Appropriate Use of Preoperative Imaging in Feminization Cranioplasty.

Study Design: Retrospective chart review. Objective: The objective of this study was to determine if proceeding with feminization frontal cranioplasty without preoperative imaging adversely affected patient outcomes. Methods: This study retrospectively reviewed all patients undergoing frontal cranioplasty for facial feminization at a single tertiary care center between 2013 and 2019. All procedures were performed by a single surgeon (JS), who operated at multiple sites. The site selected is where the majority of these procedures were performed during this time. Type of cranioplasty (I vs III) was recorded. Primary outcomes included postoperative cerebrospinal fluid (CSF) leak, entering the cranium, or dural exposure or injury. Results: 422 subjects underwent cranioplasty for facial feminization between 2013 and 2019. No preoperative imaging was performed. Zero patients had CSF leak. 334 subjects (79%) had type III cranioplasty, while the remaining 88 subjects (21%) had type I cranioplasty. No subjects had documented episodes of dural injury, or postoperative brain or cranial concerns. Conclusions: This study demonstrates that frontal cranioplasty for facial feminization does not require routine preoperative imaging. The authors recommend preoperative imaging for patients with a history of congenital cranial abnormality, prior significant head trauma affecting the frontal bone, and in some cases where the patient has had prior surgery or a history of sinus disease or extensive polyposis. Routine preoperative computed tomography is therefore not indicated for patients undergoing feminizing cranioplasty.

No Thromboembolic Complications After Facial Feminization Surgery in Transgender Patients Utilizing Estrogen Therapy: A Retrospective Cohort Study.

Purpose: Estrogen therapy is associated with an increased risk of venous thromboembolism (VTE). A large proportion of transfeminine patients use estrogen therapy before undergoing gender-affirming surgery. Many surgeons implement the discontinuation of hormone therapy before surgery. This study sought to evaluate the perioperative risk of VTE in transfeminine patients undergoing the procedure of facial feminization. Methods: Retrospective chart reviews were performed of all patients who underwent facial feminization by a single surgeon at an urban academic institution from 2014 to 2020. Patient characteristics including comorbidities, Caprini score, VTE chemoprophylaxis, and perioperative hormone therapy management were reviewed. The incidences of VTE during perioperative hospital stay and within 1 week and 6 months after the surgical procedure were examined. Results: There were 296 facial feminization procedures performed on 282 distinct patients who met criteria for inclusion in the study. Hormone therapy was prescribed to 83.6% of patients, 69.5% of whom reported that they held these medications before the procedure. Of those holding, 84.1% of patients reported they discontinued these medications between 2 and 4 weeks. No patients received VTE chemoprophylaxis. There were 0 VTE incidents during the patients' perioperative period up to 6 months postprocedure. Conclusion: Our findings support that transfeminine patients who use estrogen hormone therapy are at a minimal risk to experience VTE when undergoing facial feminization procedures. Future directions include evaluating the psychologic effect of discontinuing hormone therapy to help guide perioperative decision making.

Hair Restoration Techniques.

Hair restoration is an essential topic in the current management of facial plastic surgery concerns and queries. Advances in hair restoration include oral and topical medications and compounded preparations, injections including platelet-rich plasma, light therapy, and follicular unit extraction methods. This article provides a review of current techniques.

Chondrolaryngoplasty.

Chondrolaryngoplasty is a surgical procedure that reduces the prominence of the thyroid notch. Although frequently performed on transgender (man to woman) women, anyone wishing to reduce the prominence of their thyroid notch for aesthetic purposes may consider undergoing a chondrolaryngoplasty. Direct visualization of the vocal cords with flexible laryngoscopy and intraoperative needle localization of the anterior commissure directs the extent of resection, helps increase safety, and avoids devastating postoperative voice complications. This procedure can be safely performed in combination with other facial feminization surgeries.

Rare Complications in Chondrolaryngoplasty: Preparation for Safe Outcomes.

Chondrolaryngoplasty ("tracheal shave") is a common procedure requested by transgender women as well as cisgender men and women. Management of intraoperative complications is crucial given the risk of damage to the vocal cords and loss of the airway in patients who are not intubated. We present two rare complications of chondrolaryngoplasty and their management.

