Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 468 - файл
.pdf
344
https://t.me/medicina_free
R. P. Shupak et al.
References
1. Weyh A, Pucci R, Valentini V, Fernandes R, Salman S. Injuries of the peripheral mandibular nerve, evaluation of interventions and outcomes: a systematic review. Craniomaxillofac
Trauma Reconstr. 2021;14(4):337–48.
2. Kaleem A, Amailuk P, Hatoum H, Tursun R.The trigeminal nerve injury. Oral Maxillofac Surg
Clin North Am. 2020;32(4):675–87. https://doi.org/10.1016/j.coms.2020.07.005.
3. Meyer RA, Bagheri SC.Microsurgical reconstruction of the trigeminal nerve. Oral Maxillofac
Surg Clin North Am. 2013;25(2):287–302. https://doi.org/10.1016/j.coms.2013.01.002.
4. Ducic I, Yoon J.Reconstructive options for inferior alveolar and lingual nerve injuries after
dental and oral surgery: an evidence-based review. Ann Plast Surg. 2019;82(6):653–60.
5. Smith JG, Elias L-A, Yilmaz Z, Barker S, Shah K, Shah S, etal. The psychosocial and affective
burden of posttraumatic stress neuropathy following injuries to the trigeminal nerve. J Orofac
Pain. 2013;27(4):293–303.
6. Miloro M, Zuniga JR, Meyer RA.How many oral surgeons does it take to classify a nerve injury?
J Oral Maxillofac Surg. 2021;79(7):1550–6. https://doi.org/10.1016/j.joms.2021.01.006.
7. Walters BC.History of peripheral nerve repair. Vol. 1, Nerves and nerve injuries. London:
Elsevier; 2015. p.23–36. https://doi.org/10.1016/B978- 0- 12- 410390- 0.00002- 0.
8. Belen D, Aciduman A, Er U.History of peripheral nerve repair: may the procedure have been
practiced in Hippocratic School? Surg Neurol. 2009;72(2):190–3. https://doi.org/10.1016/j.
surneu.2008.03.030.
9. Wessberg GA, Wolford LM. Bilateral microneurosurgical reconstruction of inferior alveolar nerves via autogenous sural nerve transplantation. Oral Surg Oral Med Oral Pathol.
1981;52(5):465–70.
10. Mozsary PG, Middleton RA. Microsurgical reconstruction of the lingual nerve. J Oral
Maxillofac Surg. 1984;42(7):415–20.
11. Hausamen JE, Samii M, Schmidseder R.Indication and technique for the reconstruction of
nerve defects in head and neck. J Maxillofac Surg. 1974;2(C):159–67.
12. Seddon HJ.A classication of nerve injuries. Br Med J. 1942;2(4260):237–9.
13. Gaudin R, Knipfer C, Henningsen A, Smeets R, Heiland M, Hadlock T.Approaches to peripheral nerve repair: generations of biomaterial conduits yielding to replacing autologous nerve
grafts in craniomaxillofacial surgery. Biomed Res Int. 2016;2016:3856262.
14. Shanti RM, Ziccardi VB.Use of decellularized nerve allograft for inferior alveolar nerve reconstruction: a case report. J Oral Maxillofac Surg. 2011;69(2):550–3. https://doi.org/10.1016/j.
joms.2010.10.004.
15. Ducic I, Safa B, De Vinney E.Renements of nerve repair with connector-assisted coaptation.
Microsurgery. 2017;37(3):256–63.
16. Zuniga JR, Williams F, Petrisor D.A case-and-control, multisite, positive controlled, prospective study of the safety and effectiveness of immediate inferior alveolar nerve processed nerve
allograft reconstruction with ablation of the mandible for benign pathology. J Oral Maxillofac
Surg. 2017;75(12):2669–81. https://doi.org/10.1016/j.joms.2017.04.002.
17. AxoGen. 2022. https://www.axogeninc.com.
18. Callahan N, Miloro M, Markiewicz MR.Immediate reconstruction of the infraorbital nerve
after maxillectomy: is it feasible? J Oral Maxillofac Surg. 2020;78(12):2300–5. https://doi.
org/10.1016/j.joms.2020.07.211.
