A gender perspective on the global migration of scholars.

Although considerable progress toward gender equality in science has been made in recent decades, female researchers continue to face significant barriers in the academic labor market. International mobility has been increasingly recognized as a strategy for scientists to expand their professional networks, and that could help narrow the gender gap in academic careers. Using bibliometric data on over 33 million Scopus publications, we provide a global and dynamic view of gendered patterns of transnational scholarly mobility, as measured by volume, distance, diversity, and distribution, from 1998 to 2017. We find that, while female researchers continued to be underrepresented among internationally mobile researchers and migrate over shorter distances, this gender gap was narrowing at a faster rate than the gender gap in the population of general active researchers. Globally, the origin and destination countries of both female and male mobile researchers became increasingly diversified, which suggests that scholarly migration has become less skewed and more globalized. However, the range of origin and destination countries continued to be narrower for women than for men. While the United States remained the leading academic destination worldwide, the shares of both female and male scholarly inflows to that country declined from around 25% to 20% over the study period, partially due to the growing relevance of China. This study offers a cross-national measurement of gender inequality in global scholarly migration that is essential for promoting gender-equitable science policies and for monitoring the impact of such interventions.

Climate warming and sea turtle sex ratios across the globe.

Climate warming and the feminization of populations due to temperature-dependent sex determination may threaten sea turtles with extinction. To identify sites of heightened risk, we examined sex ratio data and patterns of climate change over multiple decades for 64 nesting sites spread across the globe. Over the last 62 years the mean change in air temperature was 0.85°C per century (SD = 0.65°C, range = -0.53 to +2.5°C, n = 64 nesting sites). Temperatures increased at 40 of the 64 study sites. Female-skewed hatchling or juvenile sex ratios occurred at 57 of the 64 sites, with skews >90% female at 17 sites. We did not uncover a relationship between the extent of warming and sex ratio (r62 = -0.03, p = .802, n = 64 nesting sites). Hence, our results suggest that female-hatchling sex ratio skews are not simply a consequence of recent warming but have likely persisted at some sites for many decades. So other factors aside from recent warming must drive these variations in sex ratios across nesting sites, such as variations in nesting behaviour (e.g. nest depth), substrate (e.g. sand albedo), shading available and rainfall patterns. While overall across sites recent warming is not linked to hatchling sex ratio, at some sites there is both is a high female skew and high warming, such as Raine Island (Australia; 99% female green turtles; 1.27°C warming per century), nesting beaches in Cyprus (97.1% female green turtles; 1.68°C warming per century) and in the Dutch Caribbean (St Eustatius; 91.5% female leatherback turtles; 1.15°C warming per century). These may be among the first sites where management intervention is needed to increase male production. Continued monitoring of sand temperatures and sex ratios are recommended to help identify when high incubation temperatures threaten population viability.

Asymmetrical sex reversal: Does the type of heterogamety predict propensity for sex reversal?

Sex reversal, a mismatch between phenotypic and genetic sex, can be induced by chemical and thermal insults in ectotherms. Therefore, climate change and environmental pollution may increase sex-reversal frequency in wild populations, with wide-ranging implications for sex ratios, population dynamics, and the evolution of sex determination. We propose that reconsidering the half-century old theory "Witschi's rule" should facilitate understanding the differences between species in sex-reversal propensity and thereby predicting their vulnerability to anthropogenic environmental change. The idea is that sex reversal should be asymmetrical: more likely to occur in the homogametic sex, assuming that sex-reversed heterogametic individuals would produce new genotypes with reduced fitness. A review of the existing evidence shows that while sex reversal can be induced in both homogametic and heterogametic individuals, the latter seem to require stronger stimuli in several cases. We provide guidelines for future studies on sex reversal to facilitate data comparability and reliability.

Impact of Wendler glottoplasty on acoustic measures and quality of voice in transgender women: a systematic review and meta-analysis.

