Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve?

BACKGROUND: Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online. METHODS: Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions. RESULTS: One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001). CONCLUSIONS: Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7 mo versus 13.2±31.1 mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1 h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7 d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

Tranexamic Acid in Facial Feminization Surgery: Quantifying a High-risk Setting With Exogenous Estrogen Supplementation.

Tranexamic acid (TXA) has been increasingly utilized in orthognathic surgery, aesthetic surgery, and craniofacial surgery. However, the risk of increasing venous thromboembolic events (VTE) must be carefully considered as TXA is a prothrombotic agent. Our study aimed to investigate the safety of TXA in the setting of facial feminization surgery. These patients are at an elevated risk for VTE at baseline given their uniform history of exogenous estrogen supplementation. A retrospective review of all patients that underwent facial feminization surgery at our medical center between December 2015 and September of 2022 was performed. Demographic information, procedure type, Caprini scores, hematoma rate, VTE rate, estimated blood loss, and operative time were all studied. Unpaired t tests were used to compare patients that received TXA and those who did not. In total, there were 79 surgeries performed during our study period. There were 33 surgeries (41.77%) that used TXA intraoperatively. Ten patients (12.65%) received anticoagulation postoperatively, 5 of whom received TXA intraoperatively. Of the 33 patients who received TXA, 30 patients remained on estrogen therapy. There was no statistically significant difference in VTE rates in patients who received TXA (n=33, 41.77%) and those who did not (n=46, 58.23%). Bleeding events, Caprini scores, estimated blood loss, and operative time were also not found to be significantly different between the 2 cohorts. The authors found no significant increase in VTE in facial feminization patients undergoing estrogen supplementation when intraoperative TXA was utilized. This is the first known report investigating the safety of TXA in this higher risk patient population.

Technique for Cephalometric Analysis of the Craniofacial Skeleton Following Facial Feminization Surgery.

Facial feminization surgery (FFS) is characterized by a series of relatively diverse procedures aimed at aligning skeletal and soft tissue facial appearance with one's experienced feminine gender. Although there are several well-described outcomes from surgical techniques, there is no standardized methodology to provide reliable analyses of postoperative FFS outcomes. This paper describes the first reliable and reproducible technique to accurately and consistently measure post-FFS changes to guide surgical planning to optimize patient outcomes.

A Nationwide Analysis on Major Upper Extremity Amputations and Replantations.

BACKGROUND: The loss of an upper extremity is a severely disabling condition made medically challenging by the limited window for replantation. This study aims to investigate the burden of traumatic major upper extremity amputations in the United States and uncover possibilities for improvements in treatment. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample was screened for International Classification of Diseases-9/10 diagnosis/procedure codes for traumatic and nontraumatic major upper extremity amputations and replantations within the years 2008 to 2017. The resulting pool of cases was analyzed for multiple variables, including level of injury, patient demographics, hospital type and location, length of stay, costs, comorbidities, and complications. RESULTS: A total of 15 155 major upper extremity amputations were recorded, of which 15.20% (n = 2305) were traumatic amputations-almost half of them related to the upper arm (49.6%; P = .0002). The great majority of replantations, however, was conducted at the lower arm level (87.4%; P < .0001), with an overall replantation rate of 22.3%. Nontraumatic amputations were overall associated with significantly higher burden of comorbidities relative to traumatic amputations except for long-term alcohol use (P < .0001). Both, amputations and replantations, were predominantly treated in large urban teaching hospitals, and were significantly more likely to occur in white men. The Southern region of the United States was handling the highest proportion of amputations in the United States, but had the lowest likelihood of replantation. CONCLUSION: This study provides an overview of the national trends in major traumatic upper extremity amputations and replantations, revealing potential health care shortcomings.

Quantifying Facial Feminization Surgery's Impact: Focus on Patient Facial Satisfaction.

Background: Facial feminization surgery (FFS) has been associated with improving gender dysphoria in transgender patients. This study aimed to quantify the impact of surgery on patient facial satisfaction, using the FACE-Q and a quality-of-life (QoL) survey. Methods: Transgender female patients were recruited to complete the FACE-Q and the World Health Organization's QoL Scale-Short Form (WHOQOL-BREF) if they were planning to or had undergone FFS at our institution. FACE-Q modules completed included "Satisfaction with Facial Appearance Overall," individual facial attributes (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), and the WHOQOL-BREF, which assesses patient QoL through four domains (physical, psychological, social relations, and environment). Both matched and unmatched analyses of preoperative versus postoperative cohorts were performed. Results: Overall, 48 patients participated in our study and completed 31 FACE-Q surveys preoperatively and 37 postoperatively. On average, patients were 37.2 ± 12.5 years old. FACE-Q scores increased significantly for all facial attributes and for Satisfaction with Facial Appearance Overall between cohorts (P < 0.05). The facial attribute with the greatest increase in satisfaction was the jawline, followed by the nose. The WHOQOL-BREF's psychological and physical domains both improved significantly (P < 0.05). Wait time for surgery of less than 6 months (b = 22.42, P = 0.02) was associated with higher overall facial satisfaction, whereas age at surgery (b = -1.04, P < 0.01) was associated with lower overall facial satisfaction. Conclusions: Transgender female patients experienced significant improvements in facial satisfaction and QoL after FFS. Undergoing surgery at a younger age and shorter wait times for surgery were associated with increased overall facial satisfaction.