Samizadeh27 and Samizadeh and Wu28*	• Both men and women prefer a straight to concave nose profile
Samizadeh and Wu29	• Chinese aesthetic practitioners prefer a straight and small nose
Parab and Khan30	• All preferred aesthetic nasal measurements of Indian women and men are significantly different from European standards
Saad et al16	• Concept of ideal nasal anatomy varies between different ethnicities • From a lateral view, European and Mediterranean ethnic groups have larger noses in all dimensions compared with Africans and Asians • From a front view, all ethnic groups, excluding Eastern Africans, have significantly smaller alar base than the intercanthal distance
Alharethy31	• Young Middle Eastern subjects clearly prefer what may be explained as underrotation of the nasal tip in other cultures
Sinno et al32	• Race is a statistically significant predictor of the ideal male nasolabial angle • Native Americans and African Americans prefer more acute male nasolabial angles • No statistically significant differences exist in ideal female nasolabial angle preferences across different races
Broer et al33	• No universal ideal nasal aesthetics across cultures and ethnic backgrounds • Geographic, ethnic, and cultural factors influence the aesthetic perceptions of patients and surgeons • Plastic surgeons from Latin America and the Caribbean prefer smaller and narrower noses, with more projecting tips, lips, and chins
McArdle et al34	• Both male and female participants had a statistically significant preference for a very subtle angulation of STB, compared with a larger angulation of the STB
Gomes et al35	• The lowest position of the nasal radix close to the height of the pupil was preferred, followed by the position at the superior crease of the eye • The highest position, resembling classic Greek statues, was considered the worst
Biller and Kim36	• Neither the ethnicity of the models nor that of the volunteers who rated them played a significant role in determining the ideal eyebrow apex location, nasolabial angle, or nasal tip width
Mowlavi et al37	• Both male and female subjects strongly disliked a low nasion with respect to the corneal plane • Both groups were more tolerant of nasion-level alterations with respect to the supratarsal fold, upper lid ciliary margin, and midpupil

^*Study published in the same journal in 2 different issues.

NLA, nasolabial angle; STB, supratip break.

It also seems that ideal nasal anatomy varies between different ethnicities. Europeans and Mediterranean ethnic groups have larger noses in all dimensions compared with Africans and Asians.¹⁶ Moreover, aesthetic perceptions of patients and surgeons are influenced by geographic, ethnic, and cultural factors. Plastic surgeons from Latin America and the Caribbean prefer smaller and narrower noses with more projecting tips, lips, and chins.³³

Seven studies involved East Asians,^{19,20,24–28} and 1 study was about the Indian population.³⁰ One study was published in 2 different issues of the same journal.^27,28 Determined preferences by these publications differ greatly from neoclassical European proportions, particularly among Thai and Indian populations.^19,30 Nevertheless, 60%–100% of Singaporean, Thai, Korean, and Malaysian women requested dorsal augmentation^20,26 to approximate Western nasal ideals. Han Chinese people, on the other hand, prefer a straight to concave nose profile,^28,29 and Chinese people in general prefer more subtle tip projection compared with White people.²⁵ They value exquisite and delicate “natural” tips with more subtle projection that match their own faces and are in line with baseline ethnic characteristics,^20,24,25 whereas Chinese aesthetic practitioners prefer straight and small noses.²⁷

Four studies involved individuals of Middle Eastern background.^21–23,31 No significant differences between North American and Middle Eastern individuals in ideal male or female nasolabial angle were generally noted.²² For Iranians, ideal nasolabial angles, dorsal heights, and tip projections are consistent with neoclassical canons. Thinner female noses with wider nasofrontal angles for both sexes are preferred.³² Other studies have shown that young Middle Eastern individuals clearly prefer what could be explained as nasal tip underrotation in other cultures.³¹ Syrians who have unique anthropometric measurements desire mostly to modify various aspects of their nasal measurements, except nasal tip projection,²¹ whereas both White men and women significantly prefer nasal tips with very subtle supratip break and angulation.³⁴ A low nasion is generally strongly disliked by North Americans.³⁷ Brazilians, on the other hand, prefer a low nasal radix close to the height of the pupil and strongly dislike the high nasal radix of classical Greek sculptures.³⁵

