How Computer-Aided Planning in Facial Feminization Surgery isn’t all that it is Touted to be: SHOULD PATIENTS RELY ON VIRTUAL SURGICAL PLANNING FOR FFS SURGERY?

A number of surgeons have begun to utilize virtual surgical planning, exact printed anatomical models, a Sonopet, and ultrasonic bone tools in Facial Feminization Surgery. Is it hype? Does it represent reliable outcomes? Should you trust it? 

During many of my consultations in the office, I am asked about various “new” technologies being used in facial feminization surgery.  Many new technologies are used as marketing tools by surgeons who wish to obtain more business in another niche area of medicine with only a few truly experienced surgeons in this field.  

Virtual Surgical Planning or computer-aided planning in surgery has been a very large advancement in craniofacial surgery.  However, it has very specific areas of efficacy – there are a few areas where it is extremely helpful, and other areas where it is almost a complete waste of the patient’s money. In fact, it can slow the operation down leading to increased cost and poorer outcomes for patients.  

AN EXPLANATION OF VIRTUAL SURGICAL PLANNING – UPSIDE/DOWNSIDE

Virtual Surgical Planning is a tool where you can simulate bone movements or procedures on a three-dimensional planning software.  This software was initially developed within the realm of craniomaxillofacial surgery for the use of orthognathic surgery.  Orthognathic surgery is essentially bite correction surgery.  The planning of these operations when I was initially trained involved taking models of the teeth, and then planning the operation on paper and performing “mock” surgery on models of the teeth.  You would then create surgical jigs out of acrylic or other light-activated curing materials in order to “calibrate” the surgery.  Precision was key.  The old way was quite accurate, however, it was very time-consuming.  Virtual surgical planning allows us to do the exact same thing, however, it occurs much more quickly and the precision is increased slightly.  The cost of materials and equipment is slightly higher because of the need for three-dimensional printers. This was a great use in craniomaxillofacial surgery.

There are other uses for this technology as well.  Virtual surgical planning is well used with patient-specific implants where a patient for instance has an asymmetry and needs an implant that will improve or restore symmetry.  This is something that cannot be done very well any other way.  This is most effective for a generally singular issue with many of the other factors of surgery constant. 

FFS is an extremely intricate surgery that has hundreds of consideration factors – often occurring during the procedure. For instance, many of the outcomes during facial feminization surgery cannot be precisely predicted based on exact bone movements.  What that means is that you may make a very precise change in the bone, but then you need to look at the patient and decide – based on the overall bony/tissue/muscle structure, symmetry, and patient’s goals – do you need to do more or less or make minor changes in the overall plan – and this needs to be done “on the spot”. Knowing that this is our reality – for the surgeon and our patient, it negates the time spent on “precision planning” via computer.  In addition, such planning for facial feminization surgery adds significant cost and expense to the operation without much if enough benefit; we feel we can do this planning with a perfect set of radiographic imaging and perfect measurements. That is one of the many reasons our consultations are so thorough as well as our resulting surgical planning. 

LET’S TALK MODELING 

Exact 3D anatomical models of patients are great props for use in the office while showing a patient their anatomy.  It is possible to create surgical “guides” from these models and these guides in theory tell you where to cut when doing surgery.  However, they are no more helpful to a surgeon in surgery than looking at those images on a computer screen and are not useful if the surgeon who is designing the guides doesn’t understand the skeletal characteristics of a feminine face.  

TOOLS ARE ONLY AS GOOD AS THE SURGEON USING THEM 

As for ultrasonic bone cutting tools, this technology is like all of the others; It has very occasional applications but is not a one size fits all solution for surgery of the facial bones.  Piezoelectric or ultrasound cutting bone tools are essentially similar to a basic surgical saw, only the amplitude of the oscillations are much smaller and the frequency is much higher.  They still create heat and still have the capacity to burn the bone which you are working on.  These tools do tend to be a little safer around the soft tissue, however, they are incredibly slow and dramatically increase the surgical time.  

The sonopet is a great tool for beginning surgeons who are not confident with their tools and or have less than good surgical technique.  One example of this is when I did a direct comparison of two genioplasties.  I did one genioplasty during an OR day with a traditional saw and timed how long it took to “cut the bone”.  I did another with the sonopet for a comparison.  The time it took to cut the bone with the traditional bone saw was about 45 seconds.  The time it took to cut the chin with the sonopet was about 12 minutes.  It was literally 16 times slower than the traditional saw, and there were burned areas of bone where the sonopet had created too much heat.

