1
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Diaddigo SE, LaValley MN, Asadourian PA, Feuer GB, Warner PE, Rohde CH. Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery. Plast Reconstr Surg 2024; 154:685-693. [PMID: 37843269 DOI: 10.1097/prs.0000000000011144] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Given that gender-affirming surgery (GAS) is considered medically necessary for transgender and gender-diverse individuals who desire it, the aim of this study was to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. METHODS Insurance policies for coverage of gender-affirming genital surgery ("bottom surgery"), chest surgery ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into 3 categories: no coverage, case by case, or preauthorization. Among preauthorization policies, criteria for coverage of specific procedures were analyzed for adherence to the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. RESULTS Bottom-surgery policies were most concordant for age and gender dysphoria criteria, and transmasculine top surgery policies were most concordant for hormone therapy, continuous living in a congruent gender role, and referral criteria. Transfeminine top surgery criteria were more restrictive than transmasculine criteria. The most discordant criteria were for hormone therapy, being required for at least 12 months before surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Reversal and revisionary procedures were covered by less than 25% of policies. CONCLUSIONS Compared with previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care for GAS remain.
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Affiliation(s)
- Sarah E Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Myles N LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paul A Asadourian
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Grant B Feuer
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paige E Warner
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Christine H Rohde
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
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2
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van der Wel H, Merema BJ, Kraeima J, Schepers RH, Jansma J. Facial Masculinization Surgery Using Polyetheretherketone Alloplasty: Statistical Shape Modeling-based Implant Designs. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6012. [PMID: 39086493 PMCID: PMC11289784 DOI: 10.1097/gox.0000000000006012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 06/03/2024] [Indexed: 08/02/2024]
Abstract
The face is the initial feature used to judge gender in public spaces; it is also a source of significant gender dysphoria. Surgical techniques are available for non-cisgender male patients who desire a more masculine face by augmenting certain features to change the bony framework of the skull. Augmentation using virtually designed patient-specific polyetheretherketone implants has now become a more widely applied method in maxillofacial surgery. When designing implants for augmentation, a three-dimensional (3D) reference or template is very useful. Hence, a 3D statistical shape model was developed of a male skull shape from information from a population of 40 male patients containing the mean shape and principal components of shape variation. By overlaying the template and the patient's 3D skull model, this method identified the regions of gender dimorphism in this case to be the orbital ridge, zygomatic regions, and frontal bossing area. Based on the 3D template overlay, polyetheretherketone augmentation implants were virtually designed in close consultation with a patient to augment the aforementioned regions. The virtual statistical shape modeling template offered an objective reference, and the possibility to fully involve the patient in the treatment planning.
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Affiliation(s)
- Hylke van der Wel
- From the Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Bram J. Merema
- From the Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Joep Kraeima
- From the Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Rutger H. Schepers
- From the Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Oral and Maxillofacial Surgery, Expertcenter for Orthofacial Surgery, Martini Hospital Groningen, Groningen, the Netherlands
| | - Johan Jansma
- From the Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Oral and Maxillofacial Surgery, Expertcenter for Orthofacial Surgery, Martini Hospital Groningen, Groningen, the Netherlands
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3
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LaValley MN, Diaddigo SE, Asadourian PA, Feuer GB, Warner PE, Rohde CH. National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery. Plast Reconstr Surg 2024; 153:1433-1440. [PMID: 37815328 DOI: 10.1097/prs.0000000000011123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage. METHODS Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions. RESULTS Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS. CONCLUSIONS Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.
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Affiliation(s)
- Myles N LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Sarah E Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paul A Asadourian
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Grant B Feuer
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paige E Warner
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Christine H Rohde
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
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4
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Lynne-Joseph A. The reproduction of knowledge hierarchies in transgender medicine: Professional, lay, and global expertise in clinical practice guidelines. Soc Sci Med 2024:116712. [PMID: 38443306 DOI: 10.1016/j.socscimed.2024.116712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 03/07/2024]
Abstract
The process for developing clinical practice guidelines in medicine has changed dramatically over time. Previously, small groups of clinicians crafted clinical practice guidelines based on their professional expertise, but guideline developers must increasingly consider patients' lay expertise, global expertise, and principles of evidence-based medicine. This article analyzes how the World Professional Association for Transgender Health grappled with diverse forms of expertise and evidence-based medicine in the process of creating its "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8" (hereafter, SOC-8), a prominent set of clinical practice guidelines in transgender medicine. Analysis is based on 83 interviews with clinicians, patients, and activists in the U.S. and Thailand between 2019 and 2021, as well as observation of transgender health conferences and content analysis of written materials. I find that despite the ostensible goal of incorporating more diverse expertise in this version of the guidelines, the SOC-8 ultimately reproduced traditional knowledge hierarchies in science and medicine in which the lay expertise of transgender and gender non-conforming patients and expertise from the Global South remain marginalized. I attribute this re-marginalization to the regulatory objectivity enacted in the SOC-8 revision process, which re-legitimized professional expertise, established no formal infrastructure for ensuring the equal participation of Global South stakeholders, and permitted limited inclusion of lay expertise from transgender and gender non-conforming people with relatively high levels of privilege (according to race, education, and other social statuses). These findings have implications for future research on knowledge hierarchies in science and medicine and the creation of clinical practice guidelines.
