Secondary and Revisionary Facial Feminization Surgery: an Important Consideration
Ian T. Nolan, BM1, Mona Ascha, MD2, 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, Raúl J. Bellinga, MD, FEBOMS3, Daniel Simon, DMD3, Luis Capitán, MD, PhD3, Shane D. Morrison, MD, MS7, Thomas Satterwhite, MD8.
1New York University School of Medicine, New York, NY, USA, 2Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, 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, 7Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA, 8Align Surgical Services, San Francisco, CA, USA.
For transgender women seeking facial feminization (FFS), the desired outcome may require that multiple highly-gendered facial areas including the jaw, chin, brow, and nose be addressed. We hypothesized that transgender women presenting for FFS, with history of prior FFS, would do so to either address additional facial areas not addressed in their primary surgery (secondary FFS) or to revise a previous procedure in the same facial area (revisionary FFS), and would demonstrate improved quality of life, ‘feminized’ cephalometrics, and high satisfaction.
This was a prospective, multinational cohort study of consecutive transgender women undergoing FFS. Primary outcomes included quality of life measured on the FFS outcomes score on a scale of 0-100, overall satisfaction on a 0-4 Likert scale, and cephalometric measurements preoperatively and at 1- and 6-month follow-up.
In a cohort of 66 transgender women undergoing FFS, 10 (15.2%) reported previous FFS. Of these 10, 6 had secondary FFS only, while 4 had both revisionary and secondary FFS.
The 6 secondary FFS-only patients underwent an average of 2.8 procedures, including 5 brow reductions, 3 rhinoplasties, 1 blepharoplasty, 5 chin reductions, and 3 mandibular contourings. Of the 4 revisionary patients, two underwent revisionary rhinoplasty with secondary brow reduction in one and secondary brow reduction, mandibular contouring, and hair transplantation in the other; one underwent revisionary brow reduction, rhinoplasty, genioplasty, mandibular contouring, and tracheal shaving with secondary fat grafting and hair transplantation; and one underwent revisionary hair transplant with secondary brow reduction, genioplasty, and mandibular contouring.
Mean FFS outcome score increased by 20.7 from pre-operatively to 6-month follow-up (71.9 from 49.4, p<0.05). Mean satisfaction was 3.0 (SD 0.94). Cephalometric changes included feminized brow as evidenced by increased forehead inclination from 72.2º to 75.3º (p<0.05) and decreased glabellar angle from 97.3º to 91.0º (p<0.05); feminized nose as evidenced by increased nasofrontal angle from 139.1º to 147.62º (p<0.01) and increased nasolabial angle from 104.4º to 108.2º (not significant); and feminized jaw as evidenced by increased mandibular plane angle from 22.1º to 24.2º (not significant).
Transgender women undergoing FFS may present for revisionary and/or secondary FFS to augment the results of previous surgery. Surgeons should be aware of patients’ FFS histories, as revisionary facial procedures are often more technically challenging. Outcomes of secondary or revisionary FFS regarding quality of life, satisfaction, and cephalometric changes appear promising but should be further described and compared in higher-powered studies.
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