Osseous Transformation with Facial Feminization Surgery: Improved Anatomical Accuracy with Virtual Planning

Technical Pearls and Pitfalls of Facial Feminization Surgery: A Review of Techniques From a Single Institutional Practice

BACKGROUND

Facial feminization surgery (FFS) is an emerging practice that falls under the broader umbrella of gender-affirming surgery. Various approaches exist to feminize the face, yet few published articles describe in detail the techniques of each component procedure. Considering the diversity of interventions employed, the objective of this manuscript is to highlight FFS techniques utilized by the senior author and create a corresponding media gallery.

METHODS

All patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation between June 2017 and August 2022 were reviewed. Data were retrospectively collected from electronic medical records according to the institutional review board (IRB)-approved study protocol. Data collected and analyzed included demographics, operative documentation, and postoperative follow-up. Multimedia material was collected intraoperatively and postoperatively.

RESULTS

A total of 231 patients underwent 262 operations with a total of 1224 FFS procedures. The average follow-up time was 7.7 ± 11 months. Out of the 262 operations, 24 (9.2%) patients experienced minor complications, including 3 (1.1%) with wound dehiscence, 13 (5.0%) with hematomas, and 14 (5.3%) with postoperative infection requiring antibiotics. Of those, 3 (1.1%) required a return to the operating room for washout or removal of malar implants.

CONCLUSION

Although there is a consensus on the fundamental surgical principles to achieve adequate feminization of the facial architecture, the specific techniques to do so differ according to individual practices. As techniques diverge, so do their risk profiles and outcomes; techniques must, thus, align with patients' interventional goals. The material presented here is one of many that can support trainees and junior surgeons as they build a gender-affirming practice.

Computerized Surgical Planning in Gender Affirming Facial Surgery

Computerized Surgical Planning (CSP) is a surgical tool that enables precise bony changes through the creation of custom cutting guides and/or custom plates. CSP has been shown to be a safe and effective tool in gender affirming facial surgery as well, specifically with regard to frontal sinus setback, zygomatic remodeling, genioplasty, and mandibular angle and body reshaping. CSP aids in trainee education, improves symmetry, reduces operative time, and can produce idealized results during complex revisions. Overall, CSP is a valuable tool in the field of gender affirming facial surgery that helps surgeons achieve optimal aesthetic and safety outcomes for patients.

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients

BACKGROUND

Facial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort.

METHODS

A systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations.

RESULTS

Initial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm.

CONCLUSIONS

The core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face.

LEVEL OF EVIDENCE III

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

Exploring the evolution of facial feminization and masculinization surgery: a bibliometric analysis and visualization study

BACKGROUND

This study aims to conduct a bibliometric analysis of the current literature related to facial feminization surgery (FFS) and facial masculinization surgery (FMS) to understand the patterns, trends, and evolution of research topics. In addition, it aims to objectively identify the important articles that constitute the primary backbone of the FFS/FMS literature and provide a resource for education and new studies in this emerging field.

RESULTS

Using the principles of the Leiden Manifesto, 384 publications from the Web of Science from 1987 to 2023 were analyzed. The analysis included cross-country collaboration, keyword trends, affiliations, co-citation networks, and clustering. The results showed an increasing trend in FFS/FMS publications, with the USA leading in both publications (n = 238) and citations (n = 2420). The most cited journal was the Journal of Plastic and Reconstructive Surgery. The results indicate a high growth rate, with an H-index of 34 and an average citation of 11.41 per article. Co-occurrence analysis revealed evolving keywords such as "forehead" (n = 52) and "quality of life" (n = 44). The timeline view illustrated the terms reflecting current areas of interest such as #patient satisfaction and #gender-affirming care.

CONCLUSION

The study reveals the influence of countries, institutions, authors, and emerging trends, supporting the anticipation that FFS/FMS will be a critical field of study in the future. The findings contribute to understanding the global landscape of FFS/FMS research, facilitating informed decision-making for researchers, and clinicians in the field of maxillofacial surgery.

