Abstract
Purpose:
Facial feminization surgery (FFS) is associated with improved psychological outcomes in transgender patients. We aimed to evaluate the impact of FFS on patient satisfaction with facial appearance using validated, patient-reported outcome tools.
Methods:
Patients were recruited to complete a FACE-Q survey at least 6 months after their FFS. FACE-Q modules used included “Satisfaction with Facial Appearance Overall,” “Facial Attributes” (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), “Decision,” “Outcomes,” “Psychological Function,” and “Social Function.” “Satisfaction with Facial Appearance Overall” was compared to FACE-Q outcomes in transgender patients on hormone replacement therapy (HRT), alone.
Results:
Twenty-three patients completed the survey. Rhinoplasty was the most common procedure (82.6%). Insurance was rated as a major barrier in 50% of patients. “Satisfaction with Facial Appearance Overall” using the FACE-Q was 69.3, with “Psychological Function” rated at 73.7 and “Social Function” rated at 76.1. FFS was associated with a higher overall satisfaction in facial appearance compared to patients on HRT for 3 months (69.3 vs. 48.5, p<0.01) and 12 months, alone (69.3 vs. 54.4, p<0.001). Wait time for FFS of less than a year (β=−20.4, p=0.04) and undergoing FFS at a younger age (β=−1.4, p<0.001) were independently associated with higher satisfaction scores in overall facial appearance.
Conclusions:
FFS is associated with greater satisfaction with overall facial appearance, especially compared to transgender patients only on HRT. Insurance was the greatest barrier to receiving FFS. Improved access to surgery is needed to yield higher overall satisfaction with facial appearance.
Keywords: gender affirming surgery, patient reported outcomes, patient satisfaction, survey
Introduction
Approximately 1.3 million adults in the United States identify as being transgender.1 Gender-affirming surgery (GAS) has been shown to be an important aspect of gender transition, and consequently, GAS procedures have become increasingly common in the past decade.2 In particular, interest in facial feminization surgery (FFS) has risen substantially.3 Google search trends have demonstrated increased public interest in FFS, and a 13-fold increase in procedures was performed between 2013 and 2018 based on a national database estimate.4 This growth may reflect growing insurance coverage for GAS. Despite this, FFS remains less frequently covered by insurance than chest and genital GAS.5
Facial appearance is a key initial indicator used for external perception of gender, and FFS has been shown to be effective in changing perceptions of gender. In one recent study, FFS increased the rate of correct gendering of transgender patients from 57.31% to 94.27% based on pre- and postoperative photos displayed through an online survey platform.6 Improved gender-typing of patients following FFS has also been demonstrated using artificial intelligence facial recognition.7
FFS is typically not defined by a single surgery, but rather a range of craniomaxillofacial procedure options intended to make the face appear more feminine and less masculine. Often multiple procedures are required to achieve the patient's desired outcome, which may include rhinoplasty, forehead contouring, brow lift, blepharoplasty, mandible shaping, chondrolaryngoplasty, cheek augmentation, jaw reduction, fat grafting, genioplasty, and lip augmentation.8
While the safety and esthetic efficacy of FFS have been well established, studies measuring efficacy through patient-reported outcome measures (PROMs) are limited.8 Existing literature has suggested generally positive satisfaction with FFS, but studies have utilized general quality of life surveys, rather than surveys specific to facial appearance.9 A systematic review of PROMs in GAS identified 21 articles covering FFS, but only one study utilized a validated assessment measure, the transgender congruence scale.10,11 Ainsworth and Spiegel developed a nine-question FFS outcomes evaluation tool which suggested greater satisfaction among transgender patients who had undergone FFS, but this instrument has not yet been fully validated.9
Furthermore, the FACE-Q, a PROM developed specifically to assess patient satisfaction with facial appearance, has previously been applied to transfeminine patients who have not undergone surgery.12,13 In the current study, we applied the FACE-Q instrument for assessment of satisfaction with facial appearance in transgender patients specifically following FFS.
Methods
A retrospective review of patients who received GAS at our institution was conducted. Patients were included if they had undergone one or more facial feminization procedures for the purpose of gender affirmation, including frontal sinus setback/forehead contouring, rhinoplasty, genioplasty, mandibular contouring, chondrolaryngoplasty, and/or fat grafting. Patients may have received any combination of these procedures either in a staged manner or in a single encounter. Patients were excluded if <6 months had elapsed since their most recent facial feminization procedure. This study was approved by our institution's institutional review board (HIC# 2000031685), and informed patient consent was obtained.
