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Aesthetic considerations in secondary procedures for gender reassignment
Scientific Forum
Aesthetic Considerations in Secondary Procedures for Gender Reassignment Steven P. Davison, DDS, MD; Matthew S. Clifton, BS; William Futrell, MD; Robert Priore, MD; and Ernest K. Manders, MD
Background: Patients who have successfully undergone gender reassignment surgery seek further aesthetic refinements to suit their new gender role. Objective: The study evaluated secondary aesthetic procedures, laryngeal surgery, and adjuvant hormone therapy in 22 male-to-female gender reassignment change patients. Methods: Thirty-two aesthetic procedures performed in 22 patients were evaluated for operation type, surgical technique, complications, and satisfaction rates. Aesthetic procedures included rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasty, cheek or chin surgery, and body contouring. Results: A wide range of secondary aesthetic procedures was successfully performed with only 1 minor complication and 1 major psychological depressive episode. Conclusions: Secondary surgery in gender reassignment patients extends the frontier of aesthetic surgery and provides lessons that can be extrapolated to facial and body contour aesthetic surgery in the general patient population.
G
ender reassignment is a complex and individual process that involves a large spectrum of physiologic and surgical changes. Many patients seek a life transition in outward appearance alone, and actual sexual reassignment surgery may not be a goal of many transgender individuals. Almost all patients seeking a new persona will desire surgery that alters features and reveals their new phenotypes. Most of these procedures involve the face, because it is so intimately associated with individual identity and serves as a reflection of personality and emotions.1
Medical treatment can effect some of the desired changes. In female-to-male transition, administration of testosterone can produce changes in body habitus, beard growth, hairline recession, changes in voice, and growth of body hairs. In male-to-female patients, administration of estrogens can result in widespread changes in body habitus, atrophy of the male external genitalia and testes, arrested hair loss, changes in voice, and gynecomastia. Spironolactone taken orally has a number of antiandrogenic effects.2 Primary surgery for male-to-female gender reassignment patients includes removal of the testes and phallus, vaginoplasty, and breast augmentation. Surgical treatment for the female-to-male transition includes hysterectomy, oophorectomy, vaginal obliteration, penile reconstruction, scrotal reconstruction with implants, and associated bilateral mastectomy with areolar reduction.
AESTHETIC
SURGERY
JOURNAL
~
From the Division of Plastic Surgery, Georgetown University Medical Center, Washington, DC (Dr. Davison and Mr. Clifton), and the Division of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Drs. Futrell, Priore, and Manders). Accepted for publication July 17, 2000. Reprint requests: Steven P. Davison, DDS, MD, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007. Copyright © 2000 by The American Society for Aesthetic Plastic Surgery, Inc. 1084-0761/2000/$12.00 + 0 70/1/111544 doi:10.1067/maj.2000.111544
NOVEMBER/DECEMBER
2000
477
Scientific Forum
Many patients undergoing transgender surgery are also interested in secondary aesthetic procedures and modification. These include changes in facial aesthetics, voice, and body contouring that is not limited to breast removal or subsequent breast augmentation. Female-to-male aesthetic surgery procedures include chin augmentation, suction-assisted lipectomy of the hips and lower abdomen, and laryngeal surgery to deepen the pitch of the vocal cords, which is typically followed by voice training.3 Secondary aesthetic procedures in male-to-female patients include anterior hairline reconstruction, brow lift, rhinoplasty, face lift, blepharoplasties, cheek augmentation, chin reduction, lip elevation and augmentation, tracheal shave, and raising of the vocal pitch.4 In this article, we review 32 aesthetic procedures in 22 male-to-female gender reassignment patients. The patients were followed closely with medical/surgical management, psychological evaluation, and advanced social support addressed specifically to the transgender patient. This retrospective study evaluated the types of surgery involved and the success and complication rates associated with the gender reassignment patients.
