Transgender Nasal Feminization Rhinoplasty (Part 1)

One of areas within facial plastic surgery that Thomas Lamperti, MD specializes is in performing facial feminization surgery.  In this video Dr. Lamperti reviews before and after photos of a male to female transgender patient who is undergoing facial feminization rhinoplasty to create a more feminine appearing nose. Dr. Lamperti then reviews an intra-operative video  in which he shows how he made the patient's nose smaller and more refined. Dr. Lamperti also shows how he worked to improve the patient's nasal function, improving her chronic nasal obstruction symptoms.

Video Transcript:

"This is Seattle facial plastic surgeon, Dr. Thomas Lamperti. Today we’re going to go over a nasal feminization rhinioplasty surgery case on mine.  First let’s take a look at my patient’s baseline frontal photo. She has a prior history multiple nasal fractures and chronic nasal breathing blockage as well. You can see that she has a broad hump on her bridge along with a full, over-projected tip. Given the cosmetic and functional concerns we focused on both improving the patient’s nasal breathing along with her outward appearance. When it comes to reducing the size of this patient’s nose one limitation we’ll encounter is her relatively thick nasal skin as we need to make sure that her skin can properly shrink wrap to the needed level of reduction.

We’ll start with the open rhinoplasty incisions. With this access we’ll also be able to correct the patient’s deviated nasal septum. Here you can see how I carefully elevate the nasal tip skin off of the underlying cartilage. I’m now using a three point counter-retraction method to assist in elevating the skin off of the nasal tip domes. I’m staying in a relatively bloodless plan above the tip cartilages which allows me to elevate the skin here as atraumatically as possible.

I’ll now continue by elevating the skin up off of the nasal bridge itself. Once the skin is lifted off of the bridge I shave down the excess cartilage with a scalpel. To bring down the boney part of the bridge I’ll use an osteotome. My assistant helps by tapping the osteotome as I guide the angle of the bone cuts with my hands. Here I’m removing the shaved off bone. You can see that it is a pretty sizeable amount. I’ll now check to make sure the new profile line is set where I want it. Once I’m happy with the profile I’ll further smooth the edges with a rasp (or bone file). This rasping process allows me to fine tune the bridge height along with preventing there from being any sharp bone edges that would disrupt the appearance of the bridge. I’ll now recheck the bridge again to see if I’m happy with how it looks now. I’m not happy with the bridge transition in the supra tip area so I go ahead and shave an additional amount of cartilage in this area in order to accentuate the patient’s supra tip break as this is certainly a more defining feminizing nasal feature.

I’ve now separated the medial crura that make up the columella of the nasal tip. This will give me great access to the front edge of the septum. I’ll perform a septoplasty after elevating the internal skin lining or mucosa off of the septum itself.

It’s hard to see this part in the video but I will then make incisions in the septal cartilage allowing me to remove the deviated portion. I’ll then use this harvested cartilage later on in the procedure for rhinoplasty grafting. There’s the piece of septal cartilage that I’ll now place in some saline to keep moist until I use it later in the procedure. I’ll now remove the deviated boney portions of the septum that is found further back in the nose to further open up the nasal airway. The patient also has a bony septal spur along the floor of the nose so I’ll remove this with a very small osteotome.

I’m now placing a caudal septal extension graft in order to create an internal strut upon which I can secure the nasal tip cartilages in their new, deprojected position. I’m using a fine clear nylon suture to hold the extension graft in place.
I’ll use several different sutures in a few spots to create a nice secure graft.Once the extension graft is in position I’ll place the medial crura back together. I’m using a suture that will dissolve on its own in a few months by which time the cartilage will have scarred into place. I’ll continue by attaching the remainder of the tip cartilages to the septal extension graft. It is at this point that I also use an interdomal suture to place the tip defining point distance in a more narrow position.

Next I’ll narrow the patient’s wide nasal bones by placing small bone cuts with an osteotome. I’ll start by making the medial osteotomies placed along either side of the bridge in the area where I brought down the patient’s hump. Now I’ll make the lateral osteotomies to complete the freeing up of the nasal bones and allow me to gently infracture them into a more narrow position. You can see how this is a very controlled process as the osteotome is gradually guided into position by my hands.

I’ll also refine the patient’s tip by placing dome binding sutures which will help flatten the patient’s rounded tip. Like I had mentioned earlier the interdomal suture will help to make the tip less boxy. Now I’ll secure spreader grafts into place to support the area where I shaved the patient’s bridge and to also straighten the patient’s nose. I’m now placing that interdomal suture to set the tip defining point width.

Once I’ve performed all the maneuvers that I want to make the desired changes to the nose I’ll recheck the patient’s nasal tip and bridge position and feel for any irregular edges that need to be further smoothed down. I’m happy with how everything is positioned so the last step involves the standard sutures to close the incisions followed by an external cast to support the nose and protect the nasal bones as they heal.

Stay tuned for Part 2 of this video where I’ll show you the patient’s first postoperative office visit where we remove her dressings and trim some sutures."