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Affiliation(s)
- Alyssa Lynne-Joseph
- Wichita State University, Department of Sociology, 1845 Fairmount Street, Wichita, KS, 67260, USA.
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5
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Glahn JZ, Prsic A, Alperovich M. Locating the "Feminine" in Facial Feminization Surgery. J Craniofac Surg 2024; 35:3-4. [PMID: 37665074 DOI: 10.1097/scs.0000000000009719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/07/2023] [Indexed: 09/05/2023] Open
Affiliation(s)
- Joshua Zev Glahn
- Department of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT
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6
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Mookerjee VG, Alper DP, Almeida MN, Hu KG, Parikh N, Ihnat J, De Baun HM, Alperovich M. Quantitative Analysis of Morphometric Changes in Feminization Rhinoplasty Utilizing a Standardized Forehead-Rhinoplasty Technique. Aesthet Surg J Open Forum 2023; 5:ojad095. [PMID: 38075296 PMCID: PMC10703580 DOI: 10.1093/asjof/ojad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024] Open
Abstract
Background Rhinoplasty is one of the most commonly performed facial gender-affirming surgeries (FGASs) for transgender females, but well-established morphometric parameters describing feminizing nasal changes do not exist. Objectives Describe the author's technique for feminization rhinoplasty, analyze the changes in 3-dimensional nasal anthropomorphic parameters, and describe patient-reported outcomes. Methods Three-dimensional photogrammetric evaluation was performed both preoperatively and postoperatively in transgender female patients who underwent FGAS. Measurements assessed included the nasofrontal angle, nasolabial angle, dorsal height, mid-dorsal width, alar width, nasal tip width, and tip projection. Patients were surveyed preoperatively and postoperatively using the FACE-Q Nose module. Paired t-tests were utilized to assess changes in postoperative measurements and FACE-Q Nose satisfaction scores. Results Twenty patients underwent FGAS during the study period. The average time between surgery and postoperative 3-dimensional images was 13.6 ± 6.8 months. The nasofrontal angle increased by 8.2° (148.0 ± 7.4° to 156.1 ± 6.7°, P < .001) and tip projection increased by 0.017 (0.58 ± 0.03 to 0.60 ± 0.04, P < .01). Dorsal height, mid-dorsal width, and tip width all decreased significantly (P < .05). There were significant improvements in patients' "Satisfaction with Nose," "Satisfaction with Facial Appearance Overall," "Psychological Function," and "Social Function" on FACE-Q. One revision rhinoplasty was performed, and no documented surgical complications were reported. Conclusions There were statistically significant changes in the nasofrontal angle, tip projection, dorsal height, mid-dorsal width, and tip width in patients receiving feminization rhinoplasty. These data may help surgeons with preoperative planning and intraoperative decision making. Level of Evidence 4
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Affiliation(s)
| | | | | | | | | | | | | | - Michael Alperovich
- Corresponding Author: Dr Michael Alperovich, 333 Cedar St, New Haven, CT 06510, USA. E-mail: ; Instagram: @drmikealperovich
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7
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Rodriguez AM, Savetsky IL, Cohen JM, Avashia YJ, Rohrich RJ, Rodriguez ED. Gender Considerations in Rhinoplasty. Plast Reconstr Surg 2023; 152:438e-445e. [PMID: 36728547 DOI: 10.1097/prs.0000000000010159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
SUMMARY 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.
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Affiliation(s)
| | | | - Joshua M Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center
| | | | | | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center
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8
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Massenburg BB, Ettinger RE, Morrison SD. Gender-Affirming Surgery of the Mandible: Lower Jaw Feminization and Masculinization. Facial Plast Surg Clin North Am 2023; 31:381-392. [PMID: 37348981 DOI: 10.1016/j.fsc.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
For patients with gender dysphoria, gender-affirming surgery of the face has been shown to vastly improve quality of life. The mandible is one area of the face that has distinct feminine and masculine presentations. This article will review gender-affirming surgery of the lower jaw, both for feminization and masculinization. Techniques for bony contouring and soft tissue manipulation will be discussed.
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Affiliation(s)
- Benjamin B Massenburg
- Division of Plastic Surgery, Department of Surgery, University of Washington; Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital
| | - Russell E Ettinger
- Division of Plastic Surgery, Department of Surgery, University of Washington; Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington; Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital.
