INTRODUCTION
Transgender people are individuals whose gender identity or gender expression, how
a person perceives itself and behaves, differs from the sex it was assigned at birth1. Gender dysphoria is the permanent feeling of anguish or discomfort resulting from
the incompatibility between one’s identity and the sex assigned at birth2. Dysphoria can cause various psychopathologies, such as anxiety and depression, among
others3. As it is an important tool for social interaction, the incompatibility between the
masculine features of the face and the feminine gender expressed by the individual
accentuates suffering, harming the social acceptance of transsexual women4.
To minimize the psychological discomfort resulting from gender dysphoria, in addition
to psychotherapy and hormone therapy, facial gender confirmation surgery is a key
part of the treatment3. Developed by Douglas Ousterhout, surgery plays an important role in the male-female
transition, since, by modifying male characteristics, patients have demonstrated significant
improvements in quality of life and emotional health5, 6.
Printed educational materials contribute to the communication process, in addition
to increasing adherence to treatment and promoting decision-making power7. In the medical literature, there is a consensus on the benefit of written reinforcement
of verbal instructions, as written guidance, written in an accessible manner, increases
patient understanding and confidence in the health service, in addition to promoting
better recovery after a surgical procedure8, 9. The population of transgender women must have access to quality information.
OBJECTIVE
Search the current panorama of information on facial feminization surgeries aimed
at transgender women.
METHOD
A literature review was carried out using the MEDLINE, Cochrane Library, IBECS, LILACS,
and SciELO databases. The included articles were published between 10/15/2018 and
10/15/2023 and the search strategies are described in Charts 1 and 2.
Chart 1 - Database search strategy.
| (“Transgender persons” OR “Transgender person” OR “Transexual woman” OR Transfeminine)
AND (Rhinoplasty OR “Rhytidectomy” OR “Botulinum toxin” OR “Dermal Fillers” OR “Male-to-female”
OR Chondrolaryngoplasty OR “Tracheal Shave” OR “Facial feminization” OR Laryngochondroplasty
OR (“Facial feminization” surgery) OR (“Facial Gender” surgery) OR “Cheek augmentation”
OR FFS OR “Fat grafting” OR “Facial implant” OR Genioplasty OR “Mandibular angle reduction”
OR “Chin feminization” OR (“Facial gender” “confirmation surgery”) OR “Adam’s Apple”
OR “Thyroid notch” OR “Lip lift” OR “Nonsurgical cosmetic procedures” OR “Minimally
invasive cosmetic procedures” OR “Noninvasive cosmetic procedures” OR “Orbital rim
remodeling” OR (“Facial features” “remodeling surgery”) OR “Craniofacial surgery”
OR “Periorbital surgery” OR “Forehead reconstruction” OR “Hairline” OR “Hairline lowering
surgery” OR “Setback” OR “Perceived stigma” OR “Orbital shave” OR “Jaw shave” OR “Facial
contouring”) AND (information* OR educat* OR complication*)) NOT (Masculinization
OR Chest OR Genital) |
Chart 1 - Database search strategy.
Chart 2 - Search strategy in the VHL/IBECS, LILACS, and SciELO databases.
| (“Transgender persons” OR “Transgender person” OR “Transexual woman” OR Transfeminine)
AND (Rhinoplasty OR “Rhytidectomy” OR “Botulinum toxin” OR “Dermal Fillers” OR “Male-to-female”
OR Chondrolaryngoplasty OR “Tracheal Shave” OR “Facial feminization” OR Laryngochondroplasty
OR (“Facial feminization” surgery) OR (“Facial Gender” surgery) OR “Cheek augmentation”
OR FFS OR “Fat grafting” OR “Facial implant” OR Genioplasty OR “Mandibular angle reduction”
OR “Chin feminization” OR (“Facial gender” “confirmation surgery”) OR “Adam’s Apple”
OR “Thyroid notch” OR “Lip lift” OR “Nonsurgical cosmetic procedures” OR “Minimally
invasive cosmetic procedures” OR “Noninvasive cosmetic procedures” OR “Orbital rim
remodeling” OR (“Facial features” “remodeling surgery”) OR “Craniofacial surgery”
OR “Periorbital surgery” OR “Forehead reconstruction” OR “Hairline” OR “Hairline lowering
surgery” OR “Setback” OR “Perceived stigma” OR “Orbital shave” OR “Jaw shave” OR “Facial
contouring”) AND (information* OR educat* OR complication*)) AND NOT (Masculinization
OR Chest OR Genital) |
Chart 2 - Search strategy in the VHL/IBECS, LILACS, and SciELO databases.
