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20 Gender-Afrming Facial Surgery: Ofce-Based Procedures
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The segments analyzed in the lower facial third include the mandible and the
chin. The measurements of mandibular height and length in terms of generalized
facial size differences have previously been discussed. In addition to overall size of
the mandible, the mandibular plane and gonial angles are compared. While these are
different landmarks for standardized measurements, they often correlate. These
angles tend to be sharper and more dened in males [14] (Fig.20.3).
Paralleling the greater mandibular size found in males, the male chin is wider
than in females. In the female skeleton, the transition from gonial angles to the chin
follows a smoother contour than in men, ending in a single chin point (single light
reection). Males, on the other hand, have a more rectangular chin morphology and
are considered to have a double chin point (double light reection) [13]. The chin is
also projected further anterior in males, as demonstrated by Riolo et al. [14]
(Fig.20.4).
The nal element of the craniofacial skeleton often used as an objective for facial
feminization surgery is the thyroid cartilage. Adam’s apple changes in response to
levels of testosterone during puberty with the development of secondary sex characteristics [14]. It increases along the sagittal dimension, lengthening the vocal cords
and deepening the voice [15]. This change in the sagittal dimension is due to the
interlaminar angle between the thyroid cartilage and is classically more acute in
males, causing the laryngeal prominence to protrude to a greater degree than in
females [15].
In addition to differences in the craniofacial skeleton, soft tissue differences
between men and women are also evaluated for facial feminization surgery.
Beginning with facial hair, there are several distinctions between the male and
female face. First, only males typically have facial hair due to higher levels of testosterone. Men also tend to have an “M-shaped” hairline that is at baseline higher
than the female hairline [12].
Fig. 20.3 Gonial angle, posterior border of the ramus to the mandibular plane [13]. Preoperative
(left) and postoperative (right) facial feminization surgery lateral views of mandibular gonial
angle. Superimposed normative angle measurements for males and females. Male: 124°+/−6°,
female: 122°+/−4°
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Fig. 20.4 Frontal view chin. Preoperative (left) and postoperative (right) facial feminization surgery demonstrating wider chin in the preoperative masculine face and narrowed, more-rounded
chin contour in the postoperative feminine face
A. Frazier et al.
Forehead height, nasion to trichion:
Male: 70mm
Female: 64mm
As men age, their hairline shape becomes more pronounced as their hairline
recedes at an earlier age on the lateral aspect than in the midline [12]. The male
and female eyebrows also differ in both position and shape. The male eyebrow
is positioned horizontally on the supraorbital rim, while the female eyebrow is
naturally arched with an apex is 8–10 mm superior to the supraorbital rim
[12, 13].
It has already been addressed that the zygomatic arch width is the widest portion
of both the male and female face. There are also important soft tissue differences
within the midface; specically, the Ogee curve varies signicantly between men
and women. The transition of the bony zygoma laterally to the maxilla centrally
results in a convexity over the cheek and a concavity toward the lower midface.
From looking at the face at a 45° angle, this double curve is called the Ogee curve
[16]. It is more pronounced in females as females tend to have more malar fat volume, while men have more buccal fat pad volume and is a marker of a youthful and
aesthetically pleasing feminine face [6] (Fig.20.5).
The lips also demonstrate soft tissue differences between men and women.
Length, volume, and projection of the lips are considered for facial feminization
procedures. Overall, women have a greater lip volume under the inuence of estrogen [6]. While there is no signicant difference in lower lip length, the upper lip
length is typically shorter in females: [8] Females also have an increased proportion
of vermilion height to overall lip height, resulting in greater vermillion exposure [8]
(Fig.20.5).
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Fig. 20.5 Three/four view Preoperative (left) and postoperative (right) facial feminization surgery
demonstrating Ogee curve in the feminine postoperative face and decreased upper lip length with
increased vermillion show
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Upper lip height, subnasale to stomion superius:
Male: 22+/−2mm
Female: 20+/−2mm
All of facial feminization surgery must be guided by a sound understanding of
differences between the male and female face. With these standards in mind, surgical technique can be explored. The primary surgical procedures for facial feminization address skeletal differences and include front-orbital recontouring and anterior
frontal sinus wall setback, lateral orbital recontouring, rhinoplasty, malar implants,
genioplasty, gonial angle reduction, and tracheal shave “Adam’s apple reduction.”
Facial masculinization procedures are typically less common because testosterone
supplementation in the FtM patient results in growth of facial hair, coarser features,
and recession of the hairline. As a result, “passing” as their preferred gender identity
is generally easier in this population. However, masculinization procedures typically include advancement genioplasty, mandibular angle implants, and neurotoxins
to the forehead to masculinize the brows.
Common procedures performed in-ofce under local anesthesia or sedation are
detailed in the remaining portion of this chapter. One exception is hairline advancement, which is often performed in ofce but typically also requires hair transplantation techniques to optimize outcomes.
