Maximizing Patient Satisfaction in Facial Feminizing Rhinoplasty

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

Gender-affirming surgery is a crucial component of care to reduce gender dysphoria among transgender individuals and is estimated to have increased in utilization by 400% from 2015 to 2019.¹ Facial feminization surgery, which serves to surgically transform patients' facial features to align more closely with their true gender identity, can significantly reduce symptoms of gender dysphoria in transgender women.² Facial feminization can thus significantly facilitate a patient's gender transition and improve self-esteem and quality of life.² In fact, a 2015 survey found that most transgender women expressed a greater need to change their facial appearance as a part of their gender transition than other parts of the body.³

Feminizing rhinoplasty is a commonly performed facial feminization procedure that incorporates aesthetic and craniofacial surgical principles and techniques to soften the traditionally masculine features of a patient's nose while maintaining nasal function.⁴ Feminizing rhinoplasty is often performed along with other feminizing procedures such as a frontal sinus setback, malar fat transfer, and forehead contouring to achieve a more harmonious appearance of the nose and its immediately surrounding structures. The nose serves as a central structure of the face, and its relationships with other facial structures including the forehead, midface, lip, and mandible influence perceptions of femininity.⁵ Thus, feminizing rhinoplasty can significantly improve gender recognition.² Given that gender transition is a highly personal process, the surgical approach to feminizing rhinoplasty must depend on both patient-specific and societal notions of femininity. The success of this procedure thus hinges on appropriately discerning masculine and feminine nasal characteristics. Historically, feminizing rhinoplasty has focused on dorsal length reduction and cephalic rotation of the tip, as the traditionally feminine nose is considered smaller with a narrower dorsum, supra-tip break, and smaller nostrils and nasal base than the traditionally masculine nose.^2,5

However, there are limited data on which specific nasal dimension changes are correlated with increased satisfaction among transgender patients.² Additionally, there is a paucity of evidence-based recommendations on whether approaches to cosmetic rhinoplasty for cisgender women can be applied to feminizing rhinoplasty for transgender women to maximize transgender patient satisfaction.

In this retrospective analysis, we evaluate a cohort of transgender female patients who underwent feminizing rhinoplasty and analyzed their postoperative aesthetic and functional satisfaction in relation to postoperative nasal changes. We further compare patient satisfaction and postoperative nasal dimensions between transgender women and cisgender women who underwent cosmetic rhinoplasty.

We conducted an institutional review board–approved study (Protocol #804789) at the University of California San Diego. Patient electronic health records were reviewed to identify transgender patients who had undergone a feminizing rhinoplasty between January 1, 2015 and May 1, 2022 by the senior author (A.G.) and had pre- and postoperative image data recorded in the Vectra 3D imaging platform, with postoperative images taken at least at 8 weeks post-rhinoplasty. The Vectra 3D platform, used for procedures such as rhinoplasty and face contouring, allows for 360° analysis of a patient's face, automated measurements of specific dimensions, and superimposition of preoperative and postoperative images.⁶ These patients were contacted via telephone to answer a survey rating their nasal aesthetic and functional satisfaction post-rhinoplasty. Contact via telephone was attempted a maximum of 3 times. A standardized script was utilized for each phone interview, including informed consent as outlined and approved by the institutional review board. Patients were presented with the opportunity to either answer the questions over the telephone or be sent the link to an electronic survey, and response data was recorded in a protected database. There were 14 questions asking patients to rate their post-rhinoplasty aesthetic satisfaction (7 questions) and functional satisfaction (7 questions), on a 1 to 5 Likert scale (Supplementary Table 1). Additionally, patients were asked to verify their gender identity, age, and race during the survey.

