Gender-affirming facial surgery (GFS) describes approaches and strategies to surgically feminize or masculinize the face. Although techniques for performing facial feminization surgery are widely described, surgical masculinization techniques are underreported. While hormone treatments typically accomplish adequate masculinization in most cases, nonsurgical therapy is not universally effective. Surgical masculinization may be undertaken after lack of efficacy of nonsurgical therapy. With a deep understanding of the volumetric differences of the male facial skeleton, facial masculinization surgery essentially follows an augmentative paradigm for the upper, middle, and lower thirds of the face. Herein, we describe operative techniques used for facial masculinization. Gender-affirming facial surgery (GFS) describes approaches and strategies to surgically feminize or masculinize the face. Although techniques for performing facial feminization surgery are widely described, surgical masculinization techniques are underreported. While hormone treatments typically accomplish adequate masculinization in most cases, nonsurgical therapy is not universally effective. Surgical masculinization may be undertaken after lack of efficacy of nonsurgical therapy. With a deep understanding of the volumetric differences of the male facial skeleton, facial masculinization surgery essentially follows an augmentative paradigm for the upper, middle, and lower thirds of the face. Herein, we describe operative techniques used for facial masculinization. Gender-affirming facial surgery (GFS) enables structural alterations to the face so that transgender patients may more fully achieve congruence between their internal gender identity and their facial anatomy. While receiving much less attention than facial feminization surgery, surgical techniques to masculinize the face have been utilized for decades.1.Deschamps-Braly J.C. Approach to feminization surgery and facial masculinization surgery: Aesthetic goals and principles of management.J Craniofac Surg. 2019; 30: 1352-1358https://doi.org/10.1097/SCS.0000000000005391Crossref PubMed Scopus (10) Google Scholar, 2.Deschamps-Braly J.C. Sacher C.L. Fick J. Ousterhout D.K. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam's Apple).Plast Reconstr Surg. 2017; 139: 883e-887ehttps://doi.org/10.1097/PRS.0000000000003185Crossref PubMed Scopus (24) Google Scholar, 3.Facque A.R. Atencio D. Schechter L.S. Anatomical basis and surgical techniques employed in facial feminization and masculinization.J Craniofac Surg. 2019; 30: 1406-1408https://doi.org/10.1097/SCS.0000000000005535Crossref PubMed Scopus (5) Google Scholar, 4.Sayegh F. Ludwig D.C. Ascha M. et al.Facial masculinization surgery and its role in the treatment of gender dysphoria.J Craniofac Surg. 2019; 30: 1339-1346https://doi.org/10.1097/SCS.0000000000005101Crossref PubMed Scopus (8) Google Scholar, 5.Harris J. Premaratne I.D. Spector J.A. Facial masculinization from procedures to payment: A review.LGBT Health. 2021; 8: 444-453https://doi.org/10.1089/lgbt.2020.0128Crossref PubMed Scopus (0) Google Scholar However, a comprehensive description of procedures geared toward transgender males is lacking, a need which this report aims to fill. While some transgender men achieve satisfactory facial appearance through hormonal therapy alone,6.Tebbens M. Nota N.M. Liberton N. et al.Gender-affirming hormone treatment induces facial feminization in transwomen and masculinization in transmen: Quantification by 3D scanning and patient-reported outcome measures.J Sex Med. 2019; 16: 746-754https://doi.org/10.1016/j.jsxm.2019.02.011Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar facial masculinization surgery (FMS) may be used to further masculinize facial architecture. Hormone therapy leads to a multiplicity of masculinizing effects such as the growth of facial hair, bony augmentative changes to the brows and jaws, as well as male pattern hairline changes, to name a few. In select individuals, these changes fail to provide the degree of masculinization sought by the patient. Although uncommon and not a prerequisite for surgery, some patients do not desire hormone therapy. Studies comparing sex differences in facial anatomy show that male and female faces differ most in the brow, jaw, nose and cheek.7.Bannister J.J. Juszczak H. Aponte J.D. et al.Sex differences in adult facial three-dimensional morphology: Application to gender-affirming facial surgery.Facial Plast Surg Aesthet Med. 2022; https://doi.org/10.1089/fpsam.2021.0301Crossref PubMed Scopus (4) Google Scholar As a guiding principle, male faces have more pronounced skeletal features, and the surgical techniques described below are intended to address this concept.3.Facque A.R. Atencio D. Schechter L.S. Anatomical basis and surgical techniques employed in facial feminization and masculinization.J Craniofac Surg. 2019; 30: 1406-1408https://doi.org/10.1097/SCS.0000000000005535Crossref