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Reconstructive: Head and Neck: Original Articles

Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study

Morrison, Shane D. M.D., M.S.; Capitán-Cañadas, Fermín Ph.D.; Sánchez-García, Anabel Ph.D.; Ludwig, David C. M.D., D.D.S.; Massie, Jonathan P. M.D.; Nolan, Ian T. B.M.; Swanson, Marco M.D.; Rodríguez-Conesa, Marina M.S.; Friedrich, Jeffrey B. M.D., M.C.; Cederna, Paul S. M.D.; Bellinga, Raúl J. M.D.; Simon, Daniel D.M.D.; Capitán, Luis M.D., Ph.D.; Satterwhite, Thomas M.D.

Author Information
Plastic and Reconstructive Surgery: June 2020 - Volume 145 - Issue 6 - p 1499-1509
doi: 10.1097/PRS.0000000000006837

Abstract

Facial feminization surgery plays a critical role in gender affirmation of many transfeminine people.1–4 The face is one of the most visible external purveyors of gender, and typically “masculine” features can make it difficult for transfeminine people to be perceived as their correct gender. The resulting misinterpretation by others as male or undesired “outing” as transgender may not only exacerbate mental health sequelae of facial gender dysphoria, but also may worsen external discrimination stemming from transphobia.5–14 Therefore, perhaps more so than with other types of gender-affirming surgery, facial feminization surgery may protect transgender women from real bodily harm.15

A number of procedures constitute facial feminization surgery, and surgical regimens vary based on patients’ facial characteristics. Patient-focused decisions and shared decision-making are critical for facial feminization surgery. Decisions should be based on patients’ feelings as to which facial characteristics cause them the most facial gender dysphoria, in combination with a trained surgeon’s respect of facial harmony and knowledge of typical anthropomorphic features most contributive to “masculine” and “feminine” faces. Often, multiple concurrent or staged procedures are required to achieve a desired feminine appearance, as patients may have multiple facial features that contribute to perceived masculinity.

Addressing masculine characteristics of the brows, nose, mandible, and chin is of particular interest in facial feminization surgery, as these facial areas are most influential to gender perception.16–18 Cephalometric measurements of these areas can provide objective data regarding the efficacy of facial feminization surgery. Specifically, brow or glabellar prominence can be quantified by a more negative forehead inclination in male patients, defined as the angle between the Frankfort horizontal and the plane of the forehead (in Caucasians, −9.8 degrees versus −5.9 degrees), and a decreased glabellar angle, defined as the angle between the Frankfort horizontal and the plane of the glabella.19 Procedures to reduce brow prominence include frontal sinus setback and forehead contouring through bone burring.3 Brow prominence also contributes to the nasofrontal angle, which is defined as the angle between the plane of the glabella and the plane of the nose and is usually smaller in male subjects than in female subjects (in Caucasians, 137.9 degrees versus 140.6 degrees).20 The nasolabial angle, defined as the angle between the plane of the upper lip and the plane of the columella, is typically more obtuse in female subjects as well (100 to 105 degrees versus 90 to 95 degrees in men). Nasal angles are typically addressed by means of rhinoplasty.3,21 A masculine jaw can be quantified by a larger mandibular angle and decreased mandibular plane angle, with the latter being defined as the angle between the Frankfort horizontal and the mandibular plane (in Caucasians, 26.2 degrees in men versus 29.6 degrees in women).22 Jaw reduction techniques include burring for smaller mandibular angles, ostectomies for larger mandibular angles, or masseter thinning.23

Retrospective studies have demonstrated improved quality of life and mental health from facial feminization surgery.4,24 However, prospective data do not currently exist. This is a prospective cohort study designed to determine quality-of-life outcomes from an international cohort of transgender and gender-diverse women undergoing facial feminization surgery for the treatment of gender dysphoria. Secondary outcomes were patient satisfaction, changes in objective facial measurements, and externally rated gender appearance and general aesthetics.

PATIENTS AND METHODS

Institutional review board approval was granted for the enrollment of patients in this study from the Schulman Institutional Review Board (SAIRB-14-0056) (now the Advarra Institutional Review Board) and the University of Michigan Institutional Review Board (HUM00111498). Ethical committee approval was obtained to enroll patients from Europe (Comité de Ética de Investigación Clínica, E. P. Hospital Costa del Sol, Marbella, Spain). The Strengthening the Reporting of Observational studies in Epidemiology checklist protocol was followed.