PURPOSE: Since new evidence regarding the impact of Wendler glottoplasty (WG) on the voice in transgender women became available in the literature in recent years, we aimed to perform an updated systematic review and meta-analysis to determine the actual safety and efficacy of WG in the process of vocal feminization. METHODS: PubMed, Embase, and Cochrane were searched for English-language articles published until July 4, 2023. Studies were found eligible if they evaluated the impact of WG on the acoustic-aerodynamic measures and quality of voice in transgender women. RESULTS: Twenty-three studies were identified. After exclusion of three studies due to incomplete data, 20 studies including 656 patients were included in the meta-analysis. After WG, there was a significant increase of fundamental frequency, speaking fundamental frequency, and lower limit of the frequency range (p < 0.001). Concurrently, a significant reduction of frequency range and maximum phonation time was observed (p < 0.001). No significant differences were found between the pre- and postoperative values regarding the Grade, Roughness, Breathiness, Asthenia, and Strain scale score (p = 0.339). The overall score in the Trans Woman Voice Questionnaire (TWVQ) significantly improved after WG (p < 0.001). CONCLUSIONS: WG is an effective voice feminization method in transgender women, associated with a high procedural success and low risk of postoperative complications. Significantly improved TWVQ score after surgery suggests its positive impact on the voice-related quality of life. Postoperative decrease of maximum phonation time and frequency range does not seem to significantly impact the effectiveness of voice production.

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients.

BACKGROUND: Facial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort. METHODS: A systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations. RESULTS: Initial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm. CONCLUSIONS: The core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

F-Chin/Feminizing the Chin: A Genioplasty Technique with Virtual Planning for Male-to-Female Transgender Patients.

The chin is an essential structure in facial harmony and an important gender marker. Advancing a receding chin is fundamental to improve the facial appearance, particularly in male-to-female transgender patients. However, in patients with microgenia and/or retrognathia, desiring a more feminine appearance, a chin advancement can result in a wider, square shape; an undesirable effect. Genioplasty is a versatile procedure used in facial feminization surgery that allows modifying the natural anatomy of the chin in all three spatial dimensions. The technique herein described proposes a simple genioplasty procedure for feminizing the chin (F-chin genioplasty) in transgender patients where anteroposterior advance is required. Virtual planning was used to establish the landmarks for an anteroposterior advancement with transverse reduction in the chin. A perpendicular line to the Frankfurt plane passing through the incisal edge of the upper central incisor was used to plan the anteroposterior movement, and two vertical lines on the outer wall of the nasal cavity  for the chin transverse measurement. The authors present three case reports with the F-chin genioplasty transgender technique with satisfactory results, ensuring a more feminine facial appearance.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Type I+ Forehead in Facial Feminization Surgery.

BACKGROUND: Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft. METHODS: Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques. RESULTS: In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002). CONCLUSIONS: The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessing Preferences of Facial Appearance in Transgender and Gender Nonbinary Patients.

BACKGROUND: We designed a survey to evaluate preferences of facial appearance in transgender male (TM), transgender female (TF) and gender nonbinary patients to better inform goals of facial gender affirming surgery (FGAS) in gender nonbinary patients. METHODS: TM/TF and nonbinary patients > 18 years old were identified via retrospective chart review and distributed an anonymized survey via email from October 3 to December 31, 2022. To assess facial preferences, AI-generated and open-source portraits were edited to create five image sets with a range of features from masculine to feminine for the forehead, mandible/chin and hairline. Data were analyzed using Fisher's exact tests and ANOVA in R-Studio. RESULTS: Survey response rate was 32% (180 patients identified via chart review, 58 respondents; TM = 5, TF = 39, nonbinary = 14). TM and TF patients as well as TF and nonbinary patients had significantly different preferences for all regions (p < 0.005; all series), while TM and nonbinary patients did not (p => 0.05; all series). TF patients consistently selected 4s with neutral or more feminine features. TM and nonbinary patients, however, demonstrated no consistent preference for either male or female features but rather a range of responses spanning extremes of both masculine and feminine options. When stratified by sex assigned at birth, nonbinary patients consistently identified preferences opposite to their assigned gender. CONCLUSION: Gender nonbinary and TM patients appear to have uniquely individual preferences regarding facial appearance that do not fit into classically masculine or feminine patterns/phenotypes. As a result, we recommend individualized preoperative planning for FGAS to achieve the optimal result in these patient populations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Feminization Surgery of the Upper Face as the Crucial Factor in Gender Confirmation-Pearls and Pitfalls.