As an inclusion criterion, publications in Portuguese, English, and Spanish were included,
cataloged in full in the databases, and that addressed the topic of information for
transsexual patients about facial feminization surgeries. The exclusion criteria eliminated
articles whose main theme was voice or body surgeries, the health of the trans population
in general, mental and emotional health, and medical education, in addition to duplicate
articles.
At the same time, a search was carried out for informative materials, printed or digital,
aimed at the public on the search sites: Google®, Yahoo® and Bing®, in July 2022 and
repeated in October 2023. Specifically on the Google® website, searches were made
for the keywords: “feminização facial”, “manual”, “livro”, “e-book” and “guia”, using the Google Chrome browser, in the first ten pages of results.
RESULTS
The search resulted in 57 articles, after eliminating duplications. Screening by title
and abstract resulted in the exclusion of 52 articles based on relevance. Most of
these articles addressed surgical techniques and the general health of the transsexual
population. The article selection flowchart is shown in Figure 1.
Figure 1 - Article selection flowchart.
Figure 1 - Article selection flowchart.
The abstract of 5 articles was reviewed for eligibility. All of these were excluded,
as they relate to medical education only and did not address patient education (Chart 3).
Chart 3 - Summary of the five articles submitted to qualitative analysis.
| AUTHOR |
YEAR |
TITLE |
OBJECTIVE |
CONCLUSION |
| Buhalog, et al. |
2019 |
Trainee Exposure and Education for Minimally Invasive Gender-Affirming Procedures |
This article assesses the current amount of trainee exposure in clinic and didactic
sessions in core procedural specialties nationwide via survey study of program directors. |
Low exposure of residents and fellows to MIGAPs was observed overall and a lack of
procedure-specific education. In an effort to provide excellent patient care, promote
cultural humility, and improve patients’ quality of life, further education regarding
these procedures is necessary. |
| Chipkin & Kim |
2017 |
Ten Most Important Things to Know About Caring for Transgender Patients |
Ten key principles are provided to help primary care practitioners create more welcoming
environments and provide quality care to transgender patients. |
Primary care providers also should be aware of resources in their community and online,
which can help patients optimize their transition. |
| Vinekar et al. |
2019 |
Educating Obstetrics and Gynecology Residents on Transgender Patients: A Survey Program
Directors |
To describe education on transgender health provided by obstetrics and gynecology
residency programs and to identify the facilitators and barriers to providing this
training. |
Our survey of obstetrics and gynecology residency programs highlights the interest
in transgender health education for a systemically underserved population of patients. |
| Chisolm-Straker et al |
2018 |
Transgender and Gender-nonconforming Patients in the Emergency Department: What a
Physicians Know, Think and Do |
We explore self-reported knowledge, attitudes, and behaviors of emergency physicians
in regard to the care of transgender and gender-nonconforming patients to identify
opportunities to improve care of this population. |
Although transgender and gender-nonconforming people represent a minority of ED patients
nationwide, the majority of respondents reported personally providing care to members
of this population. Most respondents lacked basic clinical knowledge about transgender
and gender-nonconforming care. |
| Pfaff et al |
2020 |
A Structured Facial Feminizations Fresh Tissue Surgical Somulation Laboratory Improves
Trainee Confidence and Knowledge |
A key element of gender-affirming surgery includes facial feminization, which necessitates
a detailed understanding of the anatomical features that differ between female and
male bony and soft tissues.3 In this communication, we describe our experience with a structured facial feminization
cadaver laboratory and evaluate its educational value in plastic surgery training. |
Simulation models are also valuable for less common procedures or where exposure of
surgical trainees to such specialized cases may be limited but desired, as in gender-affirming
surgery.5 Efforts to build on this curriculum and improve resident understanding within this
relatively new and rapidly evolving field within the specialty are ongoing |
Chart 3 - Summary of the five articles submitted to qualitative analysis.
The search for educational materials found only five products on facial feminization
procedures in transgender women for the public, however, presenting several limitations
(Chart 4).
