Prospective Outcomes of Secondary and Revisionary Facial Feminization Surgery

PURPOSE: Facial feminization surgery (FFS) for transgender and nonbinary patients typically addresses masculine characteristics of the brows, nose, mandible, chin, and thyroid cartilage, as these facial areas are most influential to gender perception. Because multiple facial areas are involved, FFS often includes multiple concurrent or staged procedures. Therefore, secondary and/or revisionary FFS are important considerations. Patients may present for completion of a planned second stage procedure, to augment their prior feminization with changes to additional facial areas not addressed in their initial FFS (both of these scenarios will be considered “secondary” if carried out in facial areas not addressed in primary FFS), or to revise an unsatisfactory surgery (revisionary FFS). This study aims to report prospective outcomes of secondary and revisionary FFS. METHODS: Patients undergoing secondary or revisionary FFS were analyzed from a prospective international multicenter cohort study of FFS patients. Preoperative and postoperative (1 month and >6 months) endpoints were obtained for self-reported facial feminization outcome scores (a scale of 0–100), satisfaction (on a Likert scale of 0–4), and cephalometric measurements. RESULTS: A total of 66 FFS patients were enrolled. Of these, 10 underwent either secondary FFS (n = 6) or secondary and revisionary FFS (n = 4) and were included in this analysis. Mean age was 41.7 years. All patients had preoperative hormone therapy, for <1 year (n = 1), 1–5 years (n = 4), 6–10 years (n = 2), or >10 years (n = 3). Thirty percent (n = 3) reported a history of tobacco use. Self-reported pre-operative most masculine facial features were the jaw/chin (n = 6), nose (n = 5), and forehead/brow (n = 5). Secondary and revisionary FFS procedures included brow reduction (n = 9), genioplasty (n = 7), mandibular contouring (n = 6), tracheal shave (n = 2), and rhinoplasty (n = 6). Mean facial feminization outcome scores improved from 51.2 preoperatively (SD = 8.9) to 71.9 at longest follow-up (SD = 14.7), P < 0.01. Mean postoperative satisfaction was 3.0. Cephalometric values indicating successful feminization included decreased glabellar angle by 6.7° (from 98.9° to 92.2°; P < 0.05) and increased nasofrontal angle by 6.0° (from 138.0° to 144.0°; P < 0.05), with other statistically nonsignificant changes as well. Complications included hypertrophic scarring (n = 1) and orbital hematoma requiring surgical drainage (n = 1). CONCLUSION: Our cohort of 10 patients reported favorable quality of life, patient satisfaction, and cephalometric outcomes, with low complication rates, comparable to those reported by primary FFS studies. Patients seeking FFS should be aware of the potential need for revisions and secondary procedures. Because of unique challenges of secondary and revisionary FFS, including tissue changes after primary FFS and psychosocial factors relating to dissatisfaction with primary FFS, these should be considered separately from primary FFS and from each other. This study is limited by our small cohort and lack of knowledge regarding our patients’ primary FFS procedures.