Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management.

Abstract

Sir: We are in agreement with the authors of the Special Topic article, “Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management,” that call for clinical protocols and structured guidelines for this burgeoning surgical field.1 However, we feel there is a need for multidisciplinary care when considering a full protocol for gender confirmation surgery, much like what exists in the field of cleft and craniofacial care. Although the focus of the article is on facial feature modification, Figure 1, left, suggests that there are other important elements of transgender patient care (e.g., counseling, hormone therapy, other gender-confirming operations). If a multidisciplinary transgender team cannot physically meet, a virtual team with good communication can still provide “best practice” for transgender patient care. Before facial feminization surgery, our team requires documented treatment notes from a hormone provider, a dedicated therapist, and other team members. As the authors demonstrated, patient selection is paramount: “The patient should be psychologically prepared for surgery.” Even with established patient care protocols, there will likely be variation in operative technique. Interestingly, less than 10 percent of the authors’ approach to the orbital nasal complex (brow) involved an anterior hairline (hairline-lowering) incision. Our experience is quite the opposite, with 90 percent of patients requiring hairline lowering. Our goal is to bring the hairline, including the temporal region, to within 12 cm of the brow. We found this diminished the subsequent need for extensive hair transplantation. With regard to the lower jaw feminization, the authors demonstrated a full inferior mandibular border resection in Figures 3 and 7. Although we have used this technique in select patients, it is unusual (also <10 percent). Instead, we typically prefer a more conservative mandibular angle ostectomy and genioplasty shortening/narrowing. Although the type and sequence of facial feminization surgery procedures (e.g., frontal sinus setback, supraorbital recontouring, rhinoplasty, mandibular angle reduction, genioplasty, laryngotracheoplasty) may be tailored to the individual patient, we believe it is the combination of multiple facial procedures that has the beneficial effect of feminizing the face. The authors mentioned that osteotomy guides were “under development” and may save time and add to precision. We agree with the authors and have found that routine use of virtual planning, cutting guides, and custom plates for facial feminization surgery cases adds to safety, efficiency, and accuracy.2 Virtual planning for facial feminization surgery does not take away from the surgeon’s autonomy or artistry; rather, it allows the patient to participate in preoperative planning. Although beyond the scope of this article, we believe it is important to demonstrate objective outcomes: facial feminization surgery has been shown by artificial intelligence and public perception to successfully reduce misgendering and increases the probability that a patient is correctly recognized as being the gender they identify as.3,4 Each year, more transgender centers are being established in the United States and worldwide. Each year, more insurance companies are considering facial feminization surgery procedures as medically necessary and reimbursing procedures. This article is timely. The authors should be commended for guiding this field with their protocol for preoperative diagnosis, surgical planning, and postoperative management. DISCLOSURE Neither author has any financial disclosures to declare. Mark Fisher, M.D.James P. Bradley, M.D.Division of Plastic and Reconstructive SurgeryNorthwell HealthZucker School of Medicine at Hofstra/NorthwellGreat Neck, N.Y.