Materials and Methods Each of the 22 male-to-female gender reassignment patients followed in this study either underwent a complete gender reassignment with secondary aesthetic procedures or had previously undergone gender reassignment surgery and returned for subsequent secondary aesthetic procedures. The patients were evaluated preoperatively in a transgender surgical and medical clinic. Two independent psychological evaluations were required for patients who underwent genital reassignment surgery but not for those who had secondary aesthetic procedures. Secondary surgery that involved the genitals or breasts, including mastectomy, breast lipoplasty, or breast augmentation, was considered to be part of the primary transgender process rather than a secondary procedure and was not included in this study. The facial aesthetic procedures performed were rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasties, and cheek or chin surgery. Advancement of the hairline after expander scalp therapy was performed to remedy the problem of male pattern baldness. Body contouring included lipoplasty and removal of the eleventh and twelfth ribs to narrow the inferior aspect of the rib cage and create a more feminine waist. Tracheal shaves and laryngeal framework surgery for
478
AESTHETIC
SURGERY
JOURNAL
~
alterations in voice pitch were considered to be secondary aesthetic procedures. Data collection included review of preoperative and postoperative clinic notes, surgical details, and perioperative hospital costs. A detailed telephone and written survey was used to record patient satisfaction. A postoperative complication was recorded as minor if it did not require surgical intervention and major if it did require such intervention. Surgical technique Facial surgery. The nose can be feminized by reducing the
dorsal hump, narrowing the tip and dorsum, increasing the nasolabial angle with upward rotation of the tip, and/ or decreasing the projection.5 A reduction genioplasty enhances the facial contour.1,6 Rhytidectomy should follow completion of electrolysis to avoid the distribution problems associated with bearded skin. Adjuvant facial resurfacing may be needed to assist in replacing coarser skin. In the male-to-female patient, the anterior hairline is a significant consideration. The ability to wear a feminine coiffure is affected by male pattern baldness. Anterior hairline incisions were used to place crescentic expanders. After appropriate expansion, the anterior receding brow exposed by hair recession was resected. Simultaneous brow lift and elevation of the lateral brow can be performed at this time. Supraorbital fullness associated with men can also be reduced.5 The expanded hair-bearing scalp allows for substantial advancement (Figure 1). Hair loss can be curtailed by administration of finasteride (1 mg/d) or minoxidil creams (2% or 5%). Currently, these are the only drugs approved in the United States for treatment of alopecia resulting from the effects of circulating androgens. Both drugs can slow the thinning process and enlarge existing hair, thereby increasing scalp coverage.7 Body contouring. Traditional approaches to body contouring have included lipoplasty of the male pattern abdominal fat deposition in the “love handles” and anterior abdomen. However, the female torso is substantially more “hourglass shaped” than the more “boxy” contour exhibited in men. Superficial lipoplasty and fat injection were used to assist in remodeling the body’s contours.8 The removal of the eleventh and twelfth ribs through minimal posterior flank incision can also help in achieving this more shapely appearance. A 4- to 5-mm incision was made along the interspace between the eleventh and twelfth ribs, which was then extended deeper to include incision of the subcutaneous tissue and muscular fascia of the latissimus dorsi muscle (Figure 2). After the underlying muscle fibers were
NOVEMBER/DECEMBER
2000
Volume 20, Number 6
Scientific Forum
A
B
C
D
Figure 1. Brow lift surgery in a transgender patient. A, Anticipated brow reduction after 3 months of scalp expansion. B, Postoperative view shows restored hairline in the temporal region 6 months after surgery. C, Exposure of the crescentic expander with anticipated resection of lateral brow recession. D, Excess scalp created by expansion. E, Recreation of a widow’s peak and anterior hairline.
