Facial Plastic Surgery

Forehead and Orbital Rim Remodeling
Facial features remodeling surgery is performed to obtain feminization of the face that corresponds to the gender perceived by patients. This includes techniques and findings to remodel the forehead and orbital rim to change the expression of the eyes, correction of the frontonasal angle in relation to rhinoplasty, hairline feminization, and eyebrow lift to correct the position and aesthetic dissatisfaction or the effects of aging.

Gender-related Facial Analysis
There exist several known anthropometric differences between the male and female facial skeleton and soft tissues. In general, the female face is less robust, rounder or heart shaped, with a shorter forehead, no supraorbital bossing, a smaller nose, more pronounced zygomatic prominences, fuller lips, a smaller mandibular width, and a more tapered chin. A method for analyzing these differences is critical for offering facial gender confirming surgery to the gender dysphoric patients, both for preoperative planning, as well as for setting postoperative expectations.

Lip Lift
The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

Lower Jaw Recontouring in Facial Gender-Affirming Surgery
Facial gender-affirming surgery can have significant impact on patient quality of life for some gender-dysphoric patients. Lower jaw contouring can be used to harmonize the face during facial gender-affirming surgery through masculinization or feminization. During feminization, the mandibular angle and body and chin are reduced in width and size. During masculinization, augmentation of the mandibular angle and body and chin are completed with alloplastic implants, fat, or bone. Complications are minimal. Further research is needed on outcomes of these procedures.

Midfacial Bony Remodeling
Craniofacial procedures to the midface in conjunction with work to the upper face and skull, and if needed the lower jaw, are a permanent and effective way to achieve feminization of the face in transgender patients. Although the surgery is more complex than other procedures, it should be considered for select patients. Further improvement of cosmesis may be considered a separate surgical entity and is not limited in scope or time by having undergone midface osteotomies. When carefully planned, bony surgery to the midface is safe and results in long-term predictive results and a favorable appearance as the patient ages.”

Cheek Augmentation Techniques
The restoration of a youthful appearance to the midface can enhance its femininity. In this article, we discuss several strategies and techniques, both surgical and nonsurgical, for augmentation of the lateral and centro-lateral midface.

Preparing for Facial Feminization Surgery
Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

Forthcoming Issues
New Trends and Technologies in Facial Plastic Surgery

Contents
J. Regan Thomas

Contributors
J. REGAN THOMAS, MD

Facial Gender Affirmation Surgery

Michael T. Somenek (Editor)

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/S1064-7406(19)30012-4
First page of article
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

Copyright

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/S1064-7406(19)30013-6
First page of article
ELSEVIER

Contributors

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/S1064-7406(19)30014-8
First page of article
J. REGAN THOMAS, MD

Contents

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/S1064-7406(19)30015-X
First page of article
J. Regan Thomas

Forthcoming Issues

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/S1064-7406(19)30016-1
First page of article
New Trends and Technologies in Facial Plastic Surgery

Facial Gender Affirmation Surgery

J. Regan Thomas, MDEmail the author MD J. Regan Thomas
Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Head and Neck Surgery, Northwestern University School of Medicine, 675 North Saint Clair Street, Suite 15-200, Chicago, IL 60611, USA

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2019.02.002 |

First page of article
A key component for those individuals who have elected to undergo procedures to address gender dysmorphia is facial modification surgery. Gender dysphoria may cause people to experience major stress and impairment on social and personal levels. For these individuals, gender role changing, including surgery, may permit their outside appearance to match what they feel internally. Gender dysmorphia, previously referred to as gender identity disorder, often is assisted through the skills and procedures provided by facial plastic surgery.© 2019 Published by Elsevier Inc.

Exploring Facial Gender Affirmation Surgery

Michael T. Somenek, MDEmail the author MD Michael T. Somenek
SomenekMD- Advanced Facial Plastic Surgery, 2440 M Street NW, Suite 507, Washington, DC 20037, USA

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2019.02.001 | CROSSMARK_Color_horizontal.svg

First page of article
Gender dysphoria (formerly gender identity disorder) is defined by strong, persistent feelings of identification with the opposite gender and discomfort with one’s own assigned sex that results in significant distress or impairment. With the transgender population now exceeding 25 million globally, there has been an increasing need to provide gender affirming care. This increased awareness looks to address gender dysphoria in a comprehensive manner, which encompasses the spectrum from mental health, hormone replacement, and surgical intervention.© 2019 Published by Elsevier Inc.

