gender? The frontonasal–orbital complex includes the forehead, supraorbital ridge, orbit, frontomalar region, temporal ridges, and frontonasal transition. These areas collectively represent the greatest determinant of facial gender. The positions of the eyebrows and periorbital soft tissues including the eyelids are dictated by these areas. In males, they are typically more pronounced with greater bone volume and prominence. The brow tends to sit lower and flatter, the eyes are typically more deeply set, and the bony prominences are more marked. The scalp and hairline are also different in males and this can be most evident because of the hairline itself, which differs in shape and position. The ears tend to be larger in males than in females, but this is not consistently the case. The chin is more prominent in males due to greater volume in the mandible. Other differences include a longer upper lip in males, larger noses, squarer jaws, and facial hair growth.1
In general terms, the main focus of facial feminization surgery is to modify, reshape, and reduce bony structures such as the brow, periorbital area, nose, and jawline to soften masculine facial features. However, management of the cheeks is different. Fixed porous polyethylene implants may be used for augmentation of the cheeks as part of facial feminization surgery. This is because of gender differences in cheek fullness between males and females. Although males have greater malar bone volume, resulting in well-defined cheeks, females have a greater amount of fat in their cheeks and midface which gives them a more rounded appearance. Fixed porous polyethylene implants can be inserted using an intraoral approach which avoids any external scars. The results are generally stable over time. Alternatively, fat grafting may be performed and this should be deposited in a supraperiosteal plane. Injected fat does tend to partially resorb after injection so results may be less well maintained and repeat procedures are often required. While useful for some aspects, fat grafting does not represent the mainstay of treatment for facial feminization. There are differences between the male and female nose, with the male nose being larger and broader due to an increased volume of bone and cartilage. Therefore, standard rhinoplasty reduction techniques may successfully be applied.1–3
3. Deschamps-Braly JC. Approach to feminization surgery and facial masculinization surgery: aesthetic goals and principles of management. J Craniofac Surg 2019;30(5):1352–1358 The thyroid cartilage is among the most prominent landmarks of male gender and is therefore something that is addressed during surgery when patients are transferring from male to female gender and vice versa. The primary function of the larynx is to protect the lower respiratory tract from aspirating food into the trachea while breathing. It also contains the vocal cords and functions as a voice box for phonation. 1130 Part VII ■ Aesthetic Surgery The thyroid cartilage is part of the laryngeal skeleton, which includes nine cartilages. These are the single thyroid, cricoid, and epiglottal cartilages, as well as the paired arytenoid, corniculate, and cuneiform cartilages. The thyroid cartilage serves to protect the anterior part of the larynx and spans it vertically from top to bottom. It is the largest of all laryngeal cartilages and has the form of a half open book, with the back facing the front. Where the two halves meet in the middle, they form the protrusion which is best known as the “Adam’s apple.” This most prominent portion of the thyroid cartilage can be modified during female feminization surgery. When such surgery is performed, the incision should be placed in the cervicomental fold in order to conceal the scar and prevent adhesions between the thyroid cartilage and the overlying soft tissues. This incision should be restricted to no more than 2 cm in length. The cartilage may be reduced with a combination of burring, rongeuring, or blade resection, depending on surgeon preference. Needless to say, sculpting close to the vocal cords must be avoided. When the reverse procedure is being performed, i.e., from female to male, the Adam’s apple can be recreated with cartilage grafts.1 The cricoid cartilage is also known as the cricoid ring or signet ring, as it is the only cartilage to encircle the trachea completely. It sits in the inferior part of the larynx, at the level of C6 vertebra. The epiglottis is an elastic cartilaginous leaf-shaped flap covering the opening of the larynx. It is attached to the internal surface of the thyroid cartilage and projects over the pharynx, allowing the passage of air into the larynx, trachea, and lungs. As the hyoid bone rises, it draws the larynx upward during swallowing to allow food or drink into the esophagus, and to prevent food from entering the trachea. Arytenoid cartilages are a pair of small, hard but flexible pyramid-shaped cartilages that sit over the posterior portion of the cricoid cartilage. The vocal cords attach to them. The corniculate cartilages are small elastic cone-shaped cartilages that articulate with the apices of the arytenoid cartilages. The cuneiform cartilages are two elongated fibrous pieces of yellow cartilage that support the vocal folds and the lateral aspects of the epiglottis. None of these cartilages should be modified during facial feminization procedures, as this risks unacceptable and unnecessary risk for vocal cord damage and respiratory compromise.