E
Aesthetic Considerations in Secondary Procedures for Gender Reassignment
AESTHETIC
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
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Scientific Forum
Table. Distribution and numbers of secondary aesthetic procedures performed Surgical procedure Tracheal shave Eleventh/twelfth rib resection Rhytidectomy/platysmaplasty Brow lift/blepharoplasty Rhinoplasty Laryngeal framework Lip/cheek augmentation surgery
Figure 2. Removal of the eleventh and twelfth ribs through minimal posterior incision.
adequately separated from the field, the rib periosteum was incised with electrocautery, separated from the rib with a periosteal elevator, and then stripped completely off the bone, care being taken not to disturb the pleura. The rib was then sectioned at the paraspinous level and excised. Continuity of the pleural space was confirmed with inspiration against a water-filled cavity. The wound was then closed with a multilayer technique. Laryngeal surgery. Laryngeal surgery includes laryngeal shave and raising of the vocal pitch. The vocal cords extend from the vocal process of the arytenoid cartilages to the isthmus of the inner surface of the thyroid cartilage. They are located at the level of the vocal fold line. The anterior point of this line is the midpoint between the thyroid cartilage notch and inferior border of the thyroid cartilage. The posterior point is measured superiorly from the lower border of the thyroid cartilage at the anterior root of the inferior cornu.9 To raise voice pitch, the vocal cord length was increased, thereby increasing cord tension and decreasing the vibration mass. In individuals without prior vocal modification, the cricothyroid muscle accomplishes this task. Its action can be replicated and/or assisted by creating a closer approximation between the thyroid and cricoid cartilages with a technique known as the Isshiki type 4. This approximation is performed through placement of 4 tension sutures, 1 pair on either side of the anterior midline of the neck, which shorten the space between the thyroid and cricoid cartilages.10
To achieve a more feminine neckline, the prominent thyroid cartilage, or “Adam’s apple,” was reduced but not eliminated.11 Incisions may be placed lateral to, above, or over the laryngeal cartilages in a natural crease. Because
480
AESTHETIC
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JOURNAL
~
No. performed 6 5 5 5 4 4 3
the resection of the thyroid cartilage is limited inferiorly by the position of the isthmus, care must be taken to preserve the laryngeal mucosa. Hormone therapy
Hormone therapy for the male-to-female transsexual consists of administration of both an estrogen and a progestin. Initial estrogen treatment consists of either ethinyl estradiol, 100 µg/d, or conjugated estrogens, 1.25 to 2.5 mg/d. Progestin administration can coincide with estrogen therapy or be delayed several months. Medroxyprogesterone acetate, 5 to 10 mg/d, is given for 10 days each month. The effects of this therapy are widespread, ranging from softening and decreasing the rate of facial hair growth to feminizing the body habitus of the patient by decreasing muscular bulk, softening the skin, and shifting body fat to the pelvic region. At least 2 years of this therapy is needed before maximum breast development is attained. Clinical and laboratory evaluations should be scheduled at 2- to 3month intervals after treatment is initiated. Further diminution of facial hair and the possible enhancement of breast development can be achieved with spironolactone, 100 to 200 mg/d in divided doses.2 The antiandrogenic effects of this drug include inhibition of 5α-reductase activity, increased peripheral conversion of testosterone to estradiol, and inhibition of testosterone synthesis pathways.12
Results Twenty-two male-to-female gender reassignment patients underwent a total of 32 aesthetic refinements. The breakdown of operations is seen in the Table. In all, 17 operations were facial aesthetic procedures, 5 were rib and body contouring procedures, and 10 were laryngealrelated. Patient satisfaction was high; 21 of 22 patients were satisfied with a more feminine appearance. However,
NOVEMBER/DECEMBER
2000
Volume 20, Number 6
Scientific Forum
after undergoing a rhinoplasty 1 patient underwent an exaggeration of preoperative psychological depression related to the transgender procedure. The one postoperative complication was a hysterical aphonia in a patient who underwent an anterior tracheal shave of the thyroid cartilage. The patient did well immediately postoperatively but within 12 hours was completely aphonic. A fiberoptic laryngeal evaluation revealed no airway obstruction, hematoma, edema, or closure of the vocal cords. The patient recovered promptly with outpatient voice therapy. The average cost per patient was approximately $9500, the average charge being $4700 incurred per procedure.
Discussion Gender reassignment surgery involves multiple phases, as follows: 1.
Physiologic changes associated with hormonal manipulation.
2.
Removal of, or change in, the primary sexual organs, including phalloplasty and vaginoplasty.
3.
Manipulation of secondary sexual organs by mastectomy or breast augmentation.
4.
