Formations of Femininity: Science and Aesthetics in Facial Feminization Surgery

Analysis of Cephalometric Differences of the Midface and Upper Face in Males and Females: A Radiographic Study

Gender affirmation facial surgery (GAFS) is an important component in treating gender dysphoria among transgender individuals by addressing gender incongruence of the face. There is a paucity of literature describing objective characterizations of the anatomic differences between male and female faces. In this study, cephalometric measurements were taken on routine CT imaging performed on cisgender patients between 2017 and 2020. Specifically defined cephalometric landmarks of the upper and midface were measured and compared between male and female cohorts. Thirty-eight patients, 19 male and 19 female, were identified for this study. Significant differences were identified in the frontal prominence, orbital size, malar height, bizygomatic width, nose, and upper lip, with moderate rates of specificity for each gender. Some important ratios are also presented. Differences in the malar region and the orbit highlight the importance of these areas as a point of focus for GAFS. These cephalometric findings provide objective evidence and parameters for perceived anatomic differences in male and female faces. In addition, they help both corroborate current surgical techniques as well as guide future approaches to GAFS.

Ethical Issues Surrounding Facial Feminization Surgery: Five Major Considerations

Facial feminization surgery (FFS) is a form of gender-affirming care for the transgender population that is currently a highly debated topic both inside and outside of the medical community. Currently, a paucity of information is available in plastic surgery literature on ethical issues surrounding FFS. In this paper, we discuss 5 major ethical considerations for plastic surgeons with regard to FFS: (1) how society's changing view of gender has impacted the importance of FFS; (2) whether FFS is medically necessary and should be covered by insurance; (3) to what extent resources should be invested in removing barriers to access FFS; (4) how patient selection criteria should address the irreversibility of the procedure and age of consent; and (5) how femininity and beauty standards contribute to each other and whether they can be disentangled. This paper aims to analyze the arguments made for and against each of these 5 nuanced issues and to expand these debates from the theoretical to the practical by suggesting approaches for reconciliation.

Facial Gender-Affirming Surgery: Frontal Bossing Surgical Techniques, Outcomes and Safety

BACKGROUND

Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250-261, 2011). This article describes the author's three main surgical techniques used in forehead feminization and reports on the results.

METHODS

The type of surgery performed is based on the patient's anatomy. Type one FGAS consists of burring the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes burring and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing.

RESULTS

We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout's methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome.

CONCLUSIONS

FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate.

LEVEL OF EVIDENCE IV

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 .

Blepharoplasty Approach to the Orbital Rim: A Novel Approach for Select Patients Presenting for Gender Affirming Facial Plastic Surgery

BACKGROUND

Gender affirming facial surgery is a valuable option for patients with gender dysphoria. Traditionally, procedures for the upper third of the face focus on hairline position and contour of bony prominences via a coronal or trichophytic incision. These traditional approaches require large incisions and extensive dissection, which is not desirable for many patients and potentially avoidable in specific situations.

METHOD

We utilized a standard blepharoplasty approach to access the superior orbital rim in patients who desired isolated lateral orbital contouring as part of their gender affirming facial surgery.

CONCLUSION

A subset of patients who require bony contouring of the orbital rim as part of their treatment for gender dysphoria will benefit from a less invasive approach to the upper face. A standard blepharoplasty incision is safe and effective to access the orbital rims in select patients, with decreased recovery and comparable results to traditional approaches.

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.

Necessity of facial contouring in feminization surgery for Chinese transgender females

Background

An increasing number of transgender females are suffering from a critical gender dysphoria, which often presents as depression and self-destructive behavior. Facial feminization surgery (FFS) is an effective method to alleviate symptoms of gender dysphoria, which could be more important than genital reassignment surgery for Chinese. Facial contour surgery is perceived as an ordinary FFS for the Chinese women to improve their facial appearance. The zygoma and jaw are key areas for feminizing the facial contour. This study mainly emphasized the necessity of FFS and discussed the importance of facial contour surgery of Chinese individuals.

Methods

The differences of facial contour before and after FFS in terms of skeletal and soft tissue were analyzed. The pre- and postoperative images were evaluated for feminization. The results of the full suite of measurements were compared to reveal the effective change of FFS. Furthermore, a surgery satisfaction survey was conducted among these patients after recovery.

Results

All the patients expressed their satisfaction with the reduction in the intergonial width as well as the middle face prominence. All the facial contour ratios changed significantly after surgery in both hard tissue and soft tissue.

Conclusions

Facial contour surgery is crucial to changing one's facial appearance and sex impression, which significantly alleviates gender dysphoria.

Reprint of: Breaking the binary: The identification of trans-women in forensic anthropology

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Breaking the binary: The identification of trans-women in forensic anthropology

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Anatomical Basis and Surgical Techniques Employed in Facial Feminization and Masculinization

Increasingly, facial feminization and masculinization techniques are being employed in the treatment of gender dysphoria. For the facial surgeon, knowledge of the anatomical differences between masculine and feminine facial skeletal structures is of utmost importance. Combining this knowledge with the various surgical and non-techniques that may be employed in order to achieve each patient's goals will allow the facial surgeon to greatly impact the lives of persons of transgender and gender diverse experience. Below, this article discusses these anatomical differences as well as current surgical practices employed in order to masculinize or feminize the face.

Gender-related Facial Analysis

There exist several known anthropometric differences between the male and female facial skeleton and soft tissues. In general, the female face is less robust, rounder or heart shaped, with a shorter forehead, no supraorbital bossing, a smaller nose, more pronounced zygomatic prominences, fuller lips, a smaller mandibular width, and a more tapered chin. A method for analyzing these differences is critical for offering facial gender confirming surgery to the gender dysphoric patients, both for preoperative planning, as well as for setting postoperative expectations.

A Capable Surgeon and a Willing Electrologist: Challenges to the Expansion of Transgender Surgical Care in the United States

Since 2014, public and private insurance coverage for transgender Americans' surgical care has increased exponentially. Training clinicians and equipping institutions to meet the surge in demand has not been as rapid. Through ethnographic research at a surgical workshop focused on trans- genital reconstruction and in a U.S. hospital working to grow its transgender health program, this article shows that effects of the decades-long insurance exclusion of trans- surgery are not easily remedied through the recent event of its inclusion because patient access is not the only thing that has been restricted by coverage denial. Decades of excluding coverage for trans- genital reconstructive surgery have limited the development and circulation of technical skills required to perform these procedures, as well as the administrative processes needed to integrate them into existing clinical workflows. One surgeon estimates that turning expanded access into realized care is "a five or six-year problem."