ORIGINAL ARTICLE

Surgical Management of the Nose in Relation With the Fronto-Orbital Area to Change and Feminize the Eyes’ Expression

Marcelo Ruben Di Maggio, MD, Joaquin Nazar Anchorena, PhD, MD, and Juan Cruz Dobarro, MD

and facial feminization. Facial features serve an integral role in Abstract: Gender affirmation in male-to-female transi- identifying an individual’s gender, with certain characteristics tion patients include breast augmentation, genital construction, and perceived as feminine or masculine.1 We refer as ‘‘Facial Features facial feminization. Facial features serve an integral role in identi- Remodeling ’’ (FFRS) for any patient undergoing surgery to fying an individual’s gender, with certain characteristics perceived change their overall facial features, regardless of their sex or as feminine or masculine. motivation. Facial features remodeling surgery includes the con- The nose, as the centerpiece of the middle third of the face, is an cepts of forehead and orbital rim remodeling and facial feminization important component of facial attractiveness and gender identity. surgery (FFS), as well as additional craniofacial and aesthetic procedures to treat and remodel the entirety of the face by simulta- Thus, reduction rhinoplasty is a mainstay of the facial feature neously addressing the soft tissue changes associated with aging, as remodeling (FFRS) and facial feminization surgery (FFS). well as correcting any disharmony in the facial bony framework. The authors usually divide the surgery planning in 2 steps, The most dramatic changes can be achieved in only 1 or 2 obviously depending on each patient needs, but generally speaking, procedures, with 10 days between one and the other. The approach the authors do the upper part of the head in one stage and the to the analysis and planning of FFRS and feminization surgery mandible and face lift in another. involves division of the face into the upper, middle, and bottom If the patient only requires frontal bone surgery and softening of thirds.2 the orbital rims, the authors always perform the nose surgery in this Remodeling and Feminization of the bottom third of the face can stage. If a mandible reduction is needed, combined with a face-lift, be addressed by procedures to decrease the angle of the mandible, the authors do it in another procedure, usually separated between 7 augmentation through the use of fillers, and narrowing of the chin via genioplasty. The nose, as the centerpiece of the middle to 10 days from the other surgery. In these cases, the authors begin third of the face, is an important component of facial attractiveness with the lower part of the face on the first stage and then, the frontal and gender identity.3 Thus, reduction rhinoplasty is a mainstay of bone and rhinoplasty on the second. FFS, while cheek augmentation can be employed to achieve a more The fronto naso-orbital complex is one of the main facial areas feminine heart-shaped contour of the face. The upper third of the that determine the identification of facial gender, the nose plays a face is considered to be the most significant portion in recognizing crucial role in FFS of the middle third. The main goal of rhinoplasty female gender.4 The male brow and forehead are typically more in FFRS is to change masculine nasal features to feminine ones by pronounced, especially in the glabella and superior orbital rim performing dorsal reduction, tip refinement, and narrowing the regions. The open approach via a bi-coronal incision for exposure of the front nasal-orbital complex has been the most common nasal bones, most often using an external approach and cartilagi- 1 nous grafts to provide good tip support and long-term stability. Lip- approach for the modification of this bone. lift and frontonasal recontouring can be technically complementary to rhinoplasties associated with facial features remodeling and Differences Between a Masculine and a feminization. Feminine Face To allow appropriate surgical procedures to be carried out to change the shape of a face to the characteristics of the desired sex, it Key Words: Facial features remodeling, facial feminization, is important to know and understand the anatomical differences rhinoplasty, transgender surgery between a masculine and a feminine face.5,6 Physical anthropolo- (J Craniofac Surg 2019;30: 1376–1379) gists and forensic pathologists are concerned with the identification and separation of the sex by skulls as Giles and Elliot described in 1963.7 Before computer and discriminant function analysis, these ender affirmation surgeries in male-to-female transition scientists primarily used 3 skeletal characteristics to separate the G patients include breast augmentation, genital construction, male from the female skull: the chin, the nose, and the forehead. The chin is, in general, more pointed in the female. The nose has From Tinogasta, Buenos Aires, Argentina. a more acute glabellar and nasolabial angle in the male than in the Received December 26, 2018. female. The male nose is often more prominent than the female nose Accepted for publication January 14, 2019. and with a dorsal hump or with a straight dorsum. The female nose Address correspondence and reprint requests to Marcelo Ruben Di Maggio, is regarded as attractive if it is a little bit smaller when compared to MD, Sanatorio Finochietto, Avenida Cordoba 2678, C1187AAN, the male nose and shows a straight or mildly concave dorsum as Buenos Aires, Argentina; E-mail: [email protected] well as an accented tip.8 The authors have no conflicts of interest to disclose. Copyright # 2019 by Mutaz B. Habal, MD The forehead is perhaps the easiest to separate. The male ISSN: 1049-2275 forehead has extensive supraorbital bossing, and above this, there DOI: 10.1097/SCS.0000000000005411 is often a flat area before the convex curvature of the upper forehead