Patient Cohort

Patients were recruited and enrolled at two clinics: Brownstein and Crane Surgical Services (Greenbrae, Calif.) and FACIALTEAM (HC Marbella International Hospital, Marbella, Málaga, Spain). Brownstein and Crane Surgical Services focuses on a variety of gender-affirmation operations, including facial feminization surgery, whereas FACIALTEAM focuses mainly on facial feminization surgery. Both clinics evaluate over 500 transgender or gender-diverse patients annually. Patients were approached for enrollment if they were 18 years or older, were being seen in consultation for facial feminization surgery, and were medically appropriate for surgery. The study was explained to the patients through a staff member versed in the study and consent procedures, and patients were given adequate time to review the informed consent before enrolling. No monetary payment was given, and patients could choose to leave the study at any point. Informed consent was translated into Spanish for those who did not speak English, and all conversation and follow-up for the study was completed in Spanish for this population, with appropriate cultural adaptation principles.25 Patients undergoing facial masculinization were not included in this study, as these procedures are rare.26 Each patient was evaluated, and an individualized surgical plan was implemented to address verbalized goals and to correct specific aspects of the face that brought on dysphoria.

Procedures

Facial feminization surgery procedures performed as a part of this study included hairline lowering, hair transplantation, brow contouring, brow/frontal sinus setback, genioplasty, mandibular contouring, rhinoplasty, thyroid cartilage reduction, lip lift, brow lift, face lift, otoplasty, blepharoplasty, and fat grafting. Brow contouring techniques provided retropositioning of the frontonasal-orbital complex using a combination of burring and osteotomies and, when necessary, titanium mesh fixation of the anterior wall of the frontal sinus. Genioplasty procedures included bony burring and ostectomy and, in some cases, sliding genioplasty for advancement and/or vertical augmentation. Mandibular contouring was achieved with a combination of burring and angle ostectomies.

As most patients require modification of multiple areas of their face for feminization and undergo multiple procedures during their initial surgery, multiple procedures on an individual patient were normal and expected.1,3,4,27,28 For each patient, all listed procedures were performed concurrently. Patients undergoing isolated nonsurgical facial feminization or alteration of the soft tissue alone were not included.29,30

Study Instrument

The instrument used in this study was adapted from a tool validated in the general facial aesthetic surgery population to assess physical, emotional, and social domains of patient satisfaction with their face.31,32 It was then adapted for use in the transgender and gender-diverse population and underwent standard reliability validation. The instrument has been used in a retrospective study on outcomes of facial feminization surgery, where it correlated with the 36-Item Short-Form Health Survey Version 2 quality-of-life outcome instrument.24 The instrument constitutes nine questions scored on a five-point Likert scale (ranging from 0 to 4, where 0 constitutes least satisfied and 4 constitutes most satisfied) which are compiled to form a composite facial feminization score (facial feminization surgery outcome score)24,33:

where a score of 100 denotes complete satisfaction. Aspects of self-perceived and others’ perception of their facial femininity and masculinity were asked as free response questions. Patient satisfaction (survey question 16) with facial feminization surgery was determined based on a five-point Likert scale (again from 0 to 4). Patient demographics including gender identity, age, education level, smoking status, employment, duration of transition, previous hormonal therapy, previous gender-affirmation surgery, and insurance coverage of gender-affirming surgery were collected. The procedures that the patients underwent along with complications were also recorded. The facial feminization outcomes survey used in this study is shown. (See Figure, Supplemental Digital Content 1, which shows the facial feminization outcomes survey used in this study, http://links.lww.com/PRS/E73.)

Study Protocol

After written informed consent was obtained, the survey was administered preoperatively, 1 week to 1 month postoperatively, and greater than 6 months postoperatively. The surveys were completed in person or electronically in a secured format. Standard photographs were taken for patients at the same intervals.34

Gender appearance and general aesthetics were rated by reviewers and compared to cisgender women controls. Gender appearance was rated on a scale of 1 to 5, with 1 being female, 2 being more female than male, 3 being equally female and male, 4 being more male than female, and 5 being male. General aesthetics were rated on a 10-point Likert scale, with 1 meaning very poor appearance and 10 meaning very good appearance. Raters were naive to patient’s gender identity and treatment history. Outcomes for facial feminization surgery patients were matched to cisgender controls. Ten facial feminization surgery photographs were chosen based on highest photograph quality for anteroposterior and frontal views available at greater than 6 months’ follow-up. Five photographs of cisgender women were chosen based on good match for sex and age of facial feminization surgery photographs. Photographs were independently rated by 32 cisgender and transgender raters.

