Facial feminization surgery (FFS)

Considerations

• • Indication

    • Gender Dysphoria – Discomfort and distress that arise from a discrepancy between a person’s gender identity and sex assigned at birth

      • Diagnostic criteria

        • Patient desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment

        • The transsexual identity has been persistently present for at least 2 years

        • The condition is not a symptom of a mental disorder

        • The condition causes clinically significant distress or social and occupational impairment

      • Prevalence 

        • Increasing 

        • Estimated range: 1 in 12-50,000

  • Relevant facial anatomy

  • Facial thirds

    • • Upper - trichion to nasion

      • Mid - nasion to subnasale

      • Lower - subnasale to gnathion

  • Gender identification based on the facial thirds

    • 2011: Facial determinants of female gender and feminizing forehead cranioplasty (Spiegel)

      • "The strong association between femininity and attractiveness can now be more specifically attributed to the upper third of the face and the interplay of the glabellar prominence of the forehead, along with the eyebrow shape and position, and hairline shape and position"

  • Conceptual approach

    • Tailor to the patient's individual anatomy and preferences

    • 2016: Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients (Raffaini)

      • The surgeon may conceptually distinguish procedures that modify either hard tissue or soft tissue and address hard or soft tissue in a stepwise manner  

Post-op Instructions

POST-OPERATIVE INSTRUCTIONS FOR WOUND CARE 

- When sleeping, keep your head elevated to minimize the amount of swelling you experience. 

- For the first 3 days, keep ice over the forehead and nose for 20 minutes per hour as tolerated 

For the hairline incision

- Keep dry for the first 2 days 

- Remove the outer dressing on the first day after surgery - your doctor will do this for you in the hospital 

- At home: Change dressings with bacitracin to incisions twice daily. Take down dressing, apply Bacitracin to the sutures, overly with fluff gauze, wrap with two ACE bandages. 

- Keep the dressing on as much as possible each day 

- May comb hair, but only TOWARDS incisions

Do not brush your hair in a posterior (backwards) direction as it can pull the suture line apart

- After 3 days: Wash the external incision area gently once or twice daily with soap and water. Ordinary bath soap is fine. 

- After washing, apply a thin layer of antibiotic ointment (for example: POLYSPORIN, BACITRACIN, double antibiotic - available without prescription). A tube has been provided for you. There will also be a refill available in the pharmacy if you need it. 

- Wounds heal fastest if no scab/crust forms. Cleaning the wound once or twice daily and applying antibiotic ointments should help prevent scab formation. However, if you develop a scab, do not pull it off, let it fall off on its own. 

- It is common to have a thin rim of redness around the wound site during normal healing. However, if the skin around the wound develops enlarging redness, swelling, and increased pain/tenderness, you may have an infected wound. It usually starts on about the 4th or 5th day after surgery. Call us promptly. 

- The scalp and upper lip sutures are nonabsorbable; they will be removed at your follow-up appointment. 

- If you are having bleeding, apply pressure directly to the wound for 20 minutes. If it is still bleeding or if the amount of blood is alarming, call your doctor. 

- Do not place anything hot on the scalp. 

For nose 

- The nasal splint will be removed at your follow-up appointment. 

- Avoid nose blowing 

For the mouth

- Rinse mouth with peridex, ok to brush top teeth lightly

MEDICATIONS 

- Take the antibiotics as prescribed. 

- Use the Peridex rinses as prescribed

- Use the pain medication and anti-nausea medication as needed 

- Use the Colace to prevent constipation 

- You can resume hormone therapy the day after discharge. 

ACTIVITY 

Rest; no heavy lifting or straining or sexual activity for 14 days. 

Be sure to walk around and not remain sedentary through the day to decrease the risk of blood clots.

Sinus precautions:

Do not blow nose - only wipe. 

Try to avoid coughing or sneezing; If needed sneeze with open mouth for 14 days. 

BATHING: 

You may shower starting 3 days after surgery.

Please only lightly wet the wounds. 

Avoid soaking and / or submerging the wounds for 2 weeks. 

DIET 

Soft diet until instructed otherwise by your physician. 

After eating, rinse your mouth out with the Peridex rinses as prescribed. 

EXPECTATIONS 

Swelling, pain, and bruising around the eyes and the face is common. 

This will improve slowly over the next week. 

Keeping your hair clean by washing daily with soapy water (not hot) is important to helping the scalp heal well. 

QUESTIONS OR PROBLEMS 

To contact the physician on-call after hours, call the advice nurse at 510 752-1190. 

To contact the physician during business hours, call the head and neck surgery clinic at 510-752-1115.

Care Instructions after Laryngochondroplasty (Tracheal Shave)

WOUND CARE:

· Apply an ice pack (crushed ice or frozen peas work well) to the wound for 5-20 minutes once an hour while awake for two days.

· Remove the Tegaderm (thin clear dressing) off the wound after 2 days and leave steri-strips (paper bandaids) intact over incision for one week.

· Keep steri-strips (paper bandaids) covering the wound intact for one week. If they start to curl, you may trim them back. The strips should be peeled off the incision after one week.

· You have absorbable stitches closing your incision. They will dissolve in 1-2 weeks.

· If you are having bleeding, apply gentle pressure directly to the wound for 10 minutes. If you notice increasing swelling, please call the nurse advice line.

ACTIVITY:

· Rest for the first day or two after surgery and gradually increase your activities.

· No heavy lifting or straining for 2 weeks after surgery.

· No sexual activity for 2 weeks after surgery.

· Do not over-extend your neck backwards for 2 weeks after surgery.

· Do not over-use your voice for the next 2-3 days.

· You may return to school or work when directed by physician.

BATHING:

· You may shower with the plastic dressing in place. However, please avoid direct water on the plastic dressing.

· When you take of the tegaderm (clear plastic) dressing in 2 days, you may also shower but keep the same precautions of no direct water on the incision site.

· Pat dry or air dry the incision site. No swimming or soaking in the bath tub for two weeks.

DIET:

· Liquids or light nourishment for today if nauseated, then progress to a regular diet.

EXPECTATIONS:

· Some bloody staining of the steri-strips is normal following the surgery

· A hoarse voice and sore throat for a couple of days is common after general anesthesia

QUESTIONS OR PROBLEMS:

· If bleeding continues despite having applied pressure and you think your neck is swelling, then call the advice nurse at 510 752 1000 or proceed to the nearest emergency room.

· If you feel deep pressure building in the neck and it progresses over a few minutes, call 911 or go to the nearest emergency room as soon as possible.

· Hoarseness may happen after surgery due to the general anesthesia or as a potential complication from the procedure. Use your voice normally, whispering and shouting may cause undue strain.

· If you do not have an appointment or do not know when your appointment is scheduled for or if you have any other questions for your surgeon, then please call the HNS clinic at 510 752 1115.

Follow Up Appointment Information:

· Below is your scheduled follow-up appointment at the Head and Neck Surgery Clinic in the 3600 Broadway Ave on the 4th floor at the orange designated clinic.

Pearls & Pitfalls

High-Yield

Links

• • http://www.tsroadmap.com/physical/face/FFS-01.pdf