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A. Frazier et al.
Ofce-Based Procedures forFacial Gender Afrmation
Tracheal Shave
A curvilinear incision is marked in a crease of the neck cephalad to the cartilage and
measuring approximately 2.5cm. A smaller incision is most ideal to hide the scar in
the crease. Access from this point instead of at a site in the submental region (as
used in access for platysmaplasty) provides easier access and exposure to the cartilage while keeping the healed incision hidden in a natural neck crease (Fig.20.6).
The incision site and subcutaneous tissues adjacent to the laryngeal cartilage are
inltrated with 1% lidocaine 1:00 K epinephrine. A #15 blade is used to incise
through skin and inltrated tissue. Dissection in the subcutaneous plane continues
with iris scissors to undermine the skin incision for closure. Dissection continues
inferiorly toward the laryngeal cartilage and careful dissection deeply through the
platysma will reveal paired infrahyoid muscles. Care should be taken in to also
avoid vascular structures including the anterior jugular vein and its tributaries.
Bipolar electrocautery is preferred. The infrahyoid muscles are released at the midline in the longitudinal plane revealing the perichondrium of the laryngeal cartilage.
In some cases, particularly in the older subset of patients, the cartilage has calcied.
The superior aspect of the laryngeal cartilage is incised bilaterally along the superior aspect and at the midline to just below the most prominent portion of the
Fig. 20.6 Anterior view of
masculine neck with
Adam’s apple prominence.
(a) Incision site in neck
crease. (b) Area of
anticipated cartilage
excision
a
b
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cartilage. A woodson or caudal elevator is used to dissect into the subperichondrial
plane onto the cartilage. If the cartilage is still immature, the incision may incise
completely into the cartilage, making dissection under the perichondrium more difcult, so it is important to minimize pressure on the #15 blade with an effort to
incise only through the perichondrium. Once a perichondrial plane has been elevated, the upper half of the laryngeal cartilage should be exposed. This should
reveal the area for cartilage removal that comprises the laryngeal prominence and
the bilateral superior wings of the cartilage.
The excision should be in the shape of a “V” and include the laryngeal prominence as long as the laryngeal prominence is superior to the insertion of the vocal
cords. In most cases, however, this can be predetermined in two ways. First preoperative CT scan can demonstrate the site of insertion of the vocal folds into the
anterior aspect of the cartilage. Second, the site of insertion can be marked at the
time of intubation of the video laryngoscopy that is used for endotracheal tube
placement. A syringe loaded with methylene blue and with a 19G needle can be
visualized by entering through the skin at the anticipated level of the vocal cords.
The video laryngoscope will demonstrate the needle at the site of the vocal cords,
and a small amount of methylene blue is injected here to mark the site of the chords
on the external surface of the laryngeal cartilage. This technique gives the surgeon
a marked hard stop for cartilage removal on the anterior aspect of the prominence.
In general, chord insertion is at the approximately 2/5 to ½ way point from the superior prominence to the inferior border of the cartilage. Measuring with a ruler and
marking this site is also an acceptable method to avoid disinsertion of the chords
(Fig.20.7).
The area intended for excision and/or reduction is marked with a surgical pen.
Removal can be completed in variety of ways. A #15 or #11 blade is used to remove
noncalcied cartilage. Rongeurs can remove the cartilage and prominence quickly,
Fig. 20.7 Schematic
lateral view of thyroid
cartilage indicating site of
vocal cord insertion
inferior to the most
prominent aspect of the
thyroid cartilage and
approximately 2/5 to ½
distance from notch to
inferior border
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as can a round diamond bur. This author prefers the use of an ultrasonic cutting
device to ensure that there is minimal damage to the perichondrium. Cartilage burring or shaving can continue below the marked level of the chords, but the surgeon
should be cautious to avoid thinning this area too much. A good marker for thinning
is that cartilage becomes a little purplish or mauve, and this indicates a necessary
stopping point of reduction to avoid voice changes. Once the area planned for excision has been removed, the tissues are replaced and the patient is viewed from the
lateral angle to ensure that adequate removal has been completed. The margins of
the excised areas are then smoothed with a bone le and wound is thoroughly
irrigated.
Closure begins by closing the perichondrium back over the laryngeal cartilage.
This step is tedious and difcult because the perichondrium is thin and often difcult to reapproximate; however, this is an imperative step to ensure that raw cartilage is not exposed to the subcutanenous tissues and results in scarring of the
cartilage directly to the skin. This leaves a tell-tale motion defect upon swallowing
where the skin is obviously tethered over the cartilage and does not move freely
upon swallowing (tracheostomy defect). The perichondrium is closed with 5-0
monocryl. The infrahyoid strap muscles are then reapproximated at the midline with
a running interlocking 4-0 vicryl suture. Closure of the skin is then completed with
5-0 monolament.