Statistical Analysis and Sample Size Calculation

Descriptive characteristics for all patients are summarized. Preoperative and postoperative facial feminization outcome scores were compared with a nonparametric Mann-Whitney test. Patient satisfaction scores were compared with a nonparametric Mann-Whitney test. Patient demographics were correlated to postoperative facial feminization outcome scores and patient satisfaction by univariate linear regression. Free responses were tabulated according to areas of the face participants denoted; for example, “jaw” was recorded as jaw, “face” was recorded as everything, and “Adam’s apple” was recorded as thyroid cartilage.

Photogrammetric analysis was performed using Dolphin Imaging and Management Solutions software (Patterson Dental Supply, Inc., Chatsworth, Calif.) and included measurements of forehead inclination, glabellar angle, nasolabial angle, Frankfort horizontal to mandibular plane angle, and nasofrontal angle obtained from preoperative, 1-week to 1-month postoperative, and greater than 6-month postoperative photographs. (See Figure, Supplemental Digital Content 2, which shows the photogrammetric analysis measurement used for analysis of participant photographs, http://links.lww.com/PRS/E74.) A Wilcoxon signed rank test was used to compare the preoperative and postoperative measurements. Statistical significance was held at p < 0.05.

To determine our sample size to detect a significance in preoperative and postoperative facial feminization outcome score, we based our calculation on the difference in facial feminization outcome score seen in transgender women with and without facial feminization surgery as determined in a previous retrospective study.24 Based on these stark differences in outcomes, a pre hoc power analysis was performed, and it was determined that 42 patients would be needed to detect a significant difference in facial feminization outcomes.

RESULTS

Patient Demographics and Procedure Details

A total of 66 consecutive facial feminization surgery patients who consented to the study were enrolled 46 from the FACIALTEAM in Europe and 20 from Brownstein and Crane Surgical Services in the United States. Mean age was 39 years, with less than one-third having a history of smoking [n = 20 (30.3 percent)]. Almost half [n =30 (46.9 percent)] had undergone previous gender-affirming surgery and 10 (15.2 percent) had undergone previous facial feminization surgery. Most had begun their gender-affirmation process less than 5 years ago [n =42 (63.7 percent)] (Table 1).

Table 1. - Demographics of Patients Undergoing Facial Feminization Surgery
Characteristic Value (%)
No. 66
Mean age ± SD, yr 39.3 ± 11.9
Nonbinary* 2 (3.1)
Smoking history 20 (30.3)
Taking hormones 63 (95.5)
Previous FFS† 10 (15.2)
 Rhinoplasty 4 (40.0)
 Thyroid cartilage reduction 6 (60.0)
 Genioplasty 3 (30.0)
 Hair transplant 2 (20.0)
 Mandible surgery 2 (20.0)
 Brow lift 2 (20.0)
 Scalp advancement 1 (10.0)
 Forehead bossing reduction 1 (10.0)
 Blepharoplasty 1 (10.0)
Previous GAS‡ 30 (46.9)
 Vaginoplasty 18 (60.0)
 Chest augmentation 14 (46.7)
 Labiaplasty 11 (36.7)
 Clitoroplasty 8 (26.7)
 Orchiectomy 7 (23.3)
 Penectomy 5 (16.7)
 Other 3 (10.0)
Education*
 Middle school 1 (1.5)
 High school 15 (23.1)
 2-yr college 11 (16.9)
 4-yr university 18 (27.7)
 Graduate/professional 20 (30.8)
Employment§
 Full-time 38 (55.9)
 Part-time 5 (7.4)
 Looking for work 7 (10.3)
 Student/homemaker/other 11 (16.2)
 Not looking for work 1 (1.5)
 Retired 3 (4.4)
 Other 3 (4.4)
Length of transition
 <1 yr 4 (6.1)
 1–5 yr 38 (57.6)
 6–10 yr 9 (13.6)
 >10 yr 15 (22.7)
FFS, facial feminization surgery; GAS, gender-affirming surgery.
*Only 65 patients responded.
†Four patients had multiple responses: one each with two, three, four, and seven responses.
‡Only 64 patients responded: 16 had multiple responses (seven had two responses, four had three responses, one had four responses, and two had five and six responses).
§Two patients responded with two answers.

