Prospective Quality of Life Outcomes after Facial Feminization Surgery: An International Multi-Center Study
Ian T. Nolan, BM1, Shane D. Morrison, MD, MS2, Fermin Capitán-Cañadas, PhD3, Anabel Sánchez-García, PhD3, David C. Ludwig, MD, DDS4, Jonathan P. Massie, MD5, Marina Rodríguez-Conesa, MS3, Paul S. Cederna, MD, FACS6, Raul J. Bellinga, MD, FEBOMS3, Daniel Simon, DMD3, Luis Capitán, MD, PhD3, Thomas Satterwhite, MD7.
1New York University School of Medicine, New York, NY, USA, 2Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA, 3FACIALTEAM Surgical Group, HC Marbella International Hospital, Marbella, Spain, 4Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA, USA, 5Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine at Northwestern University, Chicago, IL, USA, 6Section of Plastic Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA, 7Align Surgical Services, San Francisco, CA, USA.
Background: Facial feminization surgery (FFS), which typically consists of a combination of procedures to alter conventionally ‘masculine’ facial aspects such as the brow, jaw, and nose, is one surgical option for gender affirmation in transgender women. While retrospective data have demonstrated the efficacy of FFS to improve quality of life, prospective data do not exist. This prospective study sought to measure quality of life, self-perceived femininity, and objective cephalometric changes to the brow, jaw, and nose after FFS for transgender women. Methods: A prospective international multi-center cohort study with adult gender diverse patients with gender dysphoria was undertaken. Facial feminization outcome score, which is graded on a scale of 0-100 and has previously demonstrated high correlation with the SF-36v2 in FFS patients, was calculated pre-operatively and postoperatively at 1 month and > 6 months. Satisfaction was measured using the FFS outcomes scale and on 5-point Likert scale (0-4). Photogrammetric cephalometric measurements, as well as patients’ perceived pre-operative masculinity and femininity were recorded at the same time points. Univariate linear regression analyses were used to predict outcomes from FFS. Results: Sixty-six consecutive transgender female patients were enrolled. Patients noted their brows, jaws, and chins were the most masculine facial areas (54.5%, 33.3%, and 30.3%, respectively). Facial feminization outcome score substantially increased postoperatively and was stable between 1 and 6 months (48.0±12.3 pre-operatively; 74.6±15.5 at 1 month, p<0.0001 versus pre-op; and 76.5±14.6 ≥ 6 months, p<0.0001 versus pre-op, p=0.40 vs 1 month). Mean patient satisfaction was excellent and remained stable in the post-operative period (3.1±0.8 at 1 month, 3.0±1.0 at ≥6 months, p=0.46). At 6 month follow-up, cephalometric values were brought more in line with typical ‘female’ ranges: increased forehead inclination (71.1°±4.9° to 73.7°±5.1°, p=0.0001), decreased glabellar angle (100.6°±8.6° v 95.8°±9.4°, p=0.03), increased nasolabial angle (98.7°±13.0° v 100.9°±11.6°, p=0.049),
increased Frankfort horizontal to mandibular plane angle (22.6°±5.3° v 23.9°±5.1°, p=0.01), and increased nasofrontal angle (132.7°±11.0° v 139.8°±8.9º, p=0.00001). Increased age was a negative predictor of facial feminization outcome score (R =-0.290, p=0.006), and smoking history was associated with lower satisfaction (R=0.457, p=0.037). Conclusions: This cohort study is the first demonstrating improved quality of life outcomes, ‘feminized’ cephalometrics, and high patient satisfaction up to 6-month follow-up in a prospective cohort of transgender women undergoing FFS. This data suggests a valuable role of FFS in gender affirmation for many transgender women, and argues for its necessity in treating gender dysphoria in certain patients.
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