The pre- and postoperative 3D images of transgender patients who answered both aesthetic and functional survey questions were analyzed on Vectra. The preoperative image was chosen as the most recent 3D image recorded before the rhinoplasty, and the postoperative image was chosen as the most recent 3D image recorded after the rhinoplasty, with 8 weeks' post-rhinoplasty as the minimum time point. The pre- and postsurgery metrics of dorsal length; tip projection ratio; and nasolabial, nasofrontal, and nasofacial angles, as calculated by the Vectra rhinoplasty assessment, were recorded for each survey respondent (Figure). Relative percent changes between pre- and postsurgery measurements were calculated for each patient. Each patient's reported aesthetic and functional satisfaction scores on the 14 survey questions were summed together and divided by the total possible score of 70. These satisfaction scores were divided into quartiles to facilitate comparisons. Patients with a total satisfaction score of 0.75 and higher were considered "very satisfied," patients with a score between 0.5 and 0.75 were considered "satisfied," and patients with a score below 0.5 were "unsatisfied." Median percentage changes for each nasal metric between patients were compared using Wilcoxon rank-sum, chi-squared, and ANOVA tests.

Figure. Preoperative frontal (A) and basal (B) views and Vectra-generated measurements for dorsal length, tip projection ratio, nasolabial angle, nasofrontal angle, and nasofacial angle (C-G). Postoperative frontal (H) and basal (I) views and Vectra-generated measurements for dorsal length, tip projection ratio, nasolabial angle, nasofrontal angle, and nasofacial angle (J-N).

Similarly, cisgender females who underwent a cosmetic rhinoplasty and had pre- and postoperative image data recorded in the Vectra 3D imaging platform, with postoperative images taken at least at 8 weeks post-rhinoplasty, were identified from the electronic health record. These cisgender women were considered our control group and were not surveyed on satisfaction. The same pre- and postsurgery metrics from Vectra used to characterize transgender facial feminizing rhinoplasty, as described above, were recorded for each cisgender female patient, and relative changes were calculated between the pre- and postoperative nasal measurements for each cisgender patient. Median relative percent changes were compared between the cisgender and transgender female populations using Wilcoxon rank-sum, chi-squared, and ANOVA tests. Statistical significance was set at an alpha value of .05. All data processing and statistical analyses were performed in the R statistical software version 4.1.3.

A total of 25 transgender female patients met the inclusion criteria, among which 19 (76%) responded to the survey. Of the surveyed patients, 8 were Hispanic (42.1%), 8 were non-Hispanic White (42.1%), 2 were non-Hispanic other (10.5%), and 1 was non-Hispanic Black (5.3%). The median [interquartile range] age was 35 years [29.5, 40] with a median postoperative time of 12 weeks at time of survey. Most patients (n = 17, 89.5%) had additional feminizing procedures at the time of their rhinoplasty, including genioplasty (n = 14, 73.7%) and frontal sinus setback with front-orbital contouring (n = 11, 57.9%).

Among the 19 surveyed patients, after combining aesthetic and functional satisfaction scores, 12 patients (63.2%) were considered very satisfied with a mean score of 0.88, 7 (36.8%) patients were satisfied with a mean score of 0.69, and 0 patients were unsatisfied (Table 1). More specifically, 11 patients (57.9%) were very satisfied in both the aesthetic and functional categories, 5 patients (26.3%) were satisfied with the aesthetic and very satisfied with the functionality of their nose, 1 patient (5.3%) was very satisfied with the aesthetic and satisfied with the functionality of their nose, and 2 patients (10.5%) were satisfied with both the aesthetic and functional aspects of their nose. A total of 13 patients (68.4%) were very satisfied with the aesthetic appearance of their nose, and a total of 16 patients (84.2%) were very satisfied with the functionality of their nose.

Comparing the relative changes in nasal metrics between very satisfied and satisfied patients, we found significant differences in median relative changes in dorsal length, tip projection ratio, and nasolabial angles. Compared with satisfied patients, very satisfied patients had a decrease in dorsal length (-1.2% vs 5.7%, P = .043), smaller increase in tip projection ratio (2.4% vs 8.1%, P = .038), and a decrease in the nasolabial angle (-2.5% vs 9.7%, P = .026). Differences between very satisfied and satisfied patients in the median relative changes in nasofrontal angles (4.2% vs -0.6%, P = .071) and nasofacial angles (-0.7% vs -3.6%, P = .703) were not significant (Table 2).