Prior to undergoing facial feminization surgery, CT imaging including 3D reconstructions should ideally be obtained to assess anatomic features that can be addressed. In cases of financial restrictions, a panorex and lateral cephalogram will often provide adequate information, but remains a second choice. MRI scans are helpful to visualize the soft tissues of the head and neck region, but are more useful in oncologic and reconstructive cases rather than in the gender reaffirmation setting. Plain radiographic films generally add little to help planning treatment for facial feminization procedures.1,2
Forehead revision for transfemale patients modifies the frontonasal–orbital region to soften and feminize the patient’s expression. The main goal is to reposition and remodel the forehead complex to soften frontal bossing, and to reduce the supraorbital rims, frontomalar buttresses, and temporal ridges. Forehead reshaping is usually performed with an open coronal approach rather than an endoscopic approach and takes two forms: anterior frontal wall sinus repositioning or frontal bone burring. The key factor which dictates which one of these will be used is the thickness of the outer table of the frontal bone. If the thickness of the anterior table is £3 mm, a frontal bone setback will be required rather than burring. In contrast, where there is more bone stock than this, burring alone may be acceptable. In patients with a high hairline, simultaneous correction can be performed by placing the incision at the hairline and removing some excess skin anterior to this instead of using a coronal incision within the hairline. Brow reshaping may also be combined with hair transplantation in order to achieve upper third feminization in a single stage.1,2
There are gender differences in the shape of the anterior hairline. Male patients tend to have an “M”-shaped hairline with this placed more anteriorly toward the midline and with more recession laterally in the temples (i.e., male pattern baldness). This may be exaggerated by androgenic alopecia. In contrast, females tend to have more rounded hairlines with implantation higher in the midline. Attention to the hairline can make a significant difference to a transmale or transfemale patient and this can be achieved with carefully placed hair transplantation. The primary goal for transfemale is to address the recessed corners of the hairline; the central section can also be addressed if hair density is also an issue. Two approaches include follicular unit strip and follicular unit extraction. In the former, follicles are obtained from a strip of scalp removed surgically, whereas in the latter, individual follicles are obtained nonsurgically. Any hair transplantation should ideally be performed after androgenic alopecia stabilizes.1,2
Facial masculinization surgery remains less common than facial feminization surgery and the procedures typically work in reverse to those used to feminize a face. To create a more masculine appearance to the brow, augmentation of the bony architecture is required. A coronal approach is undertaken to gain access to the brow area and methyl methacrylate can be applied directly to the forehead to build up the shape and contour. It is held in place temporarily with locking screws on each side and then contoured during the polymerization process. Management of the nose uses standard rhinoplasty and reconstructive techniques to alter the shape and size of the nose. Cartilage grafts are typically required to achieve this, and they may be harvested from the septum, pinna, or ribs. The male chin is more prominent than the female chin in three dimensions: vertical height, width, and projection. Therefore, the most common way of addressing these three components is to perform segmental chin osteotomies using a sliding genioplasty. This is preferable to using implants or bone grafts where possible. In some cases, it is necessary to fill dead space created with hydroxyapatite granules to provide stability until subperiosteal calcification occurs. One of the key elements of a masculine neck is the presence of a visible and mobile “Adam’s apple.” To create this, a neck access incision is placed behind the submental crease and dissection is continued inferiorly beyond the thyroid cartilage. At this point, a deeper vertical incision is made between the strap muscles. A small piece of rib cartilage is used for the reconstruction and is placed over the thyroid cartilage and secured with permanent sutures. The cartilage is shaped into a narrow oblique pyramid with the base roughly three quarters of the width of the native thyroid cartilage. Fibula is commonly used to reconstruct the mandible following tumor resection, but not for gender reassignment.1,2