Gender-related Facial Analysis

Chrisovalantis Lakhiani, MDa
, Michael T. Somenek, MDb,∗,'Correspondence information about the author MD Michael T. SomenekEmail the author MD Michael T. Somenek

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2019.01.006 | CROSSMARK_Color_horizontal.svg

There exist several known anthropometric differences between the male and female facial skeleton and soft tissues. In general, the female face is less robust, rounder or heart shaped, with a shorter forehead, no supraorbital bossing, a smaller nose, more pronounced zygomatic prominences, fuller lips, a smaller mandibular width, and a more tapered chin. A method for analyzing these differences is critical for offering facial gender confirming surgery to the gender dysphoric patients, both for preoperative planning, as well as for setting postoperative expectations.

First page of article
There exist several known anthropometric differences between the male and female facial skeleton and soft tissues. In general, the female face is less robust, rounder or heart shaped, with a shorter forehead, no supraorbital bossing, a smaller nose, more pronounced zygomatic prominences, fuller lips, a smaller mandibular width, and a more tapered chin. A method for analyzing these differences is critical for offering facial gender confirming surgery to the gender dysphoric patients, both for preoperative planning, as well as for setting postoperative expectations.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Hormonal, Medical, and Nonsurgical Aspects of Gender Affirmation

Ronni Hayon, MDa,∗,'Correspondence information about the author MD Ronni HayonEmail the author MD Ronni Hayon
, Kristin Stevenson, MDb

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2018.12.001 | CROSSMARK_Color_horizontal.svg

Although the acronym LGBTQ is often used as a catchall label for sexual and gender minorities, transgender people have unique and individual health needs and unfortunately experience significant health disparities. This article reviews essential terminology and concepts relevant to discussions of gender and gender identity, practical tips for changes that can be made on the clinical and institutional levels in order to create a welcoming and safe environment for transgender patients, as well as current recommendations for the provision of gender-affirming medical therapy.

First page of article
Although the acronym LGBTQ is often used as a catchall label for sexual and gender minorities, transgender people have unique and individual health needs and unfortunately experience significant health disparities. This article reviews essential terminology and concepts relevant to discussions of gender and gender identity, practical tips for changes that can be made on the clinical and institutional levels in order to create a welcoming and safe environment for transgender patients, as well as current recommendations for the provision of gender-affirming medical therapy.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Preparing for Facial Feminization Surgery

Timing

Troy A. Pittman, MDa,∗,'Correspondence information about the author MD Troy A. PittmanEmail the author MD Troy A. Pittman
, James M. Economides, MDb

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2018.12.002 | CROSSMARK_Color_horizontal.svg

Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

First page of article
Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Cheek Augmentation Techniques

David M. Whitehead, MD, MSa
, Loren S. Schechter, MD, FACSb,∗,'Correspondence information about the author MD, FACS Loren S. SchechterEmail the author MD, FACS Loren S. Schechter

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2018.12.003 | CROSSMARK_Color_horizontal.svg

The restoration of a youthful appearance to the midface can enhance its femininity. In this article, we discuss several strategies and techniques, both surgical and nonsurgical, for augmentation of the lateral and centro-lateral midface.

First page of article
The restoration of a youthful appearance to the midface can enhance its femininity. In this article, we discuss several strategies and techniques, both surgical and nonsurgical, for augmentation of the lateral and centro-lateral midface.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Forehead and Orbital Rim Remodeling

Marcelo Di Maggio, MDEmail the author MD Marcelo Di Maggio
MDM Surgery Center, Sanatorio Finochietto Medical Center, Buenos Aires, Avenida Cordoba 2678, C1187AAN, Argentina

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2019.01.007 | CROSSMARK_Color_horizontal.svg

Facial features remodeling surgery is performed to obtain feminization of the face that corresponds to the gender perceived by patients. This includes techniques and findings to remodel the forehead and orbital rim to change the expression of the eyes, correction of the frontonasal angle in relation to rhinoplasty, hairline feminization, and eyebrow lift to correct the position and aesthetic dissatisfaction or the effects of aging.

