Radiologists Can Play a Role in Facial Feminization Surgery

Radiologists can play an important part in facial feminization surgery (FFS) for transgender patients by using CT, a new review article outlines.

In the Dec. 30 American Journal of Roentgenology, a team from the University of Colorado Anschutz Medical Campus walks through how providers can use these scans to help preoperative planning for this surgery that adjusts masculine features, including the prominence of the nose, chin, and brow, to create a more feminine appearance. In doing so, they highlighted how integral and critical the radiologist can be in contributing to patient care for this group.

“Facial feminization surgery (FFS) is an increasingly performed component of gender affirmation surgery for transgender women,” said the team led by Andrew Callen, M.D., assistant professor of radiology-diagnostics. “Familiarity with these (CT) findings will facilitate improved communication between radiologists and surgeons, thereby contributing to the care of transgender women.”

Pre- and post-operative CT in two different patients undergoing facial feminization surgery. Frontal 3D reformatted images (A) before and (B) after surgery in a 29-year-old transgen- der woman. Red dashed line indicates frontal bone osteotomy. Red dash-dot lines indicate mandibular angle osteot- omies. Red solid line indicates genio- plasty. Green arrowheads indicate su- perior orbital foraminal notches. Blue arrowheads indicate mental foramina. Sagittal reformatted images (C) before and (D) after surgery of 39-year-old transgender woman. Note the Oster- hout type 1 frontal sinus. Red dashed line indicates frontal bone recontour- ing. Red solid line indicates genioplas- ty. The nasofrontal angle (yellow line) is increased postoperatively. Credit: American Journal of Roentgenology

In the United States, the transgender and gender diverse population accounts for nearly 1.6 million adults. Not only do many wrangle with dysphoria, the angst that accompanies identifying with a gender other than their gender assigned at birth, but they also experience multiple health disparities. They have a higher risk of suicide, substance abuse, and cancer, and a 2015 report from the National Center for Transgender Equity revealed that 28 percent of the group postpones medical care due to fear of intimidation, 30 percent are harassed in medical settings, and 20 percent are refused care outright.

Consequently, the team said, there is a need for greater understanding from medical providers on how to best serve these patients, including contributing to FFS which can be a largely gender-affirming step. To change the more masculine features of the face, this surgery adjusts chin prominence and the squareness of the jaw, as well as the nasofrontal angle of the upper face and nasofrontal and nasolabial angles of the upper and middle face, and brow prominence.

Images captured by CT can significantly contribute to the success of this surgery, and Callen’s team outlined five steps radiologists can take to maximize the results:

• Target the complete face and orbits, extending above the front sinuses through the entire mandible, using a helical thickness of 0.625 mm, kV of 120, and auto mA from 100 to 250 to maintain the lowest possible radiation dose.
• Use bone kernels in axial, sagittal, and coronal planes to reconstruct CT data.
• Alert referring clinicians to the morphologic findings of the supraorbital ridge and the nose. These are considered specific features of male versus female gender identity, and they are significant targets in FFS surgery.
• Report CT measurements of the nasolabial angles pre- and post-operatively as they can be useful to surgeons. The intersection of the frontal and nasal bones, as well as the apex of the nasofrontal angle, are also critical FFS targets.
• Include descriptions of the location and possible anatomic variations of the inferior alveolar nerve and mental foramina in the radiology report because that information can be helpful in reducing jaw width and chin prominence – a FFS surgery goal.

Callen’s team noted that they did not explore the use of MRI in pre-operative planning, but that the modality has shown it can benefit other surgical procedures. The goal of their review, they said, was to offer more guidance for using imaging findings in gender-affirming surgeries as there is a lack of published transgender-related radiology research.

“[This] highlight[s] the need for greater awareness by radiologists of how the specialty may contribute to the care of the transgender community,” the team concluded.

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