Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures

The Effects of Perioperative Gender-affirming Hormone Therapy on Facial Feminization Surgery Adverse Events, Facial Features Addressed, and Esthetic Satisfaction: A Multimodal Analysis

OBJECTIVE

Facial feminization surgery (FFS) treats gender dysphoria in transfeminine patients by addressing the facial bony and soft tissue components. Individuals seeking FFS may be taking gender-affirming hormone replacement therapy [gender-affirming hormone therapy (GAHT)]. This study aims to better characterize the GAHT's impact on venous thromboembolism (VTE) risk, surgical planning, and outcomes.

METHODS

A systematic review and meta-analysis of the literature were carried out to assess the effect of perioperative GAHT continuation on VTE. Cochrane Q and I2 statistics measured study heterogeneity with the following meta-regression exploring these results. Simultaneously, a retrospective review of the senior author's FFS cohort was conducted to investigate GAHT duration's impact on FFS revision rate, complication incidence, and facial structures operated on.

RESULTS

Eleven articles were included: 602 patients stopped GAHT, of whom 3 VTEs were recorded (0.49%). This is compared with one episode among the 925 who continued GAHT perioperatively (0.11%). Study heterogeneity was low (0%), but limited VTE sample size precluded meta-analytic conclusions. Gender-affirming hormone therapy duration does not impact the incidence of all-cause complications (P = 0.478), wound infection (P = 0.283), hematoma (P = 0.283), or VTE (P = 1). The only procedures significantly less associated with higher GAHT were tracheal shaving (P = 0.002) and mandibuloplasty (P = 0.003). Finally, the FFS revision rate was not associated with GAHT duration (P = 0.06).

CONCLUSION

There is a paucity of data to assess the safety or harm of continuing GAHT in the FFS perioperative period. Thus, a shared provider-patient decision-making process examining the risks and benefits of GAHT perioperative continuation is warranted. As patients seeking gender-affirming care are diverse, a "one-protocol-fits-all" is not appropriate.

Effect of Duration of Feminizing Hormone Therapy on Facial Fat Volumes

BACKGROUND

Gender-affirming feminizing hormone therapy induces body fat redistribution. However, the amount and timing of facial fat changes in response to feminizing hormone therapy are unknown, despite being relevant to counseling and surgical planning for facial gender-affirming surgery. The authors assessed the influence of feminizing hormone therapy duration on malar and temporal fat volume.

METHODS

Malar and temporal fat volumes were compared using computed tomography in transfeminine patients (age, 20 to 29 years; body mass index, 18.5 to 24.9) treated with feminizing hormone therapy for less than 2 years versus 2 years or longer. Patients with previous surgical or nonsurgical facial soft-tissue interventions were excluded. Multivariable linear regressions evaluated the contribution of hormone therapy duration to malar and temporal fat volumes.

RESULTS

A total of 45 patients were included, 30 (66.7%) treated with feminizing hormone therapy for 2 years or longer and 15 (33.3%) treated for less than 2 years (median [interquartile range], 44.5 [33.5 to 65.6] versus 15.0 [11.0 to 18.0] months; P < 0.001). Patients treated with hormone therapy for 2 years or longer demonstrated a 1.6-fold greater malar fat volume (5.5 [4.2 to 6.3] versus 3.4 [2.3 to 4.2] cm 3 ; P < 0.001) and 1.4-fold greater temporal fat volume (2.8 [2.4 to 3.6] cm 3 versus 2.0 [1.7 to 2.4] cm 3 ; P = 0.01) compared with those treated for less than 2 years. When accounting for other contributory variables, such as body mass index, skull size, and total soft-tissue depth, in multivariable linear regression models, hormone therapy duration of 2 years or longer independently predicted higher malar (β = 0.51, P < 0.001) and temporal (β = 0.32, P = 0.02) fat volumes.

CONCLUSION

Feminizing hormone therapy increases malar and temporal fat volumes by approximately 2 cm 3 and 0.8 cm 3 for each area, respectively, after 2 years of treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

FACE-Q Satisfaction Ratings Are Higher After Facial Feminization Surgery Than Hormone Replacement Therapy Alone

Purpose

Facial feminization surgery (FFS) is associated with improved psychological outcomes in transgender patients. We aimed to evaluate the impact of FFS on patient satisfaction with facial appearance using validated, patient-reported outcome tools.