PubMed Scopus (5) Google Scholar,8.Ousterhout D.K. Dr. Paul Tessier and facial skeletal masculinization.Ann Plast Surg. 2011; 67: S10-S15https://doi.org/10.1097/SAP.0b013e31821835cbCrossref PubMed Scopus (25) Google Scholar It is important to note that gender-affirming procedures are individualized. A surgical treatment plan must consider the patient's existing facial features and their contribution to a patient's overall sense of gender dysphoria. The formulation of surgical plans can be facilitated through the use of virtual facial morphology software. Given the plethora of surgical options available in FMS, the purpose of this report is to consolidate some of the highest yield techniques available, which may be performed either individually or comprehensively. In the authors’ experience, a comprehensive approach to the entire face enables greater facial harmony. The contour of the brow and glabella is one of the most gender determinative features of the face.7.Bannister J.J. Juszczak H. Aponte J.D. et al.Sex differences in adult facial three-dimensional morphology: Application to gender-affirming facial surgery.Facial Plast Surg Aesthet Med. 2022; https://doi.org/10.1089/fpsam.2021.0301Crossref PubMed Scopus (4) Google Scholar In addition to the bony contour of the forehead, the position of the eyebrows in a masculine face are low and flat across the superior orbital rim, projecting anterior to the eyes. To achieve this result, augmentative procedures, typically involving implants may be performed. The senior author recommends a minimally invasive endoscopic approach to insert a microporous, high-density polyethylene orbito-frontal implant. Prior reports describe a bi-coronal approach with use of methyl methacrylate.8.Ousterhout D.K. Dr. Paul Tessier and facial skeletal masculinization.Ann Plast Surg. 2011; 67: S10-S15https://doi.org/10.1097/SAP.0b013e31821835cbCrossref PubMed Scopus (25) Google Scholar Here, the authors favor using patient-specific porous polyethylene implants, which are designed ahead of time using virtual surgical planning software (Figure 1A, B). Secondarily, during the time of augmentation cranioplasty, the arcus marginalis is released to accommodate the implant and left unsuspended to allow the eyebrows to settle at the level of the supraorbital rim. 1.Using a 15 blade, 2-3 parallel, vertically oriented incisions are made starting 1-2 cm posterior to the hairline. One incision is 3 cm long to accommodate the fronto-orbital implant(s), and the other incisions are 1 cm to allow endoscope and instrument use (Figure 1C).2.A broad periosteal elevator is used to develop a plane extending to the supraorbital rims. Both manual palpation and endoscopic visualization are used. The elevation is carried to the lateral frontal-zygomatic suture line. The central and lateral compartments are joined into a single optical space, making sure to take the conjoint tendon along the bone to avoid injury to the frontal branch of the facial nerve.3.The arcus marginalis is released in order to create space for the implant, similar in technique to an endoscopic browlift procedure.4.The supraorbital and supratrochlear neurovascular bundles are located and protected.5.Simultaneously, the implant is soaked in antibiotic solution for 15 minutes during the surgical approach.6.Using endoscopic visualization, the implant is placed through the 3 cm incision and guided endoscopically into position atop the brow.7.Once positioned, the implant can be examined for anterior-posterior projection. Fine adjustments can be made to the desired projection using a drill to further contour the implant ex vivo, if needed.8.Two small incisions are then created at the lateral eyebrows through which a drill is passed, and 1.7mm screws are placed to secure the implant bilaterally. Careful attention is required to ensure the implant is correctly seated and is flush with the bone to provide smooth transitions from implant to bone.9.Antibiotic irrigation is used to irrigate the wound. Incisions are closed with dissolvable sutures. The nose is often neglected during facial masculinization; however, given its high relative aesthetic importance, even small changes to nasal shape and profile improve overall masculinization. The male nose tends to be larger, more projected, less rotated, and the tip tends to be broader compared to the female nose.7.Bannister J.J. Juszczak H. Aponte J.D. et al.Sex differences in adult facial three-dimensional morphology: Application to gender-affirming facial surgery.Facial Plast Surg Aesthet Med. 2022; https://doi.org/10.1089/fpsam.2021.0301Crossref PubMed Scopus (4) Google Scholar To address these differences, a masculinizing rhinoplasty should consider dorsal augmentation, tip counter rotation, and various maneuvers for greater tip projection, and overall dorsal and tip broadening. 