Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Journal Metrics of the Journal of Craniofacial Surgery: An Analysis Based on the Journal Citation Report 2024

OBJECTIVES

This study aims the analysis of the journal metrics of Journal of Craniofacial Surgery based on 2024 Journal Citation Reports (JCR) data.

METHODS

In the Journal Citation Reports 2024, shared by Clarivate Analytics on June 20, 2024, the journal metrics of the Journal of Craniofacial Surgery were examined in detail.

RESULTS

According to the reports published by Clarivate Analytics in 2024, the journal's impact factor in 2023 was determined as 1.0 and the impact factor excluding self-citations was calculated as 0.8. These values show that the impact factor of the journal has increased in recent years. Also, it is seen that the Journal of Craniofacial Surgery, which has been in the fourth quartile (Q4) among the journals in the "Surgery" category for the last 10 years, has risen to the third quartile (Q3) this year.

CONCLUSIONS

The increase in the impact factor and ranking of the Journal of Craniofacial Surgery shows that the journal has strengthened its position in the scientific field and is moving toward higher levels. However, it is suggested that other metrics should be taken into consideration in addition to the impact factor.

Transoral Feminizing Chondrolaryngoplasty: Development and Deployment of a Novel Approach in 77 Patients

Importance: Transgender patients who desire a gender-congruent neck contour may forego transcutaneous procedures due to the risk of neck scar stigmata related to such procedures. Objective: To describe the development and experience with the first 77 cases of a novel gasless transvestibular technique for gender-affirming surgery of the laryngeal prominence. Design, Setting, Participants: Video and narrative description of a novel surgical technique, and case series describing the consecutive first 77 patients to undergo transoral chondrolaryngoplasty (TCLP) at a quaternary transgender referral center. Results: Between November 2019 and April 2022, 77 patients underwent the novel surgery of TCLP. Median follow-up was 8.74 months (range: 1-30 months). Four patients suffered surgical complications (two laryngotomy, two skin necrosis), and three patients requested revision surgery. Conclusions and Relevance: TCLP is reported in the largest published series to date offering hidden incision for gender-affirming care. With further prospective outcome investigations, TCLP may prove to be a reliable approach of performing chondrolaryngoplasty while avoiding visible neck incisions.

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.

A Differential Analysis of Preferred Feminine Facial Contours for Transfeminine Individuals

BACKGROUND

Facial feminization surgeries are important gender-affirming procedures for transfeminine individuals. The literature provides guidance on classically feminine facial features but the aesthetic preferences of transgender patients have not been studied. This study aimed to define the preferred feminine facial proportions of transfeminine patients and compare them to a mixed population of US adults.

METHODS

An online survey was designed consisting of virtually modified images with progressive degrees of change in 6 facial features: forehead, nasal dorsum, chin projection, nasolabial angle, mandibular angle, and chin height. It was administered to transfeminine patients in a large-scale health system as well as the general population using an online market research instrument. Respondents ranked each image on a 7-point Likert scale from "very unattractive" to "very attractive" for a feminine face.

RESULTS

Both groups agreed that a moderately convex forehead without supraorbital ridge prominence, slightly sloped nasal dorsum, ∼105-degree nasolabial angle, and decreased chin height were considered most attractive. In addition, very concave nasal slope and ∼110-degree nasolabial angle were rated significantly higher by transfeminine respondents compared with controls. The most classically masculine versions of each feature were considered significantly more unattractive by transfeminine patients when compared with controls.

CONCLUSION

Transfeminine individuals share significant preferences in feminine facial features with control respondents. However, transfeminine patients were more averse to traditionally masculine features on a feminine face and more accepting of the most traditionally feminine versions of nasal contours. Understanding these differences can facilitate surgical planning between surgeons and patients and potentially improve patient satisfaction.

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

Study Design

This is an experiential article based on the past 6 years experience of providing facial gender confirmation surgery (fGAS) at an academic medical center.

Objective

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

Methods

This is an experiential article based on the senior authors 6 year experience offering fGAS in an academic setting. The article is structured to outline both pearls and pittfalls and is supplemented by photographs and a surgical video.

Results

A total of 19 pearls and pitfalls are outlined in the article.

Conclusions

Facial gender affirming surgery mostly follows established craniofacial and esthetic surgery principles. Forehead feminization and gonial angle feminization are the 2 components that diverge most from established surgical techniques and this article hopefully provides guidance to shorten the learning curve of surgeons.