A. Frazier et al.
Gonial Angle Reduction
Several methods exist to narrow the width of the lower face at the level of the gonial
angles. The goal is to achieve a tapered feminine face with proportionate bigonial
width to bizygomatic width and increased mandibular plane angle. This ratio for
bizygomatic to bigonial width should be approximately 70% for a feminine face.
The masculine mandibular angles are generally ared, and lateral shaving of the
mandibular angles can be accomplished with bur reduction (either rasp or pineappleshaped bur) to remove the laterally projecting portion of the angles. This author’s
preferred method, however, is a complete ostectomy of the mandibular angles from
the gonial notch to the posterior aspect of the ramus. Access for either of the methods is accomplished in the same manner (Fig.20.8).
An intraoral incision is completed along the anterior ramus along the external
oblique ridge measuring approximate 3cm. Dissection is competed along the lateral
aspect of the ramus with the patient in a closed mouth position to optimize exposure
and visualization. Dissection continues in the subperiosteal plane to expose the
entire mandibular angle. A toe-out or bower retractor is placed on the posterior
aspect of the ramus to dene the superior extent of the ostectomy on the posterior
ramus. If the intention is only for lateral shaving, this can be completed at this time,
with care to avoid traumatizing the periosteum lying deep to the masseter muscle as
injury to the muscle will result in signicant bleeding and difcult visualization of
the eld. To completely excise the mandibular angles, the area of excision is marked.
20 Gender-Afrming Facial Surgery: Ofce-Based Procedures
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Fig. 20.8 Intraoperative
view of access for lateral
gonial angle reduction
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This can be completed with preformed 3D guides or simply by direct visualization
and marking of the area. A reciprocating saw, IVRO saw, or piezoelectric saw is
used to remove the demarcated angle to the gonial notch. Preoperative planning of
some form is imperative since the ostectomy should be completed at least 5mm
from the inferior alveolar canal. Osteotomes are often necessary to complete the
fracture. Once the gonial angle has been removed, or the lateral reduction completed, the site is smoothed with a rasp or bone le. The body of the mandible may
also need lateral reduction for a more feminine facial taper, but this should be minimal since the lower face tissues are supported by the mandible, and removal of the
bony support will result in increased sagging and jowling of facial tissues and overall contribute to facial aging. In some cases, the mandibular width reduction should
be accompanied by rhytidectomy to re-suspend the facial tissues in a superolateral vector.
The site is fully irrigated and closed with running interlocking chromic gut
sutures.
Genioplasty
The primary rational for genioplasty for gender afrmation in the male to female
patient is to decrease the chin width. While there are no masculine or feminine standards for chin width, the overall goal of the surgical procedure is to create a tapered
face. The masculine chin is wider and boxy, while the feminine chin is narrow,
tapered to point, and projected.
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A. Frazier et al.
Width reduction genioplasty can be accomplished without 3D planning and standard genioplasty techniques; however, 3D planning is optimal since the central portion planned for excision may be coincident with the insertion of the tongue
musculature at the genial tubercle. Accidental excision of the genial tubercle can be
catastrophic and result in glossoptosis, postoperative airway compromise, and
obstructive apnea. Therefore, it is imperative that either the genial tubercle is not
included in the resection area or the muscle insertions at that site are re-positioned
and suspended by the remaining mandibular bone or titanium plate.
Titanium or hybrid cutting guides are useful and time-saving for width narrowing genioplasty. The guides will demarcate the area of excision of the central portion for excision and the sites for the standard mandibular ostectomy. This ostectomy
should be at least 5mm below the bilateral mental foramina.
The procedure begins with standard genioplasty incision from the level of the
lower premolar teeth posteriorly progressing anteriorly into the lip mucosa and submucosa and down through the mentalis muscle. The incision should be anterior
enough to allow for enough proximal mentalis muscles and a cuff of 2–3mm of
non-attached gingival al tissues on the alveolar aspect of the wound for closure.
Dissection is completed down to bone to expose the anterior aspect of the mandible
to the inferior border. The dissection is carried laterally and the mental nerved is
identied and retracted superiorly. The central wedge for excision is marked and a
reciprocating saw, oscillating saw, or piezoelectric or ultrasonic bone cutting device
is used to create vertical osteotomies for the planned excision. A screw is placed at
this site and a suture or hemostat is placed on the screw to avoid retraction of this
central wedge into the oor of the mouth once the wedge osteotomy is completed.
The planned horizontal osteotomy through the entire anterior portion of the mandible is completed with a reciprocating saw. If necessary, osteotomes are used to
complete the posterior aspect of the cuts. The central wedge is then removed and
lateral pieces are reapproximated and held in place with the inferior lateral holes of
a square or rectangular titanium plate (Fig.20.9).