1376 The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019 Management of Naso-Fronto-Orbital Remodel

cartilage (Adam’s apple), hair-line format, cheekbones, the upper lip, facial hair, skin type, and quality, and the distribution of facial fat. With specific regard to the nose, the male nose is usually larger than the female nose because it has a greater component of bone and cartilage. Female noses tend to be narrower, the tip is often sharper, and the nostrils may be smaller. However, the nose has character- istics conditioned by ethnicity and age that are almost as important as gender-based differences. All of these aspects must be evaluated when planning a rhinoplasty.11 FIGURE 1. A-C. Before and after patient pictures. Frontal-medium profile and profile lateral view, 4 years after surgery. D-F. Before and after patient pictures. Together with forehead reconstruction, nose feminization is one Frontal-medium profile and profile lateral view, 8 months after surgery. of the most common procedures in FFS. The nose is a prominent feature on the face, and its refinement can significantly improve gender recognition. A rhinoplasty can have an overall softening begins. In the female, the degree of supraorbital bossing is consid- effect, making the face more harmonic and feminine.12 erably less, frequently non- existent, and above this, there is usually We described many years ago the concepts and procedures to less flatness and more of a continuous mild curvature.9 change the eyes’ expression, which is an important achievement Genital surgery can be an important part of gender reassignment, within this surgical approach. This is one of the key results to be but it is not a major factor in a transgender person having difficulty achieved and a crucial one if we think about facial features remodel- obtaining social acceptance as a member of the opposite sex, ing. What eyes can express goes beyond words and is the kick off for however other body features can influence this. The use of female any social interaction. We believe this improvement is a relevant hormones in male-to-female gender reassignment can soften the change in comparison with other techniques that describe facial skin; increase breast size and change fat distribution and body hair. features remodeling. In addition, the approach of the front-nasal As explained previously, facial dimensions and proportions are angle and the upper part of the nasal bone allows us to design and notably different between men and women. Facial surgery plays an sculpt naturally and with harmony, towards this fundamental transi- increasingly important role in the gender reassignment process, tion when remodeling the face’s upper third region. particularly in male-to-female transgender with a strong masculine The surgical procedures performed included rhinoplasty in appearance who may benefit from FFS10 (Fig. 1A-C). combination with forehead reconstruction, with a lip-lift when it is needed. In addition, in most cases, rhinoplasty was done in FACIAL FEATURE REMODELING AND FACIAL combination with other FFRS procedures, such as jaw lowering and chins re-contouring, Adam’s apple reduction, hair transplant, FEMINIZATION SURGERY and soft-tissue surgery.13 Facial feature remodeling and FFS are the general terms for a group of surgical procedures that are used in an attempt to alter the characteristics of the face in male-to-female transgender to make FACIAL FEATURE REMODELING AND FACIAL them appear more feminine and vice versa. Facial feature remodel- FEMINIZATION SURGERY PLANNING AND ing includes soft tissue procedures, such as rhytidectomy, brow lift, SURGICAL TECHNIQUE cheek implantation, lip augmentation, as well as corrections of the We usually divide the surgery planning in 2 steps, obviously facial skeleton or cartilage by rhinoplasty, mandibular angle reduc- depending on each patient needs, but generally speaking, we do tion, genioplasty, bi-maxillary osteotomy, and frontal cranioplasty. the upper part of the head on 1 stage and the mandible and face lift The greatest challenges in FFRS are managing patient expecta- on another. tions and the selection of appropriate procedures. If the patient only requires frontal bone surgery and softening of In most plastic facial surgeries, the aim is to improve the appear- the orbital rims, we always perform the nose surgery in this stage. If ance of individuals without changing who they are. Patients state they a mandible reduction is needed, combined with a face-lift, we do it want to ‘‘look like themselves, only younger’’ or ‘‘look like myself, in another surgery procedure, usually separated between 7 to 10 days only better’’. Patients seeking FFS wish to look dramatically differ- from the other. In these cases, we begin with the lower part of the ent. They want a radical change to their appearance and frequently face in the first stage and then, the frontal bone and rhinoplasty in believe that FFS is their ‘‘ticket to a new life.’’ It is important from the the second. outset that the surgeon reduces any unrealistic expectations the We decided this after treating several patients and having patient may have. He must find out from the patient which features assessed that it is better for many reasons: of the face are felt to represent the wrong sex and whether there are suitable procedures to change them to achieve the desired result. He 1. By dividing the surgery in 2 steps, potential complications and must consider the risks and benefits of the proposed procedures in morbidity decreased considerably. order to formulate a treatment plan in conjunction with the patient. It 2. By treating the lower part of the face, patients can breathe is important that the patient is psychologically prepared for the normally after the surgery from their nose, that has no treatment dramatic changes that are intended, and also that they have a realistic at all, and by the second stage when the nose is done, patient can expectation of the outcome. breathe normally from their mouth, which lowers patient When evaluating, diagnosing, and planning a patient’s femini- anxiety and makes the first post-surgery hours more comfort- zation needs, it is essential to understand the differences between able for them. male and female facial features. Generally speaking, the male facial 3. By doing first the lower part of the face, the and swelling skeleton has some well-defined features that distinguish it from its usually have disappeared and if there’s still any, it is on the neck female counterpart. The basic pillars for the visual identification of area so there is no problem on treating the upper part of the face. facial gender are the front nasal-orbital complex, the nose, and the The other way around, if the upper part of the face it’s done first, maxillo mandibular complex. Other aspects, structural and non- the second surgery will find the patient with all the swelling and structural, can also influence this identification, such as thyroid edema on the lower third of the face within 7 days.