19. Suhaym O, Miloro M. Does early repair of trigeminal nerve injuries inuence neurosensory recovery? A systematic review and meta-analysis. Int J Oral Maxillofac Surg.
2021;50(6):820–9. https://doi.org/10.1016/j.ijom.2020.10.002.
20. Kushnerev E, Yates JM. Evidence-based outcomes following inferior alveolar and lingual
nerve injury and repair: a systematic review. J Oral Rehabil. 2015;42(10):786–802.
21. Miloro M, Zuniga JR.Does immediate inferior alveolar nerve allograft reconstruction result in
functional sensory recovery in pediatric patients? J Oral Maxillofac Surg. 2020;78(11):2073–9.
https://doi.org/10.1016/j.joms.2020.06.033.
19 Trigeminal Nerve Reconstruction inMaxillofacial Surgery
https://t.me/medicina_free
22. Rath EM.Surgical treatment of maxillary nerve injuries. The infraorbital nerve. Atlas Oral
Maxillofac Surg Clin North Am. 2001;9(2):31–41.
23. Pogrel MA. Recovery of sensation over the distribution of the inferior alveolar nerve following mandibular resection without nerve reconstruction. J Oral Maxillofac Surg.
2021;79(10):2143–6. https://doi.org/10.1016/j.joms.2021.04.029.
24. Le Donne M, Jouan R, Bourlet J, Louvrier A, Ducret M, Sigaux N.Inferior alveolar nerve
allogenic repair following mandibulectomy: a systematic review. J Stomatol Oral Maxillofac
Surg. 2021;123:233–8. https://doi.org/10.1016/j.jormas.2021.04.007.
25. Kehoe S, Zhang XF, Boyd D.FDA approved guidance conduits and wraps for peripheral nerve
injury: a review of materials and efcacy. Injury. 2012;43(5):553–72. https://doi.org/10.1016/j.
injury.2010.12.030.
26. López-Cebral R, Silva-Correia J, Reis RL, Silva TH, Oliveira JM.Peripheral nerve injury:
current challenges, conventional treatment approaches, and new trends in biomaterials-based
regenerative strategies. ACS Biomater Sci Eng. 2017;3(12):3098–122. https://doi.org/10.1021/
acsbiomaterials.7b00655.
27. Scheib J, Höke A. Advances in peripheral nerve regeneration. Nat Rev Neurol.
2013;9(12):668–76. https://doi.org/10.1038/nrneurol.2013.227.
28. Aloe L, Rocco ML, Bianchi P, Manni L. Nerve growth factor: from the early discoveries
to the potential clinical use. J Transl Med. 2012;10(1):1–15. https://doi.org/10.1186/1479-
5876- 10- 239.
29. Li R, Li DH, Zhang HY, Wang J, Li XK, Xiao J.Growth factors-based therapeutic strategies
and their underlying signaling mechanisms for peripheral nerve regeneration. Acta Pharmacol
Sin. 2020;41(10):1289–300. https://doi.org/10.1038/s41401- 019- 0338- 1.
30. Rotshenker S.Wallerian degeneration: the innate-immune response to traumatic nerve injury.
J Neuroinammation. 2011;8:109. https://doi.org/10.1186/1742- 2094- 8- 109.
31. Wang L, Zhao Y, Cheng X, etal. Effects of locally applied nerve growth factor to the inferior
alveolar nerve histology in a rabbit model of mandibular distraction osteogenesis. Int J Oral
Maxillofac Surg. 2009;38(1):64–9. https://doi.org/10.1016/j.ijom.2008.11.010.
32. Hergt AC, Beck-Broichsitter BE, Raethjen J, etal. Nerve regeneration techniques respecting the special characteristics of the inferior alveolar nerve. J Cranio-Maxillofac Surg.
2016;44(9):1381–6. https://doi.org/10.1016/j.jcms.2016.06.020.