Background: Upper-face feminization is a frequently executed procedure in sexual reassignment surgery, owing to its ability to influence gender identity through adjustments to the hairline, forehead, and peri-orbital area. The procedure includes reducing the hairline, lifting the brows, shaving the orbital region, and applying specific techniques to reduce the frontal bone. This research aims to assess the outcomes, results, and potential complications associated with this surgery among transgender patients. Material and Method: Retrospective review of medical records of 20 patients who attended for facial feminization surgery of the upper face between June 2022 and June 2023, analyzing the previously performed procedures, complications and revision surgery outcomes, and first-time procedures. A literature review was performed for similar studies. Results: 20 patients were included in the study. Among the cohort treated elsewhere (n = 11), the primary complaint was insufficient browbone reduction and anterior frontal sinus table setback. They underwent poorly performed Type 1 reduction when full forehead reconstruction (Type 3/4) was indicated (n = 3), or no reduction was performed during hairline advancement (n = 4). Type 3 forehead reduction with orbital shaving and hairline advancement with simultaneous temporal browlift was most commonly performed in both revision and first-time surgical upper face feminization (n = 15) (75%). Type 1 osteoplasty was performed in four patients (10%), one Type 3 revision surgery was performed after insufficient Type 3 reduction, and one case of shock-induced alopecia was reported, treated with PRP/peptides and a FUE hair graft. Conclusions: The author's preferred technique, 'whole-in-one' upper face feminization by modified bi-coronal incision with frontal trichophytic hyper-beveled incision, provides sufficient insight into the frontal bone and orbital region, the desired forehead osteoplasty and the most efficient insight into the temporal area, enabling safe dissection between fasciae, ligamentous adhesion removal, and periosteal attachment, providing full soft and hard tissue feminization. Nevertheless, feminization procedures should be meticulously planned, and all concerning issues should be addressed during the first surgery in order to prevent revisions, complications, and patient dissatisfaction.

Esthetic Surgery of the Chin in Cis- and Transgender Patients-Application of T-Genioplasty vs. Single-Piece Segment Lateralization.

Background and Objectives: Correction of lower face asymmetry still remains challenging in maxillofacial surgery. This report describes techniques for the lateral transposition of the symphyseal segment to restore lower face symmetry while maintaining gender-related features in cis- and transgender patients. Materials and Methods: A retrospective review of medical records of 31 patients who attended for esthetic corrective surgery after orthodontic camouflage or orthognathic treatment, or during facial feminization of the lower face between June 2021 and June 2023 was performed. Result: All patients underwent lateralization genioplasty (with or without advancement or setback), either with or without narrowing T-osteotomy supplemented with necessary procedures in order to obtain proper facial balance and desired esthetical effects, such as bichectomy, liposuction, and face and neck lift. The mean asymmetry of the chin was 5.15 mm and was surgically corrected either by single segment lateralization or T-shape narrowing genioplasty depending on the gender and esthetical requirements. No complications were reported. Conclusions: Lateral shift genioplasty serves as a powerful tool in primary and secondary corrective surgery for lower face asymmetry that maintains gender-specific facial features. It may serve either as an additive to orthodontic camouflage or a way to correct previous orthognathic surgery pitfalls. The surgeon performing esthetic genioplasty associated with gender-specific expectations must be trained in facelift and facial liposculpting techniques in order to provide the best results and properly choose the right procedures for the right patients.

[Frontotemporal volumetry to rejuvenate and re-feminize the face]. / Volumétrie frontotemporale pour rajeunir et re-féminiser le visage.

The author became interested in facial volume in the 1990s, during the period when he oversaw the feminization of the facial skeleton to improve the social integration of male transsexual patients. At that time, it was skeletal surgery. Very quickly, these techniques were extended to genetic women who wanted a more feminine face. The study of facial aging allowed the author to define criteria for frontotemporal aging, particularly an evolution with age towards a frontotemporal masculinization. The volumetric frontotemporal correction has thus become an essential element of facial rejuvenation. The evolution then, naturally took place towards the concept of frontotemporal beauty.