Aesthetic refinements associated with the patient’s new gender. In the male-to-female gender reassignment patient, these refinements include feminization, demasculinization, and age restoration of the face and body. As many as 40% of male-to-female gender reassignment patients undergo secondary aesthetic procedures.4 In this retrospective study, 50% of the patients had undergone primary surgery elsewhere.
Areas of particular importance in assigning gender to the face and neck include the forehead, eyebrow, jaw, and thyroid cartilage. The contour typically exhibited by a female forehead is high, rounded, and more vertical2,13,14 than the male equivalent, which has a prominent supraorbital ridge13-16 and is characterized by a more wrinkled appearance.15 In women, the eyebrow lies above the supraorbital rim16 and has a considerable degree of arc.13,17 In contrast, eyebrow location in men exaggerates the impression of frontal bossing because it is positioned either immediately covering or slightly inferior to the supraorbital ridge.16 A square, pronounced jaw is traditionally associated with male gender, whereas in women a smaller, narrow, rounded chin is considered more aesthetically pleasing.9 In addition, a “cleft” in the soft tissue of the chin is typically associated with masculine features.15 The female neckline has a slender, longer appearance, caused in large part by a flattened thyroid cartilage and a
Aesthetic Considerations in Secondary Procedures for Gender Reassignment
AESTHETIC
depressed carrying angle of the shoulder girdle.7,16 The typical male neck, on the other hand, is adorned by the “Adam’s apple,” a prominent, sharply angled thyroid cartilage, and is notably thicker secondary to muscular bulk.7
Conclusion Secondary aesthetic surgery in gender patients is broad and diverse. It addresses many of the differences between genders and is certainly not limited to genital surgery. It has a high surgical success rate and satisfaction; the complications are often psychological or hysterical and related to the underlying psychological issues associated with this patient group. A sensitive approach and high index of suspicion for potential psychological and emotional problems is needed. The development and expansion of these aesthetic techniques in this patient population broadens the horizons of aesthetic surgery, and the lessons learned in hair restoration, body contouring, and aesthetic norms can further enhance aesthetic surgery for the general populace. ■
References 1. Hage J, Becking A, de Graaf F, Tuinzing DB. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg 1997;99:1799-1806. 2. Futterweit W. Endocrine therapy of transsexualism and potential complications of long-term treatment. Arch Sexual Behav 1998;27:209-226. 3. Donald PJ. Voice change surgery in the transsexual. Head Neck Surg 1982;4:433-437. 4. Ehrlich RM, Alter GJ. Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia: WB Saunders; 1999. 5. Osterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 1987;79:701-711. 6. Lines PA, Lines RR, Lines CA. Profilemetrics and facial esthetics. Am J Orthod 1978;78:648-657. 7. Price VH. Treatment of hair loss. N Engl J Med 1999;341:964-973. 8. Toledo LS. Syringe liposculpture. Clin Plast Surg 1996;23:683-693. 9. Maragos NE. The posterior thyroplasty window: anatomical considerations. Laryngoscope 1999;109:1228-1231. 10. Isshiki N, Taira T, Tanabe M. Surgical alteration of the vocal pitch. J Otolaryngol 1983;12:335-340. 11. Peck SR. Atlas of Human Anatomy for the Artist. Oxford: Oxford University Press; 1982:951. 12. Fine RM. Spironolactone therapy in hirsute women. Int J Dermatol 1989;28:23-24. 13. Whitaker LA, Morales L, Farkas LG. Aesthetic surgery of the supraorbital ridge and forehead structures. Plast Reconstr Surg 1986;78:23-32. 14. Krogman WM. Sexing skeletal remains. In: The Human Skeleton in Forensic Medicine. Springfield, Ill: Charles C. Thomas; 1973. 15. Habal MB. Aesthetics of feminizing the male face by craniofacial contouring of the facial bones. Aesthetic Plast Surg 1990;14:143-150. 16. Ligget J. The Human Face. London: Constable; 1975. 17. Tolleth H. Concepts for the plastic surgeon from art and sculpture. Clin Plast Surg 1987;14:585-598.