Among very satisfied patients, 6 were non-Hispanic White (50%), 5 were Hispanic (41.7%), and 1 was non-Hispanic other (8.3%). The median age of very satisfied patients was 32.5 years [29.75, 37]. Among satisfied patients, 3 were Hispanic (42.9%), 2 were non-Hispanic White (28.6%), 1 was non-Hispanic Black (14.3%), and 1 was non-Hispanic other (14.3%), with an older median age of 41 years [30.5, 45.5]. Median ages (P = .258) and the racial distributions (P = .88) were not significantly different between very satisfied and satisfied patients.

We additionally compared our cohort of transgender patients with the cisgender females control group (n = 5) (Table 3). Very satisfied transgender patients and cisgender patients did not vary significantly in their differences of dorsal length (-1.2% vs 0.7%, P = .49), tip projection ratio (2.4% vs -3.5%, P = .098), nasolabial angles (-2.5% vs -5.4%, P = .86), nasofrontal angles (4.2% vs 1.1%, P = .115), nasofacial angles (-0.7% vs -4.2%, P = .45). Satisfied transgender patients and cisgender patients had significant differences in changes of dorsal length (5.7% vs 0.7%, P = .047), tip projection ratio (8.1% vs -3.5%, P = .033), and nasolabial angles (9.7% vs -5.4%, P = .042). Satisfied transgender patients and cisgender patients had insignificant differences in percent change of nasofrontal angles (-0.6% vs 1.1%, P = .09) and nasofacial angles (-3.6 vs -4.2%, P = .23).

Addressing gender dysphoria is necessary; young individuals with gender dysphoria are at significant risk for suicidal and self-harming behaviors as a result of discrimination and harassment.⁷ Facial feminization surgery has been associated with positive effects on improving mental health in transgender women and public perception and discrimination, beyond the effects of hormone or nonsurgical therapy.⁴ In cohort of 66 adult gender-diverse patients with gender dysphoria, a study done by Morrison et al found that facial feminization surgery improved patients' quality of life, significantly increased the femininity of their appearance, and led to high patient satisfaction after 1 month and 6 months.⁸ Rhinoplasty is a significant component of facial feminization given the prominence of the nose and baseline nasal differences between men and women due to different proportions of nasal bone and cartilage.²

Despite the clear role of feminizing rhinoplasty in alleviating gender dysphoria and facilitating gender recognition, the literature regarding approaches to maximize aesthetic satisfaction in transgender female patients post-rhinoplasty is sparse. In our surveyed cohort, the majority (84.2%) of patients were very satisfied with their postoperative nasal function, which is consistent with existing literature that techniques to preserve nasal functionality post-rhinoplasty are well-known and well-achieved.⁹ Given the rapidly increasing rates of facial feminization surgery utilization, it is important that surgeons are better equipped with a nuanced understanding of how to maximize aesthetic satisfaction while preserving nasal functionality. In this study, we find that patients who were very satisfied had significant reductions in dorsal length, smaller increases in tip projection ratio, and decreases in nasolabial angles when compared with the satisfied patients. Additionally, very satisfied transgender patients had insignificant differences in these metrics compared with cisgender women who underwent cosmetic rhinoplasty. Relative increases in dorsal length, tip projection ratio, and nasolabial angles were noted in satisfied patients when compared with both very satisfied transgender patients and cisgender female patients. To our knowledge, our study is the first to assess transgender patient satisfaction following feminizing rhinoplasty in the context of postoperative nasal dimensions.