The World Professional Association for Transgender Health (WPATH) promotes a multidisciplinary approach for the care of transgender patients.1 According to the WPATH, transgender patients should be under the care of primary care physicians, mental health services, endocrinologists, and surgical specialists. The WPATH have set guidelines for both top (breast) and bottom (genital) surgery and these differ slightly. These are as follows for top surgery: • A persistent, well-documented history of gender dysphoria • The capacity to make a fully informed decision and to give consent • Age of majority in a given country (not a specific age of 25) • If a prospective candidate for top surgery has a significant medical or mental health concern, it must be well controlled. • At least one letter from a qualified mental health professional recommending the patient to undergo the procedure is required. There is no requirement for the patient to be in a stable relationship or working. The guidelines for bottom (genital) surgery are as follows: • Two letters from the patient’s mental health therapists recommending the patient for surgery. • The letters must include the duration of the patient–provider relationship, documentation of any associated diagnosis in addition to gender dysphoria, duration of time the patient has been living in their identified gender, a statement that the patient is mentally stable to undergo surgery, and a statement that the therapist is familiar with the WPATH Standards of Care (SOC) guidelines and that they recommend the patient to undergo surgery for transition.
The first step in reconstructing the breasts in a patient undergoing gender reassignment from male to female is to begin hormone therapy. There are obviously a number of more general systemic benefits for patients undergoing this treatment, but specifically for the breasts, it promotes mammogenesis, resulting in a softly pointed breast as seen in young girls or the small conical form found in young adolescents. Hormonal therapy can commonly provide an additional breast volume between half and one bra cup size of breast growth. Transwomen should undergo feminizing hormone therapy for a minimum of 1 year prior to breast augmentation surgery to maximize breast growth and obtain an optimal aesthetic result. Once they have reached this stage, their options will include prosthetic augmentation or fat transfer to add additional volume. They may require an adjunctive mastopexy to help reshape the breasts and address the nipple–areola complex (NAC) position, which may be too inferiorly or laterally placed. Breast expanders may be considered, to progressively expand tissues, although most patients tend to go straight to permanent implants. Fat grafting can be a good alternative to implants in patients with some breast volume from hormone treatment. It can provide a small to moderate augmentation of the breast, but patients need to be aware that variable amounts of the injected fat will be resorbed; so, they may require multiple grafting sessions to achieve the desired volume. Of course, fat grafting can also be used as an adjunct to augmentation to decrease implant visibility and help narrow a wide cleavage. Mastopexy can help correct the males NAC positioning and may help increase NAC diameter to some degree. It may be combined with fat grafting or implants, or may be performed as an isolated procedure in patients with higher body mass index.1
Of all the surgical procedures performed in patients changing gender, breast surgery can be high on the priority list. As such, it can significantly facilitate their ability to live in a gender role congruent with their preferred gender identity. Prosthetic breast implants are therefore commonly desired by patients going from male to female gender to provide additional volume and feminize the chest. Males tend to have wider chests with stronger pectoral fascia, more developed pectoralis muscles, and smaller NACs. It is key to ensure the NAC should always overlie the implant centrally, as an overly medial implant position can result in divergent nipple position. Unfortunately, even with large-volume wide implants, placed above pectoralis major, it is often not possible to avoid a wide