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Navigating Facial Masculinization Surgery
Julia Casazza • Updated Jul 8, 2024 • 36 hits
Facial masculinization surgery comprises a set of procedures aimed at achieving a face with larger, more prominent-appearing features. Due to the complexity and challenges associated with these surgeries, extensive planning is mandatory. Desired surgeries may include (but are not limited to) augmentation rhinoplasty, buccal fat removal, mandibular augmentation, and augmentation chondrolaryngoplasty. Dr. Daniel Knott of University California San Francisco (UCSF) and Dr. Rahul Seth of Golden State Plastic Surgery, leading facial plastic surgeons with expertise in gender-affirming care, recently shared their insights facial masculinization surgery via the BackTable ENT podcast.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• As with any facial plastics procedure, a thorough discussion of desired changes should precede facial masculinization surgery. Viewing photos of male family members can assist the surgeon in planning the operation.
• Due to the challenge of facial masculinization surgery, detailed planning photos – taken in both two and three dimensions – are recommended.
• Augmentation rhinoplasty using a rib cartilage graft can produce a more prominent, masculine-appearing nose.
• Other surgeries that can help the patient achieve a more masculine appearance include buccal fat removal, which makes the face appear more angular, augmentation chondrolaryngoplasty, and mandibular augmentation.
• Surgeons should take a conservative approach with augmentation rhinoplasty, as the nasal skin soft tissue envelope can only accommodate so much tissue.
Table of Contents
(1) Preparing Patients for Facial Masculinization Surgery
(2) Facial Masculinization Surgery Options
(3) Expert Pearls on Augmentation Rhinoplasty
Preparing Patients for Facial Masculinization Surgery
A thorough discussion of the patient’s desired appearance must precede any facial masculinization procedure. Asking the patient to bring in images of male family members helps the surgeon visualize the desired end result. Due to the complexity of facial masculinization surgery, Dr. Knott recommends taking both two- and three-dimensional (such as with Canfield’s imaging systems) of the patient’s pre-operative face. These high-quality images enable the surgeon to develop a detailed plan.
[Dr. Gopi Shah]
When the patient comes to your clinic specific to get more masculinizing features, what's part of your exam, and how do you use the facial analysis framework that we talked about in the intro and apply it when you're wanting to-- for gender-affirming care?
[Dr. Daniel Knott]
The patients that come to see us usually are well along the pathway and I find that they already have a very firm idea of what they're looking for. My goal is to, more or less, be a steward or an agent of change to enable them to realize their goal and their dreams, not to insert myself as this filter to tell them what they should do or shouldn't do. I really try to enable them to lead that charge. I find that images, which don't capture the whole story but that really is our map for what we want to do in surgery. Without taking a really high quality photos, it's really hard to form a really detailed plan. We take both two-dimensional and then I find 3D photos are also extremely helpful.
Then the software tools that we have at our disposal these days, provided by companies like Canfield and others, allow us then to perform these morphing sessions where we sit down with our patients and then they already have photographs, friends, brothers, fathers that they come in with. Then we try to overlay their goals and their ideas onto these morphing software platforms to create the face that they're looking for. Then I decide if I can actually achieve this goal that they have in mind.
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Facial Masculinization Surgery Options
Due to the potency of testosterone in eliciting facial changes, facial masculinization surgery is less studied than facial feminization. However, patients whose facial appearance remains insufficiently masculine after hormone therapy should be referred to a facial plastic surgeon to discuss procedural options. Surgeries that produce a more masculine face include the brow lift, brow implant, augmentation rhinoplasty (often with rib cartilage graft), buccal fat removal, mandibular augmentation, and augmentation chondrolaryngoplasty. Botox and facial fillers serve as adjuncts following the initial procedure.
[Dr. Gopi Shah]
In terms of surgical options, so we can just go through them one by one, tell me, what are the surgical options for these patients?
[Dr. Rahul Seth]
For masculinization surgery, the surgical options are, you can basically take feminization surgery, which there's a lot more out there, and put it all in reverse, as Dr. Knott was saying. The things that we want to do are more augmentative. From top to bottom, projecting the brow out more, dropping the actual hair brows down lower, enlarging the nose, giving it a more prominent profile, making the cheek flatter.