Effect of Facial Feminization Surgery (FFS) on Eyelid Anatomic Features

Facial feminization surgery (FFS) improves gender dysphoria. The brows and eyes are crucial in perceived gender, yet brow and eyelid surgeries are relatively underutilized. This study aimed to determine rates of brow and eyelid surgeries as part of FFS and characterize pre- and postoperative periocular features. We conducted a retrospective review to identify all patients with the diagnosis of gender dysphoria who underwent FFS at a single academic institution from 2019 to 2022. Thirty-four patients comprising 38 surgical cases were included. Twelve (35%) eyelid surgeries and 27 (79%) brow lifts were performed. Baseline eyelid measurements did not differ between brow lift and nonbrow lift cases. Those undergoing brow lift and eyelid surgery were older in age (p = 0.022), had a higher rate of negative canthal tilt (p = 0.050), and smaller baseline margin-reflex distance 1 (p = 0.014) than patients who had brow lift alone. Brow lift increased tarsal platform show (p ≤ 0.001) and lash-to-brow distance (p ≤ 0.001), and upper blepharoplasty increased tarsal platform show (p = 0.01). Rates of brow lift are high at our institution, and patients are appropriately selected for eyelid surgery in FFS. Brow lift and upper blepharoplasty can feminize anatomical features when using standards described for cisgender cohorts. The impact of periocular features on gender perception in transgender patients warrants further study.

Facial Feminization: Upper Third of the Face

Facial feminization surgery (FFS) is a crucial intervention for transgender women. This article delves into comprehensive reconstruction of the upper third of the face, discussing anatomic differences between masculine and feminine features, and surgical considerations. Technical considerations, preoperative planning, procedural approaches, and postoperative care are described in detail. Patient-centered operative planning and execution ensure safety and efficacy in FFS and uphold its transformative effect on quality of life in appropriately selected surgical candidates.

Epidemiology of Gender Diversity

In the United States, approximately 1.6 million individuals identify as transgender and gender diverse (TGD), encompassing a wide range of identities and experiences. Despite progress in visibility and acceptance, TGD people continue to face health care and societal disparities, especially affecting racial minorities. Although legal advancements have been achieved, the key to addressing these persistent health care disparities lies in implementing comprehensive and culturally sensitive health care practices and supportive policies. With a growing number of TGD people seeking gender-affirming care, it is imperative that health care practitioners understand the unique challenges faced by this community and provide tailored services with sensitivity and expertise.

Facial Feminization: Middle Third of the Face

Facial feminization surgery (FFS) as applied to the midfacial region targets modifications to the nasal and malar esthetic complexes. Although a global assessment is paramount in achieving desired functional results, most patients benefit from malar feminization in the form of bony and soft tissue augmentation, and nasal feminization in the form of reductive rhinoplasty. For patients with signs of aging, additional interventions in the form of rhytidectomy are powerful adjuncts to feminization. As with FFS techniques directed toward the upper and lower thirds, the overarching goal is to obtain complementary outcomes that enhance facial harmony and beauty.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

Ethical Issues Surrounding Facial Feminization Surgery: Five Major Considerations

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

Facial 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.

Quality of life outcomes in patients undergoing facial gender affirming surgery: A systematic review and meta-analysis

Background: Facial gender-affirming surgery (FGAS), one of many transition-related surgeries (TRSs), "feminizes" the faces of transgender and gender diverse (TGD) patients undergoing transition. However, it is difficult to demonstrate the medical necessity of FGAS in terms of postoperative quality of life (QoL) outcomes due to a lack of standardized assessment tools. Thus, FGAS remains largely unsubsidized in North America. Methods: A systematic review of online databases was conducted according to PRISMA guidelines. Screening and quality assessment was conducted by two independent blinded reviewers (KJ and GR). For statistical analysis, data from different Likert-scale-like questionnaires were extracted and coalesced into three-point scales on a data table of seven QoL domains; "Pre-" and "Postoperative femininity," "Psychological satisfaction," "Social Integration and Functioning," "Aesthetic Satisfaction," "Physical Health," and "Satisfaction with Surgical Results." Results: From 2000 to 2022, 1837 patients and 3886 procedures from 19 studies were included. Weighted averages across all QoL domains reflected statistically significant improvement compared to neutral following FGAS (p < 0.001). Three studies used the same questionnaire, which showed that out of all eight questions regarding facial appearance, FGAS patients most strongly agreed the surgery was important to their ability to live as a woman (mean = 4.56/5, n = 137). Secondary outcomes showed the most common complications were hardware palpability (3.45%, n = 145) and aberrant scarring (2.17%, n = 423) with an overall revision rate of 2.17% (n = 423). The most common procedure was fronto-orbital remodeling. Conclusion: FGAS significantly improves QoL with minimal risk to life and supports the literature in defining FGAS as a medically necessary procedure comparable to other TRSs.

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

Background

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

Methods

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

Results

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

Conclusions

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

Gender-Affirming Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations

BACKGROUND

The number of transgender adolescents seeking gender-affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender-affirming surgery for individuals under the age of legal majority and propose directions for future research.

METHODS

A scoping review of recent literature was performed to assess evidence on gender-affirming surgery in individuals under the age of legal majority. Articles were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion.

