For patients with gender dysphoria undergoing male-to-female transformation, a stepwise approach to facial feminization surgery (FFS) leads to good cosmetic outcomes along with psychological, social, and functional benefits, according to a study in the February issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Dr. Tommaso Agostini and colleagues of the Face Surgery Center in Parma, Italy, report high patient satisfaction rates using their standardized protocol for male-to-female FFS. "The reduction of gender dysphoria has psychological and social benefits and significantly impacts patient outcomes," the researchers write.

Six-Month Process Provides 'Excellent Cosmetic Results'

Facial feminization surgery -- along with psychotherapy, hormone treatment, and gender reassignment surgery -- is an important part of the treatment plan for some patients with gender dysphoria. "Gender dysphoria refers to the discomfort and distress arising from a discrepancy between a person's gender identity and sex assigned at birth," Dr. Agostini and coauthors explain.

Their recommended approach to FFS targets the key facial characteristics that differentiate males from females. Full FFS may include forehead remodeling, surgery to change the appearance of the nose and chin, thyroid surgery to reduce the "Adam's apple," and voice alteration procedures.

From 2003 to 2013, Dr. Agostini and colleagues performed FFS in 33 patients, aged 19 to 40. About half of the patients had previously undergone breast augmentation, while one-fifth had undergone genital surgery. For some patients, genital and FFS procedures were overlapped, speeding up the overall gender reassignment results.

The patients underwent a total of 180 surgical procedures for FFS, with no major complications. Most completed FFS in six months. The process was longer and the order of the procedures was different for patients who also required orthodontic treatment.

In follow-up surveys, the patients reported significant improvements in quality of life, including physical, mental, and social functioning. More than 90 percent of patients "very much" or "completely" agreed that they liked the appearance of their face and that it appeared feminine.

On evaluation of postoperative photographs, independent surgical specialists rated the cosmetic results as "very much improved" in 88 percent of patients, and "significantly improved" in the rest. "Both frontal and profile views achieved a loss of masculine features," the researchers write.

The researchers outline their approach to full FFS for male-to-female transition, including a flowchart prioritizing the procedures for addressing the hard and soft tissues of the upper and lower face. "Our proposed protocol is well-accepted by patients, has a low complication rate, and is reproducible by other surgical centers," Dr. Agostini comments.

The researchers believe their approach leads to excellent cosmetic results of FFS as part of male-to-female transformation, providing patients with a more feminine facial appearance and improvement in key aspects of quality of life. Dr. Agostini and colleagues conclude, "The result was a high degree of patient satisfaction, since FFS was approached as a unified process."