Innovations in Gender-Affirming Facial Plastic Surgery

Educational Objectives

The goal of this program is to improve delivery of gender-affirming facial surgery (GFS). After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the legal challenges patients face when seeking GFS.
2. Discern the qualities of attractiveness between male and female faces.
3. Synthesize factors to consider when performing GFS.
4. Modify traditional facial surgical procedures to maximize aesthetic outcomes in cisgender vs transgender individuals.
5. Achieve female aesthetic goals through lip-lifting.

Summary

Introduction: the face serves as a significant representation of an individual's personality, identity, and gender; altering facial features to match one's gender identity poses complex and profound questions; recent societal shifts, including demographic changes, legal advancements, and advancements in medical procedures have contributed to the increased attention on gender-affirming surgery (GAS); success in achieving desired patient outcomes varies depending on, eg, size, physiology, age; deep understanding of anatomy and the nuances of this patient population are essential for effective results; critical analysis of surgical outcomes is crucial for continuous improvement; examination of pre- and postoperative photographs facilitates this process; the best results will be achieved in young patients that already look feminine to some degree; older, heavier patients are more challenging

Transgender population: challenges include rates of unemployment 3-fold greater than the national average (regardless of ethnicity), limited access to health care, and heightened levels of psychosocial distress, with rates of suicide 9 to 10 times higher than the general population in the United States; transgender individuals of color, who face increased violence and discrimination, are particularly vulnerable; interventions aim to ease gender dysphoria (distress experienced due to incongruence between biological sex and internal sense of gender) and improve overall well-being

Legal landscape: the Affordable Care Act of 2010 prohibited discrimination based on sex; however, navigating the complexities of obtaining GAS remains challenging for patients, involving various rules, regulations, and documentation requirements; societal attitudes toward transgender individuals continue to be contentious, with no national consensus on how to address their needs; conflicting government statements and policies further compound the issue; while 19 states have enacted laws supporting GAS, the lack of a national consensus on transgender health care has led to varying state-based mandates across the United States, similar to the decentralized approach seen in cannabis legislation

Role of otolaryngologists: estimates indicate that transgender individuals constitute ≈0.6% of the national population, with increasing utilization of medical codes reflecting the growing demand for transgender health care services; the terminology surrounding transgender identities has evolved, with corresponding changes in diagnostic codes; despite these challenges, there has been a significant increase in procedures performed for transgender patients, as evidenced by rising current procedural terminology codes; otolaryngologists play a role in providing a variety of procedures sought by transgender patients, including, eg, electrolysis, voice therapy, facial feminization surgery, tracheal shave, silicone injections, voice surgery; with a high demand for services predicted, a pressing need for compassionate, competent care exists; consequently, many major medical centers nationwide have established centers of gender excellence to meet this demand

Insurance coverage: the expansion of GAS procedures has largely been driven by insurance coverage; genital and chest surgeries have been deemed medically necessary and are generally covered; however, debate remains surrounding the classification of gender-affirming facial surgery (GFS) as aesthetic or medically necessary, impacting insurance coverage eligibility and highlighting the diverse opinions within the medical community; results from a survey by Gadkaree et al (2021) showed that ≈90% of insurance plans do not approve or preauthorize GAS; despite this, a growing demand exists, with ≈22% of patients expressing a desire to transition in the future

Factors influencing decision-making in facial surgery

Self-resemblance: we find attractive who we already are; homogeny (the tendency for couples to look a little bit like one another) is a really important part of what we view as attractive; self-resemblance integrates not only facial appearance, but also, eg, ethnicity, religion, socioeconomic status, which reinforce attractiveness

Apparent health: unlike sickness, health is attractive; thus, whatever can be done to make a patient look healthier will increase their attractiveness

Symmetry: faces that are slightly asymmetric are less attractive than faces that are symmetric; the greater the degree of asymmetry, the greater the unattractiveness

Averageness: averageness is attractive within an ethnic group, though the same definition of averageness does not cross over into other ethnic groups; attractive faces do not need to have an average appearance, but average-appearing faces are attractive

Youthfulness: always attractive; heterosexual males always tend to seek out 20-yr-old females (the age which seems to be the most attractive)

Sexual dimorphism: facial appearance is representative of the sexual hormones present at puberty; masculine facial characteristics are attractive in male faces, while feminine facial characteristics are unattractive in male faces; women in the fertile phase of their menstrual cycle tend to favor masculine features and darker complexions; feminine female faces are consistently considered more attractive than masculine female faces; nonaged female faces are considered the most attractive; male faces tend to have square shapes, strong angles, and peaked hairlines, while female faces have softer angles, arched brows, and an inverted V or heart-shaped appearance

Facial analysis: while traditional training primarily focuses on rhinoplasty, a deeper comprehension of cephalometrics and facial analysis is necessary for GFS; analyzing ratios and relationships between facial features helps achieve a feminine appearance; using three-dimensional morphometrics, Bannister et al (2022) determined that sex accounts for 6% of facial shape variance; men have more protruding brows, noses, chins, and jaws, while women have more protruding cheekbones and upper foreheads; brow protrusion was identified as the most significant aspect of facial gender variance

Surgical procedures

Trichophytic brow lift: the incision must be irregularly irregular and strongly beveled to permit hair growth through the scar line; the central face is degloved, the brow is lifted, and redundant skin (typically ≈2 cm) is excised to reduce forehead size; analysis by David et al (2022) demonstrated a mean elevation in brow height of 4.8 mm, achievement of facial symmetry, hairline reduction by 6.4 mm, and mean reduction in forehead size by >1 cm; the peaked male hairline was converted to a rounded, more feminine hairline; the same incision for the trichophytic approach permits treatment of the bony orbital rim and glabella (most important part of the face to address in facial feminization surgery) and the anteroposterior diameter of the frontal sinus