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9
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Alper DP, Almeida MN, De Baun HM, Glahn JZ, Rivera JC, Williams MCG, Collar JL, Mookerjee V, Persing JA, Alperovich M. Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve? Ann Plast Surg 2023; 90:533-537. [PMID: 37311308 DOI: 10.1097/sap.0000000000003569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online. METHODS Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions. RESULTS One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001). CONCLUSIONS Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.
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Affiliation(s)
- David P Alper
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Mariana N Almeida
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Heloise M De Baun
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Joshua Z Glahn
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jean Carlo Rivera
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Mica C G Williams
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - John L Collar
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Vikram Mookerjee
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - John A Persing
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Michael Alperovich
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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10
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Banuchi VE, Helman SN. Scarless Neck Feminization: Chondrolaryngoplasty Through Endoscopic Transoral Vestibular Approach. Laryngoscope 2023; 133:1099-1102. [PMID: 36106862 DOI: 10.1002/lary.30326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 06/20/2022] [Accepted: 07/13/2022] [Indexed: 11/11/2022]
Abstract
We present in this paper a novel approach to perform endoscopic chondrolaryngoplasty without any external visible scars. The technique involves utilizing the endoscopic transoral vestibular approach. We have modified the technique by using the placement of a suture immediately above the anterior commissure, which provides a marker for the inferior extent of cartilage resection. Laryngoscope, 133:1099-1102, 2023.
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Affiliation(s)
- Victoria E Banuchi
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A
- Lincoln Medical Center/NYC Health and Hospitals, New York, New York, U.S.A
| | - Samuel N Helman
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A
- Lincoln Medical Center/NYC Health and Hospitals, New York, New York, U.S.A
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11
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Shoffel-Havakuk H, Cohen O, Lahav Y, Khafif A. Scarless Neck Feminization by Transoral Endoscopic Vestibular Approach Chondrolaryngoplasty: A Prospective Cohort. Otolaryngol Head Neck Surg 2023. [PMID: 36802074 DOI: 10.1002/ohn.296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/16/2022] [Accepted: 01/05/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE Chondrolaryngoplasty (laryngeal-prominence reduction) is a gender affirmation surgery for transgender women, or for cisgender people desiring an esthetic correction. Up until recently, chondrolaryngoplasty required a visible neck scar. The transoral endoscopic vestibular approach (TOEVA) is gaining widespread use as a scarless alternative for thyroid/parathyroid surgeries. This study aims to describe the feasibility, safety, and outcomes of TOEVA-chondrolaryngoplasty, based on the first-ever performed cases. STUDY DESIGN A prospective cohort. SETTING An academic referral center. METHODS Adult patients interested in chondrolaryngoplasty underwent scarless TOEVA-chondrolaryngoplasty between 2019 and 2022, according to the described protocol. Video stroboscopy was recorded pre-and postoperatively. Surgical data, adverse events, and complications were recorded. Patients' satisfaction was measured using an outcome instrument for esthetic chondrolaryngoplasty. RESULTS Twelve patients (10 transgender women, a cisgender man, and a woman) were included. The mean age was 26.7 ± 6.5 years, ranging from 19 to 37. The average operative time was 3:01 ± 0:51 hours. The thyroid cartilage and laryngeal prominence were easily and safely approached and reduced, with no adverse events or major complications. All patients were discharged on postoperative day 1. A single patient had a temporary mental nerve hypoesthesia that resolved spontaneously. Otherwise, no other complications were encountered. Vocal folds' function remained unchanged in all patients. Patients were very much to completely satisfied with the surgical results as measured by the outcome instrument; median (interquartile range), 25 (21-27.75). CONCLUSION In this first reported cohort of scarless TOEVA-chondrolaryngoplasty, this approach was proven to be safe and feasible, with no adverse events or major complications, and with high patient satisfaction.