DISCUSSION

Although “race” traditionally defines biological and physical similarities of a group of individuals, its definition has evolved during the last few centuries. At present, it does not have any inherent physical or biological meaning. It is rather a social construct based on societal rules.^38,39 “Ethnicity,” on the other hand, is an ill-defined, multidimensional sociological concept that refers to patients’ personal sense of connection, which may be based, in addition to physical similarities, on similarities in cultural beliefs and practices. Racial and ethnic concepts have changed with time and are subject to varying interpretations.^6,38–42 As for identity, individuals exhibit a stable yet dynamic identity deeply embedded in social relationships; it is both fluid and transformational.^3,43 Cultural identity describes individuals’ emotional attachment to a particular group and is related in an ever-changing social context to nationality, religion, social class, generation, and locality. Cultural and ethnic identity is also a component of awareness, self-labeling, attitude, and behavior.^43,44 Internalization of cultural values, which are in part autonomous and driven by authenticity and one’s own active and intentional choices, contributes to well-being in both individualistic- and collectivistic-oriented cultures, and is closely related to individuals’ mental health.^3,43–46

Regardless of variations in many aspects, physical appearance, especially facial features, is the main determinant of typicality and cultural and ethnic identity.^2,3,18,47,48 Furthermore, in addition to perceived age, approachability, intelligence, and success, specific facial features have a great impact on attractiveness, health, and gender expression.⁴⁹ Rather than being measurable, facial attractiveness is intuitively perceived, relying heavily on proportions and angles. Facial features, however, cannot be defined in isolation.^2,11 After rhinoplasty, a nose in harmony with the rest of the facial shape allows other facial features to be appreciated; a disproportionate nose, no matter how aesthetically pleasing, can significantly detract from all other features.⁴

Although common standards of attractiveness are shared by individuals from different cultures, “ideal” facial aesthetics cannot simply be defined by Eurocentric divine proportions. Individuals internalize beauty standards and attractiveness patterns according to their context of community and unique ideal cues of health and reproductive potential. Their motivation for pursuing ethnically sensitive surgery is mainly to achieve the perceived ideal of anatomical beauty.^{11,12,16,17,47,50–54} It is worth noting that attractiveness is defined in a homogeneous ethnic group by “cognitive averaging.” The closer an individual’s features are to the ethnicity average, the more the individual tends to be perceived as attractive.⁹

Evolutionary psychology demonstrated that “beautiful” features have developed through evolution to provide individuals with the ability to advertise to potential mates and to competing same-sex individuals.⁵¹ Perception of human features is also shaped by natural selection as evidenced by neuroaesthetics research. A recent study on runs of homozygosity with the “in-group ethnic favoritism” trait confirmed cultural–genetic coevolution in the sense that ethnic identity is a highly valued trait, favoring more in-group marriages.⁵⁵

Individuals display preferential attention toward racially concordant features of beauty.^15,54 They demonstrate the greatest recognition ability for faces of their own race, a phenomenon described as the “other-race effect.”¹⁵ Respecting this fact must not be overlooked. Keeping a natural appearance consistent with one’s own culture and ethnicity is critical.^4,8,56 Thus, classical definitions of beauty are not necessarily applicable to every individual of every ethnicity. In certain patients, application of Western ideals may contribute to loss of cultural identity, and a too drastic change may result in an overdone or “operated-on” look.^4,9 Moreover, altering features of patients in a homogeneous ethnic community beyond the unique norms of one’s group may sometimes be counterproductive, causing stress due to a lack of identification with individuals of the same group.⁴⁷

Although with today’s globalization the world has mixed racial patterns impossible to fit into specific anatomical categories, important differences still persist among ethnic groups with peculiar beauty patterns and physical characteristics.³⁸ Nevertheless, as Western societies become more ethnically and culturally diverse, navigating at least 2 cultural contexts that are themselves subject to change is becoming less of a challenge. As the dimension of adjustment and integration increases, acculturation with a diminishing effect of heritage and cultural identification is believed to play an increasingly crucial role in developing individuals’ well-being and mental health.^44,57