Survey administration
Two electronic surveys were distributed to patients meeting inclusion criteria. The first survey assessed patient experiences with obtaining FFS (i.e., insurance coverage, barriers to care, sources of information, time spent living openly in their gender before surgery, and history of other GAS). Specifically, various barriers to surgery were assessed based on a Likert scale from 1 (“not a barrier) to 4 (“major barrier”). Similarly, perceived utility of different sources of information was evaluated based on a scale from 1 (“not a source of information”) to 4 (“very helpful”).
The second survey assessed patient satisfaction with facial appearance using the FACE-Q instrument. The FACE-Q was developed by Q-Portfolio and consists of a series of validated modules for patients undergoing facial procedures. Use of this Questionnaire, authored by Drs. Klassen, Pusic, and Cano, was made under license from Memorial Sloan Kettering Cancer Center, New York, USA.14–18
Patients were asked to complete six individual modules from the FACE-Q that evaluated satisfaction with their face: “Satisfaction with Facial Appearance Overall,” “Satisfaction with Facial Attributes” (specific segments of the face were forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), “Satisfaction with Decision,” “Satisfaction with Outcomes,” “Psychological Function,” and “Social Function.” With facial appearance in mind, the “Psychological Function” scale measures concepts, such as happiness, confidence, and self-acceptance (e.g., “I like myself,” “I feel happy,” “I am accepting of myself”), while the “Social Function” scale measures social interactions with familiar people and strangers (e.g., “I make a good first impression,” “I feel confident when I meet a new person,” “I feel confident in new social situations”).
Each question of the FACE-Q consisted of a 4-point Likert scale from 1 (“very dissatisfied/definitely disagree”) to 4 (“very satisfied/definitely agree”). The modules were scored individually, and Rasch-transformed scores (range 0–100) were calculated from raw scores.
A chart review was completed to explore whether survey respondents were different from nonrespondents. Postoperative follow-up at 6-months was evaluated to determine if patients reported whether they were dissatisfied with their results or if they desired revisions.
Statistical analyses
The average standardized scores were determined for each of the FACE-Q modules. Scores were compared by the number and types of procedures. Continuous variables were summarized using mean and standard deviation, while categorical variables were expressed as proportions. Univariate comparisons were made using χ-squared tests. A correlation matrix was utilized to explore the relationships between the different FACE-Q modules. Univariate linear regression was used to determine the relationship between satisfaction with facial appearance, overall scores, and patient demographics.
FACE-Q scores were compared to previously published values for a population of transfeminine patients who received hormone replacement therapy (HRT) for 3- and 12 months.12 Patients from this cohort had a median age of 29 years old with an interquartile range of 22–32 years old. FACE-Q scores from the “Satisfaction with Facial Appearance Overall” module were compared between patients from both studies.
Significance value was set at <0.05, and all statistical analyses were completed in SAS 9.4.
Results
Patient characteristics
A total of 23 of 57 (40.6%) patients completed the FACE-Q. There were no differences between survey respondents and nonrespondents when comparing average age at surgery, average procedures, proportion of procedure types, and reported dissatisfaction/desired revisions (Supplementary Table S1). The average time from the most recent procedure to completion of the survey was 1.8±1.4 years. Average age at the time of surgery was of 39.1±13.0 years old. Patients underwent an average of 4.0±1.8 procedures on different anatomic areas for FFS before completing the survey (i.e., a combination of rhinoplasty, forehead contouring/frontal sinus setback, genioplasty, mandibular contouring, or chondrolaryngoplasty completed either in stages or as a single encounter). The most common procedure was a rhinoplasty (82.6%), followed by a genioplasty (78.3%) (Table 1).
Table 1.