Dorsal length reduction and dorsal hump straightening are well-established components of feminizing rhinoplasty, as the male dorsum is generally considered to be more prominent than the female dorsum.^3,10,11 In their study assessing gender differences in perceived nasal attractiveness based on how cisgender men and women rated noses, Springer et al reported that optimally feminine noses had short dorsal lengths and concave dorsums, while optimal male noses had straighter and longer dorsal profiles.¹¹ This trend is paralleled within our cohort, as the very satisfied patients had a relative decrease in dorsal length, while satisfied patients had a relative increase in dorsal length (-1.2% vs 5.7%, P = .043). Similarly, the literature describes male tip projection as greater than female tip projections.^4,12 The same study by Springer et al also reported that female noses with smaller tip projection were considered more attractive by cisgender women.¹¹ Our data are similarly congruent with the literature, as very satisfied patients also had relatively smaller increases in their tip projection ratio, compared with satisfied patients who had relatively larger increases (2.4% vs 8.1%, P = .038). We also found similar median relative changes between pre- and postoperative dorsal lengths and tip projections between cisgender patients and very satisfied transgender patients. Berli and Loyo found that although the technical bases for feminizing rhinoplasty and cosmetic rhinoplasty are the same, aesthetic considerations can vary, as cisgender patients typically want specific changes to their nose, while transgender patients typically want a more feminine appearance overall.¹² Given that facial feminizing surgery approaches are highly informed by patients' preferences, our reported similar relative changes in dorsal length and tip projection between cisgender women and very satisfied transgender females suggest that some approaches to maximize patient satisfaction for these 2 types of rhinoplasties can overlap.

The nasolabial angle is another important component of feminizing rhinoplasty. The literature alludes to differences in masculine and feminine nasolabial angles; the ideal male nasolabial angle is thought to be around 90° to 100° while the female nasolabial angle is around 100° to 110°.¹³ In our cohort, very satisfied patients had relatively decreased nasolabial angles compared with satisfied patients, whose nasolabial angles increased (-2.5% vs 9.7%, P = .026). Thus, very satisfied patients in our cohort had decreases rather than increases in their nasolabial angles as predicted by the literature. This discrepancy between our findings and the current guidelines may be explained by ethnic differences. Hinno et al assessed whether a random selection of 98 individuals chose the most aesthetic male nasolabial angle differently based on their age, sex, race, and education.¹⁴ Their study found that all of these factors affected what person finds as the most ideal nasolabial angle; for example, female subjects, participants over 50 years old, and Caucasian and Asian subjects chose more obtuse nasolabial angles compared with male, Native American, and younger subjects, who chose acute angles.¹⁴ Rohrich and Bolden also report the nasolabial angle as a dimension that varies among Caucasian, African American, Hispanic, Indian, and Middle Eastern individuals.¹⁵ Existing feminizing rhinoplasty guidelines are largely based on studies of ethnically homogenous cohorts of young, Caucasian transgender women.¹⁶ Our study is unique in that it includes a greater racial diversity of patients, as 42.1% of patients were Hispanic. However, given the large diversity of transgender individuals increasingly seeking care, there is a growing need to further characterize potential ethnic differences in nasolabial and other postoperative aesthetic nasal preferences in larger and more ethnically diverse cohorts of transgender patients.¹⁵

