[MUSIC] Hi my name is Bella Vanecian and I am a surgeon at Mt Sinai Center for Transgender Medicine and Surgery in association with Dr Jess Ting. My gender pronouns are she and her. And today, I will be talking to you about transgender surgery of the chest and face. Our learning objectives for this session are to understand the role of surgery in transgender patient care. Review the goals of surgery and review the surgical options for both feminization and masculinization of the face and chest. We'll begin by discussing what you should know about surgery. Surgery is a proven therapy for patients who identify as transgender. Surgery is medically necessary and should be covered by insurance. A multi-disciplinary team approach is best for optimal surgical options. Surgical goals are to improve the patient's comfort with self and improve their personal experience. To achieve results that have both good function and a natural appearance and, all-in-all, to minimize complications. These are all of the surgeries possible for transfeminine and transmasculine surgery. Today, we will be focusing on surgery of the chest and face. Chest feminization surgery, the goals of chest feminization surgery are to increase breast size, to create a natural appearing breast mound, to create a natural nipple position with the nipple centered on the breast mound, and to preserve nipple sensation when possible. All-in-all, minimize scarring. The mainstay of chest feminization surgery is breast augmentation with implants. Although lipofilling, or injecting the body's own fat into the breasts to increase their size is an option, this is rarely done. The considerations when feminizing a chest include centering the nipple on the breast mount and accounting for anatomic difference we see in transwomen. Including a wider chest as well as a more robust pectoralis major muscle. When making decisions about the implant, the first decision is whether to place it above or below the pectoralis major muscle. In our practice, we often place it above the muscle. Different surgeons have different preferences. The type of implant used can be either silicon or saline. If silicon, there's also a choice between round or shaped implants. Shaped implants are often called tear drop or gummy bear implants. And they maintain their shape regardless of the position. So when looking at the implants face on, they're round, both the round and shaped. However when they're lying flat on a surface the shaped implant maintains it shape, while the round implant settles onto the surface based on the pull of gravity. You can see that on the image along the bottom of the screen. The incision for where to insert the breast implant also depends on the surgeon's preference. A common incision is along the inframammary fold or along the breast fold. This is an example of breast augmentation in the subglandular plane or above the muscle with a shaped silicone implant. As you can see, the scar is difficult to see, but it's located here along these blue lines, along the inframammary fold. Chest masculinization, the mainstay of chest masculinization surgery is subcutaneous mastectomy. This is similar to, but much less aggressive than a mastectomy for breast cancer. The techniques vary and we'll talk more about them in a moment. But surgery may or may not include resizing or repositioning the nipple. The main things to consider when performing chest masculinization surgery, is the starting breast size, the degree of skin excess and the ultimate nipple position and size. Chest masculinization goals are to reduce the breast volume and flatten the chest, to reduce the skin envelope, often, to reduce the size of the nipple. And to reposition the nipple and less often to preserve the sensation of the nipples. Always, we try to minimize scarring. These are different incisions used for chest masculinization surgery. The first is a periareolar incision. The areola is the dark part around the nipple. This incision goes just under the areola. Through the incision, we're able to remove all breast tissue. No skin is resected, so breast size, starting out, must be very small. In the central example, in addition to removing the breast tissue, a doughnut of skin around the areola is removed. This is a viable option for the smaller breast sizes, where there's limited skin excess. When there is significant skin access, this type of incision can cause bunching. Most commonly, because breast volume and skin excess tend to be present and plentiful. The best treatment option is a double incision mastectomy with nipple reconstruction. This is basically a breast amputation. Although the surgery is more complex than that, and resizing and repositioning the nipples in the typical male pattern. Again, the double incision mastectomy is the right choice for most patients. This is an example of a patient who needs double incision mastectomy with free nipple grafts. So the breast will be amputated at this level, although the procedure is more complex than just cutting it here. And the nipples will be taken off as small grafts, or like skin stickers and reposition in the appropriate male position on the chest. And this is the final result. Here is a patient who is a good candidate for periareolar mastectomy which is also called a limited incision mastectomy. And again, doesn't allow for any skin resection. Here, the nipple size isn't at all reduced and we're making small incisions underneath the areola, and removing the breast tissue through that site. The skin here of good elasticity, and without having been cut away, it tightens up over the chest after the procedure is complete. Now we will talk about facial surgery. There are known differences between the masculine and feminine facial skeletons and this affects the contour and shape of the face. Here, we will look at generalized gender facial differences. First, the hairline contour and height tends to be shorter and rounder in women, and more M-shaped in men. The forehead contour is rounder and smoother in women, men often have a bulge or ridge near the brow. The shape of the bony orbits or eye sockets is also different, making women's upper eyelids appear more visible. The eyebrows are typically thinner, higher, and more angled in women, as compared