There are exceptions — the Sonopet is very good at cutting very thin bones in delicate places.   For example, when one is performing a le fort Osteotomy to move the “mid-face”.  There are often interferences of bone at the skull base where there are some very delicate blood vessels which if injured could cause life-threatening bleeding.  I have found great utility in these areas for the sonopet where other tools would be less ideal.  

CONCLUSION – ARE YOU CERTAIN? 

Every tool and technique has its place in the arsenal of a surgeon.  However, these tools should not be used as blanket marketing tools for inexperienced surgeons to draw patients into their practice and try and increase patient’s confidence in their surgery.  Patients do not always have the medical acumen to understand when they are being marketed too and some of these tools can detract from the actual skill of the surgeon. Be sure to ask the right questions, don’t be “dazzled” and ensure that your selected surgeon has the appropriate skills for your desired outcome.  Hopefully, this piece will shed some light on some of these current topics.

Extrinsic (external) and intrinsic (internal) factors contribute to skin aging. Extrinsic aging (photoaging) is caused by exposure to UV radiation, tobacco smoke, air pollutants, digital blue light, and other lifestyle choices. Intrinsic aging (chronologic aging) is influenced primarily by genetic factors. Between the ages of 25-30 years of age, collagen production begins to decrease by approximately 1% to 1.5% annually. Because of this, the skin thins and loses elasticity, leading to the appearance of fine lines, wrinkles, skin laxity, and discoloration.

While we can’t control our genetics, lasers and intense pulsed light (IPL) treatments can reverse the impact of sun exposure and lifestyle choices to boost collagen production, reduce the appearance of capillaries and brown spots, and improve skin texture and tone.

During an IPL treatment, specific parameters are chosen to target redness and pigmentation and stimulate new collagen production.  Multiple wavelengths in the visible light spectrum are emitted simultaneously, allowing a range of targets within the skin to be selectively heated and destroyed. Your body will naturally begin the healing process and results are fully realized in approximately six weeks.

Fractional lasers target a small portion of the skin leaving the untreated skin to rejuvenate and repair the treatment area. Many thousands of fractional microchannels are created in the skin to improve the appearance of fine lines and wrinkles, minimize pore size, and reduce the appearance of scars and stretch marks. Some downtime is to be expected, including mild redness and swelling and some light flaking after a few days. Typically a long weekend will be more than enough time to return to social activities.

Both IPL and fractional laser treatments can be performed alone. However, combining both therapies during the same treatment session compounds the results and provides a more comprehensive approach to improving the effects of extrinsic aging factors. Typically a series of 3-5 treatments spaced 3-4 weeks apart are necessary to achieve the best aesthetic outcome. Once a treatment series is complete, we recommend 1-2 treatments per year to maintain the3 results, as well as a medical grade skin care regimen.

We spend time choosing skin care products and treating lines, wrinkles, and sagging skin for our face to reverse the signs of aging. But what about our hands?

The skin and structures of the hand age in the same manner as the face. Over time, the fatty structures of the hands deflate, and the loss of tone in the intrinsic hand muscles can make veins, bones, and tendons more visible. The microscopic vasculature of the hands diminishes over time, and thinning of the skin over time can cause dryness and reduced elasticity. After the age of 50, bone density in the hands decreases by 0.72% per year (reference). Sun exposure can further damage collagen and connective tissues, further exposing the age of your hands.

I know what you’re thinking. Add it to the list….When you think about it, the hands are the most utilized part of your upper body. We use them during our waking hours for multiple tasks and functions. They deserve some attention too, would you agree?

Dermal fillers to the rescue! Adding volume to the hands can rejuvenate the hands, reversing signs of aging and add lost volume, and make the hands appear more youthful. We use Restylane® Lyft, the first FDA-approved filler to improve volume in the hands. Not only is the treatment quick and painless, but the results can also last for 9 months or more.

Restylane®Lyft is composed of hyaluronic acid, a compound found naturally in the body which holds water in our skin and provides lubrication to our joints. We produce and degrade hyaluronic acid daily in our body. The difference with hyaluronic acid fillers is that the molecules are bound together, or crosslinked, making it more difficult for the body to break down, allowing the filler to provide a longer-lasting result.