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Affiliation(s)
- Hagit Shoffel-Havakuk
- A.R.M. Center for Head and Neck Surgery and Oncology, Assuta Hospital Ramat Hachayal, Tel Aviv, Israel.,Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Cohen
- A.R.M. Center for Head and Neck Surgery and Oncology, Assuta Hospital Ramat Hachayal, Tel Aviv, Israel.,Department of Otolaryngology-Head and Neck Surgery, Soroka Medical Center, Be'er Sheva, Israel.,Faculty of Medicine, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Yonatan Lahav
- A.R.M. Center for Head and Neck Surgery and Oncology, Assuta Hospital Ramat Hachayal, Tel Aviv, Israel.,Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avi Khafif
- A.R.M. Center for Head and Neck Surgery and Oncology, Assuta Hospital Ramat Hachayal, Tel Aviv, Israel.,Faculty of Medicine, Ben Gurion University of the Negev, Be'er Sheva, Israel
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12
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Bannister JJ, Juszczak H, Aponte JD, Katz DC, Knott PD, Weinberg SM, Hallgrímsson B, Forkert ND, Seth R. Sex Differences in Adult Facial Three-Dimensional Morphology: Application to Gender-Affirming Facial Surgery. Facial Plast Surg Aesthet Med 2022; 24:S24-S30. [PMID: 35357226 PMCID: PMC9529307 DOI: 10.1089/fpsam.2021.0301] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Gender-affirming facial surgery (GFS) is pursued by transgender individuals who desire facial features that better reflect their gender identity. Currently, there are a few objective guidelines to justify and facilitate effective surgical decision making. Objective: To quantify the effect of sex on adult facial size and shape through an analysis of three-dimensional (3D) facial surface images. Materials and Methods: Facial measurements were obtained by registering an atlas facial surface to 3D surface scans of 545 males and 1028 females older than 20 years of age. The differences between male and female faces were analyzed and visualized for a set of predefined surgically relevant facial regions. Results: On average, male faces are 7.3% larger than female faces (Cohen's D = 2.17). Sex is associated with significant facial shape differences (p < 0.0001) in the entire face as well as in each sub-region considered in this study. The facial regions in which sex has the largest effect on shape are the brow, jaw, nose, and cheek. Conclusions: These findings provide biologic data-driven anatomic guidance and justification for GFS, particularly forehead contouring cranioplasty, mandible and chin alterations, rhinoplasty, and cheek modifications.
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Affiliation(s)
- Jordan J. Bannister
- Department of Biomedical Engineering, University of Calgary, Calgary, Canada
| | - Hailey Juszczak
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jose David Aponte
- Department of Cell Biology and Anatomy, Alberta Children's Hospital Research Institute and McCaig Bone and Joint Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David C. Katz
- Department of Cell Biology and Anatomy, Alberta Children's Hospital Research Institute and McCaig Bone and Joint Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - P. Daniel Knott
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Seth M. Weinberg
- Department of Oral and Craniofacial Sciences, Center for Craniofacial and Dental Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benedikt Hallgrímsson
- Department of Cell Biology and Anatomy, Alberta Children's Hospital Research Institute and McCaig Bone and Joint Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nils D. Forkert
- Department of Radiology, Alberta Children's Hospital Research Institute and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Rahul Seth
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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13
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Alcon A, Badiee RK, Barnes LL, Pardo ST, Zevin B, Pomerantz JH. Gender-Affirming Facial Feminization Surgery at a Public, Safety-Net Hospital: A Single-Center Early Experience. J Craniofac Surg 2022; 34:1010-1014. [PMID: 36210502 DOI: 10.1097/scs.0000000000009057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Facial feminization surgery (FFS) remains inaccessible to many transgender patients. Zuckerberg San Francisco General Hospital (ZSFG) was among the first public, safety-net hospitals to perform FFS. The purpose of this study is to examine the postoperative outcomes of patients who underwent FFS at ZSFG and describe barriers to providing FFS in a public hospital setting. METHODS A retrospective review identified patients who underwent FFS at ZSFG. Demographic data, comorbidity profiles, postoperative outcomes, and hospital utilization data were collected from the medical records. FACE-Q modules (scored 0-100) were used to survey patient satisfaction at least 1 year postoperatively. RESULTS Seventeen patients underwent comprehensive FFS surgery at ZSFG. The median age was 41 years [interquartile range (IQR): 38-55], median body mass index was 26.4 (IQR: 24.1-31.3). Patients underwent a median of 9 procedures, the most common of which included frontal cranioplasty (n=13, 77%), open brow lift (n=13, 77%), rhinoplasty (n=12, 71%), and mandible contouring (n=12, 71%). There were no complications, readmissions, or reoperations within 30 days. Patients reported high satisfaction with the surgical outcome (median: 87, IQR: 87-100), excellent postoperative psychological functioning (median: 100, IQR: 88-100), and low levels of appearance-related distress (median: 3, IQR: 0-35). An estimated 243 operating room hours and 51 inpatient bed days were required to cover all FFS procedures. CONCLUSIONS Performing FFS in a public, safety-net hospital was associated with zero postoperative complications, few revision procedures, and excellent patient satisfaction. Limited operating room hours and inpatient availability represented barriers to providing FFS in this setting.
