Faculty Bibliography

BACKGROUND:The demand for facial feminization surgery (FFS) amongst transgender women is on the rise, and requests for a single-stage full FFS (F-FFS) are becoming more frequent. The specific aim of this article is to present our institutional experience with both partial-FFS (P-FFS) and F-FFS with a specific emphasis on safety of each approach. METHODS:We examined the electronic medical record of all patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation at our institution, between June 2017 and October 2020. Patients were sub-grouped into those who underwent F-FFS (upper, middle, and lower facial thirds in a single anesthetic event) and those who underwent P-FFS. Univariate analysis was used to assess for difference in postoperative complications. RESULTS:We identified 77 patients who underwent 382 total procedures. The mean follow-up time was 7.5 months (Sd = 7.3) (interquartile range 1.75-12.0 months). Fifty-one (71.4%) patients underwent F-FFS and 21 (28.6%) patients underwent P-FFS. Compared to P-FFS, F-FFS was not associated with an increase in postoperative complication (1 out of 21 [4.8%] versus 4 out of 51 [7.8%]) ( P < 0.556). When comparing characteristics of patients with postoperative complications to patients with no postoperative complications, the average body mass index was significantly higher (30.9 versus 25.4, respectively). ( P < 0.029). CONCLUSIONS:Full-FFS is a set of procedures that has gained increased popularity among male-to-female transgender patients. Our results support the understanding that F-FFS is a safe and reliable approach, which may be preferable to patients and providers alike.

BACKGROUND:Facial feminization surgery (FFS) plays an instrumental role in the process of gender affirmation. These procedures are becoming increasingly appreciated for their ability to improve patient satisfaction and gender identity in a way that alleviates gender dysphoria and improves the quality of life. Despite the recent surge in popularity across the US, the current literature lacks evidence on the safety profile of combined facial feminization procedures. Our goal was to determine the safety profile of facial feminization procedures registered on a national surgical database. METHODS:Patients with a primary diagnosis of gender dysphoria undergoing facial surgical procedures were identified from the National Surgical Quality Improvement Program database between the years 2013 and 2018. Demographic characteristics along with 30-day postoperative complications were recorded. Logistic regression models adjusted for confounders were used to determine the independent predictors of postoperative complications. RESULTS:A cohort of 77 patients who underwent a total of 220 procedures was identified. The number of patients undergoing surgery per year increased from three (3.9%) in 2013 to 41 (53.2%) in 2018, a 13.6-fold increase. The most commonly performed procedure was forehead contouring/frontal sinus setback, performed on 52 patients (67.5%), followed by orbital contouring (n = 37, 48%), rhinoplasty (n = 34, 44%), mandibuloplasty (n = 34, 44%), chondrolaryngoplasty (n = 27, 35.1%), genioplasty (n = 11, 14%), brow lift (n = 9, 11.7%), cheek augmentation (n = 9, 11.7%), and lip lift (n = 7, 9.1%). The number of patients who underwent 5 or more procedures in a single anesthetic event was 41 (53.2%). The complication rate was 3.9%. Univariate analysis suggested an association between older age and postoperative morbidity (P  < 0.02). However, this was not found to be an independent predictor on multivariate analysis adjusted for confounders (P < 0.083). Additionally, an increase in operative time and the number of procedures performed during a single anesthetic were not independent predictors of 30-day postoperative complications (P < 0.317 and P  < 0.19, respectively). CONCLUSIONS:FFS can be safely performed and has a low risk of postoperative morbidity. The number of patients seeking FFS surgery has risen exponentially, with the highest demand seen for the reconstruction of the upper facial third. These findings should guide expectations for patients seeking FFS, as well as for plastic surgeons looking to perform multiple procedures per anesthetic event.

ABSTRACT/UNASSIGNED:Facial feminization surgery (FFS) with its proven safety and efficacy has become a mainstay surgical approach for those desiring gender-specific perceived feminine facial aesthetics. To date, specific characteristics of patients seeking FFS have been limited, with no studies investigating the role of the Human Immunodeficiency Virus (HIV) on FFS outcomes. The potential clinical implications of HIV and more specifically HIV-associated lipodystrophy, which can cause facial lipoatrophy, require further investigation. Given the importance of midface projection in feminizing the face, the authors aimed to investigate any associations HIV or Highly Active Antiretroviral Therapy may have on outcomes, including clinical consequences of facial lipoatrophy. The authors performed a retrospective chart review of all patients with a diagnosis of gender dysphoria referred to the senior author (EDR) for FFS between 2017 and 2020. Patients were grouped based on HIV status and demographics, history, and outcomes were assessed. Seventy-seven patients were included, with 28 patients (36.4%) having a diagnosis of HIV. A total of 25 (32.5%) and 23 (29.9%) patients underwent malar fat grafting and cheek implants, respectively. No significant difference was found between HIV-positive and HIV-negative patients when looking at the use of malar fat grafting, cheek implants, age, or complication rates. To the best of our knowledge, this study presents the largest cohort of HIV status assessment of FFS patients to date. Future studies, particularly on the long-term outcomes, are warranted, as is continued information sharing among providers and centers performing FFS, in order to continue advancing the literature and subsequently patient care.

