Is reduction rhinoplasty a feminizing procedure?

Publication date: 3/10/2025

One item that frequently arises as an issue during insurance authorization is whether a reduction rhinoplasty for decreasing the size of a dorsal hump should be considered a feminizing procedure. Among facial feminization surgeons, a reduction rhinoplasty (i.e. making the nose smaller through surgery) is widely considered to be a feminizing procedure. It is frequently performed during facial feminization surgery and is frequently discussed at national conferences as a part of facial feminization surgery. Unfortunately, there is minimal data on this topic, but there have been multiple publications focusing on the topic.

Jacobs et al., for example, state on page 39 of their article, “The feminine dorsum is considered straight or slightly concave (within 2 mm) while the ideal masculine dorsum is straight.”¹

Another paper stating the importance of a reduction rhinoplasty in facial feminization surgery is one written by Dr. Jordan Deschamps-Braly, a leading facial feminization surgeon in San Francisco.² The relevant sections are below:

Rhinoplasty is a difficult art. This maxim holds true regardless of the context in which rhinoplasty is performed. Most rhinoplasties performed in trans women are reduction rhinoplasties. […]  In the context of feminization surgery, when one reshapes and sets back the glabella, the nose will seem to be larger. In addition, recessing the forehead creates a step off at the level just above the radix.

Creating a smooth dorsal line from the forehead to the caudal tip of the septum is of critical importance. Also, one must create the proper nasofrontal angle, nasolabial angle, and angle of the nose. This means often performing large dorsal reductions. Most patients require reductions as great as 5 to 7 mm. This modification creates large openings in the bony dorsum and medialization of the nasal pyramid is usually necessary. Spreader grafts formed from septal cartilage are almost always too wide for nasal feminization. Spreader grafts are useful; however, they must be thinned. Otherwise the nose will seem to be too wide at the conclusion of the case. The tip is almost always too large and requires modification owing to oversized male lower lateral cartilages.

Alar wedge resections are much more common than in primary rhinoplasty in cis-gender patients. One of the debates in rhinoplasty is that nasal reductions lead to an increase in secondary deformities. We routinely do this during feminizing rhinoplasties, and do not find this to be the case.

Another article written by Dr. Deschamps-Braly reiterates the importance of reduction rhinoplasty with the statement below.³

Discussion of rhinoplasty techniques may be found elsewhere; however, in broad terms, significant reduction rhinoplasties are required to feminize a nose.

Another paper that recommends reducing the dorsum is written by Dr. Justine Lee. Dr. Lee is a leading facial feminization surgeon in Los Angeles who has a heavy academic practice focused on researching gender-affirming facial procedures. The section below is on page 507.⁴

Depending on the patient, dorsal reduction is frequently necessary due to the overall projection of the more masculine nose compared to feminine noses. Berli and Loyo suggested that the goal of dorsal reduction should be a nasal dorsum approximately 1–2 mm posterior to an imaginary line between the ideal nasal tip and the nasion.

In addition to the subjective evaluation of the masculine and feminine nose, there are also cultural indicators of what makes a masculine and feminine nose. For example, Megan Lane MD suggests that as surgeons, “we are made acutely aware of the makings of a ‘feminine face,’ such as a gentle slope to the nasal dorsum with a supratip break.”⁵

Summary

Achieving a natural and aesthetically pleasing nasal tip requires a deep understanding of the LCRA and its impact on nasal aesthetics. By carefully assessing the angle during preoperative planning and employing appropriate surgical techniques, rhinoplasty surgeons can create harmonious and functional nasal tips that enhance facial balance and improve nasal airflow.

Dr. Mittermiller

Dr. Mittermiller has substantial experience in Feminizing Facial Surgery (FFS) and frequently performs intricate procedures like reduction rhinoplasty as part of comprehensive facial feminization. Beyond technical expertise, Dr. Mittermiller has a thourough understanding of diverse gender identities and expressions, ensuring his surgical approach is sensitive to each patient’s journey and goals. He is highly attuned to ethnic, cultural, and gender differences and preferences in nasal aesthetics, consulting closely with patients to create a result that is both feminizing and harmonious with one’s background. Dr. Mittermiller’s goal is to help each patient achieve an appearance that reflects their truest self.

Citations

1. Jacobs J, Johnson CZ, Loyo M (2023) Feminization rhinoplasty. Operative Techniques in Otolaryngology-Head and Neck Surgery 34 (1):38-45. doi:https://doi.org/10.1016/j.otot.2023.01.006 https://www.optecoto.com/article/S1043-1810(23)00006-4/abstract
2. Deschamps-Braly JC (2018) Facial Gender Confirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery. Clinics in Plastic Surgery 45 (3):323-331. doi:10.1016/j.cps.2018.03.005 https://pubmed.ncbi.nlm.nih.gov/29908620/
3. Deschamps-Braly JC (2019) Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management. Journal of Craniofacial Surgery 30 (5):1352-1358. doi:10.1097/SCS.0000000000005391 https://pubmed.ncbi.nlm.nih.gov/31299721/
4. Dang BN, Hu AC, Bertrand AA, Chan CH, Jain NS, Pfaff MJ, Lee JC, Lee JC (2021) Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose. Archives of Plastic Surgery 48 (5):503-510. doi:10.5999/aps.2021.00199 https://pubmed.ncbi.nlm.nih.gov/34583435/
5. Bui E, Elliot I, Megan Lane “What Does Feminine Mean to You?” The Surgeon’s Role in Guiding Pre-Surgical Decision Making for Facial Feminization Surgery. FACE 0 (0):27325016251397665. doi:10.1177/27325016251397665 https://journals.sagepub.com/doi/abs/10.1177/27325016251397665