Frontal Bone Cranioplasty for Facial Feminization in Gender-Affirming Surgery: Can Fewer Screws Fixate Bone and Avoid Nonunion?

Background: Facial feminization surgery can include forehead feminizing cranioplasty (FFC). The reshaped bones are fixated together with titanium plates and screws. Objective: To define the authors' preferred plating patterns and measure complications of bony nonunion when less hardware is applied. Methods: A 7-year retrospective review of patients who underwent FFC was conducted. Data collection included cranioplasty technique, fixation patterns, and complications. Traditional fixation (≥2 screws on each side of the osteotomy) was compared with conservative fixation (<2 screws). Results: A total of 483 patients were identified with a median of 241 days of follow-up (interquartile range: 8-528 days). Most patients (77.8%) had frontal bone fixation with microplates and screws. The most common combination was placement of two plates with four screws in total, comprising two screws on each plate, with one screw on each side of the fracture line (305/483, 63.1%). No signs or symptoms of bone flap mobility were noted on examination. Conclusion: Conservative fixation of the anterior table does not appear to increase signs of nonunion in forehead reshaping gender-affirming surgery.

Approach to the Transgender Patient: Preoperative Counseling, Setting Expectations, Avoiding Potential Postoperative Pitfalls.

An increasing number of transgender patients are seeking gender-affirming facial surgery, also known as facial feminization surgery. Physicians offering these services must be well versed in how to compassionately care for this patient population. We recommend having a well-informed staff that is knowledgeable about proper verbiage, use of pronouns, and preferred names for transgender patients. We also recommend helping patients to manage expectations and seek realistic goals from the first consultation. A frank discussion about the limits of facial feminization is essential. Discussing the prolonged recovery and expected outcome is of paramount importance preoperatively to avoid postoperative disappointment.

Observer Gaze Patterns of Patient Photographs Before and After Facial Feminization.

BACKGROUND: Human interaction begins with visual evaluation of others, and this often centers on the face. Objective measurement of this evaluation gives clues to social perception. OBJECTIVES: The objective of this study was to use eye-tracking technology to evaluate if there are scanpath differences when observers view faces of cisgender men, cisgender women, and transgender women before and after facial feminization surgery (FFS) including when assigning tasks assessing femininity, attractiveness, and likability. METHODS: Undergraduate psychology students were prospectively recruited as observers at a single institution. Their eye movements were recorded by eye-tracking technology when they were presented with frontal photographs of prototypical male, prototypical female, and pre- and post-FFS faces in a random order and then with prompting to assess femininity, attractiveness, and likability. RESULTS: Twenty-seven observers performed the tasks. Participants focused their attention more on the central triangle of post-FFS and prototypical female images and on the forehead of pre-FFS and prototypical male images. Higher femininity ratings were associated with longer proportional fixations to the central triangle and lower proportional fixations to the forehead. CONCLUSIONS: This preliminary study implies the scanpath for viewing a post-FFS face is closer to that for viewing a prototypical female than a prototypical male based on differences viewing the forehead and brow vs the central triangle.

Board Certification and Surgeon's Fee for Aesthetic Rhinoplasty.

Elective rhinoplasty surgeons' fees vary considerably and are influenced by geographic surgeon density, surgeon's experience, local economic factors, patient demand, and other factors. The American Board of Facial Plastic and Reconstructive Surgery, the American Society of Plastic Surgery, and other organizations certify physicians who profess expertise in rhinoplasty. We sought to determine if specific board certification or experience correlates with higher rhinoplasty fee. An internet search was conducted of seven U.S. metropolitan areas using the search terms "rhinoplasty and "city name." Top search results were surveyed for rhinoplasty fee, years of experience, annual volume of rhinoplasties, board certification, and other demographic data. Using both univariate and multivariate comparisons, the data were analyzed for forces having significant correlation with rhinoplasty fee. Sixty-seven surgeons were included in the study. The average price for ABFPRS certified surgeons was significantly higher than surgeons with other board certifications ($10,550.00 ± 3,722.10 compared with $8,524.50 ± 2816.30, p = 0.0142). The volume of rhinoplasties performed per year was also significantly correlated with fee charged for rhinoplasty by the surgeon (r = 0.37773, p = 0.032). Additionally, surgeons practicing on the West Coast (LA) charged significantly higher fees ($12,059.09 ± 3014.53) compared with the Mid United States. ($8316.07 ± 2449.43) and the East Coast ($9152.86 ± 3639.78) (p = 0.0047). On multivariable linear regression, controlling for volume of rhinoplasty and region of the United States, ABFPRS certified surgeons charged significantly higher fees for rhinoplasty (p = 0.0230). ABFPRS board certification correlates with higher fees charged for rhinoplasty. Other important variables include surgeon's annual rhinoplasty and practice on the West Coast.