Methods

Patients were recruited to complete a FACE-Q survey at least 6 months after their FFS. FACE-Q modules used included "Satisfaction with Facial Appearance Overall," "Facial Attributes" (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), "Decision," "Outcomes," "Psychological Function," and "Social Function." "Satisfaction with Facial Appearance Overall" was compared to FACE-Q outcomes in transgender patients on hormone replacement therapy (HRT), alone.

Results

Twenty-three patients completed the survey. Rhinoplasty was the most common procedure (82.6%). Insurance was rated as a major barrier in 50% of patients. "Satisfaction with Facial Appearance Overall" using the FACE-Q was 69.3, with "Psychological Function" rated at 73.7 and "Social Function" rated at 76.1. FFS was associated with a higher overall satisfaction in facial appearance compared to patients on HRT for 3 months (69.3 vs. 48.5, p<0.01) and 12 months, alone (69.3 vs. 54.4, p<0.001). Wait time for FFS of less than a year (β=-20.4, p=0.04) and undergoing FFS at a younger age (β=-1.4, p<0.001) were independently associated with higher satisfaction scores in overall facial appearance.

Conclusions

FFS is associated with greater satisfaction with overall facial appearance, especially compared to transgender patients only on HRT. Insurance was the greatest barrier to receiving FFS. Improved access to surgery is needed to yield higher overall satisfaction with facial appearance.

Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey

PURPOSE

Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E.

METHODS

Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen.

RESULTS

A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration.

CONCLUSION

The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.

Invisibility and Stigma: Experiences of Transgender and Gender Non-Conforming Individuals in South Korea

In this qualitative study, we explored the challenges that transgender and gender non-confirming (TGNC) individuals face in South Korea. For this, we conducted in-depth interviews with 14 South Korean TGNC younger adults attending colleges or graduate schools and analyzed their data through consensus qualitative research. Analyses revealed that issues related to interpersonal relationships and medical transiting were major challenges perceived by participants. Four categories emerged in the domain of challenges in interpersonal relationships, including issues associated with family, romantic partner, coming out and outing, and transphobia and cisnormativity. In addition, two categories (i.e., medical difficulties and physical appearance-related distress) were included in the domain of challenges related to medical transition. Unique sources of stress for South Korean TGNC younger adults included high risk of being outed due to Korean resident registration numbers, dissatisfaction with bodily changes when transitioning, and misgendering caused by Korean's different honorific titles depending on gender.

Quantifying Facial Feminization Surgery's Impact: Focus on Patient Facial Satisfaction

Background

Facial feminization surgery (FFS) has been associated with improving gender dysphoria in transgender patients. This study aimed to quantify the impact of surgery on patient facial satisfaction, using the FACE-Q and a quality-of-life (QoL) survey.

Methods

Transgender female patients were recruited to complete the FACE-Q and the World Health Organization's QoL Scale-Short Form (WHOQOL-BREF) if they were planning to or had undergone FFS at our institution. FACE-Q modules completed included "Satisfaction with Facial Appearance Overall," individual facial attributes (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), and the WHOQOL-BREF, which assesses patient QoL through four domains (physical, psychological, social relations, and environment). Both matched and unmatched analyses of preoperative versus postoperative cohorts were performed.

Results

Overall, 48 patients participated in our study and completed 31 FACE-Q surveys preoperatively and 37 postoperatively. On average, patients were 37.2 ± 12.5 years old. FACE-Q scores increased significantly for all facial attributes and for Satisfaction with Facial Appearance Overall between cohorts (P < 0.05). The facial attribute with the greatest increase in satisfaction was the jawline, followed by the nose. The WHOQOL-BREF's psychological and physical domains both improved significantly (P < 0.05). Wait time for surgery of less than 6 months (b = 22.42, P = 0.02) was associated with higher overall facial satisfaction, whereas age at surgery (b = -1.04, P < 0.01) was associated with lower overall facial satisfaction.

Conclusions

Transgender female patients experienced significant improvements in facial satisfaction and QoL after FFS. Undergoing surgery at a younger age and shorter wait times for surgery were associated with increased overall facial satisfaction.