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Multiprocedural Facial Feminization Surgery: A Review of Complications in a Cohort of 31 Patients. J Craniofac Surg 2022; 33:2502-2506. [PMID: 36102911 DOI: 10.1097/scs.0000000000008760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/03/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Facial feminization surgery (FFS) is instrumental in gender affirmation for transgender patients. Multiprocedural FFS, the combination of multiple facial feminization procedures across multiple depths and planes during one surgery, crosses sterile and nonsterile planes in the oropharynx, nose, and frontal sinus. A closer look at the prevention and management of resulting complications of such reconstruction is necessary. METHODS We performed a retrospective review of patient demographics, operative variables, and postoperative complications on 31 FFS patients. Patients who underwent FFS between January 2020 and June 2021 were eligible for inclusion. Associations between prevention methods, procedure type, and complications were assessed by the Fisher exact test. The main effect of patient age and number of procedures on complication rate was assessed via the nonparametric Kruskal-Wallis test. RESULTS A total of 31 patients, with a mean age of 37 years (range: 19-65 y, SD: 13.3 y), underwent 257 procedures. Patients underwent a mean of 8 procedures (SD: 2.2) lasting 3.5 to 6 hours (mean: 5.0 h, SD: 0.9 h). Overall, 68% of patients experienced no complications. Six patients experienced a postoperative infection; 4 of these patients required return for a washout. Preventative measures implemented include: preoperative dental check, intraoperative antibiotic irrigation, locking sutures, and postoperative antibiotics. After measures were implemented, there were no further procedure-related infections recorded. CONCLUSIONS Patients do not suffer from major complications after multiprocedural FFS. Factors such as age, irrigation method, and dental history may be important variables affecting FFS outcomes.
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"Recommendations for Communication in Gender Affirming Surgical Care". Plast Reconstr Surg 2022; 150:438-445. [PMID: 35674659 DOI: 10.1097/prs.0000000000009332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
SUMMARY The surgical treatment of gender incongruence with gender affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women, as well as those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to our own mistakes during patient care. Based on the lessons learned from these experiences, we provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.
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Discussion: Surgical Treatment of Granulomatous Breast Deformities Caused by Injection of Foreign Substances in Transgender Women: A Case Series and Algorithm. Plast Reconstr Surg 2022; 149:1317-1319. [PMID: 35613285 DOI: 10.1097/prs.0000000000009169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Simon D, Capitán L, Bailón C, Bellinga RJ, Gutiérrez Santamaría J, Tenório T, Sánchez-García A, Capitán-Cañadas F. Facial Gender Confirmation Surgery: The Lower Jaw. Description of Surgical Techniques and Presentation of Results. Plast Reconstr Surg 2022; 149:755e-766e. [DOI: 10.1097/prs.0000000000008969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Evaluation and treatment of facial feminization surgery: part II. lips, midface, mandible, chin, and laryngeal prominence. Arch Plast Surg 2022; 49:5-11. [PMID: 35086301 PMCID: PMC8795653 DOI: 10.5999/aps.2021.01956] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 11/08/2022] Open
Abstract
Facial feminization surgery (FFS) refers to a set of procedures aimed at altering the features of a masculine face to achieve a more feminine appearance. In the second part of this twopart series, assessment and operations involving the midface, mandible, and chin, as well as soft tissue modification of the nasolabial complex and chondrolaryngoplasty, are discussed. Finally, we provide a review of the literature on patient-reported outcomes in this population following FFS and suggest a path forward to optimize care for FFS patients.
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Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium. Plast Reconstr Surg 2022; 149:212-224. [PMID: 34936625 DOI: 10.1097/prs.0000000000008668] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing societal acceptance of transgender people has led to broader availability of gender surgery and rapid growth in transition-related operations. Facial gender surgery aims to modify patients' facial features to be more congruent with their physical expression of gender, reducing gender dysphoria and improving quality of life. Growth in research and technique evolution has not kept pace with growth in clinical volume. Therefore, the first International Facial Gender Symposium was held at Johns Hopkins University in 2019, convening surgeons who perform facial gender surgery to share ideas and assess the state of clinical evidence. METHODS To review the literature on facial gender surgery, the authors developed a search strategy for seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) through May of 2019, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. RESULTS Based on the English language literature and clinical experience, the authors suggest guidelines for screening, management, and appropriate surgical technique for patients undergoing facial gender surgery. They highlight facial gender surgery as a medically necessary intervention and identify shortcomings in current guidelines. CONCLUSIONS Facial gender surgery represents a complex array of craniofacial and soft-tissue procedures that require application of advanced skills and decision-making. Facial gender operations are not cosmetic, are medically necessary, and require development of new CPT codes specific to facial gender surgery. It is imperative to create educational programs and methods to define sufficient training for facial gender surgery surgeons. Research priorities include better procedural outcomes data, more quality-of-life studies, and insight into variation in both patient and procedural subgroups.