1.An open septorhinoplasty approach is used to expose the nasal framework.2.For dorsal augmentation, diced cartilage in fibrin matrix is fashioned, as has been previous described.9.Bullocks J.M. Echo A. Guerra G. Stal S. Yuksel E. A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty.Aesthetic Plast Surg. 2011; 35: 569-579https://doi.org/10.1007/s00266-011-9725-9Crossref PubMed Scopus (65) Google Scholar In brief, cartilage is diced finely and placed into a 3 mL syringe which has been longitudinally cut in half. Fibrin glue is added to the syringe mold and then gently slid out to be placed and molded in vivo. If autologous rib is harvested for rhinoplasty (and other concurrent procedures such as thyroid cartilage augmentation), rib perichondrium be placed at the radix to address any step-off between the brow implant and the diced cartilage graft.3.To perform tip counter-rotation, lateral crural grafts, placement of a caudal septal extension graft (CSEG), or both can be effective. The CSEG can be fashioned from autologous septal, autologous costal cartilage, or cadaveric costal cartilage. The CSEG is placed in either an end-to-end or an end-to-side fashion to the caudal septum to permit the tongue-in-groove sutures to effectively counter-rotate and project the tip.4.The CSEG may be supported by the placement of extended spreader grafts, which widen both the mid-vault and the tip. Extended spreader grafts also facilitate the performance of an end-to-end CSEG. Attention is required to ensure that the extension graft is in the exact midline.5.For tip augmentation and broadening, a variety of maneuvers may be performed. These conflict with typical techniques which usually narrow and/or define the nasal tip. Placement of a tip graft is usually the easiest technique for tip widening. These grafts can be fashioned from autologous cartilage in the form of a shield graft or a cap graft to widen the tip. Masculine faces tend to have flat to slightly hollowed cheeks, whereas feminine faces tend to have slightly convex cheeks.7.Bannister J.J. Juszczak H. Aponte J.D. et al.Sex differences in adult facial three-dimensional morphology: Application to gender-affirming facial surgery.Facial Plast Surg Aesthet Med. 2022; https://doi.org/10.1089/fpsam.2021.0301Crossref PubMed Scopus (4) Google Scholar In both sexes, tissue projection over the zygoma is considered aesthetically desirable. In male faces, superolateral cheek augmentation enhances a desired hollowed inferior cheek appearance. To achieve this midface contour, the buccal fat pad is removed transorally, and autologous fat is used to sparingly volumize the soft tissue over the zygoma. In the authors’ experience, this approach is coupled with mandibuloplasty; therefore, it is favored to remove the buccal fat pad through the same incision used to expose the mandible (see below). 1.If performed separately from mandibuloplasty, 2 incisions, each approximately 2 cm are made in the buccal mucosa directly anterior to the ascending ramus of the mandible, posterior and superior to the parotid duct papilla.2.Blunt dissection is performed until the buccal fat pad to encountered.3.Gentle retraction is used to deliver the buccal fat, using sweeping motion with a cotton tip applicator or Kittner to ensure full mobilization of the fat, which is then truncated with bipolar cautery at its base. The fat pads are examined to ensure equal volumes are removed from each side. The buccal fat pad contains temporal, pterygoid, and buccal components. This approach allows access to the main buccal compartment, and removal should not encompass the other compartments of the buccal fad pad.4.Autologous fat is separately harvested using standard liposuction techniques. The fat is prepared and then injected to the soft tissue over the zygoma. Fat augmentation should be confined to the region of zygomatic bone that is inferior to the lateral canthus and should be done sparingly, such that the lateral projection of the zygoma does not exceed that of the mandible. Augmentation of the mandibular angle, body, and chin are critical in facial masculinization surgery. It defines a prominent jaw contour, which is independently a male characteristic, and enlarges the face, which secondarily contributes to masculinity. Here, we report use of a patient specific, porous polyethylene implant that is custom-designed prior to implantation (Figure 2A). Prior studies have described sliding genioplasty technique for masculinizing chin augmentation.10.Morrison S.D. Satterwhite T. Lower jaw recontouring in facial gender-affirming surgery.Facial Plast Surg Clin North Am. 2019; 27: 233-242https://doi.org/10.1016/j.fsc.2019.01.001Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar However, this method often requires use of hydroxyapatite granules mixed with blood or use of bone graft. Bone grafts (eg, iliac crest) pose second donor site morbidity and have the tendency to resorb with time. While sliding genioplasty allows for vertical height augmentation,11.Gui L. Huang L. Zhang Z. Genioplasty and chin augmentation with Medpore implants: A report of 650 cases.Aesthetic Plast Surg. 2008; 32: 220-226https://doi.org/10.1007/s00266-007-9106-6Crossref PubMed Scopus (32) Google Scholar we have found that the increased projection and width using porous polyethylene implants provides a robust masculinizing result without the morbidity associated with osteotomies. To facilitate soft tissue closure, mandibular implant size should be limited to the anticipated soft tissue envelope. 