Role of Rhinoplasty in Transsexual Patients

Sir: We read with great interest the article published on the Journal by Capitán et al.,1 and we focused our attention on facial surgery in transsexual patients. Facial feminization surgery is a significant part of gender transition and, although gender norms exist for facial aesthetics, there is limited evidence to guide clinical practice of facial feminization surgery. As the central structure of the face, the nose plays an important role in perception of femininity and attractiveness. Between the female and male nose, there are many important differences that should be considered. The female nose has a smaller bony framework than the male nose, and the dorsum is narrower, with an age-dependent concavity. By comparison, male noses are usually larger and longer and have broader nasal bones, and the dorsum is straighter, with very little supratip break. The nasolabial and nasofrontal angles are both more obtuse in the female nose than in the male nose. The nostrils and the nasal base are smaller in the female nose. The objective in performing feminizing rhinoplasty is to reduce the overall size of the nose and to change its angles to those more reminiscent of the female form. In a feminizing rhinoplasty, the dorsum and tip of the nose generally need to be made smaller, with the tip rotated cephalically. We conducted a systematic review that has been designed to critically summarize the current literature on operative techniques and outcomes of rhinoplasty in transsexual patients with the goal of providing a platform to guide further surgical innovation and research. All procedures performed in studies (which we reviewed) involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. To identify studies about rhinoplasty in transsexual patients, a multistep search of the Web-based PubMed database from the National Library of Medicine was performed using the search terms summarized in Table 1, with limits set to include articles published up to December of 2016. Abstracts and full-text articles were reviewed. Our search generated a total of 70 articles; 62 articles were identified using the group search terms presented in Table 1, and eight articles were found in the references of the first 62 articles. Thus, we performed the systematic review of the four studies2–5 that had sufficient data and met the inclusion criteria, all about male-to-female surgery. A total of 235 patients were included in these four cases series (Table 2). Rhinoplasty in transsexual patients was described alone or in combination with contouring the forehead, forehead reconstruction, and lip lift. The few complications reported were light to moderate paresthesia in the tip of the nose; low to moderate postsurgical edema, mainly in the root of the nose and lower eyelids; chronic infection of the tip; dorsal irregularity; unmet expectations with regard to refining the tip; or asymmetry of nasal alae. Only one study analyzed patient satisfaction with the Nose Feminization Scale, which is not a validated specific patient-reported outcomes measure.Table 1.: Search TermsTable 2.: Studies Regarding Rhinoplasty in Transsexual PatientsOur systematic review of surgical techniques and outcomes shows that rhinoplasty in transsexual surgery is safe and effective; however, the patient’s perception of the body and point of view have not been well described. Standardized and validated instruments with which to assess patient satisfaction and outcomes are lacking. PATIENT CONSENT Informed consent was obtained from all individual participants included in the studies that we reviewed. DISCLOSURE The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication. No intramural or extramural funding supported any aspect of this work. Mauro Barone, M.D.Annalisa Cogliandro, M.D., Ph.D.Paolo Persichetti, M.D., Ph.D.Plastic and Reconstructive Surgery UnitCampus Bio-Medico University of RomeRome, Italy