It is important to understand the difference between a male nose versus a female nose when attempting a feminizing procedure. In addition to generally being larger with a straight or slightly convex bridge, the male nose forms a more acute angle with the upper lip (90-95 degrees) producing less nostril show. Consequently, we aim to reduce the overall framework in a male nose and produce a gentle slope or concavity over the bridge with subtle indenting curves along the side walls, rather than the straight walls seen in men. Additionally, the angle between the bottom of the nose and the upper lip is more obtuse (95-110 degrees) and the tip is more refined and angular. Imperfections are less tolerated in a female nose, and it should blend harmoniously with the other facial features.
A prominent Adam’s apple is a very masculine feature and, consequently, its reduction is one of the first surgical procedures sought in patients transitioning from male to female. The laryngeal shave reduces this most prominent part of the laryngeal cartilage (Adam’s apple). Since the trachea has no prominences, but is the "windpipe" below the larynx, this procedure should not be called a "tracheal shave". It is generally performed through an incision in the anterior neck over the prominence or higher up. The incision site depends on whether concomitant voice surgery is being performed, the size of the prominence, the skin type and the patient’s wishes. Contrary to what one might initially think, an anterior neck incision placed in a natural skin crease and closed meticulously usually heals with an imperceptible scar. Since the vocal cords attach approximately halfway down the front portion of the laryngeal cartilage, it is only the upper one half of the cartilage that can be reduced. Fortunately, most of the Adam’s apple is in the upper one half. However, even in the most obliquely angled prominences, the results of a laryngeal shave are usually quite satisfying. Finally, since most larynges undergo some degree of calcification after puberty, burring of the prominence with an electric bur is the usual approach rather than shaving with a scalpel blade.
Females generally have fuller, more pouty lips than males. This area of a woman’s face can be quite alluring. It has been said that this inherent sexuality relates to a subconscious, psychological reference to the female genital area. In addition to being more prominent than in males, the female upper lip is slightly rotated upward, revealing the lower 2-4mm of the upper front teeth. On the other hand, men have a flatter vermilion without the pout seen in women.
When feminizing the upper lip, we aim to reduce the white lip (the area between the bottom of the nose and the vermilion), in selected cases, via resection of skin and underlying muscle under the nose. It is accomplished by an excision that follows the curvature of the bottom of the nose, going into the nostrils to hide the scar. In some cases, removing more skin than muscle can actually produce increased "vermilion show" with a slight rotation. Another method of lip augmentation involves advancing the mucous membrane behind the "wet line" (where the upper & lower lips meet) around to the front. This is called a "V to Y advancement". Generally the upper lip requires three adjacent advancements and the lower lip only one centrally. The red lip, itself, can also be enhanced with fat injections or dermal grafts. Injections of a naturally occurring substance called "hyaluronic acid" can also be performed. Though non-permanent, it lasts several months to a year and provides an immediate augmentation without having to undergo surgery. Finally, a less often used method for reducing the white lip and, at the same time, enhancing the red lip is the direct excision of tissue over the vermilion border. It is the only procedure that can change or create a desired shape to the upper lip. However, it does produce a scar which may or may not be very obvious and require the use of lipstick to conceal it.
Being centrally located, the nose should blend harmoniously with the other facial features and not draw attention to itself.
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The operation consists of correcting areas of asymmetry and deformity resulting from a prior surgery.
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The eyes are the first features noted when people meet. And having puffy, sagging or wrinkled eyelids can convey a false image of being tired, sad or old.
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Having revised thousands of rhinoplasties, I have noticed certain features common to all.
Even a structurally symmetric, aesthetically pleasing nose can be a poor result if it is out of proportion with the other facial features by being too small or too large. However, the real clues to a poor result are the asymmetries, malpositions, disproportions and decreased function that are seen. We can see collapse of the side walls and/or nostrils producing a “pinched look” or asymmetry between the two sides. The bridge can be too low or too high, and the tip can be overly rotated or not rotated enough. There can be too much “nostril show” from aggressive cartilage resection causing upward migration of the nostril rims. Or too much nostril show from failure to raise the columella (area between the nostrils). Also, irregularities or distortions in the nasal tip can occur which can present technical challenges to the revision surgeon. There can be deflections or angulations of the tip or the entire nose. As mentioned above, nostril asymmetries are particularly common with one nostril appearing higher or wider than its companion. Finally, there can be a worsening of breathing , especially if a reductive rhinoplasty was performed. Making a nose smaller has to be accompanied, many times, by measures to assure that the airflow is not compromised. This means correcting any septal deviations and/or turbinate enlargement, as well as maintaining adequate openings through the nostrils and the areas above called the internal valves. I’ve included photos of a nose showing most of these deformities with the subsequent post-operative results, after I corrected them.
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