Facial Gender Confirmation Surgery Research Articles

Flattening the Curve and Cutting Corners-Pearls and Pitfalls Facial Gender Affirming Surgery.

This is an experiential article based on the past 6years experience of providing facial gender confirmation surgery (fGAS) at an academic medical center. While trainees are getting increasing exposure to aspects of facial gender affirming surgery (fGAS), the gap between trained providers and patients who can access care is currently still widening. A handful of fellowships across the country have emerged that include fGAS in their curriculum, but it will take another decade before the principles of affirming care and surgeries are systematically taught. Fortunately, the surgical principles and techniques required to perform fGAS are part of the skill set of any specialty surgeon trained in adult craniofacial trauma and esthetic facial surgery/rhinoplasty. It is the aim of this article to provide directly applicable knowledge with the goal to assist surgeons who consider offering fGAS in flattening the learning curve and hopefully contribute to increasing the quality of care provided for the transgender and gender diverse population. We hope to provide the reader with a very tangible article with the aims to 1) provide a simple systematic framework for an affirming consultation and preoperative assessment and 2) provide translatable surgical pearls and pitfalls for forehead feminization and gonial angle resection. The frontal sinus set back and gonial angle resection in our opinion are the most unique aspect to fGAS as rhinoplasty, genioplasty and other associated procedures (e.g., fat grafting) follow well established principles. We hope that the value of this article lies in the translatability of the presented principle to any practice setting without the need for VSP, special surgical instruments or technology beyond basic craniofacial tools. This is an experiential article based on the senior authors 6year experience offering fGAS in an academic setting. The article is structured to outline both pearls and pittfalls and is supplemented by photographs and a surgical video. A total of 19 pearls and pitfalls are outlined in the article. Facial gender affirming surgery mostly follows established craniofacial and esthetic surgery principles. Forehead feminization and gonial angle feminization are the 2 components that diverge most from established surgical techniques and this article hopefully provides guidance to shorten the learning curve of surgeons.

Gender Considerations in Rhinoplasty.

Precise nasofacial analysis ahead of rhinoplasty is imperative. Features common to the White masculine nose are reviewed in a stepwise fashion and contrasted with those of the White feminine nose. A solid understanding of the cisgender male, masculine nose enables the plastic surgeon to determine the changes required for a successful facial feminizing rhinoplasty as a part of facial gender confirmation surgery.

Facial Gender Confirmation Surgery: The Lower Jaw. Description of Surgical Techniques and Presentation of Results.

Of the primary procedures associated with facial gender confirmation surgery, those involving the mentomandibular complex have received the least attention in the literature. The authors present their experience with 837 trans feminine patients operated on for facial gender confirmation surgery who underwent mandibular bone contouring procedures, including bone contouring, chin and mandibular body and angle ostectomies, and osteotomies to reposition the chin. The authors describe the surgical techniques and materials used, and present a customized lower border-supported cutting guide designed by their team and used with 205 patients. A femininity perception score was calculated preoperatively and 12 months postoperatively, and satisfaction with the results was measured 12 months postoperatively. The postoperative follow-up ranged from 12 to 110 months. The mean femininity perception score increased from 47.86 preoperatively to 76.41 at 12 months postoperatively (p < 0.001). No emergency surgical operations were required. In no case was there any permanent damage to the mental or inferior dental nerve. The reoperation percentage because of problems detected during the postoperative period was 2.63 percent (22 patients). With facial gender confirmation surgery of the jawline and chin, it is possible to modify the transverse and vertical components of the jaw; soften the gonial angles; change the format, bone volume, and position of the chin; and harmonize the entire mandibular line. The facial feminization achieved high satisfaction scores regarding the results and feminine gender appearance 12 months after surgery. The future of mandibular bone contouring techniques includes planning with virtual software and surgical support with patient-specific cutting guides.

Patients and Procedures of Facial Gender Confirmation Surgery: A NSQIP Study.

Various recent developments, including legislation in 2014 banning healthcare discrimination against gender minorities, have contributed to expanding insurance coverage for gender-affirming care, which includes facial gender confirmation surgery (FGCS). Increasing evidence suggests FGCS improves quality-of-life outcomes, but literature evaluating FGCS patient demographics, surgical risk factors, procedures, and complications is limited. Therefore, the authors conducted a study of a national surgical database from 2005 to 2019 attempting to fill in these literature gaps. Statistics were used to assess temporal trends after 2014. A total of 203 FGCS cases were identified, with the earliest occurring in 2013. Case volume increased annually from 2015-2019. The average patient age was 34.0 years and racial demographics largely mirrored national estimates for the transgender/non-binary population. Obesity (20.7%) and hypertension (3.9%) were the only patient co-morbidities, although a relatively high proportion were underweight (5.4%). The majority of cases were outpatient procedures (66.5%) conducted by either plastic surgery (38.9%) or otolaryngology (61.1%). Comparing FGCSs by anatomic site, the proportion of tracheal procedures decreased between 2015-17 and 2018-19 (25.6% vs. 10.7%, P = 0.0002) whereas the proportion of brow/forehead reconstructions increased (32.6% versus 63.1%, P = 0.0005). These changes coincided with an increase in mean operative time (168.6 minutes versus 260.0, P = 0.0002). Complications were rare (3.9%), and the most common was surgical site infection (3.4%), a previously unreported outcome in the FGCS literature. Overall, FGCS patients are mostly young healthy individuals from diverse racial/ethnic backgrounds, and they have few surgical complications. The increasing volume and complexity of FGCSs may be a result of expanding insurance coverage for previously unaffordable procedures.