Transgender rhinoplasty: feminization of a male nose involves modifying typical approaches used in cisgender rhinoplasty, due to increased skin thickness, facial sebum, and cartilage strength among men; analysis by the speaker’s institution revealed ability to achieve postsurgical measurements much closer to the female aesthetic norm with regard to, eg, alar base width, nasal width, tip width, nasofacial angle, nasofrontal angle; compared with cisgender rhinoplasty, more tip grafts were used and more alar base narrowing was performed to address thicker male skin and achieve desired contour; use of more base incisions permits incorporation of the same incisions for lifting the upper lip and performing an open rhinoplasty, producing a more concealed scar (compared with columellar scars typically seen following open rhinoplasty)

Achieving female lip aesthetics: compared with a male lip, the female lip is fuller, contains a shorter vertical cutaneous component, and exhibits slight maxillary dental show at rest; to achieve ideal aesthetics, mandibular dental show should be absent; lip-lifting procedures are used to achieve these aesthetic goals, aiming for a height of 14 to 15 mm between the vermillion border of the upper lip and the base of the nose; lip augmentation can provide natural-looking fullness for thin lips; dermal fat grafting is preferred by the speaker because of less recession over time, greater symmetry, and low risk for infection; forehead skin from a trichophytic brow lift can be used for grafting; lip numbness can persist for ≈3 mo, but sensation returns as the lip heals; changes tend to be permanent

Mandibular reduction: sliding genioplasties are generally avoided because hardware insertion is often associated with complications; mandibular osteotomies are generally avoided due to risk for mental nerve injury; the speaker favors transoral (transvestibular) reduction of the mandible bone because of the reduced risk for complications; a pineapple burr is used to remove bone anterior to the mental nerve, and an ultrasonic aspirator is used to remove bone posterior to the mental nerve

Chondrolaryngoplasty: endoscopic procedure traditionally performed through a transcutaneous neck incision (higher incisions can remain hidden through natural creases in the neck); the upper one-third of the thyroid lamina is removed to reduce prominence of the Adam apple; David et al (2022) demonstrated excellent results with scarless transoral chondrolaryngoplasty, compared with standard chondrolaryngoplasty (often results in neck scarring, which can be stigmatizing)

Face lift: reverses masculinization caused by aging, making patients appear more youthful and feminine; female faces have a heart-shaped, angular mandible, while male faces have a square shape and jowls; face lift is typically reserved for patients 40 to 50 yr of age; procedures include deep plane facelift, V-shots, buccal fat pad removal, and blepharoplasty; surgeries are typically staged 3 to 6 mo apart

Readings

Bannister JJ, Juszczak H, Aponte JD, et al. Sex differences in adult facial three-dimensional morphology: application to gender-affirming facial surgery. Facial Plast Surg Aesthet Med. 2022;24(S2):S24-S30. doi:10.1089/fpsam.2021.0301; Benjamin T, Knott PD, Seth R. Gender-affirming facial surgery: anatomy and fundamentals of care. Oper Tech Otolaryngol Head Neck Surg. 2023;34(1):3-13. doi:10.1016/j.otot.2023.01.002; David AP, Knott PD, Rosen CA, et al. Clinical feasibility and efficacy of the externally scarless transoral chondrolaryngoplasty. Facial Plast Surg Aesthet Med. 2022;24(S2):S41-S43. doi:10.1089/fpsam.2021.0295; David AP, House AE, Targ S, et al. Objective outcomes of trichophytic brow lift and hairline advancement in facial feminization surgery. Facial Plast Surg Aesthet Med. 2022 Dec 29. doi: 10.1089/fpsam.2022.0136. Epub ahead of print; Gadkaree SK, DeVore EK, Richburg K, et al. National variation of insurance coverage for gender-affirming facial feminization surgery. Facial Plast Surg Aesthet Med. 2021;23(4):270-277. doi:10.1089/fpsam.2020.0226; Kumar A, Amakiri UO, Safer JD. Medicine as constraint: assessing the barriers to gender-affirming care. Cell Rep Med. 2022;3(2):100517. doi:10.1016/j.xcrm.2022.100517; Little AC, Jones BC, DeBruine LM. Facial attractiveness: evolutionary based research. Philos Trans R Soc Lond B Biol Sci. 2011;366(1571):1638-59. doi:10.1098/rstb.2010.0404; Salesky M, Zebolsky AL, Benjamin T, et al. Gender-affirming facial surgery: experiences and outcomes at an academic center. Facial Plast Surg Aesthet Med. 2022;24(1):54-59. doi:10.1089/fpsam.2021.0060; Stroumsa D. The state of transgender health care: policy, law, and medical frameworks. Am J Public Health. 2014;104(3):e31-8. doi:10.2105/AJPH.2013.301789; Sykes JM, Dilger AE, Sinclair A. Surgical facial esthetics for gender affirmation. Dermatol Clin. 2020;38(2):261-268. doi:10.1016/j.det.2019.10.011; Thomas JR. Facial gender affirmation surgery. Facial Plast Surg Clin North Am. 2019;27(2):ix. doi:10.1016/j.fsc.2019.02.002.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Knott was recorded at the 91st Midwinter Conference: Facial Plastic Surgery and Pediatric Otolaryngology, held January 6-7, 2024, in Universal City, CA, and presented by the Research Study Club of Los Angeles. For information about upcoming CME activities from this presenter, please visit https://researchstudyclub.org. Audio Digest thanks Dr. Knott and the Research Study Club of Los Angeles for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.75 CE contact hours.

Lecture ID:

OT570801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.