In multicultural Western societies, modification of specific features to achieve Greco-Roman “cosmetic westernization” ideals may seem to be presently well acceptable.³ However, general attitudes toward cosmetic surgery remain deeply influenced by cultural and national background. They vary widely between different groups.^8,58 More negative attitudes associated with greater cultural mistrust, stronger adherence to traditional values, and stronger ethnic identity salience are expressed by some minority groups who seem not to perceive cosmetic surgery as an acceptable modality for appearance enhancement. Furthermore, because identity is more relational and transformational than individualistic, more negative attitudes toward cosmetic westernization surgery are also encountered in culturally homogeneous societies with a common heritage.^3,56

Reflecting on ongoing social changes, beauty ideals have been reinvested with new, complex meanings. Cosmetic surgery is a personal choice regarded at present as a way of adapting to redefined gender norms, a gesture toward national modernity, a strategy of asserting self-control in personal lives, and an emblem of seeking upward class mobility.^{3,9,17,50,59,60} Reaching for plastic surgery is, thus, less of an individual decision but more of a relational or role-related endeavor. However, socioeconomic success remains uncertain, and surgery as a mode of empowerment does not change the cultural and ethnic structures; on the contrary, it may further entrench the undesirability of stereotypical features.³

Cosmetic surgery of ethnic features, although regarded as a direct response to market imperatives of the beauty economy, a way of adapting to redefined identities, and a gesture toward modernity, embodies a critical interplay of cultural imperialism and cultural nationalism.^3,59,60 Nationalism implies that cosmetic improvement of features does not necessarily mean abandoning one’s identity by borrowing beauty features from another cultural group. Although at present numerous cultural patterns are influenced by the prevalence of Western culture in social media and the entertainment industry, cosmetic surgery should remain within the sociocultural evolution of the society in which it is performed, respecting its cultural patterns and paradigms.³

The aim of cosmetic surgery remains essentially to fulfill the patient’s personal preferences and desires while achieving a natural and unoperated-on look. It must be noted, however, that the current standards of facial beauty have gradually shifted from the established measurements of neoclassical canons toward harmony, symmetry, and proportion, conforming to the unique characteristics of each patient. This new approach requires a deep understanding of acceptable facial norms of patients with various ethnic backgrounds, together with a fundamental understanding of their psychological background.^7,8,61

From the perspective of cosmetic surgeons who market White Western golden proportion standards as universally applicable and devoid of ethnic significance, the globalization of Western features brands other ethnic features as inferior and flawed. Asian or African features become qualified as “abnormal” and unaesthetic. Individuals may thus be pressured and feel at a disadvantage because of their “nonstandard appearance.” Surgical procedures to modify features in this context are interpreted as “corrective,” driving individuals to get operated on just to conform to the mainstream Western norm of beauty.^3,8,50,52,62 Rather than a compensation for perceived cultural and ethnic inferiority and an internalization of “foreign” standards of beauty, body features are best modified for the purpose of improvement and self-construction within one’s own ethnic and cultural standards.^3,59 Surgeons must recognize that for any community, the “ideal normal” of beauty and attractiveness is best defined by the principle of koinophilia or “love of the average.”⁹

Rhinoplasty is one of the most popular aesthetic procedures sought out by non-White people.^{6,15,18,63–66} Its aesthetic outcome is highly influenced by ethnic background, in addition to sex, age, place of origin, and preferences. It is differently perceived by patients, surgeons, and observers.^{15,20,63,64,67,68} Although “ethnic rhinoplasty” is often referred to as a deviation from the gold standard, each of the described ethnic morphologies presents unique challenges and deserves a specific, individualized approach rather than a one-size-fits-all surgery.^{2,16,38,40,69–71}

Not all patients wish to align with Western aesthetic canons. Many prefer a natural result that blends with the characteristics of their own community.^13,56,72,73 A desire to improve balance, symmetry, and harmony to complement one’s overall facial appearance is a common principle nowadays among non-White patients.^13,74 This has shifted cosmetic rhinoplasty practice from early transformation of unique characteristics to cultural restoration revision rhinoplasty aiming to finally achieve facial harmony in parallel with the preservation of features that define an individual’s ethnicity and identity.^13,18,69,75