Sacculina-Induced Morphological Feminization in the Grapsid Crab Pachygrapsus crassipes.

Rhizocephalan barnacles (Thecostraca: Cirripedia) are parasitic crustaceans that lack appendages, segmentation, and a digestive system in adults, while instead infiltrating their hosts with a nutrient-absorbing system of rootlets. Sacculinids, belonging to the Rhizocephala order, are known for their various parasitization-induced effects on their decapod hosts, such as parasitic castration, reduction in the growth of secondary sexual characteristics, feminization of male crabs, and alteration of host behavior. In this study, we conducted field surveys in Japan at Manazuru Town (Kanagawa) on the Pacific coast, and on Sado Island and Noto Peninsula on the Sea of Japan side, and found that sacculinid-parasite-ratios on the grapsid crab Pachygrapsus crassipes were particularly high on the Sea of Japan coast. Molecular phylogenetic analysis revealed that the Manazuru population forms a single clade with Sacculina yatsui, and both Sado and Noto populations form a single clade with S. confragosa. We further demonstrated that external morphologies of male P. crassipes parasitized by sacculinids were changed to female phenotypes. This host-parasite interaction will be a useful model for understanding molecular mechanisms underlying rhizocephalan-driven morphological and behavioral feminization and castration.

Gender inequity in the medical profession: the women doctors in Spain (WOMEDS) study.

BACKGROUND: The long-standing underrepresentation of women in leadership positions in medicine is well-known, but poorly documented globally. There is some evidence of the gender gap in academia, medical society leadership, or specific problems in some specialties. However, there are no investigations analyzing all medical specialties together and reporting the glass ceiling from a 360º perspective that includes positions in academia, research, professional organizations, and clinical activity. Additionally, the majority of studies have a US perspective, and we wonder if the perspective of a European country might be different. The WOmen in MEDicine in Spain (WOMEDS) project ( https://womeds.es ) aims to describe and characterize, in a systematic and detailed way, the gender bias in the medical profession in Spain in order to monitor its evolution over time and contribute to prioritizing gender policies. METHODS: We retrieved data for the calendar years 2019-2021 from several sources and selected surveys. We built four groups of indicators to describe leadership positions in the medical profession: (i) leadership in healthcare according to specialty and region; (ii) leadership in scientific and professional bodies; (iii) academic career; and (iv) leadership in clinical research activity. As a summary measure, we reported the women ratios, calculated as the percentage of women in specific top positions divided by the percentage of women in the relevant population. RESULTS: We found gender inequity in leadership positions in all four settings. During the observed period, only 27.6% of the heads of departments in hospitals were women compared to 61.1% of women in medical staff. Ten of the 46 medical societies grouped in the Spanish Federation of Medical Societies (FACME) (21.7%) had a women president at some point during the study period, and only 4 annual congresses had ratios of women speakers higher than 1. Women were over-represented in the lower positions and underrepresented in the top academic ones. Only 26% and 27%, respectively, of the heads of departments and deans were women. The applications for public funding for research projects are led by women only in 45% of the cases, and the budget granted to women in public calls was 24.3% lower than that of men. CONCLUSION: In all the areas analyzed, the leadership positions are still mostly occupied by men despite the feminization of medicine in Spain. The severe gender inequity found calls for urgent interventions within a defined time horizon. Such measures must concern all levels, from national or regional regulation to changes in organizational culture or incentives in specific organizations.

