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Secondary Surgery in Facial Feminization: Reasons and Recommendations
Bachar F. Chaya, Danielle H. Rochlin, Ricardo Rodriguez Colon, Ogechukwu Onuh, Allison Rojas, Eduardo D. Rodriguez
Hansjorg Weiss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY

Background: As facial feminization surgery (FFS) continues to grow in access and popularity, the need for secondary FFS can be expected to increase. Given the relative novelty of FFS, little is known about reoperation on the FFS patient. The purpose of this study was to identify the reasons for secondary FFS and offer recommendations to minimize secondary surgery.
Methods: A retrospective, single-institution cohort study of all patients with gender dysphoria who underwent FFS by the senior author (E.D.R.) from October 2017 to 2021 was performed. Patients who underwent non-staged secondary surgery were identified and sorted in two non-mutually exclusive surgical cohorts: additional surgery, defined as unplanned additional feminization surgery on previously unoperated facial units, and revision surgery, defined as redo surgery on a previously operated facial unit. Clinical and demographic data were compared between the revision and total cohorts. Reasons for secondary surgery were identified and examined in the context of the senior authorís experience.
Results: Out of 161 patients who underwent FFS, 41 (25.5%) underwent secondary surgery consisting of additional surgery on a new facial unit (N=32) and/or revision surgery (N=30). There were no significant differences in clinical or demographic data between the secondary surgery and total FFS cohorts. Among patients who underwent additional feminization surgery, the facial units that had been previously operated on, in descending order of frequency, were: nose (46.3%), trachea (31.7%), forehead/brow (22.0%), chin (12.2%), lips (9.8%), and cheeks (7.3%). Among revision patients, the facial units revised were: nose (36.6%), forehead/brow (26.8%), cheeks (17.1%) and chin (17.1%), lips (12.5%), and trachea (2.4%). The main indication for revision for all facial units was undercorrection to feminine ideals.
Conclusions: Approximately one-quarter of patients who underwent FFS at our institution had prior FFS and/or sought revision. FFS surgeons must be well-versed not only in techniques to primarily feminize facial features, but also in the challenges of working with previously operated FFS patients. Keeping in mind that the dominant indication for revision was undercorrection, FFS surgeons can minimize the need for secondary surgery in the future.


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