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Stowell JT, Jha P, Martinez-Jorge J, Middlebrooks EH, Broderick DF, Bhatt AA. Neuroradiology in Transgender Care: Facial Feminization, Laryngeal Surgery, and Beyond. Radiographics 2022; 42:233-249. [PMID: 34990322 DOI: 10.1148/rg.210080] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Transgender individuals experience incongruence between their gender identity and the sex assigned to them at birth. This incongruence can cause many transgender individuals to experience distressing physical and mental discord, a diagnosis known as gender dysphoria. Craniofacial structures have distinct anthropometric characteristics that affect perceived masculinity and femininity. The face, neck, and voice are highly exposed anatomic areas that have recognizable gender-specific characteristics that may hinder a transgender individual's successful social integration and public acceptance. Reconstructive facial and laryngeal procedures are among the surgical options transgender persons may elect to undergo to better align their physical appearance with their gender identity. These include feminization surgeries such as facial feminization and reduction chondrolaryngoplasty, as well as masculinizing facial and laryngeal surgeries. Maxillofacial CT is frequently used in the preoperative evaluation of patients before facial feminization surgery (FFS). Several CT measurements guide surgeons to the optimal correction required in FFS to achieve appropriate aesthetic planes. Mapping important craniofacial landmarks to avoid untoward surgical complications is crucial. Transgender patients may encounter other neurologic complications that require neuroimaging evaluation. For example, gender-affirming hormone therapy (eg, estrogen and testosterone) may increase the risk of stroke or may influence growth of various hormone-sensitive tumors such as pituitary adenomas. Radiologists may interpret imaging examinations in transgender patients for routine care or for evaluation before and after facial and laryngeal surgeries and must be aware of the role of neuroimaging in the care of this population. An invited commentary by Callen is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Justin T Stowell
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Priyanka Jha
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Jorys Martinez-Jorge
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Erik H Middlebrooks
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Daniel F Broderick
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Alok A Bhatt
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
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Abstract
ABSTRACT 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.
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Harris J, Premaratne ID, Spector JA. Facial Masculinization from Procedures to Payment: A Review. LGBT Health 2021; 8:444-453. [PMID: 34403627 DOI: 10.1089/lgbt.2020.0128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Jason Harris
- Laboratory of Bioregenerative Medicine and Surgery, Division of Plastic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Ishani D Premaratne
- Laboratory of Bioregenerative Medicine and Surgery, Division of Plastic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Jason A Spector
- Laboratory of Bioregenerative Medicine and Surgery, Division of Plastic Surgery, Weill Cornell Medical College, New York, New York, USA.,Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
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23
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Chappell AG, Kane RL, Wood SM, Wescott AB, Chung KC. Representation of Ethics in the Plastic Surgery Literature: A Systematic Review. Plast Reconstr Surg 2021; 148:289e-298e. [PMID: 34228030 DOI: 10.1097/prs.0000000000008232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A 2009 systematic review demonstrated that ethical discourse was underrepresented in the plastic surgery literature; approximately one in 1000 articles contained ethical discussions. In the decade since, advances in plastic surgery and continued social progress have created new ethical dilemmas. However, it is unclear whether these developments have augmented the representation of ethics in the plastic surgery literature. A review of publications over the past decade can assess whether progress has been made and identify where deficits persist. METHODS The authors searched eight bibliographic databases to identify peer-reviewed articles discussing ethical issues in plastic surgery over the past decade. Independent reviewers extracted characteristics and ethical principles from included articles. RESULTS A total of 7097 articles were identified from the initial search and 531 articles were included for analysis. The principle of autonomy, present in 87.9 percent of articles, had the greatest representation, followed by beneficence (74.4 percent), nonmaleficence (72.3 percent), and justice (51.2 percent). Informed consent and face transplantation were the most prevalent topics discussed. Aesthetic surgery was the subdiscipline of plastic surgery with the greatest ethical discourse, representing 29.8 percent of all included articles. CONCLUSIONS In the past decade, there was approximately a five-fold increase in plastic surgery publications that include ethical discourse, indicating a growing awareness of ethical implications by the plastic surgery community. However, representation of ethical principles remained uneven, and specific subdisciplines of plastic surgery were substantially underrepresented. Plastic surgeons should adopt a more comprehensive approach when framing ethical implications in clinical and research settings.
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Affiliation(s)
- Ava G Chappell
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Robert L Kane
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Shannon M Wood
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Annie B Wescott
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Kevin C Chung
- From the Division of Plastic Surgery, Department of Surgery, and Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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24
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De Boulle K, Furuyama N, Heydenrych I, Keaney T, Rivkin A, Wong V, Silberberg M. Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals. Clin Cosmet Investig Dermatol 2021; 14:513-525. [PMID: 34012284 PMCID: PMC8128506 DOI: 10.2147/ccid.s304032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022]
Abstract
There is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodeling and transformation. These procedures may increase transgender individuals’ satisfaction with their appearance and allow them to more effectively harmonize their physical appearance with their perception of self. There is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. In this report, the authors provide experience-based treatment considerations and recommendations for use of minimally invasive facial aesthetic procedures in transgender patients, including case studies illustrating the use of these procedures for both male-to-female and female-to-male transitioning patients. This report highlights the success of minimally invasive methods for assisting transgender patients in achieving their facial remodeling goals. Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process. When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients’ self-perception and overall quality of life.