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
481
Aesthetic Considerations in Secondary Procedures for Gender Reassignment Steven P. Davison, DDS, MD; Matthew S. Clifton, BS; William Futrell, MD; Robert Priore, MD; and Ernest K. Manders, MD
Background: Patients who have successfully undergone gender reassignment surgery seek further aesthetic refinements to suit their new gender role. Objective: The study evaluated secondary aesthetic procedures, laryngeal surgery, and adjuvant hormone therapy in 22 male-to-female gender reassignment change patients. Methods: Thirty-two aesthetic procedures performed in 22 patients were evaluated for operation type, surgical technique, complications, and satisfaction rates. Aesthetic procedures included rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasty, cheek or chin surgery, and body contouring. Results: A wide range of secondary aesthetic procedures was successfully performed with only 1 minor complication and 1 major psychological depressive episode. Conclusions: Secondary surgery in gender reassignment patients extends the frontier of aesthetic surgery and provides lessons that can be extrapolated to facial and body contour aesthetic surgery in the general patient population.
G
ender reassignment is a complex and individual process that involves a large spectrum of physiologic and surgical changes. Many patients seek a life transition in outward appearance alone, and actual sexual reassignment surgery may not be a goal of many transgender individuals. Almost all patients seeking a new persona will desire surgery that alters features and reveals their new phenotypes. Most of these procedures involve the face, because it is so intimately associated with individual identity and serves as a reflection of personality and emotions.1
Medical treatment can effect some of the desired changes. In female-to-male transition, administration of testosterone can produce changes in body habitus, beard growth, hairline recession, changes in voice, and growth of body hairs. In male-to-female patients, administration of estrogens can result in widespread changes in body habitus, atrophy of the male external genitalia and testes, arrested hair loss, changes in voice, and gynecomastia. Spironolactone taken orally has a number of antiandrogenic effects.2 Primary surgery for male-to-female gender reassignment patients includes removal of the testes and phallus, vaginoplasty, and breast augmentation. Surgical treatment for the female-to-male transition includes hysterectomy, oophorectomy, vaginal obliteration, penile reconstruction, scrotal reconstruction with implants, and associated bilateral mastectomy with areolar reduction.
AESTHETIC
SURGERY
JOURNAL
~
From the Division of Plastic Surgery, Georgetown University Medical Center, Washington, DC (Dr. Davison and Mr. Clifton), and the Division of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Drs. Futrell, Priore, and Manders). Accepted for publication July 17, 2000. Reprint requests: Steven P. Davison, DDS, MD, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007. Copyright © 2000 by The American Society for Aesthetic Plastic Surgery, Inc. 1084-0761/2000/$12.00 + 0 70/1/111544 doi:10.1067/maj.2000.111544
NOVEMBER/DECEMBER
2000
477
Scientific Forum
Many patients undergoing transgender surgery are also interested in secondary aesthetic procedures and modification. These include changes in facial aesthetics, voice, and body contouring that is not limited to breast removal or subsequent breast augmentation. Female-to-male aesthetic surgery procedures include chin augmentation, suction-assisted lipectomy of the hips and lower abdomen, and laryngeal surgery to deepen the pitch of the vocal cords, which is typically followed by voice training.3 Secondary aesthetic procedures in male-to-female patients include anterior hairline reconstruction, brow lift, rhinoplasty, face lift, blepharoplasties, cheek augmentation, chin reduction, lip elevation and augmentation, tracheal shave, and raising of the vocal pitch.4 In this article, we review 32 aesthetic procedures in 22 male-to-female gender reassignment patients. The patients were followed closely with medical/surgical management, psychological evaluation, and advanced social support addressed specifically to the transgender patient. This retrospective study evaluated the types of surgery involved and the success and complication rates associated with the gender reassignment patients.
