Perioperative Estrogen Hormonal Therapy Does Not Increase Venous Thromboembolism Risk In Facial Feminization Surgery.

BACKGROUND: Conflicting data exist regarding increased perioperative VTE risk while on feminizing hormone therapy. The effect has been poorly studied within the transgender population. Acute perioperative cessation of feminizing hormone therapy often leads to unpleasant side effects and exacerbates gender dysphoria in the perioperative period. We seek to identify the VTE incidence in patients undergoing facial feminization while continuing HRT throughout the time of surgery. METHODS: A 38-year retrospective cohort study within a two-surgeon practice (D.K.O. and J.C.D.) was designed to evaluate postoperative VTE in patients continuing hormone therapy. The primary outcome variable was identified as suffering a VTE postoperatively. RESULTS: 1,715 patients underwent facial feminization surgery within our search window. 953 patients met final inclusion criteria. 1 patient (0.10%) was diagnosed with a VTE postoperatively, comparable to reported literature rates for similar cosmetic and orthognathic procedures. The average Caprini score of all patients was 3.1±1.0 and the average case length was 491.9±111.0 minutes. Subgroup analysis of patients before and after internal practice changes identified 714 (77.7%) patients continuing full dose hormonal therapy perioperatively, 197 (20.7%) patients undergoing hormonal dose reduction to 25-50% perioperatively, and 8 patients who were either not taking hormonal therapy or stopped in the perioperative period. There was no significant difference in VTE incidence between the 3 subgroups (p > 0.99). CONCLUSIONS: Perioperative use of feminizing hormonal therapy does not increase risk for perioperative VTE in patients undergoing facial feminization surgery. Therefore, it is reasonable to continue these medications through the time of surgery.

Reprint of: Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Breaking the binary: The identification of trans-women in forensic anthropology.

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management.

The 1960s and 1970s were an important time for craniofacial surgery because of the work of Paul Tessier and Hugo Obwegeser, both mentored by Sir Harold Gillies, along with many other important monumental minds. During this era, the birth of craniofacial surgery occurred and represented a new discrete specialty within plastic surgery. In the 1980s distraction of the facial skeleton became an indispensable tool in the arsenal of the craniofacial surgeon, based on initial cases in Italy, and rigorous research by McCarthy, Grayson, and others. In more recent times, from 2000 onward, craniofacial surgery has benefitted from the advent and refinement of techniques using computer-aided planning for procedures, spring distraction, as well as the widespread use of fat grafting as part of facial reconstruction. In the last decade, innovations based on the fusion of microsurgical procedures with craniofacial procedures for face allotransplantation and improvements in safety regarding separation of craniopagus infants have been observed. The author thinks it is worth mentioning and conferring praise upon the anesthesia colleagues for improvements in anesthesia which have led to vastly decreased mortality in the infant population undergoing complex procedures.The common theme among these achievements is that they were quickly adopted by the subspecialty community. However, in the hindsight of history, the author thinks it is now understood that during this time another great achievement, long overlooked, occurred in craniofacial surgery. In the 1980s the author's associate and mentor, Douglas Ousterhout, adapted techniques of craniofacial surgery to change the lives of transgender patients. This new and powerful surgery had the potential to change the course of someone's life just as profoundly as the correction of congenital craniofacial anomalies. This quality of life improvement for trans patients undergoing facial feminization has been evaluated and found to be quite significant. However, it was essentially ignored by the specialty community, and the author and his colleagues were slow to adopt this surgery. In this study, the author will give an overview of the procedures required to feminize or masculinize a face. The history of surgery is fascinating, and the author hopes that the origins of facial gender confirmation surgery (facial feminization and masculinization), which may be found in the forward to this journal, are fascinating to the readers as well.