Mixed Reality in the Operating Room: An Initial Use in Frontal Sinus Setback in Gender-affirming Facial Surgery

Demand for gender-affirming facial surgery is growing rapidly. Frontal sinus setback, one of the key procedures used in gender-affirming facial surgery, has a particularly high impact on gender perception. Mixed reality (MR) allows a user to view and virtually overlay three-dimensional imaging on the patient and interact with it in real time. We used the Medivis's SurgicalAR system in conjunction with the Microsoft HoloLens Lucille2 (Microsoft). Computed tomography imaging was uploaded to SurgicalAR, and a three-dimensional (3D) hologram was projected onto the display of the HoloLens. The hologram was registered and matched to the patient, allowing the surgeon to view bony anatomy and underlying structures in real time on the patient. The surgeon was able to outline the patient's frontal sinuses using the hologram as guidance. A 3D printed cutting guide was used for comparison. Negligible difference between the mixed reality-based outline and 3D-printed outline was seen. The process of loading the hologram and marking the frontal sinus outline lasted less than 10 minutes. The workflow and usage described here demonstrate significant promise for the use of mixed reality as imaging and surgical guidance technology in gender-affirming facial surgery.

Appropriate Use of Preoperative Imaging in Feminization Cranioplasty

Study Design

Retrospective chart review.

Objective

The objective of this study was to determine if proceeding with feminization frontal cranioplasty without preoperative imaging adversely affected patient outcomes.

Methods

This study retrospectively reviewed all patients undergoing frontal cranioplasty for facial feminization at a single tertiary care center between 2013 and 2019. All procedures were performed by a single surgeon (JS), who operated at multiple sites. The site selected is where the majority of these procedures were performed during this time. Type of cranioplasty (I vs III) was recorded. Primary outcomes included postoperative cerebrospinal fluid (CSF) leak, entering the cranium, or dural exposure or injury.

Results

422 subjects underwent cranioplasty for facial feminization between 2013 and 2019. No preoperative imaging was performed. Zero patients had CSF leak. 334 subjects (79%) had type III cranioplasty, while the remaining 88 subjects (21%) had type I cranioplasty. No subjects had documented episodes of dural injury, or postoperative brain or cranial concerns.

Conclusions

This study demonstrates that frontal cranioplasty for facial feminization does not require routine preoperative imaging. The authors recommend preoperative imaging for patients with a history of congenital cranial abnormality, prior significant head trauma affecting the frontal bone, and in some cases where the patient has had prior surgery or a history of sinus disease or extensive polyposis. Routine preoperative computed tomography is therefore not indicated for patients undergoing feminizing cranioplasty.

F-Chin/Feminizing the Chin: A Genioplasty Technique with Virtual Planning for Male-to-Female Transgender Patients

The chin is an essential structure in facial harmony and an important gender marker. Advancing a receding chin is fundamental to improve the facial appearance, particularly in male-to-female transgender patients. However, in patients with microgenia and/or retrognathia, desiring a more feminine appearance, a chin advancement can result in a wider, square shape; an undesirable effect. Genioplasty is a versatile procedure used in facial feminization surgery that allows modifying the natural anatomy of the chin in all three spatial dimensions. The technique herein described proposes a simple genioplasty procedure for feminizing the chin (F-chin genioplasty) in transgender patients where anteroposterior advance is required. Virtual planning was used to establish the landmarks for an anteroposterior advancement with transverse reduction in the chin. A perpendicular line to the Frankfurt plane passing through the incisal edge of the upper central incisor was used to plan the anteroposterior movement, and two vertical lines on the outer wall of the nasal cavity  for the chin transverse measurement. The authors present three case reports with the F-chin genioplasty transgender technique with satisfactory results, ensuring a more feminine facial appearance.Level of Evidence V 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 .