33. Nemoto A, Akashi Y, Nakajima K, et al. The effects of recombinant human basic broblast growth factor on nerve regeneration in a partial defect inferior alveolar nerve model
in rabbits. J Oral Maxillofac Surg Med Pathol. 2021;33(3):348–53. https://doi.org/10.1016/j.
ajoms.2020.12.003.
34. Sarker MD, Naghieh S, McInnes AD, Schreyer DJ, Chen X. Regeneration of peripheral
nerves by nerve guidance conduits: inuence of design, biopolymers, cells, growth factors,
and physical stimuli. Prog Neurobiol. 2018;171(July):125–50. https://doi.org/10.1016/j.
pneurobio.2018.07.002.
35. Madduri S, Feldman K, Tervoort T, Papaloïzos M, Gander B.Collagen nerve conduits releasing the neurotrophic factors GDNF and NGF.J Control Release. 2010;143(2):168–74. https://
doi.org/10.1016/j.jconrel.2009.12.017.
36. Ma F, Xu F, Li R, etal. Sustained delivery of glial cell-derived neurotrophic factors in collagen
conduits for facial nerve regeneration. Acta Biomater. 2018;69:146–55.
37. Roam JL, Yan Y, Nguyen PK, et al. A modular, plasmin-sensitive, clickable poly(ethylene
glycol)-heparin-laminin microsphere system for establishing growth factor gradients
in nerve guidance conduits. Biomaterials. 2015;72:112–24. https://doi.org/10.1016/j.
biomaterials.2015.08.054.
38. Wood MD, Gordon T, Kim H, etal. Fibrin gels containing GDNF microspheres increase axonal regeneration after delayed peripheral nerve repair. Regen Med. 2013;8(1):27–37.
39. Giannaccini M, Calatayud MP, Poggetti A, etal. Magnetic nanoparticles for efcient delivery of growth factors: stimulation of peripheral nerve regeneration. Adv Healthc Mater.
2017;6(7):1601429. https://doi.org/10.1002/adhm.201601429.
345
346
https://t.me/medicina_free
40. Chen X, Ge X, Qian Y, et al. Electrospinning multilayered scaffolds loaded with melatonin and Fe3O4 magnetic nanoparticles for peripheral nerve regeneration. Adv Funct Mater.
2020;30(38):1–12. https://doi.org/10.1002/adfm.202004537.
41. Wei Z, Hong FF, Cao Z, Zhao SY, Chen L.In situ fabrication of nerve growth factor encapsulated chitosan nanoparticles in oxidized bacterial nanocellulose for rat sciatic nerve regeneration. Biomacromolecules. 2021;22(12):4988–99. https://doi.org/10.1021/acs.biomac.1c00947.
42. Mokarram N, Merchant A, Mukhatyar V, Patel G, Bellamkonda RV.Effect of modulating macrophage phenotype on peripheral nerve repair. Biomaterials. 2012;33(34):8793–801. https://
doi.org/10.1016/j.biomaterials.2012.08.050.
43. Mokarram N, Dymanusb K, Srinivasan A, etal. Immunoengineering nerve repair. Proc Natl
Acad Sci U S A. 2017;114(26):E5077–84. https://doi.org/10.1073/pnas.1705757114.
44. Khodorova A, Nicol GD, Strichartz G. The TrkA receptor mediates experimental thermal
hyperalgesia produced by nerve growth factor: modulation by the p75 neurotrophin receptor.
Neuroscience. 2017;340:384–97. https://doi.org/10.1016/j.neuroscience.2016.10.064.
45. Hayakawa Y, Sakitani K, Konishi M, etal. Nerve growth factor promotes gastric tumorigenesis through aberrant cholinergic signaling. Cancer Cell. 2017;31(1):21–34. https://doi.
org/10.1016/j.ccell.2016.11.005.
46. Li Y, Fraser D, Mereness J, etal. Tissue engineered neurovascularization strategies for craniofacial tissue regeneration. ACS Appl Bio Mater. 2022;5(1):20–39. https://doi.org/10.1021/
acsabm.1c00979.