to men. In women, the nose is typically narrower, and has a smaller tip. The angles between the nose and the forehead, the nasofrontal angle, and the nose and the upper lip, the nasolabial angle, are both more obtuse in women. This gives them a more delicate appearance. Upper lip height, or the distance between the nose and the bottom of the upper lip, tends to be shorter in women than in men. In women, the chin is often narrower, shorter, and less projecting than in men. The lower jaw, also part of the mandible, is also generally smaller, shorter, and less broad in women. It's very important to know that these are, again, generalizations, they do not define masculinity or femininity. Now we'll talk about facial feminization surgery. When talking about facial feminization, we want to address all of the features we just talked about. We want to be careful to individualize the treatment. Very few patients will need all of these procedures. The goal is to do only what is necessary for the individual. At the upper third of the face, we focus on lowering the hairline to shorten the forehead and round the contour of the hairline, to smooth the forehead contour and remove any bulging or ridging in the brow bone. We lift the eyebrows and we contour the upper orbits, or eye sockets, to open up the eyes and upper eyelids. All of these changes are done through a long incision from ear to ear which can be completely hidden in the hair bearing scalp if we're not addressing the hairline itself, or maybe in front of the hairline if it's a feature to be lowered. Next, when addressing the nose, the goal is often to narrow the bridge of the nose and to make the nasal tip more delicate. Also to soften the nasofrontal and nasolabial angles. Again, make these angles less acute, and these are the angles between the nose and the forehead and the nose and the upper lip. These procedures are done through standard, open rhinoplasty incisions which go across the columella and inside the nostrils. So they also are fairly well hidden. When addressing the lower face, options include reducing the height of the upper lip. This is typically done through an incision under the base of the nose. Or reducing the height, projection, and width of the chin, part of the mandible bone. As well as narrowing or shortening the lower jaw, also the mandible. These are done through intraoral incisions. To preserve patient privacy, I will not be showing photos of facial feminization. Instead, we will look at some diagrams. Here we will discuss one of the more complex parts of the surgery. Contouring of the frontal or forehead bone. As we had mentioned, there's often a prominent ridge or bulge at the level of the brow. This bulge is at the site of an air filled space in the forehead bone called the frontal sinus. If the bone at the anterior table or in front of the sinus is thick, we can contour it just by shaving it down. When the bone is thin, however, we need to break it and set it deeper into the face to achieve that smooth feminine contour. This procedure is called a frontal sinus setback osteotomy. This blue mark shows where the bone would be purposely broken to allow it to then be set deeper within the skull. It's very important to note that behind a very thin back wall of bone at the frontal sinus, is the brain. This illustrates why only someone well trained in craniofacial surgery should perform this procedure. In this diagram, we see the goal change in forehead contour that we are able to achieve after setback osteotomy. Or in some cases after simply shaving down the thick bone in this area. Tracheal cartilage reduction, now we will talk about tracheal cartilage reduction. More commonly known as, trach shave, also known as chondroplasty. The goal of the surgery is to reduce the visibility of the Adam's apple. We don't want to put an incision directly over the Adam's apple. Instead, we aim to put it higher up along one of the neck creases. It's usually under an inch in length. This is an example of a before and after photo after tracheal cartilage reduction. You can see a stitch still remains in place in the after photo. This blue line is where her incision is. This is very early in her post operative follow up. Facial masculinization, although facial masculinization surgery would typically involve making features larger or wider. And this can be done to the chin, jaw, forehead, brow, nose, really any part of the face. And it can be done with the use of either autologous tissues, or the body's own tissues, or with synthetic materials like implants. Although various options exist, this surgery is currently much less common than facial feminization. It's possible that facial hair growth, as a result of testosterone therapy, contributes to this. It's also possible it's society's general acceptance of feminine men. In conclusion, surgery is a proven therapy for patients who identify as transgender. It is medically necessary and should be covered by insurance. Surgery improves a patient's comfort, and aims for a natural appearance and good function. To review the surgeries, for chest feminization, breast augmentation with implants is the main treatment. The goal is to center the nipple on the breast mound. For different surgeons and patients implant position, style of implant, and the incision used to put the implant in, can vary. With chest masculinization surgery, the mainstay surgery is subcutaneous mastectomy with or without nipple reconstruction. The best technique depends on the size of the breasts and the amount of skin excess. The most common type, because significant breast volume and skin excess are often present, is a double-incision mastectomy with nipple reconstruction, which is the breast pseudo-amputation technique that we had discussed. Facial feminization surgery is individualized and many techniques exist. Generally, the forehead contour is smooth. The sizes of the nose, chin, lower jaw and other facial features are reduced. And if there's a prominent tracheal cartilage, that contour is smoothed as well. Facial masculinization surgery, at this time, is much less common. Thank you for joining me today in this segment. I hope this module increased your understanding of transgender chest and facial surgery, thank you. [MUSIC]