Preoperative Radiology and Virtual Surgical Planning

Virtual surgical planning enables precise surgical planning and translation of this planning into the operating room. Preoperative maxillofacial computed tomography scans are compared to a reference skull to identify desired surgical changes. In facial feminization surgery, these include forehead recontouring/frontal table setback, gonial angle reduction, and possible chin repositioning/reshaping, while in facial masculinization surgery, this includes forehead augmentation and gonial angle/chin augmentation. Cutting and recontouring guides as well as custom implants are then custom manufactured. Common guides include osteotomy guides, depth drilling guides, ostectomy guides, and guides for one/two-piece genioplasty or chin burring. Common implants include mandibular and chin implants.

Facial Feminization: Perioperative Care and Surgical Approaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the regional anatomy involved in facial feminization surgery, the key differences between the male and female face, and surgical approaches for modification. 2. Appreciate the integration of preoperative virtual planning and nonoperative approaches for facial feminization care. 3. Understand the perioperative process and potential complications and sequela. 4. Understand the importance of transgender care acceptance as it pertains to clinical outcomes.

SUMMARY

Facial feminization surgery (FFS) is composed of a broad spectrum of gender-affirming surgical procedures with the goal of modifying specific facial features to create a more feminine appearance. As FFS continues to evolve as a subspecialty of transgender care, it is important to consider the psychosocial evaluation, evolving aesthetic tastes, nonoperative facial feminization care, preoperative virtual planning, specialized instrumentation, and potential complications/sequelae when performing these procedures. Computed tomographic imaging and virtual preoperative planning may be used to assist the surgeon with morphologic typing of the brow, supraorbital rim, chin, and lateral mandible regions and aid in performing safer, more efficient procedures. The increasing number of FFS procedures performed on transwomen annually has been supported by objective outcome studies that demonstrate progress in minimizing both misgendering in social environments and reducing dysphoric feelings.

Facial Feminization Surgery: Anatomical Differences, Preoperative Planning, Techniques, and Ethical Considerations

Facial Feminization Surgery (FFS) is a transformative surgical approach aimed at aligning the facial features of transgender women with their gender identity. Through a systematic analysis, this paper explores the clinical differences between male and female facial skeletons along with the craniofacial techniques employed in FFS for each region. The preoperative planning stage is highlighted, emphasizing the importance of virtual planning and AI morphing as valuable tools to be used to achieve surgical precision. Consideration is given to special circumstances, such as procedure sequencing for older patients and silicone removal. Clinical outcomes, through patient-reported outcome measures and AI-based gender-typing assessments, showcase the efficacy of FFS in achieving proper gender recognition and alleviating gender dysphoria. This comprehensive review not only offers valuable insights into the current state of knowledge regarding FFS but also emphasizes the potential of artificial intelligence in outcome evaluation and surgical planning to further advance patient care and satisfaction with FFS.

Technique for Cephalometric Analysis of the Craniofacial Skeleton Following Facial Feminization Surgery

Facial feminization surgery (FFS) is characterized by a series of relatively diverse procedures aimed at aligning skeletal and soft tissue facial appearance with one's experienced feminine gender. Although there are several well-described outcomes from surgical techniques, there is no standardized methodology to provide reliable analyses of postoperative FFS outcomes. This paper describes the first reliable and reproducible technique to accurately and consistently measure post-FFS changes to guide surgical planning to optimize patient outcomes.

Assessment of Cranial Sexual Dimorphism Using 3D Reconstruction: Implications for Gender-Affirming Surgery

BACKGROUND

As more centers offer gender-affirming procedures, dissemination of best practices is critical to ensuring quality care. This study is the first to use advanced 3-dimensional visualization software to characterize cranial differences between natal males and females, as they relate to planning for facial gender-affirming operations.