Materials and Methods Each of the 22 male-to-female gender reassignment patients followed in this study either underwent a complete gender reassignment with secondary aesthetic procedures or had previously undergone gender reassignment surgery and returned for subsequent secondary aesthetic procedures. The patients were evaluated preoperatively in a transgender surgical and medical clinic. Two independent psychological evaluations were required for patients who underwent genital reassignment surgery but not for those who had secondary aesthetic procedures. Secondary surgery that involved the genitals or breasts, including mastectomy, breast lipoplasty, or breast augmentation, was considered to be part of the primary transgender process rather than a secondary procedure and was not included in this study. The facial aesthetic procedures performed were rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasties, and cheek or chin surgery. Advancement of the hairline after expander scalp therapy was performed to remedy the problem of male pattern baldness. Body contouring included lipoplasty and removal of the eleventh and twelfth ribs to narrow the inferior aspect of the rib cage and create a more feminine waist. Tracheal shaves and laryngeal framework surgery for
478
AESTHETIC
SURGERY
JOURNAL
~
alterations in voice pitch were considered to be secondary aesthetic procedures. Data collection included review of preoperative and postoperative clinic notes, surgical details, and perioperative hospital costs. A detailed telephone and written survey was used to record patient satisfaction. A postoperative complication was recorded as minor if it did not require surgical intervention and major if it did require such intervention. Surgical technique Facial surgery. The nose can be feminized by reducing the
dorsal hump, narrowing the tip and dorsum, increasing the nasolabial angle with upward rotation of the tip, and/ or decreasing the projection.5 A reduction genioplasty enhances the facial contour.1,6 Rhytidectomy should follow completion of electrolysis to avoid the distribution problems associated with bearded skin. Adjuvant facial resurfacing may be needed to assist in replacing coarser skin. In the male-to-female patient, the anterior hairline is a significant consideration. The ability to wear a feminine coiffure is affected by male pattern baldness. Anterior hairline incisions were used to place crescentic expanders. After appropriate expansion, the anterior receding brow exposed by hair recession was resected. Simultaneous brow lift and elevation of the lateral brow can be performed at this time. Supraorbital fullness associated with men can also be reduced.5 The expanded hair-bearing scalp allows for substantial advancement (Figure 1). Hair loss can be curtailed by administration of finasteride (1 mg/d) or minoxidil creams (2% or 5%). Currently, these are the only drugs approved in the United States for treatment of alopecia resulting from the effects of circulating androgens. Both drugs can slow the thinning process and enlarge existing hair, thereby increasing scalp coverage.7 Body contouring. Traditional approaches to body contouring have included lipoplasty of the male pattern abdominal fat deposition in the “love handles” and anterior abdomen. However, the female torso is substantially more “hourglass shaped” than the more “boxy” contour exhibited in men. Superficial lipoplasty and fat injection were used to assist in remodeling the body’s contours.8 The removal of the eleventh and twelfth ribs through minimal posterior flank incision can also help in achieving this more shapely appearance. A 4- to 5-mm incision was made along the interspace between the eleventh and twelfth ribs, which was then extended deeper to include incision of the subcutaneous tissue and muscular fascia of the latissimus dorsi muscle (Figure 2). After the underlying muscle fibers were
NOVEMBER/DECEMBER
2000
Volume 20, Number 6
Scientific Forum
A
B
C
D
Figure 1. Brow lift surgery in a transgender patient. A, Anticipated brow reduction after 3 months of scalp expansion. B, Postoperative view shows restored hairline in the temporal region 6 months after surgery. C, Exposure of the crescentic expander with anticipated resection of lateral brow recession. D, Excess scalp created by expansion. E, Recreation of a widow’s peak and anterior hairline.
E
Aesthetic Considerations in Secondary Procedures for Gender Reassignment
AESTHETIC
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
479
Scientific Forum
Table. Distribution and numbers of secondary aesthetic procedures performed Surgical procedure Tracheal shave Eleventh/twelfth rib resection Rhytidectomy/platysmaplasty Brow lift/blepharoplasty Rhinoplasty Laryngeal framework Lip/cheek augmentation surgery
Figure 2. Removal of the eleventh and twelfth ribs through minimal posterior incision.