cleavage between breasts, and the temptation to move them more medially to address this must be tempered. Approaches to implant placement in this setting include the usual axillary, periareolar, and inframammary fold locations. The latter is usually preferred because it allows good access, with discrete scars, while the axillary approach limits the user to saline implants and the periareolar approach is limited by the small incision permitted. The implant should be placed lower than the preoperative inframammary fold because the inferior areolar margin and inframammary fold will expand after augmentation, much the same as when a large implant is placed in a slim female patient who has little breast tissue. This results in skin and subcutaneous tissue being recruited from the chest below the breasts. As with standard breast augmentation approaches, implants may be placed subglandular or submuscularly and decisions about placement will need to be made on an individualized patient basis. A subglandular placement is typically easier to perform, less painful, and has good aesthetic results in patients with more subcutaneous and glandular tissue. In contrast, subpectoral placement (or dual plane) provides more soft-tissue cover for implants and is necessary in thin patients.1–3
Management of the breasts in female-to-male gender reassignment involves techniques similar to those used for gynecomastia in males and breast cancer treatment in females. The technique should be determined primarily by the amount of excess skin and skin elasticity rather than breast volume. The size and location of the NAC should also be considered. The most commonly performed procedure for transmale breast surgery is the double-incision mastectomy with free nipple grafts, and this would be indicated in this patient due to the characteristics of their breasts. The surface markings for this procedure are shown in Fig. 126.1. The double-incision mastectomy with free nipple grafts is a versatile technique, as it allows skin reduction, volume reduction, and resizing and repositioning of the NAC. It also carries the lowest complication rate of all procedures. However, it does leave a long horizontal scar that passes close to the midline medially along the lower border of pectoralis major laterally. It also affects the appearance and sensitivity to the NAC and patients must understand this. It is optimal for cases such as this one where the breasts are large and ptotic with much skin excess. The semicircular incision mastectomy is more like a gynecomastia technique and is ideal for patients with small breasts, but care must be taken to ensure sufficient glandular tissue is left under the NAC to prevent nipple depression. The scar is well-concealed, being confined to the edge of the lower half of the areola. However, this operation is technically challenging due to the small operative window. The transareolar approach is good for patients with small breasts and large prominent nipples, as it allows for immediate subtotal resection of the upper aspect of the nipple. It is the least commonly used technique, and carries the highest risk for complications. The scar traverses the areola horizontally and passes around the upper aspect of the nipple with optional extension medially and laterally. This technique is also technically challenging due to the small operative window. The concentric circular approach is recommended in patients with medium-size breasts with a good skin envelope or 1134 Part VII ■ Aesthetic Surgery smaller breasts with poor skin elasticity. The concentric incision can be designed as a circle or an ellipse allowing for a precise amount of de-epithelialization to be performed (Fig. 126.2). Access is made to the glandular tissue through the inferior aspect of the lateral incision. Because there is a dermal pedicle for the NAC, there is no need to leave excess glandular tissue beneath it. A permanent purse-string suture is used to set the desired areolar diameter. The extended concentric approach involves triangular excision of skin and subcutaneous tissue medially and laterally. It can be undertaken with free nipple grafts to facilitate the resizing and repositioning of the NAC. It is a technique indicated for patients with larger breasts, e.g., C cup or above and with more significant ptosis.1–3 Fig. 126.1 Double-incision mastectomy with free nipple grafts showing surgical markings/incisions and final scar placement. Preoperative (left) and postoperative (right).