Most participants felt the most masculine aspects of their faces before surgery were their brows [n =36 (54.5 percent)], jaw [n =22 (33.3 percent)], and chin [n =20 (30.3 percent)]. Their most self-perceived feminine features were their eyes [n =33 (50.0 percent)] and lips [n =17 (25.8 percent)]. (See Table, Supplemental Digital Content 3, which shows self-perceptions of facial femininity and masculinity preoperatively, http://links.lww.com/PRS/E75.) Similar results were seen in what others perceived were their most masculine and feminine facial features. (See Table, Supplemental Digital Content 4, which shows others’ perceptions of facial femininity and masculinity preoperatively, http://links.lww.com/PRS/E76.) Insurance coverage was provided for hormones for most patients [n =40 (58.0 percent)], but only approximately one-third of patients had their gender-affirming surgery covered by insurance [n =18 (32.1 percent)]. (See Table, Supplemental Digital Content 5, which shows insurance coverage for gender-affirming treatments for participants, http://links.lww.com/PRS/E77.)

A total of 279 procedures were performed on 66 patients, for an average of 4.2 procedures per patient. Patients had procedures on one [n =1 (1.6 percent)], two [n =14 (22.2 percent)], three [n =15 (23.8 percent)], four [n =14 (22.2 percent)], five [n =11 (17.5 percent)], six [n =4 (6.3 percent)], or seven [n =4 (6.3 percent)] facial areas, broken down by hairline, forehead, brow, eyes, nose, midface, ears, mouth and lips, jaw and chin, and thyroid cartilage. Procedures included brow reduction including frontal sinus setback or forehead contouring by means of bony burring [n =59 (89.4 percent)]; genioplasty by means of bony burring, ostectomy, or sliding genioplasty [n =45 (68.2 percent)]; rhinoplasty [n =43 (65.2 percent)]; mandibular contouring, angle reduction, or tapering by means of bony burring and/or ostectomy [n =39 (59.1 percent)]; hair transplant [n =25 (37.9 percent)]; lip lift [n =23 (34.8 percent)]; thyroid cartilage reduction [n =20 (30.3 percent)]; brow lift [n =12 (18.2 percent)]; hairline lowering [n = 10 (15.2 percent)]; upper or lower lid blepharoplasty [n =2 (3.0 percent)]; and other procedures that included dermal fat grafting, lobuloplasty, midface lift, and otoplasty [n =1 (1.5 percent each)] (Table 2).

Table 2. - Procedures Performed as Part of Facial Feminization
Procedure No. of Participants
Brow reduction 59
Genioplasty 45
Rhinoplasty 43
Mandibular contouring 39
Hair transplant 25
Lip lift 23
Thyroid cartilage reduction 20
Brow lift 12
Hairline lowering 10
Upper or lower lid blepharoplasty 2
Miscellaneous procedures* 1
*Dermal fat graft, lobuloplasty, midface lift, and otoplasty.

Facial Feminization Outcomes and Satisfaction

Facial feminization outcome scores improved significantly after surgery [preoperative median score, 47.2 (interquartile range, 38.9 to 55.6); 1-week to 1-month postoperative median score, 75.0 (interquartile range, 63.9 to 86.1) (p < 0.0001)]. This relationship was stable at greater than 6 months’ follow-up [median outcome score, 80.6 (interquartile range, 66.7 to 83.3); significance versus preoperative score, p < 0.0001; significance versus 1-week to 1-month postoperative score, p = 0.40] (Fig. 1, left). (See Table, Supplemental Digital Content 6, which shows the overall change in facial feminization surgery outcome score and impact of facial feminization surgery, http://links.lww.com/PRS/E78.)

Fig. 1.
Fig. 1.:
Box plots showing quality-of-life outcomes and satisfaction after facial feminization surgery (FFS). (Left) Facial feminization quality-of-life outcome scores (0 to 100) assessed preoperatively, 1-week to 1-month postoperatively, and greater than 6 months postoperatively. (Right) Patient satisfaction after facial feminization surgery (Likert scale ranging from 0 to 4) assessed at 1-week to 1-month postoperatively and greater than 6 months postoperatively.

Likewise, patient satisfaction as measured by a five-point Likert scale remained stable postoperatively (median, 3.0 at both 1-week to 1-month and >6 months postoperatively; p = 0.46) (Fig. 1, right) (see Table, Supplemental Digital Content 6, http://links.lww.com/PRS/E78).