adequately separated from the field, the rib periosteum was incised with electrocautery, separated from the rib with a periosteal elevator, and then stripped completely off the bone, care being taken not to disturb the pleura. The rib was then sectioned at the paraspinous level and excised. Continuity of the pleural space was confirmed with inspiration against a water-filled cavity. The wound was then closed with a multilayer technique. Laryngeal surgery. Laryngeal surgery includes laryngeal shave and raising of the vocal pitch. The vocal cords extend from the vocal process of the arytenoid cartilages to the isthmus of the inner surface of the thyroid cartilage. They are located at the level of the vocal fold line. The anterior point of this line is the midpoint between the thyroid cartilage notch and inferior border of the thyroid cartilage. The posterior point is measured superiorly from the lower border of the thyroid cartilage at the anterior root of the inferior cornu.9 To raise voice pitch, the vocal cord length was increased, thereby increasing cord tension and decreasing the vibration mass. In individuals without prior vocal modification, the cricothyroid muscle accomplishes this task. Its action can be replicated and/or assisted by creating a closer approximation between the thyroid and cricoid cartilages with a technique known as the Isshiki type 4. This approximation is performed through placement of 4 tension sutures, 1 pair on either side of the anterior midline of the neck, which shorten the space between the thyroid and cricoid cartilages.10
To achieve a more feminine neckline, the prominent thyroid cartilage, or “Adam’s apple,” was reduced but not eliminated.11 Incisions may be placed lateral to, above, or over the laryngeal cartilages in a natural crease. Because
480
AESTHETIC
SURGERY
JOURNAL
~
No. performed 6 5 5 5 4 4 3
the resection of the thyroid cartilage is limited inferiorly by the position of the isthmus, care must be taken to preserve the laryngeal mucosa. Hormone therapy
Hormone therapy for the male-to-female transsexual consists of administration of both an estrogen and a progestin. Initial estrogen treatment consists of either ethinyl estradiol, 100 µg/d, or conjugated estrogens, 1.25 to 2.5 mg/d. Progestin administration can coincide with estrogen therapy or be delayed several months. Medroxyprogesterone acetate, 5 to 10 mg/d, is given for 10 days each month. The effects of this therapy are widespread, ranging from softening and decreasing the rate of facial hair growth to feminizing the body habitus of the patient by decreasing muscular bulk, softening the skin, and shifting body fat to the pelvic region. At least 2 years of this therapy is needed before maximum breast development is attained. Clinical and laboratory evaluations should be scheduled at 2- to 3month intervals after treatment is initiated. Further diminution of facial hair and the possible enhancement of breast development can be achieved with spironolactone, 100 to 200 mg/d in divided doses.2 The antiandrogenic effects of this drug include inhibition of 5α-reductase activity, increased peripheral conversion of testosterone to estradiol, and inhibition of testosterone synthesis pathways.12
Results Twenty-two male-to-female gender reassignment patients underwent a total of 32 aesthetic refinements. The breakdown of operations is seen in the Table. In all, 17 operations were facial aesthetic procedures, 5 were rib and body contouring procedures, and 10 were laryngealrelated. Patient satisfaction was high; 21 of 22 patients were satisfied with a more feminine appearance. However,
NOVEMBER/DECEMBER
2000
Volume 20, Number 6
Scientific Forum
after undergoing a rhinoplasty 1 patient underwent an exaggeration of preoperative psychological depression related to the transgender procedure. The one postoperative complication was a hysterical aphonia in a patient who underwent an anterior tracheal shave of the thyroid cartilage. The patient did well immediately postoperatively but within 12 hours was completely aphonic. A fiberoptic laryngeal evaluation revealed no airway obstruction, hematoma, edema, or closure of the vocal cords. The patient recovered promptly with outpatient voice therapy. The average cost per patient was approximately $9500, the average charge being $4700 incurred per procedure.
Discussion Gender reassignment surgery involves multiple phases, as follows: 1.
Physiologic changes associated with hormonal manipulation.
2.
Removal of, or change in, the primary sexual organs, including phalloplasty and vaginoplasty.
3.
Manipulation of secondary sexual organs by mastectomy or breast augmentation.
4.