Gender reassignment surgery is normally the final surgical procedure in the surgical pathway for transgender patients. Prior to gender reassignment surgery, patients must complete WPATH SOC documentation which includes two letters from the patient’s mental health therapists recommending the patient for surgery. The letters must include the duration of the patient–provider relationship, documentation of any associated diagnosis in addition to gender dysphoria, duration of time the patient has been living in their identified gender, a statement that the patient is mentally stable to undergo surgery, and a statement that the therapist is familiar with the WPATH SOC guidelines and that they recommend the patient to undergo surgery for transition. To reach the stage described earlier, patients need to have demonstrated their commitment and ability to live in their identified gender. Part of being able to do this effectively involves surgery to target the other areas which would otherwise give away their previous gender. This includes changes to the face and neck as well as the breasts and chest wall.1
to undergo single-stage surgery to create a neophallus and scrotum, and be able to micturate while standing. Traditionally, genital or bottom surgery for transmen was relatively uncommon, as compared to genital or bottom surgery for transwomen and top or breast surgery for transmen, but this is probably becoming more common for a number of reasons including insurance coverage and patient awareness of the options available. Furthermore, the benefits of a metoidioplasty approach are now well documented and recognized. In general terms, the main goals of female-to-male bottom surgery are threefold: 1. To make male appearing external genitalia 2. To facilitate standing micturition 3. To enable sexual activity ideally allowing both penetrative sexual intercourse and orgasm A metoidioplasty is a surgical procedure that uses the hormonally enlarged clitoris to reconstruct a neophallus. The main advantages are the creation of an acceptable size and shape neophallus, while preserving erogenous sensation. This can also allow for standing micturition and the incorporation of other procedures such as vaginectomy, scrotoplasty, testicular implant placement, and hysterectomy with oophorectomy all within a single stage. There are essentially three types of metoidioplasty performed: a simple variant, a ring variant, and the Belgrade variant. The Belgrade variant is based on the repair of the most severe forms of hypospadias and incorporates an advanced urethroplasty to achieve standing micturition for all patients. It also allows refashioning of the labia to create a scrotum which can receive implants at the same time. Belgrade metoidioplasty begins with removal of vaginal tissue except a small part around the urethral opening, which is used for urethral lengthening. The clitoris is degloved and lengthened by release of the suspensory ligaments and the urethral plate. Buccal grafts are used to line the lengthened urethra which are covered with labial flaps. The labia are also used to resurface the neophallus and create the new scrotum. The other metoidioplasty techniques are more limited in what they achieve. A simple metoidioplasty also involves degloving and releasing the clitoris. However, the native urethral opening is left in place without urethral lengthening. Therefore, patients are unable to micturate while standing. One benefit of this technique is that the vagina may be left in situ if desired for penetrative intercourse and reproductive function can be maintained. A ring metoidioplasty involves additional dissection of the clitoris and elevation of a dorsal urethral ring flap from the vaginal introitus, which is used to extend the urethral plate. Some, but not all, patients will be able to micturate while standing following this procedure. The complication rate is higher than for the Belgrade approach. In contrast to metoidioplasty, phalloplasty is far more involved and has multiple stages to it. The main benefit is that penetrative intercourse may be possible once all stages are complete because the phallus size is more in keeping with a genetic male and rigidity may be achieved.1,2 1136 Part VII ■ Aesthetic Surgery
Phalloplasty is a technique used to create a functional phallus while achieving the ability to micturate while standing and perform penetrative sex. It is usually the preferred approach for patients wishing to live fully as a male, although it is more involved and multifaceted than metoidioplasty. A range of different donor sites have been used for phalloplasty, including the anterolateral thigh, the latissimus dorsi, and the fibula. However, the radial forearm free flap (RFFF) remains the most frequently used surgical technique. It may be performed with a prelaminated urethra or using a tube within a tube technique.1,2 The advantages of the radial forearm are that it provides thin, malleable, and sensate tissue with a long vascular pedicle. It can also subsequently accept a penile prosthesis to provide erection potential. The downside is the visible donor site even where scarring is optimal and of course microsurgical skills are required. Anterolateral thigh flaps can be useful alternatives in thin patients as can latissimus dorsi flap variants and both donor sites have the advantage over the RFFF of direct closure being possible and scars better hidden in clothing. Unfortunately, many patients’ tissues at these donor sites will be too thick for these to work satisfactorily. The use of bone from either the radius or fibula has been used to provide rigidity to the neophallus; however, this is not popular due to high rates of bone resorption and donor-site morbidity. Instead, penile prostheses are normally used to provide stiffness.2,3