Increasing age was negatively associated with both facial feminization outcome scores (R = −0.390; p = 0.006) and patient satisfaction (R = −0.49; p < 0.001) in univariate linear regression analysis. A higher education level was negatively associated with patient satisfaction (R = −0.281; p = 0.05). A history of not using tobacco in the last week was positively associated with patient satisfaction (R = 0.457; p = 0.037). Nonsignificant variables included gender identification, time since transition, past hormonal use, current hormonal use, previous facial feminization surgery, previous nonfacial gender-affirming surgery, payment type, gender appearance outcome, general aesthetic outcome, areas of the face on which surgery was performed, and number of areas of the face that were operated on (Table 3).

Table 3. - Predictors of Outcomes of Facial Feminization Surgery
Characteristic Facial Feminization Outcome >6 Mo Patient Satisfaction
Coefficient Estimate R p Coefficient Estimate R p
Age −0.390 0.006* −0.49 <0.001*
Gender identification −0.2 0.174 −0.091 0.536
Education −0.145 0.321 −0.281 0.05*
Smoking 0.086 0.554 −0.096 0.506
Abstinence from tobacco in the past week 0.143 0.537 0.457 0.037*
Transition beginning 0.025 0.866 −0.132 0.361
Past hormone use N/A† N/A† N/A† N/A†
Currently on hormones 0.065 0.655 0.119 0.411
Previous FFS 0.024 0.866 0.094 0.517
Previous gender-affirming surgery 0.138 0.345 0.160 0.272
Payment type 0.129 0.410 0.133 0.395
Gender appearance score‡ 0.357 0.312 0.283 0.429
General aesthetic outcome‡ 0.078 0.434 0.339 0.338
FFS, facial feminization surgery.
*Statistically significant.
†As all patients took hormones in the past, this was unable to be calculated.
‡For these comparisons, n = 10.

Cephalometric Analysis of Femininity

Photogrammetric analysis showed significant changes toward facial feminization at various postoperative periods based on what would be expected from anthropometric measurements determined from cohorts of men and women.19,35,36 Relative to preoperative measurements, postoperatively patients had increased forehead inclination [71.1 ± 4.9 degrees versus 73.7 ± 5.1 degrees (p = 0.0001) at ≥6 months postoperatively), decreased glabellar angle [100.6 ± 8.6 degrees versus 95.8 ± 9.4 degrees (p = 0.03) at ≥6 months postoperatively], increased nasolabial angle [98.7 ± 13.0 degrees versus 100.9 ± 11.6 degrees (p = 0.049) at ≥6 months postoperatively], increased Frankfort horizontal to mandibular plane angle [22.6 ± 5.3 degrees versus 23.9 ± 5.1 degrees (p = 0.01) at ≥6 months postoperatively], and increased nasofrontal angle [132.7 ± 11.0 degrees versus 139.8 ± 8.9 degrees (p = 0.00001) at ≥6 months postoperatively] (Tables 4 and 5). Although these changes seem small, their synergistic effects on overall alteration of the face are substantial, and select outcomes of patients are shown in Figure 2.

Table 4. - Photogrammetric Analysis of Outcomes for Facial Feminization Surgery Preoperatively Compared with ≤1 Month Postoperatively (n = 58)
Preoperatively* ≤1 Mo Postoperatively* p
Forehead inclination, deg 70.0 ± 5.2 72.2 ± 5.9 0.0001
Glabellar angle, deg 101.7 ± 10.1 96 ± 8.7 <0.00001
Nasolabial angle, deg 97.7 ± 12.2 104.2 ± 15.2 <0.00001
Frankfort horizontal–mandibular angle, deg 21.4 ± 5.1 22.7 ± 4.5 0.0034
Nasofrontal angle, deg 131.8 ± 11.1 139.5 ± 10.0 <0.00001
*Mean ± SD.
†Wilcoxon signed rank test.

Table 5. - Photogrammetric Analysis of Outcomes for Facial Feminization Surgery Preoperatively Compared with >6 Months Postoperatively (n = 36)
Preoperatively* ≥6 Mo Postoperatively* p
Forehead inclination, deg 71.1 ± 4.9 73.7 ± 5.1 <0.0001
Glabellar angle, deg 100.6 ± 8.6 95.8 ± 9.4 0.03
Nasolabial angle, deg 98.7 ± 13.0 100.9 ± 11.6 0.049
Frankfort horizontal–mandibular angle, deg 22.6 ± 5.3 23.9 ± 5.1 0.01
Nasofrontal angle, deg 132.7 ± 11.0 139.8 ± 8.9 <0.00001
*Mean ± SD.
†Wilcoxon signed rank test.