Best Practices for FACE-Q Aesthetics Research: A Systematic Review of Study Methodology

BACKGROUND

The FACE-Q Aesthetics module is a validated patient-reported outcome measure (PROM) that evaluates perspectives on facial aesthetic treatments. Improper administration and poor study methodology can compromise the validity and interpretation of this PROM.

OBJECTIVES

This systematic review sought to evaluate the administration and scoring of the FACE-Q Aesthetics scales within the literature.

METHODS

A search of Ovid Medline, Embase, Cochrane, and Web of Science was performed on December 20, 2022, with the assistance of a health-research librarian (CRD42022383676). Studies that examined facial aesthetic interventions using the FACE-Q Aesthetics module as a primary or secondary outcome measure were included for analysis.

RESULTS

There were 114 studies included. The Face Overall (n = 52, 45.6%), Psychological (n = 45, 39.4%), and Social (n = 43, 37.7%) scales were most frequently reported. Errors in FACE-Q administration were identified in 30 (26.3%) studies. The most common error was the presentation of raw ordinal scores rather than the converted Q score (n = 23). Most studies reported a time horizon for their primary analysis (n = 76, 66.7%); however, only 4 studies provided a rationale for this selection. Sample size calculations for the primary outcome were rarely performed (n = 9, 7.9%).

CONCLUSIONS

There continues to be limitations in PROM administration and the quality of articles that report FACE-Q Aesthetic scale data. The authors suggest that future investigators using the FACE-Q refer to the User's Guide regarding administration and scoring of this scale, report a rationale for the study time horizon, and provide an a priori sample size calculation for the primary outcome of interest.

Facial Feminization Surgery: Preoperative Planning and Surgical Technique for a Harmonious Outcome

Feminization of the face is as important as genital or chest surgeries in alleviating gender incongruence in transgender individuals. It comprises a myriad of procedures that address the skeletal and/or soft tissue components to give a harmonious result. The surgeries are custom-tailored for each individual based on facial anatomy as well as her desired changes for optimal results. A thorough understanding of the differences in male and female facial anatomy is crucial. The use of computed tomographic imaging with three-dimensional reconstruction and stereolithography models can greatly improve the planning as well as execution of these surgeries. There is an increase in demand for these surgeries, with a paucity of centers providing them. The aim of this article is to highlight the comprehensive facial feminization procedures, which have a high patient as well as surgeon satisfaction rate.

Facial Morphometrics in Black Celebrities: Contemporary Facial Analysis Using an Artificial Intelligence Platform

The diversity of patients pursuing facial aesthetic and facial gender-affirming surgery (FGAS) is increasing, yet there is a paucity of objective guidelines to facilitate surgical decision-making in patients of color. We conducted a quantitative analysis of black celebrities using standardized frontal photos of 21 female and 21 male celebrities. Celebrities were chosen from popular entertainment magazines and websites, including People Magazine, the Internet Movie Database (IMDb), Cosmopolitan, and Essence. For each celebrity, 100 facial landmarks were detected through a facial analysis artificial intelligence (AI) program. Black males had greater facial height, bizygomatic width, lower facial height, and bigonial width than females. However, the facial height to bigonial width ratio was similar between genders and approximated the golden ratio (1.618). Female faces demonstrated a greater mid-face height to total facial height proportion, and males had a greater lower facial height proportion. Females exhibited an upward-slanted medial brow and shorter total eyebrow length, nose height, and alar width. Forehead height above the lateral brow was greater in males, while central forehead height was similar to females. This is the first study that has utilized AI to provide ethnicity-specific facial morphometrics relevant to facial rejuvenation and FGAS in the black population.

Analysis of Hairline and Forehead Sexual Dimorphic Aesthetics in 60 Celebrities Using Artificial Intelligence

Upper facial third morphometrics are an important consideration in aesthetic facial surgery and facial gender-affirming surgery. Although there are generally accepted sexual dimorphic differences, an in-depth analysis of forehead morphometrics in attractive individuals is lacking.

Methods

Thirty white female and 30 white male celebrities were included. Three full-face front-view photographs of each celebrity were evaluated by a facial analysis program, using Vision framework and MATLAB. After converting pixel distances to absolute distances, midline and lateral forehead heights were calculated and compared between men and women.