# 2019 Mutaz B. Habal, MD 1377 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Di Maggio et al The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019

Feminization of the Nose In a general sense, male noses, and less attractive female noses are large and over projected. The surgeon must be prepared to significantly reduce the nasal dorsum, commonly to produce a gentle concavity or slope.10 Although this sloped nose has been considered to look overly operated or ‘‘done’’ within the rhinoplasty community at different times, it is important to remember that a transgender woman has to overcome a constellation of physical traits that send male gender cues. Thus, creating an unequivocal feminine form to the nose is beneficial. The nasal dorsum is commonly reduced simultaneously with a forehead cranioplasty to reduce the glabellar prominence and orbital rims. Standard rhinoplasty techniques can be used to make the nose smaller and give it a more feminine contour with proportions in harmony with the rest of the face and forehead. Generally, a reduction rhinoplasty consists of making the dorsum of the nose smaller and discreetly lifting the tip. Rhinoplasty is a highly individualized procedure, which requires thorough evaluation of the bone and cartilaginous structures that form the nose. Feminization rhinoplasty usually is performed under gen- eral and in combination with other procedures, usually FIGURE 3. (A) Lateral intraoperative view. Complete facial remodeling. Open frontal bone reduction. The surgical approach options available are rhinoplastia and lip lift. (B) FFRS. Rhinoplasty with classic alar cartilages and via trans columellar incision or standard close approach depending on nostrils treatment. (C) FFRS. Rhinoplasty. Reduction of the glabellar the individual needs of the patient (Fig. 2A). prominence, treatment of the fronto-nasal angle, dorsum, and different cartilages. FFRS, facial feature remodeling surgery.