The surgeries, so far, that I've mentioned are a reverse brow lift, and an implant to the brow, an augmentation rhinoplasty, which usually involves a rib cartilage graft, a buccal fat removal to flatten out the cheek more, and a augmentation of the mandible, so putting implants onto the jaw itself to making it greater in height and width. Then an augmentation chondrolaryngoplasty. The opposite of a trach shave, where we're reducing the thyroid cartilage or Adam's apple, take a piece of rib and carve it and assemble it into a prominent-appearing Adam's apple, and putting that into a neck incision onto the thyroid cartilage to give a prominence to the Adam's apple. It's a pretty intensive augmentation surgery.
Expert Pearls on Augmentation Rhinoplasty
When performing augmentation rhinoplasty, surgeons should keep in mind that the skin's soft tissue envelope accepts limited enlargement. Therefore, Dr. Knott advocates keeping augmentation goals on the conservative side. His strategy to enlarge the nose relies on osteotomies that push the nasal bones wider and cartilage grafts that reshape the structure. He uses rib cartilage for a dorsal graft and septal cartilage for tip and double spreader grafts.
[Dr. Gopi Shah]
In terms of the rhinoplasty, when you do have to do that, you said you normally take rib graft. Is that for the use for the dorsum and then do you have to do adjustments at the tip, at the ala? How do you put it all together when you make it wider?
[Dr. Daniel Knott]
Yes. Typically, you'd like to use their own septal cartilage, because it's like, septal cartilage is like platinum. It's the best thickness, the best suture holding. It's stiff but not too stiff. It's such a great material for the tip of the nose. Frequently, we'll have to use tip grafts to more project and widen the nose, the tip of the nose. It has to be performed in an overall way that the nose will be harmonious, and even so that way the mid vault's not super wide the tip's under projected or vice versa. To do that, you really do need an abundance of material because essentially, you're sculpting the nose. We'll put in these double spreader grafts, thick grafts along the mid vault to widen the middle vault of the nose. You may do osteotomies to like literally push the nasal bones a little bit wider. Then the dorsal onlay grafting techniques have evolved considerably. Those were challenged by warping in years past. I typically like to use these diced cartilage autografts where we take cartilage, we dice it up into about one millimeter or submillimetric size and form more or less a putty of finely diced cartilage that then we can overlay along the whole dorsum. That reliably would project from the radix all the way down towards the tip. Then we pair it with a variety of techniques also to maintain airway. We don't want to neglect the function of the nose as we're also changing the shape considerably.
[Dr. Rahul Seth]
As any rhinoplasty surgeon will tell you, augmentation is often much more challenging than reduction rhinoplasty. It really takes quite a bit of maneuvers to do all the things that Dr. Knott was mentioning. He makes it sound really straightforward, but it is a lot, especially lengthening the nose and down rotating it. You really have to augment the septum and the dorsal onlay to be able to achieve those things.
[Dr. Daniel Knott]
The skin soft tissue envelope is only so large and it will only accept so much enlargement. You have to stay a little bit modest in your goals. Otherwise, you create this tremendous structure, but you can't close the skin over it. You have to make sure that you don't get overly ambitious.
[Dr. Gopi Shah]
Do you have to make wear incisions or incisions at the ala often as well as that standard since everything's getting wider and bigger?
[Dr. Rahul Seth]
Typically, wear incisions are used to reduce the nostril size or do an alar base reduction. It's really hard to enlarge a nostril. That is an area that we just aren't able to really provide a great solution yet when it comes to facial masculinization. Also in non-facial masculinization, having a nostril stenosis, a very challenging thing to fix often will require a composite cutaneous and cartilaginous graft to be able to enlarge. I typically don't put that in my algorithm of masculinization surgery.
[Dr. Daniel Knott]
Every time you make an incision, you have to think about the potential disfigurement of the scar. I don't like to make incisions around the alar base in general, because I think it can look terrific, but at times that scar can be very obvious and telling. That morphology of that beautiful crease is just so beautiful, it's hard for us to recreate it. You can create a Z-plasty where you take the skin outside the alar base, lateralize the ala and put that skin then from the outside into the inside of the nose, and in that way be able to do it. Again, the scarring can be very problematic.
Podcast Contributors
Dr. P. Daniel Knott
Dr. P. Daniel Knott is a professor in the Facial Plastic, Aesthetic and Reconstructive Surgery Division and the director of Facial Plastic and Aesthetic Surgery with UCSF in San Francisco, California.
Dr. Rahul Seth
Dr. Rahul Seth is a facial plastic and reconstructive surgeon with Golden State Plastic Surgery and Golden State Dermatology in San Fracisco, California.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 14). Ep. 148 – Facial Masculinization in Gender Affirming Care [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.