Aesthetic refinements associated with the patient’s new gender. In the male-to-female gender reassignment patient, these refinements include feminization, demasculinization, and age restoration of the face and body. As many as 40% of male-to-female gender reassignment patients undergo secondary aesthetic procedures.4 In this retrospective study, 50% of the patients had undergone primary surgery elsewhere.
Areas of particular importance in assigning gender to the face and neck include the forehead, eyebrow, jaw, and thyroid cartilage. The contour typically exhibited by a female forehead is high, rounded, and more vertical2,13,14 than the male equivalent, which has a prominent supraorbital ridge13-16 and is characterized by a more wrinkled appearance.15 In women, the eyebrow lies above the supraorbital rim16 and has a considerable degree of arc.13,17 In contrast, eyebrow location in men exaggerates the impression of frontal bossing because it is positioned either immediately covering or slightly inferior to the supraorbital ridge.16 A square, pronounced jaw is traditionally associated with male gender, whereas in women a smaller, narrow, rounded chin is considered more aesthetically pleasing.9 In addition, a “cleft” in the soft tissue of the chin is typically associated with masculine features.15 The female neckline has a slender, longer appearance, caused in large part by a flattened thyroid cartilage and a
Aesthetic Considerations in Secondary Procedures for Gender Reassignment
AESTHETIC
depressed carrying angle of the shoulder girdle.7,16 The typical male neck, on the other hand, is adorned by the “Adam’s apple,” a prominent, sharply angled thyroid cartilage, and is notably thicker secondary to muscular bulk.7
Conclusion Secondary aesthetic surgery in gender patients is broad and diverse. It addresses many of the differences between genders and is certainly not limited to genital surgery. It has a high surgical success rate and satisfaction; the complications are often psychological or hysterical and related to the underlying psychological issues associated with this patient group. A sensitive approach and high index of suspicion for potential psychological and emotional problems is needed. The development and expansion of these aesthetic techniques in this patient population broadens the horizons of aesthetic surgery, and the lessons learned in hair restoration, body contouring, and aesthetic norms can further enhance aesthetic surgery for the general populace. ■
References 1. Hage J, Becking A, de Graaf F, Tuinzing DB. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg 1997;99:1799-1806. 2. Futterweit W. Endocrine therapy of transsexualism and potential complications of long-term treatment. Arch Sexual Behav 1998;27:209-226. 3. Donald PJ. Voice change surgery in the transsexual. Head Neck Surg 1982;4:433-437. 4. Ehrlich RM, Alter GJ. Reconstructive and Plastic Surgery of the External Genitalia: Adult and Pediatric. Philadelphia: WB Saunders; 1999. 5. Osterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 1987;79:701-711. 6. Lines PA, Lines RR, Lines CA. Profilemetrics and facial esthetics. Am J Orthod 1978;78:648-657. 7. Price VH. Treatment of hair loss. N Engl J Med 1999;341:964-973. 8. Toledo LS. Syringe liposculpture. Clin Plast Surg 1996;23:683-693. 9. Maragos NE. The posterior thyroplasty window: anatomical considerations. Laryngoscope 1999;109:1228-1231. 10. Isshiki N, Taira T, Tanabe M. Surgical alteration of the vocal pitch. J Otolaryngol 1983;12:335-340. 11. Peck SR. Atlas of Human Anatomy for the Artist. Oxford: Oxford University Press; 1982:951. 12. Fine RM. Spironolactone therapy in hirsute women. Int J Dermatol 1989;28:23-24. 13. Whitaker LA, Morales L, Farkas LG. Aesthetic surgery of the supraorbital ridge and forehead structures. Plast Reconstr Surg 1986;78:23-32. 14. Krogman WM. Sexing skeletal remains. In: The Human Skeleton in Forensic Medicine. Springfield, Ill: Charles C. Thomas; 1973. 15. Habal MB. Aesthetics of feminizing the male face by craniofacial contouring of the facial bones. Aesthetic Plast Surg 1990;14:143-150. 16. Ligget J. The Human Face. London: Constable; 1975. 17. Tolleth H. Concepts for the plastic surgeon from art and sculpture. Clin Plast Surg 1987;14:585-598.
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
481