47. Khalian S, Sarhane KA, Tammia M, et al. Stem cell-based approaches to improve nerve
regeneration: potential implications for reconstructive transplantation? Arch Immunol Ther
Exp. 2015;63(1):15–30. https://doi.org/10.1007/s00005- 014- 0323- 9.
48. Hu Y, Wu Y, Gou Z, etal. 3D-engineering of cellularized conduits for peripheral nerve regeneration. Sci Rep. 2016;6(August):1–12. https://doi.org/10.1038/srep32184.
49. Sun AX, Prest TA, Fowler JR, et al. Conduits harnessing spatially controlled cell-secreted
neurotrophic factors improve peripheral nerve regeneration. Biomaterials. 2019;203:86–95.
https://doi.org/10.1016/j.biomaterials.2019.01.038.
50. di Summa PG, Kalbermatten DF, Pralong E, Raffoul W, Kingham PJ, Terenghi G.Long-term
invivo regeneration of peripheral nerves through bioengineered nerve grafts. Neuroscience.
2011;181:278.
51. Wang Y, Zhao Z, Ren Z, etal. Recellularized nerve allografts with differentiated mesenchymal
stem cells promote peripheral nerve regeneration. Neurosci Lett. 2012;514(1):96–101. https://
doi.org/10.1016/j.neulet.2012.02.066.
52. Onode E, Uemura T, Takamatsu K, etal. Bioabsorbable nerve conduits three-dimensionally
coated with human induced pluripotent stem cell-derived neural stem/progenitor cells promote peripheral nerve regeneration in rats. Sci Rep. 2021;11(1):1–13. https://doi.org/10.1038/
s41598- 021- 83385- 9.
53. Fan L, Liu C, Chen X, etal. Directing induced pluripotent stem cell derived neural stem cell
fate with a three-dimensional biomimetic hydrogel for spinal cord injury repair. ACS Appl
Mater Interfaces. 2018;10(21):17742–55. https://doi.org/10.1021/acsami.8b05293.
54. Lee AS, Tang C, Rao MS, Weissman IL, Wu JC.Tumorigenicity as a clinical hurdle for pluripotent stem cell therapies. Nat Med. 2013;19(8):998–1004. https://doi.org/10.1038/nm.3267.
55. Arcaute K, Mann BK, Wicker RB. Fabrication of off-the-shelf multilumen poly(Ethylene
glycol) nerve guidance conduits using stereolithography. Tissue Eng Part C Methods.
2010;17(1):27–38. https://doi.org/10.1089/ten.tec.2010.0011.
56. Yao L, de Ruiter GCW, Wang H, etal. Controlling dispersion of axonal regeneration using
a multichannel collagen nerve conduit. Biomaterials. 2010;31(22):5789–97. https://doi.
org/10.1016/j.biomaterials.2010.03.081.
57. Koh HS, Yong T, Teo WE, et al. In vivo study of novel nanobrous intra-luminal guidance channels to promote nerve regeneration. J Neural Eng. 2010;7(4):046003. https://doi.
org/10.1088/1741- 2560/7/4/046003.
R. P. Shupak et al.
19 Trigeminal Nerve Reconstruction inMaxillofacial Surgery
https://t.me/medicina_free
58. Singh A, Asikainen S, Teotia AK, etal. Biomimetic photocurable three-dimensional printed
nerve guidance channels with aligned cryomatrix lumen for peripheral nerve regeneration.
ACS Appl Mater Interfaces. 2018;10(50):43327–42. https://doi.org/10.1021/acsami.8b11677.
59. Huang L, Zhu L, Shi X, etal. A compound scaffold with uniform longitudinally oriented guidance cues and a porous sheath promotes peripheral nerve regeneration invivo. Acta Biomater.
2018;68:223–36. https://doi.org/10.1016/j.actbio.2017.12.010.
60. Du J, Liu J, Yao S, etal. Prompt peripheral nerve regeneration induced by a hierarchically
aligned brin nanober hydrogel. Acta Biomater. 2017;55:296–309. https://doi.org/10.1016/j.
actbio.2017.04.010.
