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.

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.

Laterality and severity of nasal obstruction does not correlate between physicians and patients, nor among physicians.

BACKGROUND: Nasal obstruction is a common patient complaint and has a variety of etiologies, and a specific anatomical abnormality can often be found within the nasal cavity on physical examination. In practice, this observed pathology does not always correlate with the laterality, severity, and exact intranasal site of the patients' perceived obstruction. OBJECTIVES: We seek to answer the following questions: 1) Does a physician's evaluation of nasal obstruction correlate with subjective patient complaints? 2) Is there reasonable correlation between physicians of similar training in the routine evaluation of nasal obstruction? METHODS: First, we asked patients presenting to the otolaryngology clinic with a primary complaint of nasal obstruction to fill out a modified NOSE survey. Nasal endoscopy was performed on all subjects to assess all potential sites of obstruction. We then determined whether there is an association between patient complaints and findings on physical examination. Second, we determined if there is correlation between similarly trained physicians in their interpretation of a basic nasal examination. Otolaryngologists were shown a series of standardized videos of an endoscopic nasal examination that were recorded with a primary complaint of nasal obstruction. Findings were reported in an anonymous online survey focusing on laterality, severity, and specific site of perceived obstruction. RESULTS: A total of 38 patients were included in the first part of the study. The Cohen's kappa coefficient was used to determine the interrater agreement between the patient and physician in the degree of nasal obstruction. The kappa coefficient was 0.03 (p value 0.372) for the comparison of the left-sided scores (fair agreement), and 0.16 (p value 0.014) for the right-sided scores (slight agreement). A comparison was also done between the side of the nose the patient felt was most obstructed to the most obstructed side found on physical exam by the otolaryngologist. Thirteen of the 38 patients (34%) had perceived nasal obstruction on the opposite side of that noted to be most obstructed on physical exam. Despite this, the kappa coefficient in this comparison was 0.43 (p value <0.001) revealing moderate agreement between the two groups. Seventeen otolaryngologists participated in the second part of the study. Data extrapolated revealed very little agreement among the physicians in reporting which side of the nose was most obstructed, what anatomical structure contributed to the obstruction the most, and what percentage obstruction was present. DISCUSSION: Based on our findings, patients can reasonably determine based on their symptoms which side is most obstructed, but symptoms do not correlate with severity of obstruction when compared to physical exam. There is also very little consistency between otolaryngologists in their assessment of the degree of nasal obstruction on exam. The results of this study may have far-reaching implications for patient management, surgical intervention, and medicolegal documentation as it relates to the current surgical treatment of nasal obstruction.

Facial Plastic Surgery on Instagram: What Is Trending? What Is Working?

BACKGROUND: Instagram has become a prominent way for facial plastic surgeons to advertise their work and communicate with patients. Some providers develop globally popular profiles, becoming "influencers" in their field. OBJECTIVES: We sought to characterize posts found on top profiles by type and determine the degree of patient interaction within each type. METHODS: A social media tracking tool (Awario, Belarus) compiled a list of the top 33 facial plastic surgery Instagram profiles based on number of followers and "reach," obtained on September 22, 2019. Profiles not belonging to American Board of Facial Plastic and Reconstructive Surgery (ABFPRS)-certified surgeons were excluded, leading to 20 profiles. The most recent 18 posts at the time of data extraction were categorized into: (1) clinical or professional, (2) lifestyle, and (3) patients. The average number of "likes," as a percentage of total followers, was calculated for each category for each profile. Data were gathered from September to November 2019. RESULTS: Most top profiles belong to ABFPRS-certified surgeons and were not verified. Clinical pictures and patient posts were 42.78% and 41.94% of those sampled, respectively. Lifestyle content was 19.05%. Followers interacted with clinical posts the most, having an average of 6.79% of follower interaction. Patient and lifestyle posts had 2.88% and 3.81%, respectively. CONCLUSIONS: Instagram is an important communication tool for facial plastic surgeons to engage in promotion and education. It is important to understand what trends tend to attract followers and engagement. Our study showed that more clinical content, separate from patient pictures, tended to be popular with both providers and followers.

Differences in Female and Male-to-Female Transgender Facial Skin Micro-Vessel Density.

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind this gender-associated risk is poorly developed and requires further investigation. Objective: The objective of this study was to compare facial skin micro-vessel density of female and male-to-female (MTF) transgender patients undergoing rhytidectomy to better understand the mechanism of gender-correlated hematoma risk factors. The authors hypothesized that transgender patients would have higher micro-vessel density compared with female patients. Design, Setting, and Participants: This was a prospective histopathological analysis of pre- and post-auricular facial skin samples from patients undergoing primary rhytidectomy. Patient clinical data and skin samples were collected. Histopathological slides were prepared and stained with CD-31, a marker of vessel endothelium, followed by image analysis allowing for micro-vessel stained pixel counts and calculated pixel density comparisons at a single academic hospital. Female, MTF transgender, and male patients >18 years of age were studied. Exposure: Patients undergoing primary rhytidectomy between 2015 and 2018. Main Outcomes: Gender-associated pre- and post-auricular micro-vessel pixel density. Results: Forty-one patients contributed skin samples for analysis. Post-auricular micro-vessel pixel density was greater than pre-auricular density (mean difference post-pre 0.359 percentage points [p.p.], standard error [SE] = 0.135, p = 0.009). The mean post-auricular micro-vessel pixel density was 1.60% (SE = 0.13 p.p.), 2.16% (SE = 0.19 p.p.), and 2.77% (SE = 0.34 p.p.) for female, transgender, and male patients, respectively (p = 0.016). Pre-auricular micro-vessel pixel density showed no difference among females, males, and transgender patients (p = 0.30). Gender was a strong predictor of increased post-auricular micro-vessel pixel density on stepwise linear regression, but it did not predict pre-auricular micro-vessel density. Both preoperative hair removal and a history of hypertension were associated with increased pre-auricular micro-vessel density. Conclusions and Relevance: Facial skin micro-vessel density differs by gender, in addition to pre- and post-auricular locations in patients undergoing rhytidectomy.

Evaluation of Validity and Specificity of the Cottle Maneuver in Diagnosis of Nasal Valve Collapse.

BACKGROUND: Despite the widespread use of the Cottle maneuver as a finding to define nasal valve collapse, no studies have confirmed the association between a positive Cottle maneuver and need for nasal valve repair. This study demonstrates the low construct validity of the Cottle maneuver. METHODS: One hundred healthy volunteer students and employees at Boston Medical Center were recruited for this study. Participants were asked to evaluate their breathing on a 10-point scale, rating their subjective airflow in each nostril while occluding the contralateral nostril, where 0 indicated complete obstruction and 10 indicated complete patency. Following the baseline ratings, participants were asked to rate their breathing once again while examiners preformed the Cottle and modified Cottle maneuvers. RESULTS: Overall, 97 percent of participants reported improved airflow in each nostril following the Cottle maneuver (p < 0.00001); 98 percent reported improved airflow in each nostril following the modified Cottle maneuver (p < 0.00001). CONCLUSIONS: If the clinical consensus regarding the observed improvement in nasal airflow is to be followed, nearly all the participants recruited are experiencing some surgically correctable nasal obstruction. Given the population from which our cohort was collected-students and residents from a medical campus-such a conclusion seems extremely unlikely. We believe the more likely explanation for the high positive test rate is flawed assumptions of the Cottle and modified Cottle maneuvers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.