References:

https://academic.oup.com/biomedgerontology/article/58/2/M146/593573?login=true

One of the most common points of confusion I hear during consultations is patients trying to decipher between implants or fat grafting. This is especially true when they hear from another surgeon that cheek implants are necessary for feminization and/or that fat grafting “does not last”. 

The truth is: it depends. There is not a right answer that applies to every person’s face. There is not a sexual dimorphism basis for actually increasing the size of one’s cheeks as part of facial feminization surgery –  having larger or smaller cheeks is not inherently feminine or masculine. 

CHEEK IMPLANTS – THE GOOD AND THE BAD

Cheek implants have one main selling point:  they are very reliable in terms of affecting a shape. However, the shape and placement of those implants often is often imperfect and they  also have the drawback of having close to a 3% infection rate, if an implant gets infected then it is necessary to remove the implant.  If one implant is removed, it usually makes sense to remove both so that the patient does not have an awkward appearance.

Cheek implants also do not tend to affect the anterior and medial most portion of the cheek or malar region because of the location of the maxillary branch of the trigeminal nerve prevents practical placement of an implant in this region.  Therefore patients tend to be left with a bulbous or exaggerated appearance in the lateral part of their cheek while their under eyes appear more  hollow and the anterior part of the cheek remains under projected. 

Another issue in particular to trans women is that transfeminine patients have often lost a significant amount of weight as part of their transition, and implants in very thin patients often tend to look exaggerated and visible while lacking the finesse of other techniques.

MY CLINICAL APPROACH

My main application for facial implants on the cheeks in patients is when there is significant asymmetry. In that case I will create a custom made implant for that individual patient based on a 3D CT scan of their skull in order to provide for better symmetry. 

When there is not significant asymmetry, I will generally choose fat grafting. The other main benefit of fat grafting to the face is that you have a very versatile ability to sculpt the entire face in a way that you cannot do with facial implants.  You can easily add fat to areas such as the temple, the zygomatic arch area, the cheek, the under eye areas where people often have depressions or dark circles, and you can add volume to the nasolabial folds therefore adding youth to the face.  This versatility is not present with facial implants and is one of the main adaptive selling points of using fat transfer.

Surgeons who do not offer fat grafts or do not do them well will say that fat grafts do not live.  This is a deceptive statement. The “true” story is that not all of the fat that is injected survives the transfer and usually around ⅓ of the fat that is transferred does not live.  However, the remaining portion of the fat that survives is in fact permanent.  This has been well studied not only in the laboratory but in real world academic research and any statement to the contrary is simply false.

Therefore, my most frequent go to technique is using fat grafting with the exception of a few unusual circumstances. 

To be completely forward, I should say that fat grafts tend to not have quite as predictable an outcome as implants do, however, I feel that our patients have been extremely satisfied, and it provides the opportunity to go back and add some additional fat or touch up certain areas.  That type of finesse is not possible with facial implants.  Fat grafts avoid most of the risk of infection that an implant will often hold, it doesn’t have the same risk of injury to nerves in the face that facial implants do, and of course holds the possibility of improving skin quality. 

THE BEST WAY TO GET AN ANSWER FOR YOUR FACE

A thorough consultation, essential facial imaging, thoughtful planning, and precise measuring is the key to getting a stellar result. We encourage you to have this discussion with us if you have any lingering concerns about which technique is right for you. 

We are often asked to evaluate patients who have previously had orthognathic surgery and are unsatisfied with their results.  One would think that the most common problem after orthognathic surgery is an occlusion issue (the relationship of how the teeth fit).  The reality is that the real issue tends to be more subtle and complex – simply “I liked the way my face looked before”.  

The profile of a masucline vs feminine face is very different.  Not only in terms of vertical height but when viewed on profile in terms of the relationship between the nose, lips, and chin.  This relationship must be taken into account when performing orthognathic surgery in order to maintain a gender appropriate appearance of the face upon which surgery is being performed.

Surgical Techniques Often Solve One Problem – But Create Another Incidental Problem 

After seeing dozens of such patients, one of the most common things we see is that the chin is sometimes elongated, making the face (and especially the lower face) too tall regardless of whether the maxilla was impacted or not. This is often because of the rotation of the two jaws.

Another common issue we often see is that as the occlusal plane has been flattened, the chin has overly rotated and become excessively prominent for femine proportions.  These two surgical techniques may lead to a masculine appearing chin and or lower face. Ultimately, this  may be hard for patients to describe to a surgeon without exceptional clinical knowledge – they just see the result in the mirror. 