61. Yang S, Zhu J, Lu C, etal. Aligned brin/functionalized self-assembling peptide interpenetrating nanober hydrogel presenting multi-cues promotes peripheral nerve functional recovery.
Bioact Mater. 2022;8:529–44. https://doi.org/10.1016/j.bioactmat.2021.05.056.
62. Magaz A, Faroni A, Gough JE, Reid AJ, Li X, Blaker JJ.Bioactive silk-based nerve guidance
conduits for augmenting peripheral nerve repair. Adv Healthc Mater. 2018;7(23):e1800308.
https://doi.org/10.1002/adhm.201800308.
63. Wei GJ, Yao M, Wang YS, et al. Promotion of peripheral nerve regeneration of a peptide
compound hydrogel scaffold. Int J Nanomedicine. 2013;8:3217–25. https://doi.org/10.2147/
IJN.S43681.
64. Li A, Hokugo A, Yalom A, etal. A bioengineered peripheral nerve construct using aligned
peptide amphiphile nanobers. Biomaterials. 2014;35(31):8780–90. https://doi.org/10.1016/j.
biomaterials.2014.06.049.
65. Álvarez Z, Kolberg-Edelbrock AN, Sasselli IR, etal. Bioactive scaffolds with enhanced supramolecular motion promote recovery from spinal cord injury. Science. 2021;374(6569):848–56.
https://doi.org/10.1126/science.abh3602.
66. Lopez-Silva TL, Cristobal CD, Lai CSE, Leyva-Aranda V, Lee HK, Hartgerink JD. Selfassembling multidomain peptide hydrogels accelerate peripheral nerve regeneration after crush
injury. Biomaterials. 2021;265:120401. https://doi.org/10.1016/j.biomaterials.2020.120401.
67. Wu X, He L, Li W, etal. Functional self-assembling peptide nanober hydrogel for peripheral
nerve regeneration. Regen Biomater. 2017;4(1):21–30. https://doi.org/10.1093/rb/rbw034.
68. Leach JB, Brown XQ, Jacot JG, Dimilla PA, Wong JY.Neurite outgrowth and branching of
PC12 cells on very soft substrates sharply decreases below a threshold of substrate rigidity. J
Neural Eng. 2007;4(2):26–34. https://doi.org/10.1088/1741- 2560/4/2/003.
69. Wheeldon I, Farhadi A, Bick AG, Jabbari E, Khademhosseini A.Nanoscale tissue engineering:
spatial control over cell-materials interactions. Nanotechnology. 2011;22(21):212001. https://
doi.org/10.1088/0957- 4484/22/21/212001.Nanoscale.
70. Levin A, Hakala TA, Schnaider L, Bernardes GJL, Gazit E, Knowles TPJ.Biomimetic peptide self-assembly for functional materials. Nat Rev Chem. 2020;4(11):615–34. https://doi.
org/10.1038/s41570- 020- 0215- y.
71. Wang X, Hu W, Cao Y, Yao J, Wu J, Gu X.Dog sciatic nerve regeneration across a 30-mm
defect bridged by a chitosan/PGA articial nerve graft. Brain. 2005;128(8):1897–910.
72. Sufan W, Suzuki Y, Tanihara M, et al. Sciatic nerve regeneration through alginate with
tubulation or nontubulation repair in cat. J Neurotrauma. 2001;18(3):329–38. https://doi.
org/10.1089/08977150151070991.
73. Takata M, Murayama M, Sasaki K, Shibahara T.Histomorphometric observations of surgical methods for partial amputation injury of the inferior alveolar nerve using polyglycolic
acid. J Oral Maxillofac Surg Med Pathol. 2018;30(2):95–110. https://doi.org/10.1016/j.
ajoms.2017.10.001.
74. Ribitsch I, Baptista PM, Lange-Consiglio A, etal. Large animal models in regenerative medicine and tissue engineering: to do or not to do. Front Bioeng Biotechnol. 2020;8(August):1–28.
https://doi.org/10.3389/fbioe.2020.00972.