Chart 4 - Search results for informational materials.
| AUTHOR |
YEAR |
TITLE |
TYPE |
LIMITATION |
| Coleman et al. |
2012 |
Standarts of Care fot the health of transsexual, transgender, and gender-nonconforming
people, version 7 |
manual |
Focus on definitions, hormonal treatment and body surgeries. Only cites facial surgeries |
| Simpson & Goldenberg |
2016 |
Surgery: A guide dor MTFs |
manual |
It offers only an overview of facial surgeries. The content is very short and lacks
scientific rigor in its preparation |
| Eric Plemons |
2017 |
The look of a woman |
printed book |
Addresses the subject from an anthropological perspective. It does not mention feminization
surgeries |
| José Carlos Martins Jr |
2020 |
Transgêneros: Orientações médicas para uma transição segura |
printed book |
Available only in Portuguese. It presents the personal opinion of an individual, and
there is a personal marketing bias |
| Deschamps & Ousterhout |
2021 |
Facial Feminization: Facial Feminization Surgery: The Journey to Gender Affirmation
- Second Edition |
printed book |
High-cost book. It presents the view of two experts on the subject but lacks scientific
rigor |
Chart 4 - Search results for informational materials.
DISCUSSION
In the past, numerous anthropological studies have addressed the anatomical differences
in the bone structure and soft tissues between the male and female face. In recent
years, facial feminization surgery has been a popular topic in medical literature,
but with an emphasis on medical education and not addressing patient education.
Of the five materials found on search platforms, two do not provide information about
facial feminization surgery, being a printed book that addresses anthropological aspects
and a free manual available in several languages, although until the last version
it only mentions facial surgeries. The remaining three have content on facial feminization
surgery written for the public, however, in addition to being a very restricted number
of products, they all still have limitations: a high-cost printed book available only
in English, a high-cost printed book available only in Portuguese and a free and very
brief digital manual available only in English. It should be noted that none of the
material was prepared with scientific rigor, that is, it was written based on articles
selected through a systematic review of the topic.
There is a growing interest in research that addresses the need for patient information,
but there is a lack of work on the importance of this topic regarding the transsexual
population. Such studies are pertinent, as the trans population suffers from social
exclusion and marginalization, and from prejudices that make it difficult to consult
health topics with quality and credibility, which result in more unfavorable health
outcomes when compared to the general population10, 11.
Facial feminization surgery is a broad term that encompasses various surgeries and
procedures on the face, such as the forehead, nose, cheeks, and neck, intending to
make the face more feminine. Trans women who suffer from gender dysphoria must know
what types of treatment are available, as well as general information about each one,
including risks so that they can seek treatment according to their needs and be sure
that this information is accessible, serious, and assertive. A study of search parameters
on Google Trend showed that the search for facial feminization procedures on the Internet
tripled between 2008 and 2018, showing a growing interest in the topic among the public12.
A systematic review looking at the state of the art on consumer health education concluded
that it is important to make efforts to improve the quality of digital health information,
given the impact of these media today13.
One of the ways to educate patients is through digital material. Tablets containing
informative health material were distributed in waiting rooms and caused a feeling
of greater education on the part of patients on health topics of interest7. The topic of facial feminization is complex and verbal information alone may be
insufficient. Creating support materials for consultations, such as tablets in the
waiting room, and post-consultation emails with extra reading, among others, can help
consolidate the information provided.
The development of educational technologies can promote behavioral changes, making
the client confident in carrying out certain health-promoting behaviors. Among these
educational technologies, the educational manual stands out, which helps in memorizing
content and contributes to the direction of health education activities14, 15.
It is desirable that multiple communication strategies are developed to inform the
public at all stages of treatment and the private sector can significantly contribute
to the development of this type of material. This resource is of great relevance,
considering that a considerable number of patients find it difficult to acquire basic
health information.
In this sense, the contribution of written educational technologies in the context
of health education and the role of this resource in promoting health, preventing
complications, developing skills, and promoting patient autonomy and confidence becomes
relevant.
Educational materials contribute favorably to the decision-making process, increase
treatment adherence, and promote better recovery in surgical procedures, as they offer
consistent information and reinforce verbal instruction. Due to the great interest
in the topic and condition of social exclusion, investment should be made in the development
of educational materials on facial feminization for the transsexual population and
research into its impact.
CONCLUSION
Despite the relevance of the topic, there are no articles in the medical literature
that address the importance of education about facial feminization surgeries aimed
at the lay public.
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1. Universidade Federal de São Paulo, São Paulo, SIP Brazil
Corresponding author: Patricia de Azevedo Marques Av. Moema, 300, conjunto 71, São Paulo, SP Brazil. Zip Code: 04077-020. E-mail: consultorio@drapatriciamarques.com.br