MATERIALS AND METHODS

A retrospective analysis was conducted on randomly selected patients with facial computed tomography imaging performed at a single institution between February 2020 and July 2021. Patients with acquired bony deformity on computed tomography or documented history of hormone replacement therapy were excluded. The images were retrieved and analyzed using advanced 3-dimensional visualization software (Vitrea). Independent sample t tests were performed to analyze variation in typically sexually dimorphic facial features between natal males and females.

RESULTS

We identified 50 patients (25 natal males and 25 natal females) who met the inclusion criteria. Ages ranged from 19 to 91. Natal males were found to have significantly greater frontosellar distances (difference between means, SEM: 2.7±1.2; P =0.03) and mandible volumes (difference between means, SEM: 14.0±4.2; P =0.002) than natal females. Statistical analysis revealed no significant differences in gonial angle, chin width, nasofrontal angle, or nasolabial angle between natal males and females.

CONCLUSION

In this diverse sample of natal males and females, statistical analysis revealed that the sexually dimorphic facial characteristics most relevant to the planning of facial gender-affirming surgery are frontosellar distance and mandible volume. When planning facial gender-affirming surgery, we recommend that these characteristics be considered to achieve optimum results.

Gender Affirming Surgery in Nonbinary Patients: A Single Institutional Experience

Background  An increasing number of nonbinary patients are receiving gender-affirming procedures due to improved access to care. However, the preferred treatments for nonbinary patients are underdescribed. The purpose of this study was to investigate the goals and treatments of nonbinary patients. Methods  A retrospective study of patients who self-identified as nonbinary from our institutional Gender Health Program was conducted. Patient demographics, clinical characteristics, surgical goals, and operative variables were analyzed. Results  Of the 375 patients with gender dysphoria, 67 (18%) were nonbinary. Over half of the nonbinary patients were assigned male at birth ( n  = 57, 85%) and nearly half preferred the gender pronoun they/them/theirs ( n  = 33, 49%). A total of 44 patients (66%) received hormone therapy for an average of 2.5 ± 3.6 years, primarily estrogen ( n  = 39). Most patients ( n  = 46, 69%) received or are interested in gender-affirming surgery, of which, almost half were previously on hormone therapy ( n  = 32, 48%). The most common surgeries completed or desired were facial feminization surgery ( n  = 15, 22%), vaginoplasty ( n  = 15, 22%), mastectomy ( n  = 11, 16%), and orchiectomy ( n  = 9, 13%). Nonbinary patients who were assigned male at birth (NB-AMAB) were more often treated with hormones compared to nonbinary patients assigned female at birth (NB-AFAB) (72% vs. 30%, p  = 0.010). Conversely, patients who were AFAB were more likely to complete or desire surgical intervention than those who were AMAB (100% vs. 63.0%, p  < 0.021). Conclusion  Majority of nonbinary patients were assigned male at birth. NB-AFAB patients all underwent surgical treatment, whereas NB-AMAB patients were predominantly treated with hormone therapy.

Point of Care Virtual Surgical Planning and 3D Printing in Facial Feminization Surgery

The use of virtual surgical planning (VSP) and three-dimensional printing (3DP) technologies in the routine facial feminization surgery practice has gained a significant popularity over the past few years. The clinical applications of them are claimed to improve safety, accuracy, and efficiency of facial feminization surgeries. In this article, we review and discuss the current applications of VSP and 3DP in different facial feminization procedures.

Surgical techniques used in chin feminization: Literature review and knowledge update

Genioplasty is commonly performed as part of facial feminization surgery. Commonly addressed areas in facial feminization surgery include the chin. According to some authors, 100% of patients request genioplasty surgery in order to feminize their faces. Specific genioplasty techniques (involving generally reduction surgery) applied to transgender patients have been rarely described in the literature. Objective: We aimed to carry out a review of the literature to update the current knowledge on this subject while achieving a comprehensive synthesis of the available surgical techniques for reduction genioplasty in trans Male to Female patients. Conclusion: Reduction genioplasty is frequently performed in facial feminization surgery. Multiple surgical techniques for chin feminization have been described in the existing literature. Reduction genioplasty requires combined work in the sagittal and transverse planes so as to obtain a harmonious result. However, no comparative study on the different surgical techniques has as yet been conducted. Patient satisfaction or surgical complications (which tend to be rare) cannot be related to any specific surgical technique.

