Osseous Transformation with Facial Feminization Surgery: Improved Anatomical Accuracy with Virtual Planning

Abstract

Background: Facial feminization surgery entails a series of surgical procedures that help the transwoman pass as their affirmed gender. Although virtual surgical planning, with intraoperative cutting guides, and custom plates have been shown to be helpful for craniomaxillofacial reconstruction, they have not yet been studied for facial feminization surgery. The authors used cadaveric analysis for morphologic typing and to demonstrate the utility of virtual surgical planning in facial feminization surgery procedures. Methods: Male cadaveric heads underwent morphologic typing analysis of the frontal brow, lateral brow, mandibular angle, and chin regions (n = 50). Subsequently, the cadavers were split into two groups: (1) virtual surgical planning intraoperative cutting guides and (2) no preoperative planning. Both groups underwent (1) anterior frontal sinus wall setback, (2) lateral supraorbital recontouring, (3) mandibular angle reduction, and (4) osseous genioplasty narrowing. Efficiency (measured as operative time), safety (determined by dural or nerve injury), and accuracy (scored with three-dimensional computed tomographic preoperative plan versus postoperative result) were compared between groups, with significance being p < 0.05. Results: For frontal brow and lateral lower face, morphologic type 3 (severe) predominated; for lateral brow and chin, type 2 (moderate) predominated. For frontal sinus wall setback, virtual surgical planning improved efficiency (19 minutes versus 44 minutes; p < 0.05), safety (100 percent versus 88 percent; p < 0.05; less intracranial entry), and accuracy (97 percent versus 79 percent; p < 0.05) compared with no preoperative planning. For mandibular angle reduction, virtual surgical planning improved safety (100 percent versus 88 percent; p < 0.05; less inferior alveolar nerve injury) and accuracy (95 percent versus 58 percent; p < 0.05). Conclusions: Preoperative planning for facial feminization surgery is helpful to determine morphologic typing. Virtual surgical planning with the use of cutting guides/custom plates improved efficiency, safety, and accuracy when performing four key craniofacial techniques for facial feminization.

Point of Care Virtual Surgical Planning and 3D Printing in Facial Feminization Surgery

“…The use of VSP and 3DP provides a significant assistance during the execution of the planned FFS in a safe (avoiding nerve injury, intracranial entry, and other complications), accurate (precise and desired intervention), and efficient (reduced operative time) way. 20 25 26 In this regard, patient-specific, colored bony thickness measurement maps allow for safer execution of the plan and more precise surgical intervention (e.g., burring or osteotomy of the frontal bone during feminizing foreheadplasty) 25 ( Fig. 1 ).…”

“…3 12 13 14 15 16 17 18 19 20 In addition to multiple studies describing the utilization of VSP and 3DP in head and neck reconstruction, cranial vault reconstruction, craniomaxillofacial trauma, and aesthetic surgery, 16 18 21 22 23 24 lots of studies involving the use of VSP and 3DP in FFS have also been published recently. 17 19 20 25 26 27 In this review, we will discuss the current applications of VSP and 3DP in FFSs along with reported outcomes in the literature.…”

Developments in facial feminization surgery

“…There is likely benefit to preoperative planning and using cutting guides for trainees, but it is not clear that there is the same benefit for proficient surgeons. In the Gray et al [23] study, the rate of success without VSP was only 79%, meaning that in these cadavers 21% of the time there was intracranial or dural injury. Previous reports mentioned in this paper show a far lesser complication rate, and 0% intracranial entry, indicating that this is a safe procedure in experienced hands.…”

Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium

“…Given the complexity of bony osteotomies necessary to achieve a gender-congruent facial appearance, virtual surgical planning is often indicated. 35…”