First page of article
Facial features remodeling surgery is performed to obtain feminization of the face that corresponds to the gender perceived by patients. This includes techniques and findings to remodel the forehead and orbital rim to change the expression of the eyes, correction of the frontonasal angle in relation to rhinoplasty, hairline feminization, and eyebrow lift to correct the position and aesthetic dissatisfaction or the effects of aging.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Midfacial Bony Remodeling

Kalle Conneryd Lundgren, MD, PhD∗,'Correspondence information about the author MD, PhD Kalle Conneryd LundgrenEmail the author MD, PhD Kalle Conneryd Lundgren
, Maarten J. Koudstaal, MD, DMD, PhD
Department of Craniofacial Diseases, Karolinska University Hospital, Stockholm 171 77, Sweden

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2018.12.004 | CROSSMARK_Color_horizontal.svg

Craniofacial procedures to the midface in conjunction with work to the upper face and skull, and if needed the lower jaw, are a permanent and effective way to achieve feminization of the face in transgender patients. Although the surgery is more complex than other procedures, it should be considered for select patients. Further improvement of cosmesis may be considered a separate surgical entity and is not limited in scope or time by having undergone midface osteotomies. When carefully planned, bony surgery to the midface is safe and results in long-term predictive results and a favorable appearance as the patient ages.”

First page of article
Craniofacial procedures to the midface in conjunction with work to the upper face and skull, and if needed the lower jaw, are a permanent and effective way to achieve feminization of the face in transgender patients. Although the surgery is more complex than other procedures, it should be considered for select patients. Further improvement of cosmesis may be considered a separate surgical entity and is not limited in scope or time by having undergone midface osteotomies. When carefully planned, bony surgery to the midface is safe and results in long-term predictive results and a favorable appearance as the patient ages.”

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Hair Transplantation Techniques for the Transgender Patient

Anthony Bared, MD∗,'Correspondence information about the author MD Anthony BaredEmail the author MD Anthony Bared
, Jeffrey S. Epstein, MD
Private Practice, Foundation for Hair Restoration, 6280 Sunset Drive, Suite 504, Miami, FL, USA

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2018.12.005 | CROSSMARK_Color_horizontal.svg

Hair transplantation can play a complementary role in the spectrum of gender transformation procedures sought by transgender patients undergoing gender transformation surgery. The authors’ clinic has seen an increase in the demand for hair restoration in transgender patients. Hairline lowering, eyebrow transplantation, and pubic hair transplantation can play roles for male-to-female transgender patients whereas beard hair transplantation and body hair transplantation can play integral roles for female-to-male patients seeking gender transformation surgery. This article delineates an experience in the role hair restoration plays for transgender patients and outlines a surgical approach for these hair restoration procedures.

First page of article
Hair transplantation can play a complementary role in the spectrum of gender transformation procedures sought by transgender patients undergoing gender transformation surgery. The authors’ clinic has seen an increase in the demand for hair restoration in transgender patients. Hairline lowering, eyebrow transplantation, and pubic hair transplantation can play roles for male-to-female transgender patients whereas beard hair transplantation and body hair transplantation can play integral roles for female-to-male patients seeking gender transformation surgery. This article delineates an experience in the role hair restoration plays for transgender patients and outlines a surgical approach for these hair restoration procedures.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Lower Jaw Recontouring in Facial Gender-Affirming Surgery

Shane D. Morrison, MD, MSa,∗,'Correspondence information about the author MD, MS Shane D. MorrisonEmail the author MD, MS Shane D. Morrison
, Thomas Satterwhite, MDb,1

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2019.01.001 | CROSSMARK_Color_horizontal.svg

Facial gender-affirming surgery can have significant impact on patient quality of life for some gender-dysphoric patients. Lower jaw contouring can be used to harmonize the face during facial gender-affirming surgery through masculinization or feminization. During feminization, the mandibular angle and body and chin are reduced in width and size. During masculinization, augmentation of the mandibular angle and body and chin are completed with alloplastic implants, fat, or bone. Complications are minimal. Further research is needed on outcomes of these procedures.