347
Chapter 20
https://t.me/medicina_free
Gender-Afrming Facial Surgery:
Ofce- Based Procedures
AbigailFrazier, PoolakBhatt, andEldaFisher
Transgender care has become a critical point of discussion within healthcare
spheres. With the number of patients seeking gender-afrming care on the rise, it is
crucial to provide insight into transgender populations, along with a thorough
understanding of medical and surgical techniques to meet the needs of transgender
patients. This chapter aims to briey investigate the denition of gender dysphoria,
the basic World Professional Association for Transgender Health (WPATH) criteria
for gender-afrming care and the application of gender-afrming surgery as it
applies to ofce-based procedures for facial gender afrmation.
Transgender Populations
Terminology
Over the last few decades, transgender terminology has rapidly evolved to reect
the growing needs of the community. It is critical for surgeons to understand fundamental differences in terminology to successfully treat this population. Perhaps
most crucial to the discussion of gender-afrming surgery is distinguishing between
gender nonconformity and gender dysphoria. It is well established that biological
A. Frazier · P. Bhatt · E. Fisher (*)
Division of Craniofacial and Surgical Care, ASoD, University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA
Residency Program in Oral and Maxillofacial Surgery, University of North Carolina
Hospitals, Chapel Hill, NC, USA
e-mail: Abigail.Frazier@unchealth.unc.edu; Poolak.Bhatt@unchealth.unc.edu;
elda.sher@unc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and
Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_20
349
350
https://t.me/medicina_free
sex and gender are exclusive entities, with sex referring to specic chromosomes
and genitalia that identify people as either “male” or “female” at birth and gender
referring to the internal feelings of masculinity or femininity experienced by each
person. From these denitions, each culture has adopted both spoken and unspoken
protocols dictating how a person’s gender should align with their birth sex [1].
While the majority of the population has a gender identity that conforms with their
biological sex, a subset of people do not share this experience. Interestingly, there is
a growing body of evidence suggesting one’s brain has anatomic ndings that reect
their preferred biological sex rather than their assigned biological sex [2]. As a person’s gender identity, role, or expression begins to contrast with gender norms for a
given sex, they are considered transgender/gender nonconforming. While gender
nonconformity is a blanket statement for the extent one’s gender expression deviates from cultural norms, gender dysphoria is the marked stress and discomfort
resulting from the inconsistency between birth sex and gender identity [3]. It is
within the gender dysphoria population that gender-afrming surgeons nd themselves tasked to address surgical needs to alleviate distress on the road to acceptance
for their desired gender expression and identity.
Validation and support for the transgender community begin long before the surgery date. In addition to understanding transgender terminology, the proper use of
pronouns is vital to generating trust and respect with patients. Misgendering patients
continues to serve as a barrier to healthcare access for the transgender community
[3–5]. To counteract this issue, it is recommended that gender-afrming surgeons
make inclusive questions and language part of their daily routine, including asking
each patient their preferred pronouns. Proactive measures are the foundation for
building relationships and achieving long-term treatment goals.
A. Frazier et al.
Epidemiology
The question that arises during gender-afrming surgery discussions is that of need.
What is the prevalence of people who identify as transgender, and how many have
gender dysphoria that requires medical and surgical intervention? In the United
States, most recent studies have identied anywhere between 0.4% and 3% of the
population identify themselves as transgender [6, 7]. This equates to, at the very
least, over one million people in the United States who are transgender. International
studies over the years have discovered the prevalence of those living with gender
dysphoria to range from 1:11,900 to 1:45,000 for male-to-female individuals (MtF)
and 1:30,400 to 1:200,000 for female-to-male (FtM) individuals [3]. Though studies
range in their methodology, there is a common theme among scholars: the population of transgender and those living with gender dysphoria is grossly underestimated. Reasons for this discrepancy include but are not limited to access to
healthcare, discrimination and fear surrounding gender nonconforming individuals,
and lack of education to both healthcare providers and the public [3, 6, 7]. Since it
20 Gender-Afrming Facial Surgery: Ofce-Based Procedures
https://t.me/medicina_free
is assumed the true population of transgender individuals is underrepresented, the
question becomes not whether the need exists, but how can surgeons advocate for
transgender patients through medical and surgical intervention.