Another commonly noted thing among patients: when advancements of the mandible are larger, the corners of the jaw may appear unusually narrow and patients may lose definition of the jaw line.  This often leads to people feeling that they have an aged appearance and that their neck and jaw are not as beautiful as they once were prior to having surgery.

What Are My Options? 

Depending on your exact previous surgical plan, there are a few options to bring back a more feminine appearance. Don’t fret: treatment rarely ever consists of completely redoing the orthognathic procedure.  Although this may be occasionally necessary, it is usually possible to improve the situation with less drastic measures.  

It is often possible to perform a feminization of the chin, by shortening the height of the chin using very precise osteotomies (bone cuts) as well as a reduction to reposition the chin into a shorter space.  In addition, it may be necessary to reposition the chin either forwards or sometimes slightly backwards in order to correct the position of the chin.  

If the issue is loss of definition along the jawline, then a jaw contouring operation along with placing implants along the border and angle of the jaw can restore a more natural and harmonious appearance.  The implants needed in this area often are surprisingly conservative.  We have worked on a number of patients in whom we have placed implants and have learned that there is a very fine balance between placing an implant that is too large in this area and leading to a masculine appearance and of that of a patient having bruxism.  Therefore we usually recommend very conservitive sized implants to correct this situation.  The implants must be placed with finesse and often contoured to make sure that the implant edges sit flush with the bone so that the edges of the implant are not palpable and/or visible.

What Is My Next Step? 

It’s always advisable to schedule a consultation with your surgeon as the possible scope of what may be needed is more complex than can be addressed in a short summary.  Your surgeon should be able to give you suggestions as to what the problem is and what may be done about.  Rarely is redoing the entire orthognathic operation the solution to these problems, because an acute understanding of the differences between masculine and feminine facial morphology and features is critical, be sure to select surgeons who specialize in Craniomaxillofacial surgery, have proven results you can see, as well as understand the minute details of facial proportion and balance. 

Elegance isn’t solely defined by what you wear. It’s how you carry yourself, how you speak, what you read. We have got to change our ethics and our personal financial system and our whole way of understanding the world. It has to be a world in which people live rather than die a sustainable world.

I didn’t want to be a fashion designer, and for a good half of my career I didn’t like it. I always wanted to do other things. It’s the attitude you bring to clothes that make the difference. Everything I do is a matter of heart, body and soul.

We are excited to announce the opening of our new office space along with a simultaneous feature in the online and print editions of Wallpaper* magazine.

Located in the Tiffany Building overlooking Union Square in San Francisco’s downtown district, this modernist space was designed by Delugan Meissl Associated Architects, Vienna — designers of the Porsche Museum Stuttgart, Germany.

“The extraordinary precision, subdued beauty, and intimate ambiance reflect the approach of both architect and doctor: ‘We very consciously sought to avoid associations with a sterile clinical space,’ explains Delugan.”

– read more in Wallpaper* magazine 

Rhinoplasty for Persian (Iranian) Noses

Rhinoplasty (“nose job” or nasal surgery) is very popular with Iranians, or Persians, with Iran having one of the highest rates of nasal surgery in the world. As a consequence, people with a Persian or Iranian background are very knowledgeable and savvy about the look they want to achieve with rhinoplasty. There are large Persian communities in the United States, including in Los Angeles, who actively seek to change the shape and size of their noses for various reasons.

Even though one of the most common plastic surgeries, a typical nose job is one of the most difficult of all plastic surgery procedures. Surgeons need technical excellence and a sense of artistry to understand how to design a new nose that will suit you and take into consideration your cultural background.

Dr. Deschamps-Braly has extensive experience in plastic surgery and rhinoplasty for people of all major ethnicities and has the flexibility to adapt his work to suit a range of needs for people with a Persian or Iranian background.

His training in three surgical disciplines enables him to combine surgical experience and artistry with an understanding of the differences in the proportions of facial features to provide a result that best suits his clients’ needs.

Reasons People with Persian Backgrounds may seek a Nose Job

For many years, plastic surgeons created the same shape nose for every client and often that nose was based on a Caucasian or “white” standard. However, a good surgeon should listen and understand your needs and design a nose in harmony with the rest of your face and, if you prefer, with aesthetics that suit your ethnic or cultural background.