First page of article
Facial gender-affirming surgery can have significant impact on patient quality of life for some gender-dysphoric patients. Lower jaw contouring can be used to harmonize the face during facial gender-affirming surgery through masculinization or feminization. During feminization, the mandibular angle and body and chin are reduced in width and size. During masculinization, augmentation of the mandibular angle and body and chin are completed with alloplastic implants, fat, or bone. Complications are minimal. Further research is needed on outcomes of these procedures.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Feminization of the Chin

Genioplasty Using Osteotomies

Jordan Deschamps-Braly, MD, FACSEmail the author MD, FACS Jordan Deschamps-Braly
Deschamps-Braly Clinic of Plastic & Craniofacial Surgery, 360 Post Street, Suite 901, San Francisco, CA 94108, USA

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2019.01.002 | CROSSMARK_Color_horizontal.svg

Chin reshaping can provide a more identifiable female appearance for transitioning male to female patients undergoing facial feminization. The “sliding” genioplasty has the most potential for dramatically reshaping the chin, while also avoiding many of the issues that may occur with implants. A chin should be evaluated radiologically and by physical examination to determine what changes should be made to any particular chin. When performing osseous genioplasty, the mental nerve can be protected by performing any osteotomies at least 6 mm below the inferior border of the mental nerve canal.

First page of article
Chin reshaping can provide a more identifiable female appearance for transitioning male to female patients undergoing facial feminization. The “sliding” genioplasty has the most potential for dramatically reshaping the chin, while also avoiding many of the issues that may occur with implants. A chin should be evaluated radiologically and by physical examination to determine what changes should be made to any particular chin. When performing osseous genioplasty, the mental nerve can be protected by performing any osteotomies at least 6 mm below the inferior border of the mental nerve canal.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Gender-confirming Rhinoplasty

Jens Urs Berli, MDa,∗,'Correspondence information about the author MD Jens Urs BerliEmail the author MD Jens Urs Berli
, Myriam Loyo, MDb

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2019.01.003 | CROSSMARK_Color_horizontal.svg

Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

First page of article
Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Lip Lift

Ara A. Salibian, MD
, Rachel Bluebond-Langner, MD∗,'Correspondence information about the author MD Rachel Bluebond-LangnerEmail the author MD Rachel Bluebond-Langner
Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 305 East 33rd Street, New York, NY 10016, USA

Facial Plastic Surgery Clinics, Volume 27, Issue 2

Published online: March 02, 2019
DOI: https://doi.org/10.1016/j.fsc.2019.01.004 | CROSSMARK_Color_horizontal.svg

The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

First page of article
The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Chondrolaryngoplasty—Thyroid Cartilage Reduction

Angela Sturm, MDa,b
, Scott R. Chaiet, MD, MBAc,∗,'Correspondence information about the author MD, MBA Scott R. ChaietEmail the author MD, MBA Scott R. Chaiet

Facial Plastic Surgery Clinics, Volume 27, Issue 2

DOI: https://doi.org/10.1016/j.fsc.2019.01.005 | CROSSMARK_Color_horizontal.svg

Chondrolaryngoplasty, also known as tracheal shave, is a surgical procedure performed for a prominent Adam’s apple, usually in transfeminine patients with gender dysphoria to this marker of male sex. Although laryngeal anatomy is complex, knowledge of landmarks and techniques discussed in this article results in a safe procedure with rare complications and improvement in quality of life.

First page of article
Chondrolaryngoplasty, also known as tracheal shave, is a surgical procedure performed for a prominent Adam’s apple, usually in transfeminine patients with gender dysphoria to this marker of male sex. Although laryngeal anatomy is complex, knowledge of landmarks and techniques discussed in this article results in a safe procedure with rare complications and improvement in quality of life.

© 2019 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

Facial Plastic Surgery

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