Technical and Clinical Considerations for Facial Feminization Surgery With Rhinoplasty and Related Procedures

Abstract

Importance: Together with the forehead reconstruction, feminization of the nose is one of the most common procedures in facial feminization surgery. Rhinoplasty surgical techniques, which provide correct support and stability in the midterm to long term, are essential for obtaining a predictable result.

Objective: To report on the technical and clinical considerations of rhinoplasty and related procedures to feminize the nose, harmonize the nose in relation to the other modified structures (mainly the forehead and maxillomandibular complex), and achieve an aesthetic result beyond gender differences.

Design, setting, and participants: Case series study of feminization rhinoplasties, in combination with lip-lift techniques, forehead reconstruction, and other procedures, were performed at a private practice between January 11, 2010, and May 29, 2015, in 200 consecutive male-to-female transgender patients. The mean (SD) medical follow-up for patients was 32 (18.84) months (range, 12-77 months). Frontonasal angles were objectively measured. Postoperative and long-term patient satisfaction were assessed.

Main outcomes and measures: Clinical analysis and evaluation using the 5-point Nose Feminization Scale, with 1 indicating very masculine or nose is worse and 5 indicating very feminine or exceptional result.

Results: In these 200 patients, the mean (SD) age was 40.2 (12.2) years (range, 18-70 years). The mean (SE) frontonasal angle changed from 133.64° (0.63°) to 149.08° (0.57°) (difference in means, -15.44; 95% CI, -17.12 to -13.76; P < .001). Most patients considered their nose to appear more feminine after the surgery, and the degree of satisfaction after the rhinoplasty was 4 (much better) of 5 points on the Nose Feminization Scale. During the evaluation of feminization rhinoplasties, special attention was given to how the nose relates to other features essential to the identification of facial gender: the forehead and maxillomandibular complex. Emphasis was placed on the midterm to long-term stability of the results by reinforcing the internal structure.

Conclusions and relevance: In this case series of feminization rhinoplasties in combination with lip-lift techniques and forehead reconstruction, frontonasal angles were changed, and patient satisfaction with outcomes was high. The main goal of rhinoplasty in facial feminization surgery is to obtain feminine nasal features and the harmonization of the nose with the rest of the face. Lip-lifts and frontonasal recontouring can complement rhinoplasties associated with facial feminization surgery.

Level of evidence: 4.

Figure 1.. Frontonasal Transition

Before (A) and after (B) lowering the frontonasal transition during a forehead reconstruction with intraoperative detail of the technique showing the opened frontal sinus and the transition with the nasal bones (C).

Figure 2.. Elevation of the Columellar Skin Flap

A, Drawing of the incisions for the external nasal approach and lip-lift. B, Marking the columellar flap and removal of the lip skin strip. C, Elevation of the proposed columellar flap and complete exposure of medial crura and domes.

Figure 3.. Lip-Lift Technique

A, Design of modified bullhorn lip-lift (front view). B, Design of modified bullhorn lip-lift (basal view). C, Nose and lip-lift combined approaches. We show 2 different approaches depending on the patient’s anatomy and the surgeon’s choice. Blue dots show marking the lip-lift; yellow, skin removed for the lip-lift; red dotted line, incision level in a traditional open approach rhinoplasty; and white dotted line, incisions performed for the rhinoplasty and lip-lift.

Figure 4.. Preoperative and Postoperative Clinical Results After Facial Feminization Surgery Including Rhinoplasty, Forehead Reconstruction, and Lip-Lift

Before (A) and after (B) rhinoplasty and forehead reconstruction by coronal approach, and before (C) and after (D) rhinoplasty, forehead reconstruction by coronal approach, and lip-lift.

Figure 5.. Preoperative and Postoperative Clinical Results After Facial Feminization Surgery Including Rhinoplasty Associated With Other Procedures

Before (A) and after (B) rhinoplasty, forehead reconstruction by coronal approach, and Adam’s apple reduction; before (C) and after (D) rhinoplasty, forehead reconstruction by coronal approach and simultaneous hair transplant, lower jaw and chin recontouring, and Adam’s apple reduction.