RESUMEN EN ESPAÑOL: ANTECEDENTES: La prolongada infrarrepresentación de las mujeres en los puestos de liderazgo en medicina es bien conocida, pero está poco documentada de forma global. Hay evidencia sobre la brecha de género en la universidad, en el liderazgo en sociedades médicas o en determinadas especialidades. Sin embargo, no hay investigaciones que analicen el techo de cristal de cada una de las especialidades médicas desde una perspectiva 360º que incluya el liderazgo en la universidad, en la investigación con fondos públicos, en la representación en sociedades científicas y colegios profesionales y en la actividad clínica. Además, la mayoría de los estudios tienen una perspectiva estadounidense y nos preguntamos si la perspectiva de un país europeo podría ser diferente. El proyecto Mujeres en Medicina en España (WOMEDS) ( https://womeds.es ) tiene como objetivo describir y caracterizar de forma sistemática y detallada sesgo de género en la profesión médica en España, para monitorizar su evolución en el tiempo y contribuir a priorizar las políticas de género. MéTODOS: Construimos cuatro grupos de indicadores sobre liderazgo de mujeres médicos: (i) en la asistencia sanitaria; (ii) en las organizaciones científicas y profesionales; (iii) carrera académica, y; and (iv) l en la investigación basándonos en datos públicos y resultados de encuestas propias s referidas a los años 2019­2021. Como medida de análisis, calculamos los ratios de mujeres, definidos como el porcentaje de mujeres en puestos altos específicos dividido por el porcentaje de mujeres en la población relevante. RESULTADOS: Encontramos un sesgo de género en los cuatro ámbitos. Durante el periodo observado, solo el 27.6% de los jefes de servicio de los hospitales eran mujeres, frente al 61.1% de mujeres en la plantilla. Diez de las 46 sociedades médicas agrupadas en la Federación de Asociaciones Científico Médicas Españolas (FACME) (21.7%) tuvieron una mujer como presidente en algún momento del periodo de estudio y sólo 4 congresos anuales tenían ratios de mujeres ponentes superiores a 1. Las mujeres estaban sobrerepresentadas en los cargos inferiores e infrarrepresentadas en los cargos académicos superiores. Sólo el 26% y el 27%, respectivamente, de los jefes de departamento y decanos eran mujeres. La solicitud de proyectos de investigación con financiación pública fue liderada por mujeres en un 45% de los casos y la financiación media de los proyectos concedidos a las mujeres fue un 24.3% inferior a la de los hombres. CONCLUSIóN: En todos los ámbitos analizados, las posiciones de liderazgo siguen siendo mayoritariamente ocupada por varones a pesar de la feminización de la medicina. Para cambiar esto, será necesario tomar medidas, tanto regulatorias -a nivel nacional y nacional regional como promover cambios en la cultura organizativa o en los incentivos en organizaciones concretas.

Chest Feminization in Transwomen with Subfascial Breast Augmentation-Our Technique and Results.

BACKGROUND: The increasing population of this minority community is approaching plastic surgeons more frequently to achieve their dream of becoming a phenotypic female, the breast being the single sure identity. After undergoing the bottom surgery (SRS) which is essential for them to gain entry into the transgender community, very few take up hormone therapy; the rest approach plastic surgeons for chest feminization which includes breast augmentation. METHODS: A total of 177 transgenders underwent subfascial breast augmentation between 2014 and 2023. They were followed up for 10 years. Their demographics were documented. Operative details and postoperative complications were analyzed. Patient-related outcome measures were performed for size, appearance and cleavage. RESULTS: A well-performed surgery in our cohort had a good aesthetic outcome even after many years. Only three patients were dissatisfied with the size; revision surgeries of 12 patients done elsewhere had many complications like wound dehiscence and exposure, scar hypertrophy, low placed axillary scars, capsular contracture, asymmetry, and nonspecific pain. All of them had submuscular placement. CONCLUSIONS: The subfascial placement of implants in transwomen had good aesthetic outcomes with fewer complications and good acceptance. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk Factors for Postsurgical Infections in Facial Feminization Surgery.