Demographic Characteristics of Patients Who Completed the FACE-Q Survey
| Characteristics | Value |
|---|---|
| n | 23 |
| Average age at procedure (years) | 39.1±13.0 |
| Average time from surgery to survey (years) | 1.8±1.4 |
| Average number of procedures | 4.0±1.7 |
| Procedure type | |
| Frontal sinus setback/brow contouring, n (%) | 16 (69.6) |
| Rhinoplasty, n (%) | 19 (82.6) |
| Genioplasty, n (%) | 18 (78.3) |
| Mandibular contouring, n (%) | 16 (69.6) |
| Fat grafting, n (%) | 11 (47.8) |
| Chondrolaryngoplasty, n (%) | 12 (52.2) |
Patient experience with FFS
Of the patients who responded to the demographic survey, a majority (57.9%) reported living openly in their gender for more than 5 years before surgery, and most patients (57.9%) waited <1 year to undergo surgery. Medicaid was the primary insurance used for most (78.9%) surgeries, with one patient (5.2%) reporting paying out-of-pocket. A proportion of patients received either “top” or “bottom” surgery before FFS (36.8% and 21.1%, respectively), with a single patient (5.2%) having received both.
Personal acquaintances and craniofacial surgeons were the sources of information most commonly reported as “very helpful” (61.1%), followed by mental health providers and social media (47.1% and 41.2%, respectively). Negative experience associated with a clinic or hospital, geographic distance to care, and time away from work were rarely reported as significant or major barriers to receiving FFS (8.3%, 5.2%, and 0.0%, respectively). Difficulty finding a surgeon and required mental health assessments were listed as significant or major barrier(s) in a minority of cases (both 21.0%). Lack of insurance coverage was most commonly reported as a significant or major barrier (50.0%) to receiving FFS (Table 2).
Table 2.
Reported Patient Experience with Facial Feminization Surgery
| Value | |
|---|---|
| n | 19 |
| Coverage for FFS, n (%) | |
| Medicaid or Medicare | 15 (78.9) |
| Private insurance | 3 (15.8) |
| Out of pocket | 1 (5.2) |
| Prefer not to answer | 1 (5.2) |
| Time spent living openly in gender, n (%) | |
| 1–3 years | 5 (26.3) |
| 3–5 years | 3 (15.8) |
| 5–10 years | 6 (31.6) |
| 10–20 years | 3 (15.8) |
| >20 years | 2 (10.5) |
| Time spent waiting for FFS, n (%) | |
| <6 months | 5 (26.3) |
| 6–12 months | 6 (31.6) |
| 12–18 months | 2 (10.5) |
| 18–24 months | 2 (10.5) |
| 2–3 years | 2 (10.5) |
| 3–5 years | 0 (0.0) |
| >5 years | 2 (10.5) |
| Received other GAS, n (%) | |
| None | 6 (31.6) |
| Top surgery | 7 (36.8) |
| Bottom surgery | 5 (21.1) |
| Top and bottom surgery | 1 (5.2) |
| Prefer not to answer | 1 (5.2) |
| Barriers to receiving FFS, n (%) | Not a barrier | Minor barrier | A significant barrier | A major barrier |
|---|---|---|---|---|
| Difficulty finding a surgeon |
8 (42.1) |
7 (36.8) |
2 (10.5) |
2 (10.5) |
| Requirement for mental health assessment |
6 (31.6) |
9 (47.4) |
2 (10.5) |
2 (10.5) |
| Lack of insurance |
9 (50.0) |
0 (0.0) |
5 (27.8) |
4 (22.2) |
| Geographic distance to clinic/hospital |
11 (57.9) |
7 (36.8) |
1 (5.2) |
0 (0.0) |
| Taking time off work |
12 (66.7) |
6 (33.3) |
0 (0.0) |
0 (0.0) |
| Negative experience with clinic/hospital | 14 (77.8) | 4 (22.2) | 0 (0.0) | 0 (0.0) |
| Usefulness of sources, n (%) | Not a source | Not very helpful | Somewhat helpful | Very helpful |
|---|---|---|---|---|
| Transgender care-focused website |
6 (31.6) |
1 (5.4) |
5 (26.3) |
7 (36.8) |
| General online medical info |
6 (35.3) |
0 (0.0) |
6 (35.3) |
5 (29.4) |
| Personal blogs |
5 (31.3) |
0 (0.0) |
6 (37.5) |
5 (31.3) |
| Personal acquaintance |
4 (22.2) |
0 (0.0) |
3 (16.7) |
11 (61.2) |
| Published media |
10 (58.8) |
0 (0.0) |
2 (11.8) |
5 (29.4) |
| Social media |
8 (47.1) |
1 (5.9) |
1 (5.9) |
7 (41.2) |
| Primary care provider |
4 (26.7) |
2 (13.3) |
4 (26.7) |
5 (33.3) |
| Mental health provider |
3 (17.6) |
3 (17.6) |
3 (17.6) |
8 (47.1) |
| Craniofacial surgeon | 3 (16.7) | 0 (0.0) | 4 (22.2) | 11 (61.1) |
FFS, facial feminization surgery; GAS, gender-affirming surgery.