Results

Forehead height was similar between attractive men and women, but forehead width was shorter in women. Analysis of forehead height at various points along the hairline demonstrated that forehead measurements above the lateral brow and brow peak were significantly greater in men. Mean forehead height above the lateral eyebrow was 3.51 cm in women and 4.16 cm in men (P = 0.017). Forehead height above the eyebrow peak was 4.34 cm in women and 5.55 cm in men (P < 0.001). Medial forehead height was similar between men and women, indicating that the greatest difference in attractive male and female foreheads is in the lateral forehead and forehead width.

Conclusions

Analysis of attractive white celebrities demonstrated no significant differences in central forehead heights between men and women. Forehead width and lateral forehead height were significantly smaller in women, with an overall downward slanting contour. Male hairlines were more horizontal and slanting upward laterally. These results have implications in facial rejuvenation and facial gender-affirming surgery.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

The Effects of Gender-Affirming Hormone Therapy on Body Satisfaction, Self-Esteem, Quality of Life, and Psychopathology in People with Female-to-Male Gender Dysphoria

Purpose

Gender-affirming hormone therapy (GAHT) is one of the most important therapeutic interventions sought by people with gender dysphoria (GD). In the present study, we aimed to examine the effects of GAHT on body satisfaction, self-esteem, quality of life, and psychopathology in people with female-to-male (FtM) GD.

Methods

Thirty-seven FtM GD participants who did not receive any gender-affirming therapy, 35 FtM GD participants who received GAHT for over 6 months, and 38 cisgender women were included in the study. The Body Cathexis Scale (BCS), Rosenberg Self Esteem Scale (RSES), World Health Organization's Quality of Life Questionnaire Brief Form (WHOQOL-BREF), and Symptom Checklist-90-Revised (SCL-90-R) were completed by all participants.

Results

The BCS scores of the untreated group were significantly lower than both the GAHT group and the female controls (p<0.001); while the WHOQOL-BREF-psychological health scores of the untreated group were significantly lower than those of the female controls (p=0.003). The psychoticism subscale scores on the SCL-90-R of the untreated group were higher than those of the GAHT group (p=0.04) as well as the female controls (p=0.003). With regard to the RSES, there were no significant differences between the groups.

Conclusion

Our findings suggest that people with FtM GD who receive GAHT are more satisfied with their bodies and have less psychopathological problems compared to those who do not receive GAHT, but their quality of life and self-esteem do not change as a result of GAHT.

The Use of the FACE-Q Aesthetic: A Narrative Review

INTRODUCTION

In the past decade there has been an increasing interest in the field of patient-reported outcome measures (PROMs) which are now commonly used alongside traditional outcome measures, such as morbidity and mortality. Since the FACE-Q Aesthetic development in 2010, it has been widely used in clinical practice and research, measuring the quality of life and patient satisfaction. It quantifies the impact and change across different aspects of cosmetic facial surgery and minimally invasive treatments. We review how researchers have utilized the FACE-Q Aesthetic module to date, and aim to understand better whether and how it has enhanced our understanding and practice of aesthetic facial procedures.

METHODS

We performed a systematic search of the literature. Publications that used the FACE-Q Aesthetic module to evaluate patient outcomes were included. Publications about the development of PROMs or modifications of the FACE-Q Aesthetic, translation or validation studies of the FACE-Q Aesthetic scales, papers not published in English, reviews, comments/discussions, or letters to the editor were excluded.

RESULTS

Our search produced 1189 different articles; 70 remained after applying in- and exclusion criteria. Significant findings and associations were further explored. The need for evidence-based patient-reported outcome caused a growing uptake of the FACE-Q Aesthetic in cosmetic surgery and dermatology an increasing amount of evidence concerning facelift surgery, botulinum toxin, rhinoplasty, soft tissue fillers, scar treatments, and experimental areas.

DISCUSSION

The FACE-Q Aesthetic has been used to contribute substantial evidence about the outcome from the patient perspective in cosmetic facial surgery and minimally invasive treatments. The FACE-Q Aesthetic holds great potential to improve quality of care and may fundamentally change the way we measure success in plastic surgery and dermatology.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hormonothérapies de transition chez les personnes transgenres

Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.