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Affiliation(s)
| | | | - Izolda Heydenrych
- Cape Town Cosmetic Dermatology Centre, Cape Town, South Africa.,Division of Dermatology, Faculty of Health Sciences, University of Stellenbosch, Stellenbosch, South Africa
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Forehead and Hairline Surgery for Gender Affirmation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3486. [PMID: 33786265 PMCID: PMC7994012 DOI: 10.1097/gox.0000000000003486] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 11/25/2022]
Abstract
Background: With the improvement of the results of surgical treatment for facial transformation globally, many female transgender individuals seek surgical management for their faces, especially the forehead and hairline. These are critical aspects in the surgical management of the frontonasal-orbital area because the anatomy of the frontal sinuses is complicated and shows a high variation. Methods: The author presents a grid method to measure the boundary of the frontal sinus in the female transgender forehead contouring and reconstruction. The surgical technique of forehead set back and simultaneous hairline advancement is described. Results: Between January 2015 and December 2017, there were 23 cases of forehead and hairline feminization procedures by the author. Patient age was between 20 and 74 years (mean 32.56). There were 11 Asians and 12 White patients. Eleven patients underwent supraorbital ridge contouring, and 12 underwent forehead reconstruction. Hairline advancement was simultaneously performed in 9 patients, and 3 underwent forehead augmentation at the supraorbital ridge. The postoperative follow-up time ranged from 3 weeks to 18 months. Conclusions: The key to the success of forehead contouring surgery in female transgender patients is the precise measurement of the boundary of the frontal sinus. This technique offers a practical way to estimate the frontal sinus sizes and shapes to avoid intraoperative complications and reduces the possibility of surface irregularity.
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Gadkaree SK, DeVore EK, Richburg K, Lee LN, Derakhshan A, McCarty JC, Seth R, Shaye DA. National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery. Facial Plast Surg Aesthet Med 2020; 23:270-277. [PMID: 32865436 DOI: 10.1089/fpsam.2020.0226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% (n = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures (p = 0.043), whereas those in restrictive states offered less overall coverage (p = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.
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Affiliation(s)
- Shekhar K Gadkaree
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Elliana Kirsh DeVore
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kayla Richburg
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda N Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Adeeb Derakhshan
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin C McCarty
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Seth
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - David A Shaye
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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27
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Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study. Plast Reconstr Surg 2020; 145:1499-1509. [PMID: 32459779 DOI: 10.1097/prs.0000000000006837] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND No data exist on the prospective outcomes of facial feminization surgery. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes for gender-diverse patients. METHODS A prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria was undertaken. Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and >6 months). Photogrammetric cephalometries were measured at the same time points. Self-perceived preoperative masculinity and femininity were recorded. Externally rated gender appearance (scale of 1 to 5, with 1 being most feminine) and general aesthetics (scale of 1 to 10, with 10 being very good) for 10 facial feminization surgery patients were compared with those of five cisgender controls. Univariate linear regression analyses were used to predict outcomes from facial feminization surgery. RESULTS Sixty-six consecutive patients were enrolled. Patients noted that their brows, jaws, and chins were the most masculine aspects of their faces (54.5 percent, 33.3 percent, and 30.3 percent, respectively). Median facial feminization outcome score increased from 47.2 preoperatively to 80.6 at 6 months or more postoperatively (p < 0.0001). Mean satisfaction was excellent (3.0 at both 1-month and ≥6-month follow-up; p = 0.46). Cephalometric values were significantly more feminine after surgery. Gender appearance was feminine to very feminine (1.83 ± 0.96) and general aesthetics were good (6.09 ± 2.01) but different from those of cisgender women controls (1.25 ± 0.49 and 7.63 ± 1.82, respectively; p < 0.001 for each). CONCLUSION Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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29
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Ngaage LM, McGlone KL, Xue S, Knighton BJ, Benzel CA, Rada EM, Coon D, Berli J, Rasko YM. Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape. Aesthet Surg J 2020; 40:NP202-NP210. [PMID: 31883267 DOI: 10.1093/asj/sjz262] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. OBJECTIVE The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. METHODS The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. RESULTS Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. CONCLUSIONS There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Shan Xue
- Medical College of Georgia, Augusta, GA
| | | | | | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jens Berli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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30
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Boas SR, Ascha M, Morrison SD, Massie JP, Nolan IT, Shen JK, Vyas KS, Satterwhite T. Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty after Gender-Affirming Genital Surgery. Plast Reconstr Surg 2019; 144:1451-1461. [PMID: 31764668 DOI: 10.1097/prs.0000000000006282] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty. METHODS A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed. RESULTS A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent). CONCLUSIONS Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Samuel R Boas