People consider a “nose job” for a range of reasons such as:

• Changing the size and shape of the nose to improve the appearance of the face
• Correcting structural changes caused by accidents or injuries

Many people of Persian or Iranian background prefer their new nose to look totally natural–as if they haven’t even had a nose job procedure. They also have major concerns about the possibility of complications or the need for additional work or revision after rhinoplasty.

To ensure the best possible result, choose a surgeon with diverse experience who listens to your needs and has the flexibility to design a surgical approach to suit you and your face.

A Personalized Approach to Rhinoplasty for People with a Persian Background

Of course, everyone’s nose and face are different, but people with a Persian background who want rhinoplasty may have nasal features including:

• a crooked nose
• a drooping tip
• a bulbous tip
• a bump on the bridge of the nose (dorsal hump)
• a nose that is too large, long or wide

No matter the size and shape of your nose, Dr. Deschamps-Braly will listen to your concerns and conduct a thorough physical examination of your nose and photograph you from several angles, including your profile and other features.

If your nose job is successful, your new nose should always be in harmony with the rest of your face. Some people with a Persian or Iranian background prefer their new noses to be in keeping with their cultural identity, while others do not. Once Dr. Deschamps-Braly understands the changes that you would like, he will use his vast experience and artistry to design a nose that he believes will give you the best possible result.

Want to know more about nasal surgery?

• Rhinoplasty (Nasal Surgery or “Nose Job”)
• Revision Rhinoplasty (Corrective Nasal Surgery)

Jaw Reduction Surgery, FFS, and Asymmetrical Jaws

Nothing in nature is truly symmetrical and all faces have a degree of asymmetry. But if your face has a more pronounced form of asymmetry, a range of approaches used during facial feminization surgery (FFS) can be helpful.

Many areas of the face can appear asymmetrical – from the hairline and forehead down to the chin and jaw. Asymmetry of the jaw and chin can especially impact the aesthetics of your face.

Depending on the nature of the asymmetries of your face, FFS can help to create a more harmonized and symmetrical look while also creating a natural, feminine face that reflects the inner you.

Dr. Deschamps-Braly has trained in three surgical specialties and has proven expertise in the artistry of facial feminization. He can advise an integrated approach and optimal timing for any surgeries needed to enhance the symmetry of your face while creating a naturally feminine look.

Options for correcting jaw asymmetry

Asymmetry of the jaw can affect both the aesthetics of your face and functions such as chewing. Physical asymmetries have a range of causes such as:

• Genetics – the jaw shape you were born with
• Developmental changes
• Injuries and/or illness
• Dental work

Depending on the nature of your facial structure, surgical options for jaw reshaping can include:

• Jaw correction surgery (orthognathic surgery)
• Jaw reduction or contouring surgery as a part of your FFS
• A combination of jaw correction and jaw reduction (contouring) surgery

If jaw correction (orthognathic surgery) is needed, we suggest you have this surgery first and ensure your bone is healed before you begin FFS. In that way, jaw reduction and chin surgery can be used to complete the feminine look of your lower face. Also, a word of caution, if jaw reduction is done before orthognathic surgery, it may no longer be possible to make the precise cuts needed for your orthognathic or FFS procedure.

Jaw reduction during FFS can improve jawline asymmetries

Feminizing the jaw with jaw reduction typically involves removing bone to contour and shape the jaw so it is narrower and less square. The procedure refines jawline angles and improves the proportions of the face, including asymmetries.

Whether or not corrective jaw surgery is needed, jaw reduction will be able to improve your jawline to give you the best possible result.

Jaw reduction and contouring procedures include:

• Reshaping of the back corner of the lower jaw bone so it appears rounder and less square
• Shaving bone off the lower edge of the jaw to make the jawline narrower and more feminine
• Shaving layers of bone off the sides of the jaw – the jaw bone (mandible) is structured like an oreo cookie, with a hard outer layer and a spongy middle layer followed by a hard inner layer. The entire cortical outer layer can be removed without damaging the structural integrity of the jaw
• Reduction of chewing muscles to give a narrower appearance (Masseter muscle reduction – can be either a surgical or non-surgical procedure).

Any asymmetry of the chin will also contribute to the overall look of your lower face. As the chin and jaw are often treated together in FFS, surgery to feminize the chin (genioplasty/mentoplasty) can help to correct any chin asymmetry at the same time.

Want to know more?