1.An incision is made in the inferior gingivobuccal sulcus from retromolar trigone to retromolar trigon, preserving a generous mucosal cuff (Figure 2B).2.Using a periosteal elevator, the buccal surface of the mandible is exposed from ramus to ramus, taking care to visualize and protect the mental nerves. Centrally, the mentalis muscle attachments are taken down with electrocautery. As the implant will usually also extend inferiorly, the inferior surface of the mandible is exposed. Similarly, the posterior border of the ramus is exposed and elevated of its periosteum; however, careful dissection should proceed here due to proximity of larger blood vessels of the external carotid system and the retromandibular vein.3.During the approach, the porous polyethylene implants are soaked in antibiotic solution.4.The implant construct is designed as three interlocking pieces (Figure 2A) which are assembled in vivo.5.Once positioned, a drill and screwdriver are used to secure the implants using 2 monocortical screws per segment. The lateral segments may require a right-angle drill and screwdriver.6.The mentalis muscle should be resuspended. The mucosal incision is then closed with dissolvable, interrupted, horizontal mattress sutures to ensure a water-tight seal. Colloquially termed the “Adam's apple,” the male thyroid cartilage is a defining masculine feature which can be constructed from rib cartilage.2.Deschamps-Braly J.C. Sacher C.L. Fick J. Ousterhout D.K. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam's Apple).Plast Reconstr Surg. 2017; 139: 883e-887ehttps://doi.org/10.1097/PRS.0000000000003185Crossref PubMed Scopus (24) Google Scholar In the male neck, the thyroid cartilage is more pronounced and has a narrow thyroid notch, approximately 90 degrees. In our experience, use of cadaveric rib cartilage can provide durable and predictable augmentation. Autologous rib are preferred; however, if procedural demand for cartilage is high in situations of simultaneous rhinoplasty, cadaveric grafts are suitable. 1.A shoulder roll is placed to extend the neck and bring the laryngeal framework anteriorly.2.A 4-5 cm incision is placed in a high cervical skin crease, so that it hides in the shadow of the cervicomental angle and is obscured by the chin except in upward neck movement.3.Dissection is carried down to the midline raphe and the strap muscles are retracted laterally to reveal the thyroid cartilage.4.An incision is made into the perichondrium taking care not to injury the thyroid cartilage, and perichondrial flaps are elevated laterally.5.The thyroid cartilage height is then measured. Two strips of cartilage are fashioned to precisely fit this size and provide the desired augmentation. The edges are trimmed and beveled and sutured together. The construct is then sutured in place onto the thyroid cartilage and secured in place with the periosteal flaps. Typically, at least 5-7 mm of projection can be achieved with this technique. Just as with nasal tip grafts, the degree of projection and the sharpness of the edges must be adjusted to achieve the desired, natural profile which depends upon the thickness soft tissue cover (Figure 3A, B).6.Strap muscles are then reapproximated over the construct and the skin incision is closed (Figure 3C). Gentle compressive dressings are applied for two days postoperatively. Patients are typically admitted for overnight observation, given the duration of general anesthesia required to perform the entirety of the aforementioned palette of techniques. Postoperative antibiotics are prescribed if an implant is used, an intra-oral incision is made, and/or rhinoplasty is performed. With the ongoing expansion of healthcare access to transgender patients, there will be a rise in demand for facial masculinization surgery. Here, we describe a comprehensive surgical approach for facial masculinization to address the concerns of transgender men. The techniques are generally augmentative in nature, using either autologous or cadaveric costal cartilage, fat grafts, and/or exogenous implants. Patient-specific implants permit careful preoperative planning and predictable results. While the entirety of the toolkit may certainly be utilized in a single anesthetic event, one also has the option of selecting procedures from which the patient may most benefit or most desire.
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