Current Concepts in Feminizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

Current Concepts in Masculinizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital masculinization. 3. Recognize key steps and anatomy during chest-wall contouring and phalloplasty reconstruction. 4. Discuss major risks and complications of chest-wall contouring and phalloplasty reconstruction. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various masculinizing gender-affirming surgical procedures.

Facial Gender Confirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery.

Facial feminization surgery was pioneered in the 1980s to provide options for trans women who were having difficulty with their outward appearance. This process presented a novel application of craniofacial surgery at the time. This text outlines the basic differences between male and female facial morphology, as well as the procedures we use to feminize the face.

First Female-to-Male Facial Confirmation Surgery with Description of a New Procedure for Masculinization of the Thyroid Cartilage (Adam's Apple).

Although male-to-female transgender patients commonly seek facial feminization surgery, facial masculinization surgery in the female-to-male transgender population is unreported in the literature. This report documents the first known female-to-male facial masculinization surgery, including a new technique for creating an "Adam's apple" to enhance the facial masculine appearance of a natal female. The authors "reversed" the methods typically used to feminize male facial features, and modified the forehead, nose, and chin to masculinize the patient's natal female facial features. The authors devised a novel technique to augment the thyroid cartilage using autologous rib cartilage to create a visible Adam's apple. Initially, masculinization of the chin was accomplished with a multisegment chin osteotomy with grafts to vertically expand and widen the chin along with correcting pronounced microgenia. Subsequently, a second facial masculinization procedure was performed to masculinize the forehead, nose, and thyroid cartilage. Rib cartilage was harvested and carved into an appropriately shaped thyroid cartilage onlay graft and then attached and integrated with the native thyroid cartilage, creating a fully mobile cartilage that translocates up and down with swallowing and a visible Adam's apple. Previously described techniques to masculinize the facial features of natal male patients were adapted to masculinize the female-to-male patient. Those procedures were combined with the novel technique to create a visually perceptible and naturally mobile Adam's apple in the female-to-male transsexual patient. Collectively, these described procedures can now provide most female-to-male transsexual patients with a satisfying transformation of their facial features. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Safety and efficacy of recombinant human bone morphogenetic protein 2 on cranial defect closure in the pediatric population.

BACKGROUND: Traditional reconstructive options for cranial defects include autogenous bone graft, bone substitutes, and synthetic materials. The established standard for repairing cranial defects is autogenous bone. However, young children do not have abundant donor sites for bone harvest, which leads to challenges in closing calvarial defects. Synthetic materials are not ideal alternatives because they require subsequent retrieval and are prone to infection. Their long-term effects on growth of the skull are also not well studied. Bone morphogenetic protein 2 (BMP-2), are shown to positively affect closure of cranial defects in animal models. We present a study comparing the efficacy and safety of closure of cranial defect with bone graft augmented with recombinant human BMP-2 (rhBMP-2) and compared with a series of patients treated with bone graft alone. METHODS: This study is a retrospective multicenter evaluation of 36 patients spanning 5 years. Twenty-one patients undergoing cranial defect closure augmented with rhBMP-2 were compared with 15 patients who underwent cranial defect closure using cranial bone shavings alone. We measured preoperative and postoperative defect size on volumetric computed tomographic scan reconstructions to compare defect sizes. RESULTS: The rhBMP-2 group had slightly increased proportional closure compared with the control group, 86% versus 76% (P < 0.018), respectively. Two patients in the rhBMP-2 group had postoperative fusion of a suture that was known to be patent at the time of cranial defect closure. No instances of brain edema, herniation, airway compromise, or other adverse effects directly attributable to rhBMP-2 were observed. CONCLUSIONS: Bone morphogenetic protein 2 may increase the amplitude and uptake of cranial bone grafts in cranial defect closure. This study shows that defect sizes of up to 16 cm can be reliably closed using this technique. Postoperative fusion of uninvolved sutures in 2 patients indicates that rhBMP-2 may have unreported adverse effects; consideration of this finding should be weighed against the benefit of improved closure of calvarial defects.