Fig. 2.
Fig. 2.:
Clinical cases before (left) and after (right) facial feminization surgery. Frontal view (above and third row) and lateral view (second row and below). Patient 1 (above and second row; preoperatively and 6 months postoperatively) underwent brow contouring, hair transplantation, lower jaw contouring, and thyroid cartilage reduction. Patient 2 (third row and below; preoperatively and 1 year postoperatively) underwent brow contouring, hair transplantation, and rhinoplasty.

Externally Rated Femininity and Cosmesis

On a scale of 1 to 5, with 1 being most feminine and 5 being most masculine, mean gender appearance score was 1.83 ± 0.96 for the facial feminization surgery cohort (n =10) and 1.25 ± 0.49 for a cohort of five cisgender women controls (Table 6). Aesthetic outcomes on a scale of 1 to 10 were 6.09 ± 2.01 for the facial feminization surgery cohort and 7.63 ± 1.82 for cisgender controls.

Table 6. - Gender Appearance and General Aesthetic Outcomes
Facial Feminization Cohort Control p
No. 10 5
Outcome
 Mean gender appearance score ± SD 1.83 ± 0.96 1.25 ± 0.49 <0.001*
 Mean general aesthetic outcome ± SD 6.09 ± 2.01 7.63 ± 1.82 <0.001*
*Statistically significant.

Complications

Procedures performed on each participant along with complications are shown. (See Table, Supplemental Digital Content 7, which shows individual patient outcomes, http://links.lww.com/PRS/E79.) Complications seen include hypertrophic scarring (five patients), orbital emphysema and hematoma (four patients), nasal hematoma and epistaxis (two patients), alopecia (one patient), and iatrogenic jowling or “witches chin” deformity after bony manipulation (two patients) (see Table, Supplemental Digital Content 7, http://links.lww.com/PRS/E79). Four complications (6.1 percent) required intervention. There was no statistically significant effect of history of tobacco use on complication rates.

DISCUSSION

This study supports the efficacy of facial feminization surgery in improving quality of life for transgender women; enacting objective cephalometric changes; and achieving high satisfaction, feminine gender appearance, and good overall aesthetics with minimal complications. Our cohort’s facial feminization surgery outcome score increased from 47.2 preoperatively to 80.6 at greater than or equal to 6 months postoperatively (p < 0.0001) (Fig. 1, left) (see Table, Supplemental Digital Content 6, http://links.lww.com/PRS/E78). These values are similar to retrospective data provided by Ainsworth and Spiegel (preoperatively, 44.3 ± 15.7; postoperatively, 76.0 ± 17.7; p < 0.01), who also demonstrated that their results correlated with improved mental health quality of life in transgender women who had facial feminization surgery relative to those who did not based on the previously validated 36-Item Short-Form Health Survey Version 2 questionnaire.24 Importantly, Ainsworth and Spiegel showed that transgender women with facial feminization surgery outcome scores similar to our postoperative cohort have mental health outcomes scores on the 36-Item Short-Form Health Survey Version 2 instrument almost equal to those of cisgender women, suggesting that facial feminization surgery may play a critical role in gender dysphoria and/or external discrimination that lower quality of life for transgender women.

Our study demonstrates both immediate and sustained outcomes of facial feminization surgery (Fig. 1, right ) (see Tables, Supplemental Digital Content 6 and 7, http://links.lww.com/PRS/E78and http://links.lww.com/PRS/E79). The immediate high satisfaction, despite significant swelling and continued healing at the 1-month follow-up, could possibly be attributable to patients’ relief of finally having the feminizing procedures for which they have often waited a significant amount of time. Considering the significant financial and emotional energy invested in these procedures, immediate satisfaction may also reflect a psychological defense mechanism against unsatisfactory results. However, because facial feminization surgery outcome scores were also improved by 1-month follow-up, it is likely that feminization was seen at a satisfactory level even before healing was completed. Sustained outcomes regarding satisfaction and facial feminization surgery outcome scores corroborate the true efficacy of facial feminization surgery.