Refinement of the Tip be resected is less than 2 mm, a Fomon rasp is most often used to A strip of the cephalic margin of the lower lateral cartilages is reduce the bony bridge. If the hump is larger, a monobloc osteotomy removed, leaving at least 6 mm in the caudal border of the lateral crura is performed, including the cartilaginous part previously excised to provide enough tip support and avoid collapse. Tip reshaping is one with septal scissors. With this procedure, it is crucial to insert the of the key points in feminization rhinoplasty, and to provide long- instruments correctly otherwise, an over resection or un-aesthetic term stability, grafts, such as a caudal extension graft in combination step in the middle of the bridge may be produced (Fig. 3C). with a tongue-in-groove maneuver, shields, or on-lay grafts on top, are essential. Suturing the medial and lateral crura (intra-domal sutures and interdomal sutures) is important to create an attractive Shortening the Nose nose projection, refinement, and rotation3 (Fig. 3B). By removing a caudal portion of the septum, including some mucosa, significant changes can be achieved in length, along with some tip rotation, if a mild angulation is performed at the level of Feminization of the Profile the septal angle. This piece of septal cartilage may be used as a Any excess bridge composed of bone and cartilage is removed to columellar strut, which provides an adequate columellar break. In lower the profile for an optimal result. If the amount of the hump to addition, with the tongue-in-groove maneuver, suturing the medial crura to the septum can achieve an attractive shortening and rotation of the tip.3

Narrowing of the Nasal Bone If the bridge is wide, it can be reduced by a nasal bone fracture on each side and a posterior approximation of both sides toward the midline. We use both techniques: either an endonasal or a percuta- neous osteotomy (2-mm-wide osteotome) to close the open roof. If the hump resection has been aggressive, it is important to avoid distortion of dorsal aesthetic lines and functional deformities by using different options: spreader grafts between the septum and upper lateral cartilages, upper lateral cartilage tension spanning sutures, spreader flaps, or simple reap- approximation of the upper lateral cartilages (Fig. 3A).

The Frontonasal Transition The frontonasal transition is another important area regarding facial gender differences. In male patients, the forehead is flat with prominent supraorbital ridges. On the other hand, female foreheads are vertically higher, more rounded with a smoother, gentle arc. In relative proportions of FIGURE 2. A. Before and after pictures. FFRS. Rhinoplasty. Frontonasal angle the overall facial mass, the orbits in women are larger and appear treatment. B-D. Intraoperative view. Complete facial remodeling surgery. Rhinoplasty. Treatment of the fronto-nasal angle with glabellar and dorsum higher. The male eyebrows are heavier, straighter, and closer to the reduction. FFRS, facial feature remodeling surgery. eyes. In contrast, a woman’s eyebrows are more arched. The soft,

1378 # 2019 Mutaz B. Habal, MD Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery  Volume 30, Number 5, July 2019 Management of Naso-Fronto-Orbital Remodel delicate and ‘‘sincere’’ female expression can be attributed partly to cartilaginous grafts to provide good tip support and long-term this wider opening of the orbits. Female orbital margins are sharper stability.3 Lip-lift and frontonasal recontouring can be technically and rounded.14 complementary to rhinoplasties associated with facial feminization. In males, the angle formed by the transition between forehead and nose tends to be more acute. Correction of the supraorbital rim 15 REFERENCES and frontal bossing softens this angle. During forehead recon- 1. Salgado CJ, AlQattan H, et al. Feminizing the face: combination of struction, when the root of the nose is too high or projected, a frontal bone reduction and reduction rhinoplasty. 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# 2019 Mutaz B. Habal, MD 1379 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.