As with the nasolabial angle, increases in nasofrontal angles have been reported in the literature as a goal of feminization procedures. This recommendation is influenced by the male nasofrontal angle being smaller than the female angle. Dang et al report the ideal male nasofrontal angle to be approximately 130° while the female nasofrontal angle is approximately 145°.⁴ Although the difference between the groups was not significant, very satisfied patients had larger relative increases in their nasofrontal angles compared with satisfied patients (4.2% vs -0.6%, P = .071). Bellinga et al underscore the importance of the nasofrontal angle in facial feminization in their analysis of 200 patients who underwent feminizing rhinoplasty in combination with lip-lift and/or forehead reconstruction procedures, reporting that patients were highly satisfied with the femininity of their appearance after significant changes to their nasofrontal angles.² In fact, it is common for feminizing rhinoplasty to be performed in combination with other procedures, such as forehead reconstruction, lip-lift, or jaw contouring, to construct a harmonious appearance for the patient.^3,17 Chaya et al report that within a cohort of 77 transgender patients, most patients underwent at least 5 different facial feminization procedures during their gender transition, including feminizing rhinoplasty.¹⁷ This trend is reflected within our cohort, as 89.4% of patients also received other facial feminization surgeries at the time of the rhinoplasty. The nasofrontal angle is not thought to be significantly altered by rhinoplasty alone, and it often requires frontal sinus setback and front-orbital contouring as part of the procedure.¹² In fact, 7/12 (58.3%) and 4/7 (57.1%) of very satisfied and satisfied patients, respectively, in our cohort also underwent frontal sinus setback and front-orbital contouring. The similar utilization of the rhinoplasty in conjunction with frontal sinus setback and front-orbital contouring in both groups may explain our observed nonsignificant differences in nasofrontal angles between very satisfied and satisfied patients.

 Limitations of this study include the small cohort size of 19 transgender patients and 5 cisgender female patients, which underpowered our significance analyses and limited our ability to construct multivariable logistic regression models and assess which factors were associated with increased satisfaction. In controlling for confounding by only selecting patients operated on by the senior author and with 3D image data in Vectra to standardize the surgical techniques and mode of measurements, our cohort size was reduced. Additionally, as described by Rohrich and Bolden, preferences for an optimal feminine nose can differ based on ethnicity. Our cohort was mostly non-Hispanic White and Hispanic, but given the small cohort size, it was difficult to discern any ethnic differences in postoperative satisfaction; we look to future studies with larger and more racially diverse cohorts to identify if any such differences exist. Further, facial feminizing rhinoplasty is often performed along with other feminizing surgical procedures. In our cohort, 89.5% of patients also received other surgeries at the same time as the rhinoplasty, including genioplasties, face lifts, brow lifts, mandibular contouring, facial bone osteoplasty, and frontorbital contouring, to create a more harmonious and feminine appearance of the face. The effects of these other procedures could not reliably be assessed using the Vectra software beyond the metrics studied. As a result, we must consider the limitation that a patient's overall satisfaction is also dependent on the outcomes of the other surgeries, which alter the dimensions of the face and thus affect the measurements of the nose in relation to other facial features. Thus, it may be difficult for a patient to rate their satisfaction with rhinoplasty alone. However as feminizing rhinoplasty is not always performed in isolation, analysis of patient satisfaction with final postoperative dimensions in the setting of other simultaneous procedures is important. There are also other nasal metrics that could have provided further context to postoperative nasal changes that were not calculated by the software, such as alar base and tip width. Additionally, given the constraints of the cohort size, the cisgender female cohort could not be matched based on age and race to the transgender female cohort, which would have further strengthened nasal metric comparisons between the two groups. Data on satisfaction of the control cisgender female patients was not collected, as the focus of the research was on obtaining aesthetic outcomes of femininity in line with our transgender patients' identities and their satisfaction with their appearance as a result. Another limitation is that patients were surveyed at different postoperative times. Even though 8 weeks post-rhinoplasty was the minimum and most postoperative swelling is resolved within the first 3 to 4 weeks, some patients may still experience swelling for up to a year based on the nature of the procedures performed, which may affect their perceived satisfaction. Future studies could be strengthened by analyzing postoperative nasal metrics at 6 months or later to minimize any effects from postoperative swelling and better approximate the final nasal form. We look toward studies with larger and more diverse cohorts across several institutions to enhance our understanding of how to best maximize patient satisfaction in feminizing rhinoplasty.

Very satisfied transgender patients had decreases in dorsal length, smaller increases in tip projection ratio, and decreases in the nasolabial angle compared with satisfied patients. These data can help focus feminizing rhinoplasty approaches to maximize satisfaction. Further, very satisfied transgender patients had similar changes as cisgender females, reaffirming the utility of applying cisgender female rhinoplasty considerations to feminizing rhinoplasty.