FACE-Q scores
The average score for “Satisfaction with Facial Appearance Overall” was 69.3±19.8. The average scores for “Satisfaction with Decision” and “Satisfaction with Outcomes” were 77.8±32.7 and 72.9±30.7, respectively. Average scores for “Psychological Function” and “Social Function” were 73.7±20.6 and 76.1±24.8, respectively. Among facial attributes assessed, the highest satisfaction was reported for cheekbones (85.0±17.7), followed by neck (84.2±29.6), cheeks (83.3±19.8), and forehead/eyebrows (82.5±15.6) (Table 3).
Table 3.
Average Score of FACE-Q Subscales Completed
| FACE-Q subscale | Average score±SD |
|---|---|
| Satisfaction with overall appearance | 69.3±19.8 |
| Satisfaction with facial attributes | |
| Forehead/eyebrows | 82.5±15.6 |
| Nose | 81.0±17.2 |
| Cheeks | 83.3±19.7 |
| Cheekbones | 85.0±17.7 |
| Chin | 73.0±31.4 |
| Jawline | 78.8±22.7 |
| Neck | 84.2±29.6 |
| Satisfaction with decision | 77.8±32.7 |
| Satisfaction with outcomes | 72.9±30.7 |
| Psychological function | 73.7±20.6 |
| Social function | 76.1±24.8 |
SD, standard deviation.
Higher scores in “Satisfaction with Facial Appearance Overall” were positively correlated with higher satisfaction in “Satisfaction with Decision” (r=0.72, p<0.05), “Social Function” (r=0.56, p<0.05), and “Psychological Function” (r=0.61, p<0.05). There was no significant difference in individual scales (e.g., “Satisfaction with Facial Attributes: Nose”) when comparing an anatomic region between patients who underwent surgery in that region versus those who did not (Table 4). Wait time for facial feminizations surgery of less than a year (β=−20.4, p=0.04) and undergoing the procedure at a younger age (β=−1.4, p<0.001) were each independently associated with higher scores for “Satisfaction in Facial Appearance Overall.” There was no association between overall satisfaction in facial appearance scores and the time spent living openly in one's gender or total number of FFS procedures.
Table 4.
Average Scores of FACE-Q Subscales Between Patients Who Obtained Specific Surgeries
| Had the procedure | Did not have the procedure | p | |
|---|---|---|---|
| Frontal sinus setback/brow contouring | |||
| n | 16 | 7 | |
| Satisfaction with overall appearance | 72.1±18.1 | 61.7±23.9 | 0.28 |
| Satisfaction with facial attributes: forehead/eyebrows | 84.0±13.9 | 78.7±20.2 | 0.49 |
| Rhinoplasty | |||
| n | 19 | 4 | |
| Satisfaction with overall appearance | 70.3±20.7 | 62.7±14.6 | 0.54 |
| Satisfaction with facial attributes: nose | 82.4±17.6 | 72.7±16.2 | 0.38 |
| Genioplasty | |||
| n | 18 | 5 | |
| Satisfaction with overall appearance | 70.2±20.8 | 62.3±16.8 | 0.66 |
| Satisfaction with facial attributes: chin | 71.2±32.4 | 80.8±29.4 | 0.60 |
| Mandibular contouring | |||
| n | 16 | 7 | |
| Satisfaction with overall appearance | 68.9±18.7 | 70.2±24.6 | 0.90 |
| Satisfaction with facial attributes: jawline | 80.2±21.8 | 74.4±27.5 | 0.63 |
| Fat grafting | |||
| n | 11 | 12 | |
| Satisfaction with overall appearance | 75.5±20.4 | 63.1±18.1 | 0.15 |
| Chondrolaryngoplasty | |||
| n | 12 | 11 | |
| Satisfaction with overall appearance | 72.1±18.7 | 66.5±21.5 | 0.52 |
| Satisfaction with facial attributes: neck | 89.9±34.2 | 78.5±24.71 | 0.40 |
Comparison to published FACE-Q values
When comparing satisfaction of patients after FFS with a published cohort that underwent only HRT, the post-FFS cohort had significantly higher scores on the “Satisfaction with Facial Appearance Overall” scale compared to both HRT-only for 3 months (69.3 vs. 48.5, p<0.01) and HRT-only for 12 months (69.3 vs. 54.4, p<0.001) (Fig. 1).