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Mona Ascha
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Shane D Morrison
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Jonathan P Massie
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Ian T Nolan
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Jacson K Shen
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Krishna S Vyas
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
| | - Thomas Satterwhite
- From Case Western Reserve University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University; New York University School of Medicine; the University of Sydney School of Medicine; the Department of Plastic Surgery, Mayo Clinic; Brownstein and Crane Surgical Services
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Ascha M, Swanson MA, Massie JP, Evans MW, Chambers C, Ginsberg BA, Gatherwright J, Satterwhite T, Morrison SD, Gougoutas AJ. Nonsurgical Management of Facial Masculinization and Feminization. Aesthet Surg J 2019; 39:NP123-NP137. [PMID: 30383180 DOI: 10.1093/asj/sjy253] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures. OBJECTIVES The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization. METHODS A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review. CONCLUSIONS Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Mona Ascha
- Division of Plastic Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Marco A Swanson
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan P Massie
- Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Morgan W Evans
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Christopher Chambers
- Division of Oculoplastic Surgery, Department of Ophthalmology, University of Washington School of Medicine, Seattle, WA
| | - Brian A Ginsberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Alexander J Gougoutas
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
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Morrison SD, Satterwhite T. Lower Jaw Recontouring in Facial Gender-Affirming Surgery. Facial Plast Surg Clin North Am 2019; 27:233-242. [PMID: 30940389 DOI: 10.1016/j.fsc.2019.01.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Facial gender-affirming surgery can have significant impact on patient quality of life for some gender-dysphoric patients. Lower jaw contouring can be used to harmonize the face during facial gender-affirming surgery through masculinization or feminization. During feminization, the mandibular angle and body and chin are reduced in width and size. During masculinization, augmentation of the mandibular angle and body and chin are completed with alloplastic implants, fat, or bone. Complications are minimal. Further research is needed on outcomes of these procedures.
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Affiliation(s)
- Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, 325 9th Avenue Mailstop #359796, Seattle, WA 98104, USA.
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Facial Masculinization Surgery and its Role in the Treatment of Gender Dysphoria. J Craniofac Surg 2019; 30:1339-1346. [DOI: 10.1097/scs.0000000000005101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Morrison SD, Wilson SC, Mosser SW. Breast and Body Contouring for Transgender and Gender Nonconforming Individuals. Clin Plast Surg 2018; 45:333-342. [PMID: 29908621 DOI: 10.1016/j.cps.2018.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Even after long-term hormone therapy, many transwomen still have challenges in the size and shape of their breasts and also of the contour of their trunk areas. Though distinct anthropomorphic differences in skeletal structure exist and pose limitations to an ideal result, considerable improvements can be obtained through breast augmentation and trunk feminization. There are challenges that are unique to the transfeminine chest and trunk, and important considerations for the priority of fat grafting to the buttocks and hips when grafted fat is in short supply.
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Affiliation(s)
- Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, University of Washington, Harborview Medical Center, 7th Floor Center Tower Room 73.1, 325 9th Avenue, Mail Stop #359796, Seattle, WA 98104, USA
| | - Stelios C Wilson
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, 305 East 33rd Street Lower Level, New York, NY 10016, USA
| | - Scott W Mosser
- Private Practice, The Gender Confirmation Center of San Francisco, Suite 1010, 450 Sutter Street, San Francisco, CA 94108, USA.
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Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication? Plast Reconstr Surg 2018; 141:220e-229e. [PMID: 29019859 DOI: 10.1097/prs.0000000000004061] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty. METHODS A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed. RESULTS A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty. CONCLUSIONS Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.
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Predictors of Patient Satisfaction and Postoperative Complications in Penile Inversion Vaginoplasty. Plast Reconstr Surg 2018; 141:911e-921e. [DOI: 10.1097/prs.0000000000004427] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lipschitz N, Wolf M, Amir O, Sagiv D, Primov-Fever A. Thyroid chondroplasty: Smoothing the thyroid cartilage— A retrospective study of thyroid chondroplasty for feminine neck appearance. INT J TRANSGENDERISM 2017. [DOI: 10.1080/15532739.2017.1363679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Noga Lipschitz
- Department of Otolaryngology and Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Michael Wolf
- Department of Otolaryngology and Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Amir
- Department of Communication Disorders, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Doron Sagiv
- Department of Otolaryngology and Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Primov-Fever
- Department of Otolaryngology and Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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