JAMA FPS JAMA Facial Plastic Surgery · 2017

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

Bellinga RJ, Capitán L, Simon D, Tenório T.

PubMed 27978554 Publisher (DOI)Free full text (PMC)

What this paper says

In 200 consecutive transgender women, feminization rhinoplasty changed the mean frontonasal angle from 133.64 degrees to 149.08 degrees, and mean patient satisfaction was 4 of 5 on a nose feminization scale.

Overview

Along with forehead reconstruction, reshaping the nose is one of the most common parts of facial feminization surgery. This case series from a private practice reports the surgical considerations and measured results, with emphasis on techniques that keep the nose stable over the medium to long term and on how the nose relates to the rest of the face.

Sections of note

Case series of 200 consecutive male-to-female transgender patients operated between January 11, 2010, and May 29, 2015.
Mean age 40.2 years, SD 12.2, range 18 to 70.
Mean medical follow-up 32 months, SD 18.84, range 12 to 77 months.
Rhinoplasty was combined with lip-lift techniques, forehead reconstruction, and other procedures.
Frontonasal angle changed from a mean of 133.64 degrees, SE 0.63, to 149.08 degrees, SE 0.57; difference in means -15.44, 95% CI -17.12 to -13.76, P less than .001.
Outcome was rated on the 5-point Nose Feminization Scale, where 1 is very masculine or worse and 5 is very feminine or exceptional; most patients rated 4, much better.
Attention was given to the relationship between the nose, the forehead, and the maxillomandibular complex. Level of evidence 4.

What it means for a patient

The angle between the forehead and the bridge of the nose is a measurable target in feminization, not just an impression.
The nose is treated together with the forehead and jaw rather than in isolation.
Structural reinforcement was emphasized so the result holds over years.
Limits: one private practice, no comparison group, satisfaction rated on a scale specific to this work, and follow-up as short as 12 months in some patients.

Why this paper matters

This is one of the larger reported series in facial feminization and puts objective numbers on a procedure often described only in technique terms. It also documents the combined-procedure approach. It does not compare surgical strategies or use an independently validated satisfaction instrument.

Terms

Facial feminization surgery: Procedures altering facial features associated with male appearance.
Frontonasal angle: The angle formed where the forehead meets the bridge of the nose.
Lip-lift: A procedure shortening the distance between the nose and the upper lip.
Maxillomandibular complex: The upper and lower jaw bones together.
Case series: A report on a group of patients treated the same way, with no comparison group.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

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.

Abstract as indexed by PubMed; the article is open access (PubMed Central).