PURPOSE/OBJECTIVE:The purpose of this study was to measure the association between the magnitude of advancement and dental and skeletal relapse in patients with cleft lip and palate (CLP). METHODS:A single-institution retrospective cohort study of skeletally matured patients with CLP who underwent isolated Le Fort I advancement surgery between 2013 and 2019 was studied. Patients were included if they had lateral cephalograms or cone-beam computed tomography (CBCT) at preoperative (T1), immediately postoperative (T2), and 1-year follow-up (T3). Lateral cephalometric landmarks were digitized and measured. The sample was divided on the basis of the magnitude of skeletal advancement: minor (<5 mm), moderate (≥5 but <10 mm), and major (≥10 mm) advancement groups. The mean advancement and relapse were compared between groups using 1-way ANOVA. Correlation between the amount of surgical advancement and relapse was evaluated. RESULTS:Forty-nine patients with nonsyndromic CLP with hypoplastic maxilla met inclusion criteria and the sample consisted of 36 males and 13 females with the mean age of 19.5 years. In the minor, moderate, and major advancement groups, the mean advancement at point A was +4.1 ± 0.4, + 7.5 ± 1.4, and +11.3 ± 1.3 mm, respectively. At 1-year follow-up, the mean relapse at point A was -1.3 ± 1.2, -1.1 ± 1.2, and -1.7 ± 1.5 mm, respectively. There was no significant difference in the relapse amount between all surgical groups. No correlation between the magnitude of advancement and relapse was found. CONCLUSIONS:This study demonstrated no statistically significant difference in skeletal stability between a minor (<5 mm), moderate (≥5 but <10 mm), and major (≥10 mm) Le Fort I advancement groups in patients with clefts. Regardless of the degree of advancement, mild skeletal relapse was observed in all 3 groups.

BACKGROUND:Facial transplantation is a complex surgical procedure that requires education of medical professionals, patients, and the general public. The objective of this randomized controlled trial was to compare the educational efficacy of facial transplantation digital animation versus text resources for teaching medical students a complex surgical procedure and its applicable anatomical and surgical principles. METHODS:Medical student volunteers were recruited and prospectively randomized to an animation or a text group. Students completed preintervention and postintervention assessments of confidence and knowledge of head and neck anatomy and facial transplantation. Student Evaluations of Educational Quality survey assessed student satisfaction with both tools following study crossover. Knowledge assessment was developed using National Board of Medical Examiners guidelines and content validated by four experts. The Cohen d statistic was used to measure the effect size of each intervention. RESULTS:Thirty-six students were assigned randomly to the animation group (n = 19) or the text (n = 17) group. Postintervention analysis demonstrated significantly higher performance scores in the animation group compared to the text group (p = 0.029). The animation group had a larger effect size (Cohen d = 1.96 versus 1.27). Only students in the animation group reported significantly improved confidence in head and neck anatomy after the intervention (p = 0.002). Both groups demonstrated significantly increased postintervention confidence in knowledge of facial transplantation (p < 0.001). Satisfaction scores revealed that students significantly favored the animation resource (p < 0.001). CONCLUSIONS:Animation can be an effective tool for facial transplantation education and results in improved student knowledge, confidence, and satisfaction compared to text resources. Facial transplantation can also be used as an educational framework for teaching medical students anatomical and surgical principles.

SUMMARY:The coronavirus disease of 2019 pandemic became a global threat in a matter of weeks, with its future implications yet to be defined. New York City was swiftly declared the epicenter of the pandemic in the United States as case numbers grew exponentially in a matter of days, quickly threatening to overwhelm the capacity of the health care system. This burgeoning crisis led practitioners across specialties to adapt and mobilize rapidly. Plastic surgeons and trainees within the New York University Langone Health system faced uncertainty in terms of future practice, in addition to immediate and long-term effects on undergraduate and graduate medical education. The administration remained vigilant and adaptive, enacting departmental policies prioritizing safety and productivity, with early deployment of faculty for clinical support at the front lines. The authors anticipate that this pandemic will have far-reaching effects on the future of plastic surgery education, trends in the pursuit of elective surgical procedures, and considerable consequences for certain research endeavors. Undoubtedly, there will be substantial impact on the physical and mental well-being of health care practitioners across specialties. Coordinated efforts and clear lines of communication between the Department of Plastic Surgery and its faculty and trainees allowed a concerted effort toward the immediate challenge of tempering the spread of coronavirus disease of 2019 and preserving structure and throughput for education and research. Adaptation and creativity have ultimately allowed for early rebooting of in-person clinical and surgical practice. The authors present their coordinated efforts and lessons gleaned from their experience to inform their community's preparedness as this formidable challenge evolves.