Developments in facial feminization surgery

PURPOSE OF REVIEW

Facial feminization surgery (FFS) is being performed by facial plastic surgeons with increasing frequency. As insurance companies expand benefits to cover these procedures, more and more institutions are developing programs to treat transgender patients. The purpose of this review is to summarize recent literature on the subject so that those interested in this subject may have a framework to analyze these works.

RECENT FINDINGS

The most significant findings are that FFS does appear to be safe with low complication rates, despite long operative times due to multiple procedures performed. Much of the recent literature is reviews of each practice's techniques. This is valuable to educate those interested in beginning to perform these surgeries. Further, these reviews can eventually be compiled into a standard of care. Virtual surgical planning is currently being used by some departments, but its value is yet to be determined.

SUMMARY

FFS is performed with increasing frequency. Current literature reviews best practices with the goal of eventually establishing a standard of care.

Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes

Background:

Facial feminization is a critical step in a transfeminine patient’s surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures.

Methods:

An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns.

Results:

A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM.

Conclusions:

FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.

Applications of three-dimensional surgical planning in facial feminization surgery: A systematic review

BACKGROUND

Despite some reports that have shown an increase in safety, efficiency, and accuracy during feminizing craniofacial procedures utilizing three-dimensional (3D) technology, there are no reports summarizing the available evidence on this matter for facial feminization surgery (FFS). Here, we aimed to systematically review the application of 3D technology on FFS.

METHODS

We conducted a comprehensive search across PubMed, SCOPUS, Ovid MEDLINE®, Web of Science, and ScienceDirect looking for studies reporting the use of 3D surgical planning in the setting of FFS following the PRISMA guidelines. We extracted data on photographic assessment, imaging, surgical application, and surgical technique and outcomes.

RESULTS

This review included 10 studies comprising 1473 transgender female patients and 50 cadaveric cranial specimens. Four studies employed virtual surgical planning (VSP) and the concomitant use of prefabricated cutting guides. One study reported the implementation of 3D VSP using a female skull as a reference. One study used computer-aided design cutting guides and custom plates for FFS. Standardized incorporation of 3D printed models allowed for preoperative planning in three studies. Three studies reported VSP using 3D reconstruction of CT images, but without the use of 3D printing. Three studies used 3D photography with specialized camera technology to enrich clinical documentation and provide a comprehensive facial analysis of soft tissue. Accuracy ranged from 85.7% to 97%. Morbidity ranged from 0% to 12.5%.

CONCLUSION

Based on this data, we believe 3D VSP has promising outcomes in terms of accuracy and low morbidity, encouraging its implementation in FFS. However, further prospective double-arm cohort studies are required.

EPPOCRATIS: Expedited Preoperative Point-of-Care Reduction of Fractures to Normalized Anatomy and Three-Dimensional Printing to Improve Surgical Outcomes

SUMMARY

Virtual surgical planning and three-dimensional printing have been invaluable tools in craniomaxillofacial surgery. From planning head and neck reconstruction to orthognathic surgery and secondary reconstruction of maxillofacial trauma, virtual surgical planning and three-dimensional printing allow the surgeon to rehearse the surgical plan and use patient-specific surgical guides for carrying out the plan accurately. However, the process of virtual surgical planning and three-dimensional printing requires time and coordination between the surgeon on one hand and the biomedical engineers and designers on the other hand. Outsourcing to third-party companies contributes to inefficiencies in this process. Advances in surgical planning software and three-dimensional printing technology have enabled the integration of virtual surgical planning and three-dimensional printing at the treating hospital, the point of care. This allows for expedited use of this process in semiurgent surgical cases and acute facial trauma cases by bringing the surgeon, radiologist, biomedical engineers, and designers to the point of care. In this article, the authors present the utility of EPPOCRATIS, expedited preoperative point of care reduction of fractures to normalized anatomy and three-dimensional printing to improve surgical outcomes, in the management of acute facial trauma.

Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium

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.

Neuroradiology in Transgender Care: Facial Feminization, Laryngeal Surgery, and Beyond

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.

Low-Cost and Simple Frontal Sinus Surgical Cutting Guide Modeling for Anterior Cranioplasty in Facial Feminization Surgery: How To Do It

BACKGROUND

This study demonstrates a novel and simple design to create a low cost frontal sinus surgical cutting guide, using patient's frontal sinus cavities as references, to perform an anterior cranioplasty in facial feminization surgery. A clinical series demonstrates its clinical use and safety.

MATERIAL AND METHODS

Authors used a 4 open-source software protocol for the virtual surgical modeling (VSP). Retrospectively, pre- and post-operative complications were reviewed, and a FACE-Q questionnaires were used to evaluate patient's postoperative "Satisfaction with forehead and eyebrows." Recordings of the VSP and surgical technic are presented.

RESULTS

Sixteen patients were operated between November 2018 and November 2020 using in-house surgical guides. All were performed by authors in 5 to 10 minutes using Blender open-source Software. No complications were reported and authors always found an optimal retention of the surgical guide on the convex bony surface of the forehead and frontonasal area. FACE-Q questionnaire reported a very high satisfaction for all patients (mean score: 22/24).

DISCUSSION

This simplify organic design can be performed efficiently by any surgeon even without previous training in home staging VSP. Patient satisfaction was very high, along with an absence of postoperative complications.

Facial Feminization Surgery under Insurance: The University of California Los Angeles Experience

Despite improved insurance coverage for gender confirmation surgeries in the United States, coverage for facial feminization surgery (FFS) continues to be difficult. Here, we describe our institutional experience on navigation, time, and costs of the FFS insurance authorization process.

EPPOCRATIS: A Point-of-Care Utilization of Virtual Surgical Planning and Three-Dimensional Printing for the Management of Acute Craniomaxillofacial Trauma

While virtual surgical planning (VSP) and three-dimensional planning (3DP) have become important tools in acute craniomaxillofacial surgery, the incorporation of point of care VSP and 3DP is crucial to allow for acute facial trauma care. In this article, we review our approach to acute craniomaxillofacial trauma management, EPPOCRATIS, and discuss current challenges and future directions in acute facial trauma management.

Three-Dimensional Custom-Made Surgical Guides in Facial Feminization Surgery: Prospective Study on Safety and Accuracy

BACKGROUND

Facial feminization surgery (FFS) includes several osseous modifications of the forehead, mandible, and chin, procedures that require precision to provide the patient with a satisfactory result. Mispositioned osteotomies can lead to serious complications and poor aesthetic outcomes. Surgical cutting guides are commonly employed in plastic and maxillofacial surgery to improve safety and accuracy. Yet, to our knowledge, there is no report in the literature on the clinical application of cutting guides in FFS.

OBJECTIVES

The authors sought to assess the safety and accuracy of custom surgical cutting guides in FFS procedures.

METHODS

A prospective follow-up of 45 patients regarding FFS with preoperative virtual planning and 3-dimensional custom-made surgical guides for anterior frontal sinus wall setback, mandibular angle reduction, and/or osseous genioplasty was conducted. Accuracy (superimposing preoperative data on postoperative data by global registration with a 1-mm margin of error), safety (intradural intrusion for the forehead procedures and injury of the infra alveolar nerve for chin and mandibular angles), and patient satisfaction were assessed.

RESULTS

A total 133 procedures were documented. There was no cerebrospinal fluid leak on the forehead procedures or any infra alveolar nerve or tooth root injury on both chin and mandibular angle operations (safety, 100%). Accuracy was 90.80% on the forehead (n = 25), 85.72% on the mandibular angles (n = 44), and 96.20% on the chin (n = 26). Overall satisfaction was 94.40%.

