Facial Feminization Surgery: Key CT Findings for Preoperative Planning and Postoperative Evaluation

Quantification of Changes in Chin Morphometric Parameters Following Feminization Genioplasty

Genioplasty is frequently performed in facial feminization surgery, typically aiming to reduce chin height and projection for more feminine appearance. Quantification of the bony changes occurring during surgery have to date not been published. This study presents a method for segmentation of the chin using CT imaging to quantify changes to the chin after feminization genioplasty. CT scans of 21 patients before and after feminization genioplasty were segmented in Mimics to isolate the chin region. Surface area, volume, vertical chin projection, and horizontal chin projection were measured before and after surgery. Patient outcomes were evaluated using the FACE-Q and World Health Organization Quality of Life patient-reported outcome measures. Surface area, volume, and vertical chin projection demonstrated statistically significant decreases after surgery. The magnitude of changes in surface area and vertical chin projection were significantly associated with their presurgical values. In particular, patients with greater presurgical vertical projections experienced greater decreases in vertical projection after surgery, with some patients having increases in postsurgical vertical projection. Patient FACE-Q scores improved significantly on all scales, including chin, jawline, and neck satisfaction. This study demonstrates a method for evaluating bony changes on CT scan after feminization genioplasty. The measured changes cohere with the changes expected to create a more feminine chin. Furthermore, changes created by feminization genioplasty are in the context of the patient's overall facial harmony and are not uniform across all patients.

Functional and Cosmetic Considerations in Gender-Affirming Feminization Rhinoplasty

Gender-affirming facial surgery is increasing in prevalence, and rhinoplasty plays an integral role in its success. The nose displays considerable gender dimorphism, and maneuvers performed during gender-affirming rhinoplasty may differ considerably from those performed during cis-gender surgery. During feminization rhinoplasty in particular, cosmetic goals often rely on reductive techniques such as osteotomies, dorsal reduction, sidewall narrowing, tip narrowing, and alar base narrowing. These maneuvers collectively have important ramifications when considering the functional aspects of the nose. Herein, we outline the status of feminization rhinoplasty, and the interplay of cosmetic and functional considerations of the field.

Quantification of Cephalometric Changes in Gonial Angle Morphology Following Facial Feminization Surgery

Facial feminization surgery (FFS) is a type of gender-affirming surgery aimed at bringing masculine facial features more in line with typically feminine characteristics. Specifically, mandibular contouring can create a softer jawline and help create a more round, feminine face. As the popularity of FFS continues to increase, improving surgical techniques and patient satisfaction is imperative. However, no quantitative measurement system currently exists to measure these changes. In this study, the authors describe the use of a novel segmentation technique using computerized tomography imaging to quantify the bony changes that occur during gonial angle reduction. Further, authors utilize this technique to describe changes in a cohort of 13 patients, and how these changes correlate with patient satisfaction. The authors found that gonial angle volume and surface area significantly decreased, as well as the intergonial:interzygomatic ratio, with a smaller ratio associated with more feminine features. In addition, patient satisfaction significantly increased post-operatively both specifically regarding jawline appearance (P = 0.0014) and regarding overall social and psychological function (P = 0.0021 and P = 0.0032, respectively), as captured by the FACE-Q and World Health Organization Quality of Life (WHOQOL) surveys. Patients with greater changes in surface area reported greater improvements in WHOQOL psychological scores (P = 0.0086), and patients with greater changes in the intergonial:interzygomatic ratio reported greater improvements in WHOQOL social scores (P = 0.0299). Overall, our novel technique captures significant changes in gonial angle shape and can be applied to a wide range of future studies to improve the quality and accessibility of FFS.

Overview of gender-affirming surgery

This publication will discuss the diversity of procedures that are common to those with intersex traits,/differences of sex development (I/DSD), and transgender and gender diverse (TGD) patients. It will address how these procedures are performed, and common after care and long-term considerations which are relevant to the pediatric radiologist. Some surgeries offered to these patient populations have shared surgical approaches and radiographic considerations. With the growth of TGD procedures as a field, more pediatric subspecialties are performing these procedures, and the approaches are informing the surgical care of the growing number of I/DSD individuals who are seeking surgery in adolescence and young adulthood. Surgeries discussed will include procedures to masculinize or feminize breast/chest tissue, facial bony contours, as well as internal and external genital structures. Patients are diverse and this includes their embodiment goals. As such, not all TGD and I/DSD patients will desire to undergo these procedures. It is important for radiologists to have a foundational understanding of this heterogenous set of procedures so they can provide optimal care for these patient populations.

Peri-surgical imaging of intersex and gender diverse youths

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Gender Affirmation Surgery of the Face for the Transfeminine Patient

This article discusses the aspects of facial feminine affirmation surgery including forehead reconstruction, midface feminization, and lower face/neck feminization. We will present a brief history of gender affirmation. We discuss the anatomical differences between born XY males and XX females and discuss the subsequent procedures that aim at feminizing the face. The effects of silicone injections are also discussed as this was a trend in the past to feminize the face. Understandably so we discuss the anatomical differences as being a fluid expression and differences based on ethnic background.

Preparing for Facial Feminization Surgery

Preparing for facial feminization surgery (FFS) or gender-affirming facial surgery is a daunting task. Patients do extensive research online to see what FFS means. Oftentimes it is the patients who are educating their physicians when discussing medical clearance or the esteemed "therapy letter." The therapy letter is a letter that details the support for surgery in a stable patient and reaffirms the need to have FFS in a person diagnosed with gender dysphoria. This typically follows the World Professional Association for Transgender Health standards-of-care guidelines. Besides having the therapy letter, patients must be counseled on concurrent mental health illnesses.

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.

Feminization Rhinoplasty

Facial gender affirmation surgery is currently growing worldwide and is an important treatment for gender dysphoria that will improve quality of life. The most frequently sought modifications by transgender women are forehead and supraorbital ridge reduction, cheek augmentation, upper lip surgery (lip lift), laryngeal chondroplasty, jaw reduction, and rhinoplasty. Rhinoplasty for transgender women uses the same techniques as rhinoplasty for a cisgender patient. However, knowledge of transgender care is necessary and must be widely adapted to all health professionals. This article intends to explain the author's personal approach to feminization rhinoplasty.

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.