Inaccurate representation of the transgender population is in part due to discrimination in healthcare environments. Roughly one-third of transgender patients have
reported some form of harassment or outright denial of service in a medical setting,
causing many transgender people to postpone medical care altogether [2]. There
are, therefore, health disparities unique to the transgender population such as higher
than average rates of HIV, drug, and alcohol dependence found in transgender populations. Notably, with the absence of regular care to monitor hormone therapy, one
in four transgender people have turned to self-prescribing illegally obtained crosssex hormones to manage their dysphoria [2]. Further, without adequate attention to
the subject, transgender patients who should be screened for cancer/disease associated with sex are overlooked. Not only is this dangerous if pathological processes
go undiagnosed, but without transgender-competent providers, transgender patients
who are screened for organ-associated disease processes can experience further
physical and emotional distress when the screening does not afrm their gender [3].
Finally, suicide and suicidal ideation are alarmingly high in this population and
should be addressed in the context of psychosocial considerations as a whole.
In the United States, the annual rate for suicidal ideation is 4%. This is a staggering contrast to the transgender community, where reports of suicidal ideation reach
as high as 50% of the population [8]. The reason behind such a stark contrast is
multifactorial but is centered around the psychosocial pain and stress faced by the
transgender community due to discrimination within society. Transgender people
are twice likely to be refused a job compared to cis-LGB (lesbian, gay, and bisexual
individuals who identify with their assigned birth gender) employees, have 2.2×
greater risk of homelessness than non-LGBT (lesbian, gay, bisexual, transgender)
individuals, experience 71.1 violent victimizations per 1000 people compared to
19.2 per 1000 non-LGBT people, and are overall more likely to experience prejudice and bullying from peers and family [3, 9, 10, 11]. The levels of anxiety, depres-
sion, eating disorders, self-harm, and suicidal ideation are inuenced heavily by the
experiences transgender people have in their daily lives. It is important to be cognizant of health disparities and psychosocial considerations in the transgender community to educate, refer to specialists, and support them in continuity of care.
351
Gender-Afrming Care
With a broad understanding of transgender terminology and epidemiology, the discussion can appropriately shift to medical interventions and their associated criteria
for transgender patients. The current authority on transgender treatment guidelines
is The Standards of Care Version 7, researched and constructed by the World
Professional Association for Transgender Health (WPATH). In short, this document
352
https://t.me/medicina_free
A. Frazier et al.
functions “to provide clinical guidance for health professionals to assist transsexual,
transgender, and gender-nonconforming people with safe and effective pathways to
achieving lasting personal comfort with their gendered selves, in order to maximize
their overall health, psychological well-being, and self-fulllment.” [3] An important aspect of these guidelines are criteria for hormonal and surgical intervention.
For both hormonal and surgical intervention, it is required to have (1) persistent,
well-documented gender dysphoria (12months for surgical intervention), (2) the
capacity to make fully informed decision and to consent for treatment, (3) age of
majority in a given country, and (4) reasonably well-controlled medical or mental
health concerns if present. Additional requirements for surgery include (1) referrals
from a qualied mental health professional, (2) hormone therapy, and (3) 12 continuous months of living in a gender role that is congruent with their gender identity.
The 12-month criteria serve as an evidence-based timeline to give patients ample
time to socially adjust to the desired gender role before undergoing irreversible
interventions [3].
Given the above criteria, most gender dysphoria patients who present for
gender- afrming facial surgery consultations have had hormone and other surgical therapy. For hormone therapy, dosage and regimen vary greatly depending on
the person and predisposing risks for complications. For feminizing medications,
a combination of estrogen and anti-androgens are most commonly used. Given the
risk of venous thromboembolism (VTE) associated with high-dose exogenous
estrogen, transdermal estrogen is recommended, and anti-androgen medications
minimize the amount of estrogen needed to suppress testosterone [3]. Common
anti-androgenic hormones include spironolactone (Aldactone), cyproterone
(Androcur), GnRH agonists (Eligard, Lupron Depot), and 5-alpha reductase
inhibitors (Avodart, Propecia). For masculinizing hormones, testosterone is sufcient, although progestins can be used in the early stages for a short time to aid
in menstrual cessation [3]. The degree/rate of physical effects and development of
risks depends on the medication(s) of choice, dose, and route of administration.