Understanding global concepts of beauty, as well as ethnic facial and nasal features, and appreciating the interplay of culture, race, and ethnicity, is imperative when offering patients an individualized approach in the context of ethnically sensitive preferences. Expectations that rhinoplasty will emphasize cultural and racial preservation are prevalent among patients of African descent who have a particularly strong desire for ethnically congruent results.^73,76,77 Similarly, preservation of authenticity and identity must not be overlooked in Asian patients. Avoidance of artificial alterations to the point of obvious noticeability is preferable by most Asian women. In 1 study, however, a sample of Japanese women showed a preference for some White-like nasal features, despite living in a society with homogeneous patterns.⁷⁸ Obvious alterations with complete cultural transformation deviating from observers’ expectations are considered “unnatural” and generally unaesthetic.^{3,17,20,40,62,63,67,69,74,75,79–81}

Objectives of non-White people who belong to a minority group and who desire to blend in by eliminating ethnic features or gender dimorphism are radically different from those who wish to have only more attractive and refined noses while preserving their ethnic characteristics.^52,56,82,83 More than with any other surgical intervention, achieving patients’ satisfaction requires a thorough understanding of their attitudes toward cosmetic surgery, motivations, and expectations.^{12,17,41,64,67} Surgeons need to consider the cultural setting in which a patient lives, as preferences vary depending on regional exposure and community demographics.⁹

To assure that surgical outcomes align with patients’ desires and goals, and to avoid racial incongruity, appreciation of the ethnicity they identify with is essential. Some patients may have identities that do not seem to align with their projected ethnicity.^18,50,84,85 On the other hand, the effects of perceptual adaptation in influencing patients’ desires and expectations, which sometimes transcend cultural identity and characteristics, need serious consideration.⁸⁶ Similarly, the influence of social media in the construction of a cognitive average not reflecting the community’s average needs to be apprehended.⁹

Neoclassical standards are no longer considered targets to achieve. They are guidelines for facial analysis that allow the determination of an ideal goal for each individual.^4,9,56 The concept of only 1 ideal nose prototype is outdated and inapplicable to the diverse range of patients.¹⁶ However, identifying aesthetic standards and preferences for patients of various backgrounds remains challenging.⁹ Although applying proportions from other ethnicities does not alter aesthetic nasal attractiveness,¹⁴ most non-White patients wish today to preserve their heritage and identity.^50,72,87,88 Furthermore, younger patients desire a more “natural” nasal appearance regardless of their background.⁸⁹ With obvious transformative rhinoplasty, the outcome is often disharmonious relative to other facial features. How patients view themselves becomes noncongruent with how they are perceived by others.^18,64,76,90 Such patients must be made aware that public perception is just as important, if not more so, than self-satisfaction⁸⁶ and that individuals tend to favor faces that are more familiar and similar to what they have been exposed to.⁹

LIMITATIONS

Different characteristics of various ethnic noses are well documented and classified. Unfortunately, cognitive investigation of aesthetic preferences of non-White patients is very limited, which constitutes a potential drawback to this review. This highlights the necessity of conducting further research to better define the goals of rhinoplasty in different population groups.

CONCLUSIONS

It is clear at present that classification of various nasal features into geographical and ethnic categories is no longer adequate or accurate. It is clear also that Western Eurocentric beauty, long considered the reference standard, is far from universal. Across all ethnicities, most patients seeking rhinoplasty desire a “natural” looking nose that fits and complements their facial features. Beauty features and their perception are determined by evolution and natural selection. Any morphological alterations to eliminate these features, or borrowing beauty characteristics foreign to one’s identity, may engender a conflictual situation. Despite increasing acculturation in a multicultural and multiethnic environment, it is more politically correct for aesthetic surgery to aim at improving rather than correcting existing features to achieve an outcome that fits the specific cultural and ethnic background of each patient within the context of mate preference and cognitive averageness.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.