Objective cephalometric changes further corroborate the efficacy of facial feminization surgery in reducing “masculine” features and attaining a more “feminine” face. Our cohort demonstrated significantly increased forehead inclination because of decreased frontal bossing, decreased glabellar angle resulting from decreased frontal bossing, increased nasofrontal angle, and greater mandibular plane angle given the change in angularity of the mandibular angle (Table 4). The postoperative nasolabial angle, mandibular plane angle, and frontonasal angles all approximated typical female ranges.3,20,22

Our cohort of facial feminization surgery patients had feminine gender appearance and good overall aesthetic outcomes. However, their gender appearance and general aesthetic outcomes were still not equal to those of cisgender women controls. This may be attributable to a number of factors, including masculine appearance of other facial features not addressed during facial feminization surgery.

Factors that were associated with less favorable outcomes in our cohort, by means of univariate linear regression analysis, include those that are typically associated with suboptimal outcomes in any plastic surgery patient.11,14,37 These include increased age, which was negatively associated with facial feminization outcome score and patient satisfaction, and recent history of smoking, which was associated negatively with patient satisfaction. These may stem from physical effects, such as soft-tissue laxity or bony architecture changes in the aging face, or the known effects of nicotine on wound healing and skin quality. However, especially with increased age, other factors may be at play, including potential limited social flexibility or support among older transgender patients.

Further characterization as to which facial feminization surgery procedures specifically are associated with improved outcomes is warranted, yet will likely prove difficult to assess, as facial feminization surgery is patient-specific and generally requires multiple concomitant procedures. Of note, no particular area of the face (hairline, forehead, brow, eyes, nose, midface, ears, or lips), or number of procedures (range, 1 to 7 per patient; mean, 3.8 per patient) was associated with a statistically significant effect on facial feminization surgery outcome score or satisfaction outcomes in our cohort.

Patients may also seek procedures beyond what were performed in this study. Most of the procedures in this study were aimed at modification of the craniofacial skeleton. A commonly adapted approach to facial feminization surgery is a “hard-then-soft” approach, in which procedures such as those described in our study are followed by soft-tissue procedures such as fillers or delayed hair transplantation to fine-tune results.1,3,4

Facial feminization surgery alone is likely insufficient to achieve complete gender affirmation for many patients. Even objective changes achieved by facial feminization surgery, as measured by cephalometry, may not be sufficient to characterize a face as male or female, as differences in gender assignment of identical faces are also heavily influenced by the interpreter’s sex and other characteristics.16,17 Moreover, facial femininity is just one of many cues that transgender women can use to affirm their gender to themselves and others, in combination with physical characteristics such as body habitus, breast size, clothing and hairstyle, and nonphysical characteristics such as voice quality and communication style.38–41

Our data support that facial feminization surgery may be considered medically necessary for many patients. Designation of medical necessity by the World Professional Association for Transgender Health is often cited as support for insurance coverage of gender-affirming surgery procedures.1,3,42 However, facial feminization surgery has traditionally not been considered medically necessary because of interpretation as cosmetic. Our data suggest that facial feminization surgery is not merely cosmetic and that it clearly targets gender dysphoria to achieve improved quality of life.7,9,43–46

Limitations exist in this study and include response bias of participants, heterogeneity of procedures used in facial feminization surgery, and the use of a quality-of-life instrument that was not initially developed for the transgender or gender-diverse population, although it has been specifically adapted for the transgender population.4,24,33,47 In addition, gender appearance and general aesthetic outcomes scale used were not validated. Studies are currently underway to develop a robust patient-reported outcome measure for the transgender and gender-diverse population.48

CONCLUSIONS

This prospective cohort study demonstrates that facial feminization surgery, including brow surgery, lower jaw and chin contouring, rhinoplasty, thyroid cartilage reduction, hairline treatment, and laser hair treatment or electrolysis in various combinations, achieved improved quality of life and increased facial feminization scores, resulted in more feminine cephalometries and sustained patient satisfaction at 6 months, and resulted in improved feminine gender appearance and good general aesthetic outcomes.

PATIENT CONSENT

Patients provided written consent for the use of their images.

ACKNOWLEDGMENTS

Plastic Surgery Foundation Pilot Grant no. 402674 was used for funding of this study (Shane D. Morrison, M.D., Jeffrey B. Friedrich, M.D., M.C., Paul S. Cederna, M.D., and Thomas Satterwhite, M.D.).

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