Risks as dened by the standard of care are categorized by “likely increased risk,”
“possible increased risk,” and “no increased risk or inconclusive.” Feminizing
hormones are associated with a likely increased risk of complications like VTE
and hypertriglyceridemia, but there is currently no increased risk of breast cancer.
Masculinizing hormones are associated with a likely increased risk of complications like polycythemia, male pattern balding, and sleep apnea, but there is currently no evidence to support risk of breast, cervical, ovarian, or uterine cancer
[3]. These risks and other potential risks are summarized in Table20.1. In general
and although highly variable, physical changes are expected to occur over the
course of 2years [3] (Table20.1).
20 Gender-Afrming Facial Surgery: Ofce-Based Procedures
https://t.me/medicina_free
Table 20.1 Risk of various diseases associated with feminizing and masculinizing hormones
Feminizing hormones Masculinizing hormones
• Breast cancer • Breast cancer
• Cervical cancer
• Decreased bone density
• Ovarian cancer
• Uterine cancer
• Hyperprolactinemia
• Hypertension
• Prolactinoma
• Type 2 diabetes
• Cholelithiasis
• Elevated liver enzymes
• Hyperlipidemia
• Venous thromboembolism
• Weight gain
• Cardiovascular disease
• Elevated liver enzymes
• Exacerbation of psychiatric disorder
• Hyperlipidemia
• Hypertension
• Type 2 diabetes
• Acne
• Andogenic alopecia
• Polycythemia
• Weight gain
• Obstructive sleep apnea
No known increased
risk of these outcomes
Possible increased risk
Increased risk
353
The Facial Skeletal andSoft Tissue Differences
The foundation for facial feminization surgical planning must be a sound knowledge of anatomy and its variations between men and women. Over the years, anthropometric and cephalometric studies have determined facial sex differences are most
noticeable in the forehead/supraorbital ridges, orbital borders, malar eminences,
nose, mandible, and neck form [12, 13]. It is important to note there are other variables that affect facial shape and proportions besides gender, such as race and age;
however, for the purpose of this discussion, craniofacial and soft tissue standards
are compared only between males and females.
The craniofacial skeleton has distinct bony that are the target of facial feminization procedures. Overall, the male face is wider and longer in regard to both the
skeletal and soft tissue due to the length of exposure to and amount of testosterone
during development. There are standard measurements that delineate the general
differences in facial width and height between men and women: Fig.20.1.
Not only is the male face larger overall, but variations exist within each facial
third. With the upper facial third, the forehead and orbital rims differ between males
and females. In females, their forehead slope tends to be more vertical, they have
more obtuse nasofrontal angle, and less projection of lateral orbital rims. The angulation in the forehead slope is measured relative to the vertical plane through the
glabella [13].
354
https://t.me/medicina_free
A. Frazier et al.
The supraorbital and lateral orbital rims normally project 5–10mm beyond the
anterior corneal plane and are far more pronounced in men than women [13]. In
addition, the nasion in males is deeper than in females [6]. As a result, the nasofrontal angle in men is more acute than in females [13] (Fig.20.2).
Fig. 20.1 Masculine and feminine craniofacial skeletal measurement norms. (a) Bizygomatic
width, the widest portion of the face [13]: male: 140mm+/−4mm; female: 130mm+/−5mm (b)
Bigonial width, generally 70–75% of the bizygomatic width [13]: skeletal: male: 96+/−7mm;
female: 90+/−7mm
Fig. 20.2 Preoperative (left) and postoperative (right) lateral view demonstrating increase in nasofrontal angle postoperatively in facial feminization surgery
Соседние файлы в папке @xirurgi_2025