Narrative review of facial gender surgery: approaches and techniques for the frontal sinus and upper third of the face.

Facial gender confirmation surgery (FGCS) is a series of procedures which seek to harmonize a patient's face with his/her self-image and gender identity. Originally described in San Francisco in the 1980s, FGCS has evolved to encompass all elements of the craniofacial skeleton and facial soft tissue. This field in plastic and reconstructive surgery has quickly gained more attention in the past decade due to the pioneering work of groups around the world along with increased social acceptance and medical care of the transgender community. This narrative review focuses on the upper third of the face. Key differences in the forehead and the hairline of cis men and women are discussed which inform pharmacologic and surgical interventions. Hairline modifying therapies including pharmacotherapy and hair transplantation are explained. Virtual surgical planning (VSP), a tool broadly used in surgical fields, has a special role in FGCS and we offer advice in using VSP when addressing the frontal sinus. Use of VSP allows the surgeon to provide reproducible and accurate results. We then discuss the history of the frontal sinus setback and offer our algorithmic approach to recontouring the forehead with detailed description of the operative steps and decision making. Finally, postoperative care and complications considered.

Point of care virtual surgical planning and 3D printing in facial gender confirmation surgery: a narrative review.

Facial gender confirmation surgery (FGCS) is a powerful set of procedures in the armamentarium of plastic surgeons that can transform the male face into a gender-congruent female face and provide the transgender individual with improved quality of life, positive body image and help in social integration. The goals of the FGCS procedures are to address the individual patients' concerns and expectations about their facial appearance, offer safely executed surgery, minimize complications, and optimize surgical outcomes. Pre-operative computed tomography (CT) scanning and three-dimensional (3D) reconstruction before facial feminization or masculinization delineates important skeletal and sinus anatomy and can also be a useful tool in patient consultation. Virtual surgical planning (VSP) is a valuable tool in facial surgery. From free flap bony reconstruction after tumor resection and orthognathic surgery to craniosynostosis planning, VSP has become widely utilized in modern day cranio-maxillofacial surgery. The use of patient-specific cutting guides and implants helps in improving symmetry and safety of these procedures. Furthermore, 3D printed models are valuable tools in patient education and counseling prior to surgery. In this article we describe our approach to FGCS through the integration of point of care (POC) VSP and 3D printing (3DP) to help deliver safer and accurate FGCS outcomes.

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

During the past 10 years, academic publications that address facial feminization surgery have largely examined the technical aspects of the different surgical procedures involved and clinical evaluations of postoperative results. This Special Topic article focuses on aspects that are underdeveloped to date but useful with regard to taking the correct therapeutic approach to transgender patients who are candidates for facial gender confirmation surgery. The authors propose a protocolized sequence, from the clinical evaluation to the postoperative period, based on a sample size of more than 1300 trans feminine patients, offering facial gender confirmation surgery specialists standardized guidelines to handle their patients' needs in a way that is both objective and reproducible.

The Upper Third in Facial Gender Confirmation Surgery: Forehead and Hairline.

The upper third of the face contains 2 features that are particularly important for facial gender recognition: the frontonasoorbital region and the hairline. The supraorbital ridge, which determines the position and exposure of the eyebrows, is almost invariably more developed in the male than in the female. Surgical modification of the frontonasoorbital complex, considered a standard procedure in facial feminization, is reliable and predictable, and also delivers satisfactory results that are stable over time.A prototypical male hairline has an M-shaped pattern compared to the more rounded shape often seen in female hairlines. Feminization of the hairline requires minimizing the temples as well as rounding out the overall shape, optimizing hair density, and occasionally changing the height of the hairline.This article provides an update on our forehead reconstruction technique and our experience in the treatment of hairline redefinition.

Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management.

