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Editor’s Note: This story will be updated with comments from experts.

The surgical procedure known as feminizing cranioplasty results in measurable and objective changes to the forehead contour in male-to-female transgender patients seeking a more feminine appearance, according to preliminary results of a retrospective study including 28 individuals.

“The field of facial feminization has expanded quickly in recent decades following the seminal work of Dr Douglas Ousterhout and Dr Jeffrey Spiegel,” said Rui Han Liu, MD, of the Massachusetts Eye and Ear teaching hospital at Harvard Medical School, Boston, in an interview.

A growing body of literature on clinical outcomes following facial feminization surgery has accompanied this expansion, erythromycin after amoxicillin she said. “However, despite the technical focus on bony contouring, the underlying bony changes to the skull have not been examined radiographically. To our knowledge, our study is the first to do so,” she noted.

The feminizing cranioplasty procedure involves the surgical reduction of supraorbital bossing. The upper third of the face has demonstrated the strongest association with femininity and attractiveness based on prior studies, Liu explained. The surgery is designed to both reduce the prominence of the brow bone, smoothen the slope of the forehead, and increase the nasofrontal angle.

In the study, presented at the American Academy of Otolaryngology–Head and Neck Surgery 2023 Annual Meeting, Liu and colleagues reviewed data from 28 male-to-female transgender adults who underwent feminizing cranioplasty at a single center.

The primary outcomes were comparisons of pre- and post-operative radiographic measurements from computed tomography (CT) scans, including assessment of the nasofrontal angle, and angle of deviation from the ideal female forehead slope.

All patients had a pneumatized frontal sinus and preliminary data demonstrated an increase in nasofrontal angle and a decrease in the angle of deviation from that of the ideal female forehead. There was also a decrease in the anteroposterior dimension of the frontal sinus at the prior site of supraorbital bossing.

Results Meet Patients’ and Clinicians’ Goals

“The findings were aligned with our expectations,” Liu told Medscape Medical News. “When we see patients back postoperatively, the feminization effect is evident and the changes that we perceive visually correlate with the radiographic change seen on their postoperative CT scans as compared to their preoperative scans.” 

The results show that feminizing cranioplasty can be performed safely and effectively in transgender patients, Liu said. However, “it is important to tailor the surgical technique according to the anatomy of the [patient’s] frontal sinus, which lies just behind the prominent brow bone,” she noted. Overall, the preliminary data supports that “feminizing cranioplasty can lead to measurable and significant radiographic changes to the supraorbital prominence and slope,” she said. 

The findings were limited by the relatively small sample size at this time and the study is still ongoing. More research is needed to explore the correlation between radiographic outcomes and outcomes reported by physicians and patients, said Liu.

Additional steps for research would be to repeat the radiographic analysis for facial feminizing surgery of the middle and lower thirds of the face, and these radiographic measurements should then be correlated with patient-reported and physician-reported outcomes, she said.

“Additionally, as misgendering is a significant motivator behind pursuing facial feminization surgery, the degree of radiographic change should be correlated to the incidence of misgendering by blinded observers,” she added.

The study received no outside funding. The researchers report no relevant financial relationships.

OTO-HNSF 2023: Radiographic Analysis of Outcomes in Feminizing Cranioplasty. Presented Oct. 1, 2023.

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