RESULTS

Twelve articles were identified that met inclusion criteria. Ten of these articles discussed ethical challenges in adolescent GAS, seven discussed legal challenges, and five discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the effects of puberty blockade on natal tissue.

CONCLUSIONS

Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p < 0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

Facial Analysis for Gender Affirmation/Gender-Related Facial Analysis

There are anthropometric differences between the bony and integumentary facial features of male and female individuals. When compared to males, female faces in general are more heart-shaped, with a shorter and smoother forehead, a smaller more defined nose, and a tapered chin.

Feminization Rhinoplasty

This article provides a brief cross-cultural history of transgender, nonbinary, and other diverse gender identities, before exploring the background of gender-affirming care and facial feminization surgery in the United States. A variety of techniques for feminization rhinoplasty are discussed in detail. The authors provide insight into assessment and counseling of this unique patient population, timing of surgery, functional nasal considerations, and performing rhinoplasty in the context of other facial feminization procedures. Finally, complications of feminization rhinoplasty are identified and methods to prevent and treat such complications are enumerated.

Gender Facial Affirmation Surgery: Cheek Augmentation

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.

Comparative Outcomes of Malar Implants Versus Fat Transfer to Cheeks Among Transfeminine Individuals Undergoing Malar Augmentation

BACKGROUND

Malar augmentation is a key procedure sought out by transfeminine individuals seeking to feminize their facial appearance. Different surgical techniques have been described in the literature including fat transfer to the cheeks and malar implant placement. Because of the paucity of information in the literature, there is no consensus on best practices for this procedure. The objective of our study is to determine the effectiveness and safety of malar implants as compared with fat transfer to the cheeks in transfeminine individuals.

METHODS

We examined all patients with the diagnosis of gender dysphoria that were referred to the senior author seeking consultation for feminizing facial procedures between June 2017 and August 2022. Patients who underwent fat transfer to the cheeks or malar implant placement were included in our study. We reviewed the electronic medical record of each patient, and we retrieved and analyzed data regarding demographics, medical and surgical history, operative dictations, clinic notes, and postoperative follow-up. Univariate analysis was used to assess for differences in postoperative complications between these 2 groups.

RESULTS

We identified 231 patients underwent feminizing facial gender affirming surgery, with 152 patients receiving malar augmentation through malar implants or fat grafting. One hundred twenty-nine patients (84.9%) underwent malar implant placement and 23 (15.1%) underwent fat grafting to the cheeks. The mean follow-up time was 3.6 ± 2.7 months. Patient satisfaction was greater in the malar implant group (126/129, 97.7%) compared with the fat transfer group (20/23, 87%, P < 0.045). Two patients who received implants (1.8%) experienced postoperative complications. No patient undergoing fat transfer experiences similar adverse outcomes. Nevertheless, the difference was not statistically significant (P = 1.00).

CONCLUSIONS

Our findings support the contention that malar implants are a safe alternative for malar augmentation among transfeminine individuals. While autologous fat transfer to the cheek is an indispensable option in patients requiring minor malar enhancement, malar implants offer a more permanent option with a better aesthetic outcome in patients requiring major malar enhancement. To minimize postoperative complications, surgeons should emphasize patient compliance with postoperative directions.

Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery

PURPOSE

Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities.

METHODS

Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects.

RESULTS

A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience.

CONCLUSION

To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

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.

Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes

Purpose: Gender-affirming surgery (GAS) has become an important component of the treatment of gender dysphoria. Although the frequency of these procedures is on the rise, a complete safety profile has yet to be established. The goal of our study is to analyze the trends and outcomes of these surgical procedures. Methods: All patients with a primary diagnosis of gender dysphoria undergoing GAS were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between the years 2009 and 2018. Patient demographics and 30-day postoperative outcomes were recorded. We performed a multivariate logistic regression for postoperative complications, controlling for several confounding variables. Results: We identified 2956 patients, of which 1767 (59.78%) were transgender men and 1189 (40.22%) were transgender women. The number of patients undergoing GAS per year increased from 7 in 2010 to 1069 in 2018, a 152-fold increase. For patients undergoing top surgery, Black race (odds ratio [OR] = 2.255, 95% confidence interval [CI] 1.189-4.277, p = 0.013) and diabetes (OR = 4.156, 95% CI 1.571-10.999, p = 0.004) were independent predictors of 30-day postoperative complications. For patients undergoing bottom surgery, total operative time in minutes (OR = 1.005, 95% CI 1.003-1.007, p = 0.001) was an independent predictor of 30-day postoperative complications. Conclusion: The demand for GAS has increased exponentially since 2014. While postoperative complication rates are acceptable, Black race was shown to be an independent predictor of postoperative morbidity in patients undergoing top surgery, a finding that calls for further investigation of racial disparities among transgender patients.

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.

Multiprocedural Facial Feminization Surgery: A Review of Complications in a Cohort of 31 Patients

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.