The 1960s and 1970s were an important time for craniofacial surgery because of the work of Paul Tessier and Hugo Obwegeser, both mentored by Sir Harold Gillies, along with many other important monumental minds. During this era, the birth of craniofacial surgery occurred and represented a new discrete specialty within plastic surgery. In the 1980s distraction of the facial skeleton became an indispensable tool in the arsenal of the craniofacial surgeon, based on initial cases in Italy, and rigorous research by McCarthy, Grayson, and others. In more recent times, from 2000 onward, craniofacial surgery has benefitted from the advent and refinement of techniques using computer-aided planning for procedures, spring distraction, as well as the widespread use of fat grafting as part of facial reconstruction. In the last decade, innovations based on the fusion of microsurgical procedures with craniofacial procedures for face allotransplantation and improvements in safety regarding separation of craniopagus infants have been observed. The author thinks it is worth mentioning and conferring praise upon the anesthesia colleagues for improvements in anesthesia which have led to vastly decreased mortality in the infant population undergoing complex procedures.The common theme among these achievements is that they were quickly adopted by the subspecialty community. However, in the hindsight of history, the author thinks it is now understood that during this time another great achievement, long overlooked, occurred in craniofacial surgery. In the 1980s the author's associate and mentor, Douglas Ousterhout, adapted techniques of craniofacial surgery to change the lives of transgender patients. This new and powerful surgery had the potential to change the course of someone's life just as profoundly as the correction of congenital craniofacial anomalies. This quality of life improvement for trans patients undergoing facial feminization has been evaluated and found to be quite significant. However, it was essentially ignored by the specialty community, and the author and his colleagues were slow to adopt this surgery. In this study, the author will give an overview of the procedures required to feminize or masculinize a face. The history of surgery is fascinating, and the author hopes that the origins of facial gender confirmation surgery (facial feminization and masculinization), which may be found in the forward to this journal, are fascinating to the readers as well.

The Role of Facial Gender Confirmation Surgery in the Treatment of Gender Dysphoria.

The population of transgender patients seeking gender confirmation surgery for gender dysphoria is increasing in the United States. Facial gender confirmation surgery (FGCS) is one of the treatment modalities patients require and is often a combination of soft tissue and cranio-maxilla-facial procedures. Despite evidence of the efficacy of FGCS, there remains some extant controversies to address, such as reimbursement for these procedures, categorization of aesthetic versus functional surgery, and evaluation of outcomes. This review provides a discussion of these topics, as well as the historical and psychosocial issues specific to transgender patients that surgeons should know when providing FGCS. We provide practice pearls for providing affirming transgender healthcare, illustrative patient clinical vignettes, and a discussion of the Standards of Care of the World Professional Association for Transgender Health to help guide surgeons who are interested in providing FGCS to transgender patients.

Facial Gender Confirmation Surgery: A New Nomenclature

Sir: Transgender patients do not identify with their biological gender assigned at birth. Both the genital sex and the secondary sex characteristics that develop during puberty lead to clinically significant psychological distress, also known as gender dysphoria. A complex and extended transition period is usually required that involves numerous diagnostic processes, medical-surgical treatments, and extensive psychological care. All of this is aimed at allowing patients to achieve the physical expression of the gender with which they identify, averting severe psychological conflicts; improving self-esteem and quality of life; and fostering the patient’s successful integration into the workplace, family, and society.1 One of these medical-surgical treatments, facial surgery (popularly known as facial feminization surgery), has steadily gained importance and is emerging as a key element in the complex transition process, primarily for male-to-female transgender patients.2 Despite the evidence regarding the importance of and need for facial treatment for this group, many gaps remain that must be addressed, and views differ about the role that this surgery plays in the treatment algorithm. There is a need for a clear, concise definition of the different treatments involved, the type of patient for whom this surgery is indicated, and its place in the transition process timeline. One constructive step in this definition process would be to determine the most appropriate nomenclature, one that would establish precise limits regarding the surgical field, when this surgery is indicated, and what its procedures are. In this context, the term “facial gender confirmation surgery,” as proposed in the recent article by Berli et al.,3 provides a more suitable description of this surgery than “facial feminization surgery.” This new term indicates that although the surgical techniques are the same, their objective is very distinct and, moreover, they are intended for specific patients with well-defined needs. At this time, there is some controversy and confusion regarding the line separating purely aesthetic procedures from procedures required to modify the facial features that are responsible for gender identification.4 Although in some rare cases, the ultimate aim of the procedure is disputable, it is possible to categorically describe the procedures in which the ultimate objective is the modification of the features responsible for facial gender. Basically, facial gender confirmation surgery focuses on those determined by the subject’s craniofacial structure: the frontonaso-orbital complex, the mentomandibular complex, and the thyroid cartilage (Adam’s apple). With more readily available access to care, it is to be expected that patients who identify as trans males will also increasingly seek out some aspects of facial gender confirmation surgery as outlined above.5 In short, a more precise and inclusive nomenclature with a better definition of the core surgical procedures included in facial gender confirmation surgery will help to better consolidate and clarify this developing discipline for patients, professionals, and society in general. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENTS The authors thank their team, their families, and their patients. Luis Capitán, M.D., Ph.D.Daniel Simon, D.M.D.FACIALTEAM Surgical GroupHC Marbella International HospitalMarbella, Málaga, Spain Jens U. Berli, M.D.Division of Plastic and Reconstructive SurgeryDepartment of SurgeryOregon Health & Sciences UniversityPortland, Ore. Carlos Bailón, M.D.Raúl J. Bellinga, M.D.Javier G. Santamaría, M.D.Thiago Tenório, M.D.Anabel Sánchez-García, Ph.D.Fermín Capitán-Cañadas, Ph.D.FACIALTEAM Surgical GroupHC Marbella International HospitalMarbella, Málaga, Spain