BACKGROUND Middle Eastern rhinoplasty is becoming more frequent in the United States. Mature patients request a more refined, feminine nose, whereas younger patients (aged 15 to 25 years) want a smaller, "cuter" nose. METHODS The author completed a prospective study of 50 consecutive female primary Middle Eastern rhinoplasty patients. The presenting anatomy, including the alar anatomy, and selected surgical techniques and their variations for particular cases were recorded. RESULTS The majority of patients requested and received a significant change in their nasal appearance. Of the 40 patients followed for 18 months, three (7.5 percent) had revisions, two minor and one moderate. There were no functional complaints. CONCLUSIONS The author emphasizes the need for structure throughout the nose, with use of both spreader grafts and columellar struts, to support the large and often heavy skin sleeve. Tip suture techniques, with or without tip grafts, are highly effective and there is no need for destructive tip techniques.