Facial Feminization Surgery: Part 1 of the Plastic Surgeon's Perspective of Gender-Affirming Surgery

The perceived feminine face is distinctly unique from the perceived masculine face. Facial feminization surgery (FFS) includes a range of surgical procedures designed to change characteristically masculine facial features into feminine ones. FFS encompasses a set of bone and soft-tissue reconstructive procedures including, but not limited to, forehead contouring with or without frontal sinus setback, hairline adjustment, brow lift, rhinoplasty, lip lift, mandibular shaping, genioplasty, and "tracheal" shave, and fat grafting. Some patients choose to undergo one, all, or groupings of the procedures. The surgical decision is tailored to the individual and based on clinical opinion, patient desire, and insurance status or means to pay. FFS improves patient quality of life, has good general aesthetic outcomes, and improves feminine gender appearance (Morrison et al., 2020).

The ENIGI (European Network for the Investigation of Gender Incongruence) Study: Overview of Acquired Endocrine Knowledge and Future Perspectives

Literature on the efficacy and safety of gender-affirming hormonal treatment (GAHT) in transgender people is limited. For this reason, in 2010 the European Network for the Investigation of Gender Incongruence (ENIGI) study was born. The aim of this review is to summarize evidence emerging from this prospective multicentric study and to identify future perspectives. GAHT was effective in inducing desired body changes in both trans AMAB and AFAB people (assigned male and female at birth, respectively). Evidence from the ENIGI study confirmed the overall safety of GAHT in the short/mid-term. In trans AMAB people, an increase in prolactin levels was demonstrated, whereas the most common side effects in trans AFAB people were acne development, erythrocytosis, and unfavorable changes in lipid profile. The main future perspectives should include the evaluation of the efficacy and safety of non-standardized hormonal treatment in non-binary trans people. Furthermore, long-term safety data on mortality rates, oncological risk, and cardiovascular, cerebrovascular and thromboembolic events are lacking. With this aim, we decided to extend the observation of the ENIGI study to 10 years in order to study all these aspects in depth and to answer these questions.

Facial Masculinization from Procedures to Payment: A Review

As the demand for gender-affirming procedures continues to increase, patients and providers have a greater imperative to understand the current state of facial masculinization. Facial reconstruction for transgender women has been shown to treat gender dysphoria effectively and reduce rates of discrimination and victimization. Although facial masculinization surgery for transgender men is less common, there are multiple surgical and nonsurgical options to supplement the effect of hormone therapy on facial appearance, including but not limited to: receding the hair line, flattening the forehead, expanding the supraorbital ridge, increasing the dorsal nasal projection, squaring the jaw, and augmenting the chin. This review aims to summarize these techniques for providers who wish to inform transgender male patients about their options and discuss them in the context of patient satisfaction and availability of insurance coverage.

Perception of femininity and attractiveness in Facial Feminization Surgery

Background

Facial Feminization Surgery (FFS) alters bone and soft tissue to feminize facial features of transgender females. This study aims to evaluate perceptions of femininity, attractiveness, and ideal surgical outcomes in transgender females, non-transgender females and plastic surgeons.

Methods

The data was extracted from a survey of transgender females (n=104), non-transgender females (n=192) (completion rate of 48.4%) and plastic surgeons who performed FFS (n=23) (survey response rate of 31.5%). Five virtually-modified forms of three facial features, the nasal tip width, supratip break, mandibular gonial angles, and the composite images of the above features of an individual, assigned male at birth, were used. Respondents were requested to select and rank images based on personal perceptions of femininity and attractiveness.

Results

Transgender females chose a narrower nasal tip width as more attractive (P≤0.001), and evaluated a more acute supratip angle, and more obtuse mandibular gonial angle as both more feminine and attractive (all P≤0.023) compared to non-transgender females. Plastic surgeons chose a more obtuse mandibular gonial angle as more feminine (P=0.007) and a more ideal surgical outcome (P=0.046), compared to transgender female respondents. In the assessment of composite images, non-transgender female ranked the options with more obtuse mandibular gonial angle as more feminine (all P≤0.036) than transgender females.

Conclusions

Acknowledging the difference in transgender females' perceptions of facial femininity and attractiveness from non-transgender females and plastic surgeons could assist plastic surgeons in managing expectations of surgical outcomes.