CONCLUSIONS

Custom-made surgical cutting guides could be a safe and accurate tool for forehead, mandibular angles, and chin procedures for FFS.

LEVEL OF EVIDENCE: 4

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

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

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

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

Facial Feminization Surgery: A Review of 220 Consecutive Patients

Background Facial feminization surgery (FFS) is a combination of facial bony and soft tissue surgeries designed to modify and convert a masculine face to feminine. One’s face plays a very central role in gender incongruence and FFS helps patients overcome this. There are prominent differences between the male and the female facial anatomy (bony and soft tissue) which can be surgically altered to change the visual perception of the face.

Methods The author presents the method used at his center for treating 220 patients of gender incongruence requesting FFS from June 2016 to June 2019. The alterations to known methods of forehead contouring, hairline lowering, and jaw shave adopted by his team are discussed. He also presents the logic of performing the entire FFS in two stages at an interval of 7 to 10 days.

Results A total of 220 cases of FFS are presented, along with surgical details of techniques used, the sequence and staging of procedures performed, and the results obtained. A two-staged approach to FFS is proposed to maximize the recovery and minimize complications and promote faster healing. Different methods of forehead contouring are also explained in detail.

Conclusions FFS is a very rewarding surgery for the plastic surgeon and has high patient satisfaction rate. With proper training in craniomaxillofacial and soft tissue surgery, it is possible for the plastic surgeon to be the main team leader for this procedure. A two-stage approach is highly recommended.

Gender affirming and aesthetic cranioplasty: what's new?

PURPOSE OF REVIEW

Esthetic cranioplasty is an important part of facial feminization surgery. Additionally, it is an often underappreciated procedure for facial beautification. This chapter reviews current trends in esthetic cranioplasty for transgender women and others. Valuable techniques and innovations that do not advance the field are reviewed.

RECENT FINDINGS

Although promoted in recent literature, among the key concepts discussed in this review are the limitations of cutting guides, the rare indications for preoperative imaging, and when burring the glabellar area is appropriate rather than doing a full osteoplastic flap setback.

SUMMARY

Forehead feminization cranioplasty is a highly dependent upon the surgeon's artistic ability. Modeling and guides are potentially helpful for the novice surgeon but better is to learn appropriate anatomy for a more refined result.

Facial Feminization Surgery Changes Perception of Patient Gender

BACKGROUND

The goal of facial feminization surgery (FFS) is to feminize the sexually dimorphic characteristics of the face and enable transwomen to be correctly gendered as female. Studies have demonstrated high patient satisfaction with FFS. However, the correct gendering of patients after FFS has never been objectively studied.

OBJECTIVES

The aim of this study was to determine if FFS changed the perceived gender of patients in the public eye.

METHODS

An online survey platform with control photographs of cis-gender males and cis-gender females as well as preoperative and postoperative FFS patients was created. Respondents were asked to identify patients as "male" or "female" and to assign a confidence score ranging from -10 (masculine) to +10 (feminine) (n = 802).

RESULTS

Cis-gender male and female controls were gendered correctly 99% and 99.38% of the time and with a confidence metric (CM) of -8.96 and 8.93, respectively. Preoperative FFS patients were gendered as female 57.31% of the time with a CM of 1.41 despite hormone therapy, makeup, and hairstyle. Postoperative FFS patients were gendered as female 94.27% of the time with a CM of 7.78. Ninety-five percent of patients showed a significant improvement in CM after FFS.

CONCLUSIONS

This study illustrates that FFS changes the social perception of a patient's gender. Patients after FFS are more likely to be identified as female and with greater confidence than before surgery. This is despite preoperative female hormone therapy, and nonsurgical methods that patients use to feminize their appearance.

LEVEL OF EVIDENCE: 4