If projection of the chin is also indicated, the plate is also bent to accomplish the
desired chin projection. Projection of the chin is typically aesthetically favorable if
the gonial angles have been resected– this helps to enhance the jaw contour and
Fig. 20.9 Intraoperative
view of width reduction
genioplasty after
placement of titanium
xation plate
20 Gender-Afrming Facial Surgery: Ofce-Based Procedures
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suspend the soft tissues that can contribute to jowling. If there is signicant vertical
space between the new chin position and the native bone, interpositional grafts from
the mandibular angles can be inserted here. The plate is secured with titanium
screws and the suprahyoid musculature is suspended to the inferior aspect of the
titanium plate with long-lasting resorbable sutures.
Attention is then turned to the bilateral inferior borders of the mandible.
Excision of the wedge of bone produces a step deformity of the inferior cortex. An
egg- shaped bur should be used to smooth the defect and produce a more discreet
contour from native bone to the newly medially advanced portion of the anterior
mandible. The wound is then thoroughly irrigated. The mentalis muscle is carefully reapproximated with 3-0 vicryl, followed by closure of the mucosa with
chromic gut.
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Lip Lift
The lip lift procedure is an ideal procedure for in-ofce gender afrmation in the
male to female transgender patient. The procedure can be completed under local
anesthesia or sedation. It is generally well tolerated and typically takes less than 1 h
to complete.
The masculine upper lip is longer than that of the feminine lip, and aging will
contribute to the overall upper lip length. This combination makes the lip lift procedure both important and highly effective in gender afrmation surgery for the male
to female patient.
Lip length is measured preoperatively, and lengths in excess of 20mm are generally masculine and unaesthetic. Additionally, if less than 8 mm of vermillion is
shown at rest, then the patient would likely benet from a lip lift procedure. The lip
lift has two main effects, (1) decreasing the overall upper lip length and (2) increasing the amount of pink vermillion demonstrated at rest.
The bullhorn incision is preferred because the scar is easily hidden in the natural
limits of the aesthetic subunit. The lip is marked preoperatively and a dened area
of excision is measured to create a nal lip length of approximately one-third of the
total height of the lower face height. This is typically around 14mm. Excision of too
much skin from this area is problematic, since there will be too much tooth show
and may result a gummy smile.
Once the area of excision is marked, local anesthesia is injected at bilateral inferior orbital blocks with 2% lidocaine 1:100k epi and local inltration at the incision
site only. This ensures that the tissues are not distorted with local inltration.
A #15 blade is used to create the bullhorn subnasal incision (Fig.20.10). The
inferior tissue is undermined in the subcutaneous plane. The paired columellar
arteries are encountered and cauterized. Once dissection is completed to the vermillion border, a single 4-0 vicryl suture can be used horizontally at the level of the
cupids bow to re-establish philtral columns. Alternatively, in highly aged or atrophic
lips lacking architecture, philtral columns can be created with running 5-0 vicryl
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Fig. 20.10 Intraoperative
photo of bullhorn-shaped
incision for feminizing
upper lip lift
A. Frazier et al.
suture in the subdermal plane from each cupids bow peak to the corresponding lateral columella. Deep 4-0 vicryl sutures are used to close the incision followed by
6-0 monolament suture in the skin.
Use ofInjectable Medicines inGender Afrmation
The use of injectable medicines such as neurotoxins and hyaluronic acid llers can
be important adjuncts in facial gender afrmation. In the male to female patient,
neurotoxins are benecial reducing horizontal and vertical forehead rhytids and
raising the brows for a more arched and feminine position so that the apex of the
brow is positioned 1cm above the orbital rim and the tail at approximately 12mm
above the rim. This can be accomplished with neurotoxin injections to the forehead,
glabella, and lateral orbicularis oculi muscles. Conversely in the female to male
transgender patient, neurotoxin can be delivered throughout the forehead only without treatment of the forehead depressors. This lowers the brows uniformly into a
horizontal position onto the orbital rim and creates the appearance of a prominent
frontal bone projection at the level of the brow. Neurotoxin is also benecial for the
male to female for lip projection and eversion. 4–8units of neurotoxin into the
upper portion of the orbicularis oris creates a temporary lip lift and exposes more
vermillion. Similarly, injection of neurotoxin into the depressor septi muscle at can
rotate the nasal tip upward and create a slightly more feminine nose projection for
those patients with downturned nasal tip.
Hyaluronic acid and other llers are also a useful adjunct for gender afrmation.
Creating an Ogee curve and feminine cheek with heavy body ller in the malar
region can be highly feminizing. Lip augmentation with ller is also typically indicated in transfeminine patients and can be completed either before or after surgical
lip lifting. In many cases, malar implants or dermal-fat lip grafts can be a more
permanent solutions in these areas, and these procedures are often coupled with
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