BACKGROUND: Facial feminization surgical procedures are involving several surgical disciplines in multiple surgical sites and therefore may carry the risk of developing infections. Data on the development of postsurgical infection (PSI) and contributing factors in male-to-female transgender people (transwomen) undergoing facial feminization surgery are scarce. The aim of this study was to investigate the contributing factors to develop PSIs in facial feminization surgical procedures. METHODS: Data from the medical records of 40 transwomen who underwent facial feminization surgeries in our institution between 2019 and 2021 were analyzed. The independent variables included demographic parameters (weight, body mass index, medical comorbidities and age), details of the surgical procedure (type, duration and whether another procedure had been performed concomitantly), type, dosage and route of administration of postoperative antibiotics and steroids, length of hospitalization and follow-up duration. Postsurgical infection was designated a dependent variable. RESULTS: Five out of 40 patients (12.5%) developed PSI. The surgery of those with PSIs involved more sites, and the duration of nasal tamponade was more than four times longer than for patients who did not develop a PSI. CONCLUSIONS: The current study revealed higher postsurgical infections rates after lengthy surgeries or when it involves several surgical facial feminization procedures. Multicenter clinical trial on a big cohort may enable better evidence-based results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facial Gender-Affirming Surgery: Frontal Bossing Surgical Techniques, Outcomes and Safety.

BACKGROUND: Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250-261, 2011). This article describes the author's three main surgical techniques used in forehead feminization and reports on the results. METHODS: The type of surgery performed is based on the patient's anatomy. Type one FGAS consists of burring the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes burring and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing. RESULTS: We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout's methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome. CONCLUSIONS: FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Female participation or "feminization" of medicine.

More and more women chose medicine as their profession. Female students and graduates outnumber their male colleagues in Austria and the EU. However, the career paths of men and women differ after a certain point, and more and more female talent is lost along the career stages. Women hold only 30% of professor positions at state medical universities in Austria and only 11.9% of all chief physicians are female. Motherhood and related absence is the main career obstacle, but gender bias and missing role models are also factors hindering women to thrive. Improved working conditions would be beneficial for all members of the medical profession. Future generations (Generation Y, Generation Z) will likely expedite changes toward a better work-life balance and claim the right to find fulfillment besides work. Compatibility of family and work and the chance to individualize career paths could be important factors for employers to find and bind their employees. Additionally, (gender) diverse teams improve the group process and collective intelligence. Therefore, patient care and innovation can only benefit from a diverse medical workforce.

Facial Feminization Surgery: Anatomical Differences, Preoperative Planning, Techniques, and Ethical Considerations.

Facial Feminization Surgery (FFS) is a transformative surgical approach aimed at aligning the facial features of transgender women with their gender identity. Through a systematic analysis, this paper explores the clinical differences between male and female facial skeletons along with the craniofacial techniques employed in FFS for each region. The preoperative planning stage is highlighted, emphasizing the importance of virtual planning and AI morphing as valuable tools to be used to achieve surgical precision. Consideration is given to special circumstances, such as procedure sequencing for older patients and silicone removal. Clinical outcomes, through patient-reported outcome measures and AI-based gender-typing assessments, showcase the efficacy of FFS in achieving proper gender recognition and alleviating gender dysphoria. This comprehensive review not only offers valuable insights into the current state of knowledge regarding FFS but also emphasizes the potential of artificial intelligence in outcome evaluation and surgical planning to further advance patient care and satisfaction with FFS.

[Eye feminization]. / Féminisation du regard.

Eye feminization embraces surgical and non-surgical aesthetic procedures used in order to feminize upper third of the face. Eye feminization is indicated for transwomen during facial gender affirming surgery, and also for aging women. During aging, volume of facial osseous and soft tissues is decreasing, the orbit is squeletonizing, with skin sagging, evolving in a more masculine appearance of the orbital area. Upper eye area analyze (forehead, temple, eyebrow, eyelid, external canthus) as lower eye area analyze (zygoma, dark circle, palpebral bags, eyelid skin) must be assessed in preferential order in order to maximize good post-therapeutic results. Procedures include bony surgery (frontoplasty, orbitoplasty), browlift, external canthoplasty, fat grafting, and also classic eyelid surgery or aesthetic medicine injections.

[Facial feminization, history, evolution of objectives]. / Féminisation faciale, historique, évolution des objectifs.

The author's experience dates from 1990, during the period when he was in charge of the feminization of the facial skeleton in order to improve the social integration of male transsexual patients. Very quickly, these techniques were extended to genetic women who wanted a more feminine face. This facial skeletal surgery was then supplemented with soft tissue surgery. This skeletal and volumetric surgery has become an important contribution in the search of facial rejuvenation and beauty.