• Orthognathic (Jaw) Surgery
• Jaw Contouring (Reshaping/Tapering)
• Feminizing Chin Contouring (Genioplasty/Mentoplasty)
• Facial Feminization Surgery – Overview
• Key Elements of Facial Feminization for Women with Masculine-Looking Faces
• Considering Facial Feminization? Unsure About V-Line Surgery vs Feminizing Jaw Surgery?

References – for those who like to dig deeper

• Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and
  Principles of Management.
• Deschamps-Braly JC. Journal of Craniofacial Surgery, 2019; Apr 2 [Epub ahead of print].
• Feminization of the Chin: Genioplasty Using Osteotomies.
• Deschamps-Braly J. Facial Plastic Surgery Clinics of North America, 2019;27(2):243–250.

Is a “Nose Job” really that different for people of Indian and Pakistani backgrounds?

Of the plastic surgery disciplines, rhinoplasty (“nose job” or nasal surgery) is one of the most difficult. To get the most pleasing result, your surgeon needs a sense of artistry to design a new nose that suits you and your cultural or ethnic background.

For many years, plastic surgeons have created the same shape nose for every client and often that nose was based on a Caucasian or “white” standard. But a good surgeon listens and understand the needs of their client and designs a nose in harmony with the face and, if requested, cultural background.

Dr. Deschamps-Braly has extensive experience in plastic surgery and rhinoplasty for people of all major ethnicities. His training in three surgical disciplines enables him to combine surgical experience and artistry with an understanding of the differences in the proportions of facial features to provide a result that best suits his clients’ needs.

This diversity of experience means Dr. Deschamps-Braly has the flexibility to adapt his work to suit a range of needs for people of Indian or Pakistani backgrounds.

Rhinoplasty and People of Indian and Pakistani backgrounds

In South-Asian countries (including India and Pakistan), rhinoplasty has become increasingly popular, so now we have a much better understanding of the shape of noses of people from different regions.

It is not surprising that such a large land area contains people from many different cultures. If you are originally from South Asia or your family’s background is from that part of the world, your surgeon must be aware of the potential differences in your facial proportions and listen to your needs as you consider rhinoplasty.

People consider “nose jobs” for a range of reasons including:

• Correcting structural changes caused by accidents or injuries
• Changing the size and shape of the nose to improve the appearance of the face

No matter the reason, many people with Indian or Pakistani backgrounds want to have a nose job that results in a nose that sits in harmony with the rest of their face, while also maintaining their cultural identity.

A personalized approach to rhinoplasty for people of Indian and Pakistani backgrounds

The shape of South Asian noses is an active research area in the medical literature. Research shows there is not one single typical South Asian nose, per se, although there are some regional characteristics that may affect the outcome of your nose job.

The noses of people with North Indian and Pakistani backgrounds are more likely to have features in common with people with Persian or Middle Eastern backgrounds including:

• A drooping tip that can make the nose appear longer
• A bump on the bridge of the nose (dorsal hump)
• Wide bones in the upper nose

The noses of people from South India are more likely to have features including:

• A less defined tip of the nose
• A short nose bridge
• A wide base of the nose
• Thicker skin over the nose

No matter the physical characteristics of your nose and face, Dr. Deschamps-Braly will listen to your concerns and conduct a thorough physical examination of your nose and photograph you from several angles, including your profile and other features. Thicker skin can tend to mask the underlying surgical changes of rhinoplasty and, in this case, he can advise you if a different approach to your procedure is needed.

Once Dr. Deschamps-Braly fully understands both your facial features and the changes you would like, he will use his vast experience and artistry to design a nose that he believes will give you the best possible result.

Want to know more about nose job surgery?

• Rhinoplasty (Nasal Surgery or Nose Job)
• Revision Rhinoplasty (Corrective Nose Job)
• Masculinizing Rhinoplasty
• Feminizing Rhinoplasty

References – for those who like to dig deeper

• The Indian Nose, Nagarkar P, Pezeshk RA, Rohrich RJ. Plastic and Reconstructive Surgery, 2016, 138(5):836e–843e.
• Anthropometric Analysis of the South Indian Woman’s Nose, Packiriswamy V, Bashour M, Nayak S. Facial Plastic Surgery, 2016, 32(3):304–308.
• The Indian nose: An anthropometric analysis, Mehta N, Srivastava RK. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2017, 70(10):1472–1482.