Facial Feminization Surgery and The Standards of Care

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generally true that the more “congruent” and “passable” an individual is the better thequality of life and the lower the stress involved.It is somewhat ironic that the patients the current University of California benefitshave been designed to serve is characterized by those most in need of facialfeminization surgery. The “Transgender Surgery Benefit” is only available for facultyand staff of the University of California (and their dependents). Since most faculty andstaff are older, having already established careers and credentials as a qualificationfor employment, they are more likely to have followed the second developmentalcourse 2 of Gender Identity Disorder. A majority of the patients that follow the seconddevelopmental course require FFS before beginning the “real life experience” stage oftheir transition. In reality, it may be effectively impossible for many of the patients inthe covered population to ever take advantage of the new benefits without theavailability of FFS.The types of facial feminization surgeryThe effect of testosterone on facial features varies widely from individual toindividual and more broadly by racial and ethnic heritage. The characteristics anddegree of sexual dimorphism are quite variable and the facial gender characteristicsstereotypical of northern Europeans may not translate widely beyond that group. Ingeneral however, the differences between male and female skulls are a reflection ofthe evolutionary need for more robust and resilient structures on male faces. Maleskulls are generally larger and characterized as “robust” with bony ridges above theeyes and more massive mandibles and chins. Female skulls on the other hand, aresmaller and more “gracile”, lacking the thickened bones evolved to protect males.Every facial element (e.g. brow, nose, chin, etc.) plays a part in constructing thegender gestalt but the dominate players are always the increased size and thicknessof the bones associated with the forehead, jaw and nose.Figure 1: Differences in the structure of male and female facial bones.(Feminization of the Transsexual (Except SRS) Appendix D, Ousterhout)- 8 -
Many of the procedures used to modify facial features (FFS) in the context ofGender Identity Disorder (GID) are coded as so-called “cosmetic” procedures. Thesurgical procedures that, taken together, constitute FFS are broadly categorized intomodification of “bony structure” and “soft tissue”. The “soft tissue” procedures arevery commonly employed for purely cosmetic purposes to alleviate aging patterns (i.e.face-lift) in other contexts. However, the modification of “bony structures” such asbrow shaving or chin and jaw restructuring are almost never done except in thetreatment of GID or to repair catastrophic injuries. Many of the major “bony structure”modifications are by their very origin and design treatments specifically for GenderIdentity Disorder (GID).Partial List of Facial Feminization Surgical ProceduresFacial Bone Modification Surgeries CPT CodeFeminization of the brow (Forehead Reconstruction)Types 1,2,3 and 4 21139Chin Feminization (genioplasty) 21122Mandibular angle bone reduction 21209Feminizing rhinoplasty/septoplasty 30420Thyroid cartilage (tracheal shave) 31599"Soft" Tissue Modification SurgeriesScalp Advancement 14041Forehead LiftUpper and Lower Eyelid BlepharoplastyFace and neck liftVertical lip lift 40799Massert Muscle ShavingAlarplastyAncillary Surgical ProceduresCheek ImplantsFat grafting to the lips and nasolabial foldsIn the context of GID some of the procedures normally employed for purelyaesthetic purposes (e.g. blepharoplasty) are necessary as a direct result of theapplication of bony structure modifications (e.g. forehead re-contouring) for a patient.For example, rhinoplasty is commonly done for purely cosmetic purposes but is mademedically necessary when done in concert with a Type III forehead re-contouringprocedure (Feminization of the Transsexual (Except SRS) Appendix D). The frontal sinus isheavily modified in the course of the re-contouring of the forehead and the rhinoplastymust be done to maintain proper biological function. In a similar fashion a “face andneck lift” would normally be done for purely cosmetic purposes but it becomesfunctionally necessary when the jaw and chin are restructured to female proportionsand shape. The greater size of the male jaw leaves substantial excess skin after ithas been restructured to female proportions. Failure to perform the soft tissue workmade necessary by extensive bony modifications to the face is to functionally treat- 9 -
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Page 10 and 11: only the first part of the problem.
Page 12 and 13: Despite long term exposure to such
Page 16 and 17: The Harry Benjamin International Ge
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Page 21 and 22: Readiness Criteria. The readiness c
Page 23 and 24: June 16, 2006Harry Benjamin Interna
Page 25 and 26: HBIGDA letter on FFS • page 3job
Page 27 and 28: Sources for “Before and After”
Page 29 and 30: Facial Feminization Surgerywith Dr.
Page 31 and 32: Facial Feminization Surgery Example
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Page 35 and 36: Lynn ConwayMarch 29, 2000: Lynn at
Page 37 and 38: Introduction and Commentary on the
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Page 41 and 42: Face lift:I have not simulated a fa
Page 43 and 44: Facial Feminization Surgery: Jennif
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Facial Feminization Surgery and The Standards of Care

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