Frontal Bone Cranioplasty for Facial Feminization: Long-Term Follow-Up of Postoperative Sinonasal Symptoms.

Background: Forehead feminization cranioplasty (FFC) risks entering the frontal sinus to achieve the desired contour. To date, no study has investigated long-term FFC complications. Objective: Determine if long-term sinus and headache symptoms worsen secondary to frontal sinus mucosal violation, measured by patient-reported outcomes. Methods: Single database retrospective chart review of patients who underwent forehead contouring between August 2012 and August 2019 was conducted. Two cohorts-frontal sinus mucosal violation versus mucosal preservation-were surveyed postprocedurely for postprocedure SNOT (Sinonasal Outcome Test)-22 scores and pre- and postprocedure sinus and headache symptoms. Results: Frontal sinus violation, mean time between surgery and response was 4.16 ± 1.88 years (range: 1-8). Without violation, mean time between surgery and response was 2.5 ± 1.10 years (range: 1-5). Postoperative SNOT-22 severity scores were not different (12.55 vs. 8.6, p = 0.20). Postoperative SNOT-22 scores were equivalent to a control nonrhinosinusitis population. No difference was found between violation of the frontal sinus with worse postoperative sinus (22 vs. 5, p = 0.60) or headache symptoms. Conclusion: Our data did not detect a difference in sinus or headache outcomes in patients who experienced violation of the anterior frontal table compared with a similar population with preservation of the frontal sinus, over an 8-year follow-up.

Association of vaping with decreased vascular endothelial growth factor expression and decreased microvessel density in cutaneous wound healing tissue in rats.

Vaping is suggested to be a risk factor for poor wound healing akin to smoking. However, the molecular and histologic mechanisms underlying this postulation remain unknown. Our study sought to compare molecular and histologic changes in cutaneous flap and non-flap tissue between vaping, smoking and control cohorts. Animal study of 15 male Sprague-Dawley rats was randomized to three cohorts: negative control (n = 5), e-cigarette (n = 5) and cigarette (n = 5) and exposed to their respective treatments with serum cotinine monitoring. After 30 days, random pattern flaps were raised and healed for 2 weeks after which skin punch biopsies of flap and non-flap tissues were collected for quantitative-reverse transcription-polymerase chain reaction of three selected wound healing genes (transforming growth factor ß [TGF-ß], vascular endothelial growth factor [VEGF], matrix metalloproteinase-1 [MMP-1]); then, immunohistochemistry for CD68 expression, α-smooth muscle actin looking at microvessel density (MVD) and in situ hybridization to localize VEGF production were undertaken. In flap tissue, vaping (mean[SEM]) (0.61[0.07]) and smoking (0.70[0.04]) were associated with decreased fold change of VEGF expression compared with controls (0.91[0.03]) (p < 0.05, p < 0.05, respectively). In non-flap tissue, only vaping was associated with decreased VEGF expression (mean[SEM]) (0.81[0.07]), compared with controls (1.17[0.10]) (p < 0.05) with expression primarily localized to basal keratinocytes and dermal capillaries. Immunohistochemistry showed decreased MVD in smoking (0.27[0.06]) and vaping (0.26[0.04]) flap tissue compared to matched controls (0.65[0.14]) (p < 0.05, p < 0.05, respectively) and decreased areas of fibrosis compared with controls on gross histology. Vaping and smoking were similarly associated with decreased VEGF expression, MVD and fibrotic changes in flap tissue. The results suggest attenuated angiogenesis via decreased VEGF expression as a mechanism for poor wound healing in vaping-exposed rats.