At the lip she requested upper lip lift to shorten the philtrum and Cupid's bow and enhance the upper lip by means of rotating it outwards; this was performed by means of the so called bullhorn lift or more properly indirect upper lip lift and philtrum shortening, with incisions concealed at the nasal base creases, alae, nostrils and columella; the bullhorn lift is one of the most feminizing maneuvers in a face, as long as it is indicated by existing a long philtrum, involving an inexpensive and minimally aggressive procedure.
The most difficult part of this facial feminization case was the profileplasty requested to fully reshape nose and chin, especially the nose about which the patient sought a very specific custom design as per her request.
This nose was featured by some of the most difficult technical challenges one can meet in the structure rhinoplasty field; to begin with the dorsum was angled and divergent, with a very prominent supratip and a very low or sunken radix, requiring a seesaw effect by means of lowering the supratip hump and raising the radix using an onlay graft of cartilage and camouflage perichondrium spared from the cartilaginous supratip hump, suitably tailored to fit such extremely hollow radix; the dorsum received an atypical hump shave in decrease, aggressive at the supratip, moderate in center, slight at the high dorsum and nothing but a filler graft at the radix.
The septum was very short, abnormally short and retracted, which lead to a poorly supported and upturned tip and columella, nostrils exposure, a wide nasolabial angle and, indirectly and associated with the divergent dorsum, a supratip prominence or polly beak deformity; to correct this issue a deep septum cartilage window of graft was harvested and mounted as caudal septal extension graft, one on one modality, and using this neo septum as strut by the principles of the tongue in groove maneuver the tip and the medial cruras were assembled and secured to it, acting then as pure extended columellar strut.
Finally the cephalic excess of the alar cartilages was removed to reduce the bulbous shape, the tip was deprojected and the domes received plasties, plication and an extended tip and columella graft plus an onlay shield graft at the very right tip to allow the desired customization effect aiming to feminize the tip and the columella.
At the end of the procedure an alar base reduction to reduce the nostrils flare was applied, which turned in a very nice and proportionate look at the alae.
About the chin the goal was clear, making it sharp and petite like a Slavic woman would look; for such purpose a three dimensional reduction genioplasty was designed and applied, by means of an oblique osteotomy and cutting away a meticulously calculated oblique slice of bone, plus the removal of a horizontal chip of bone from the chin fragment side; thus all the three axes of the chin could be downsized and the dome of the chin made sharper, the distance from lower lip to chin's edge shorter, the frontal width made narrower and the overall chin deprojected very suitably.
As can be seen the new chin is perky, has lost the square masculine look to become narrower, round and sharper, the vertical distance between the lower lip and the chin's edge has been shortened and the projection significantly decreased to create a comprehensive effect of feminization in harmony with the patient's new facial balance.
The final result matches the patient's expectations about both her feminization and customization goals; the frontonasal depression has been raised, the profile realigned, the nose reduced and the tip fully redesigned, the chin underwent resizing and reshaping, the lip enhanced and the new facial balance is feminine and meeting the preoperative plan.
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