The main advantage of performing a phalloplasty over a metoidioplasty is that greater penile size and stiffness are achieved, so the patient is more likely to be able to perform penetrative sexual intercourse. They should also more closely represent the appearance of a genetic male when unclothed. The main downsides to a phalloplasty are that multiple procedures are required and that patients are at high risk of urinary complications including urethrocutaneous fistulas and urinary strictures. Phalloplasty involves multiple components including creation of the shaft, the urethra, scrotoplasty, glansplasty, vaginectomy, and testicular and erectile implants. It also incurs a distant donor site. Standing micturition should be possible, but this is also possible with some metoidioplasty techniques. The ability to reach orgasm will be highly dependent on the patient’s preoperative ability to do so. Furthermore, patients are commonly able to achieve this following metoidioplasty too. Erectile implants are not used for metoidioplasty but are normally required in phalloplasty patients to provide rigidity to the neophallus. Bone has been used as an alternative stiffener; however, integrating fibular and radial bone during phalloplasty has fallen out of favor due to high rates of bone resorption/erosion and donor-site morbidity.1–4
The use of penile and scrotal skin for creation of a neovagina remains the most commonly performed technique for transwomen undergoing genital (bottom) surgery. The advantages are that penile skin is robust, has a low tendency to contract, provides some sensibility inside the neovagina and where the penile shaft is hair free, and the neovagina will also be hairless. There is usually sufficient skin from the penis and scrotum to recreate the neofemale external genitalia including the internal vaginal vault and the external labia. The disadvantages include the risk of poor scarring, eventual shrinkage and contracture, a risk of insufficient vaginal cavity length, intravaginal hair growth in patients with penile hair growth, and the need for lubrication during intercourse. There will also be an ongoing need for regular dilation. The procedure begins with bilateral orchiectomy, and penile disassembly with dissection of the penile skin and glans, the urethra, corpus cavernosa, and the neurovascular bundle for the neoclitoris. The penile skin flap is used to create a tube, which is subsequently inverted and inset between the urethra, bladder, and rectum. Preservation of the subcutaneous tissue underlying the penile skin is essential for the formation of a long vascularized pedicle. A hole is made at the base of the pedicle, where the urethra and neoclitoris are passed through once the neovagina is inset. On the dorsal side of the skin tube flap, a superficial incision is made, leaving the subcutaneous layer intact; the urethral flap in then embedded along the tube and sutured in place. The distal end of the tube is closed prior to placement of the neovagina in the perineal space. The urethra is separated from the remaining dorsal tissue, and blood supply is maintained through preservation of the corpus spongiosum. Lining of the anterior neovagina is achieved with spatulation of the urethral flap. The clitoris is created from the remaining glans tissue. The remaining penile and scrotal skin is used to recreate the labia and clitoral hood. A tunnel is created in the perineal cavity between the urethra, bladder, and rectum and the neovagina is secured to the sacrospinous ligament to avoid prolapse of the urethral part of the vagina.1 Colon vaginoplasty is an alternative to penile and scrotal skin use. The advantages are that vaginal depth may be better and the neovagina is self-lubricating. It is therefore indicated in patients in whom there is insufficient penile skin for penile inversion vaginoplasty and patients who have failed primary vaginoplasty and have insufficient vault depth or width due to stenosis or scar contracture. The sigmoid colon, not the transverse colon, is most commonly used. The main disadvantage is that it requires dual-specialty operating and risks potential problems with the bowel such as anastomotic leak, prolonged ileus, and adhesions. The radial forearm flap has many uses including phalloplasty, but is not normally used for the creation of a neovagina in this setting. The pudendal artery flap is a useful flap for vaginal reconstruction after tumor extirpation and can either be performed with unilateral or bilateral flaps. These are termed “Singapore flaps.” They are not typically used for transgender neovagina reconstruction, as there are other tissues more readily available, although they could be used in principle if complications were present, and the vagina needed expansion.