New Therapeutic Approach to Facial Feminization Surgery for Transgender Women
'Working Protocol' for Facial Gender Confirmation Surgery Presented in Plastic and Reconstructive Surgery

Facial Feminization Surgery (FFS), or Facial Gender Confirmation Surgery, is one of the fastest-growing areas in plastic surgery, with major advances in surgical techniques improving outcomes for transgender patients during the past decade. Still, there's a lack of guidance on how best to meet the complex needs – from initial evaluation through postoperative follow-up care – of this patient group.

Facial feminization surgery is increasingly recognized as a medically necessary treatment for gender dysphoria in many transgender patients, and a new paper, published in the April issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS), outlines a new therapeutic approach to transgender patients who are candidates for FFS.

Luis Capitán, MD, PhD, of the FACIALTEAM Surgical Group at HC Marbella International Hospital in Spain, and his coauthors explain, "It is crucial to identify the features that make a face masculine, use the appropriate tools and know the correct surgical techniques in each situation, with the principles of safety and naturalness always acting as guidelines. Disseminating gender surgery education is essential to improving patient outcomes and encouraging new innovations."

Reflecting the evolution of their approach in more than 1,300 patients, the FACIALTEAM group has developed a four-phase protocol for FFS.

Evaluation, Diagnosis and Planning. Careful planning is needed to address the primary facial features related to gender identity, from the forehead to the nose, cheekbones, jaw and thyroid cartilage ("Adam's apple"), as well as secondary aspects including the hairline, facial hair, skin texture and facial fat.

Three-dimensional photographs and other digital technologies, such as 3D scans and three-dimensional printing, are increasingly used for surgical planning, including "virtual FFS" to help provide patients with realistic expectations of the surgical results. Throughout the process, patients should receive regular counseling from a psychologist specializing in transgender health.

Patient Selection. In addition to being psychologically prepared, patients must be fully informed about the procedures to be performed, including expected recovery and possible complications. The authors suggest that patients should complete at least one year of hormone therapy and facial hair removal before undergoing FFS procedures.

Preparation and Surgery. Dr. Capitán and colleagues believe that FFS procedures are best performed in an "ascending order," starting with the Adam's apple, followed by the lower jaw and forehead surgery, and concluding with surgery on the nose and other "minor" procedures. The authors discuss specific techniques for surgery on the facial bones, focusing on newer, less-invasive surgical approaches.

Postoperative Period. The protocol includes recommended steps to manage swelling and pain after surgery. Patients need guidance on exercise and nutrition, along with psychological support to address anxiety and other postoperative concerns. "The patient's evolution is monitored for at least one year until definitive and stable results can be assessed," according to the authors.

While acknowledging that other experts may have differing opinions, the FACIALTEAM group hopes their protocol will be a useful step toward developing an "objective and reproducible" approach to the care of patients undergoing FFS.

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management"

Article: "Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management" (doi: 10.1097/PRS.0000000000006686)