FIG. 1.
FACE-Q satisfaction with facial appearance overall of included patients compared with published values of patients undergoing HRT at 3- and 12 months. Reference data from Tebbens et al.12. HRT, hormone replacement therapy.
Discussion
In this single-institution retrospective study, we evaluated patient experience and satisfaction with facial appearance after gender-affirming FFS using the FACE-Q questionnaire. Compared to previously published values, patients after FFS had higher levels of satisfaction with their overall facial appearance, including compared to transfeminine patients receiving HRT alone. Undergoing surgery at a younger age and having a shorter wait time before surgery were associated with higher satisfaction with overall facial appearance in the patients in this study. Lack of insurance coverage was the greatest barrier to care reported. A variety of sources were reported to be valuable in informing patients on FFS. Surgeons were the most common source of information and most often ranked as “very helpful,” highlighting the importance of surgeon engagement for patients considering FFS.
Many previous studies have utilized the FACE-Q as a standardized method to measure patient satisfaction after facial surgeries and procedures, including rhinoplasties, facelifts, and injectables.19 Among these procedures, patient scores in a primarily cis-gender population have ranged from 66.2 to 80.7 on the overall facial appearance scale.20–23 Specifically, in the FACE-Q validation study evaluating almost 1000 patients, satisfaction with overall appearance scores was reported as 67.2 for blepharoplasties, 78.3 for facelift procedures, and 69.4 for rhinoplasties.24 In our cohort, postfacial feminization scores approached similar levels, demonstrating a comparative level of satisfaction after FFS. In addition, compared specifically to other transgender patients who completed the FACE-Q after HRT alone, GAS had higher patient satisfaction in overall facial appearance.
Facial appearance has been reported to be one of the many causes of dysphoria and dissatisfaction in transfeminine people, with satisfaction with the face considered critical for appearing sex congruent to gender.25 In a study evaluating eye movements in both cis-gender and transgender patients, it was found that transgender patients spent more time of their gaze on the forehead, mandible, and chin than other features of the face.26 Many transfeminine patients were subconsciously focusing on specific attributes that may be associated with appearing more feminine, further demonstrating the potential importance of these specific features for sex congruency and social interaction.
Furthermore, surgery may influence both social and psychological quality of life. Facial feminization, alone, has been shown to improve quality of life along various psychosocial aspects, including anxiety and depression.27 In our cohort, patients had a high score on the psychological and social function scales of the FACE-Q (76.1 and 73.7, respectively). Importantly, these scores reflect psychological (happiness) and social function (social confidence), with facial appearance in mind.
The psychological and social function scores found in our cohort are comparable to results from other studies that use the FACE-Q following other facial procedures. Schwitzer et al. reported scores of 73.2 and 70.4 for psychological and social function, respectively, following genioplasty.28 In addition, Gibstein, et al. reported a score of 81.7 and 84.4 for psychological and social function, respectively, following facelift surgery.29 However, in the transgender population, there are no studies evaluating psychological and social function with facial appearance in mind using the FACE-Q. Thus, a direct comparison of the effects of surgical intervention in comparison to other forms of treatment for gender dysphoria (e.g., HRT alone) cannot be made. Future study would be needed to assess the changes in psychological and social function following facial feminization.
Access to FFS is specifically challenging for patients in regards to insurance coverage.30,31 Although over two-thirds of the patients in our cohort reported utilizing Medicaid as their source of coverage for FFS, half reported insurance coverage to be a major barrier. Coverage for gender affirming surgeries often varies between facial feminization and top or bottom surgery. Coverage for top and bottom surgery is more accepted as a needed change than facial feminization, given that many insurers categorize FFS as “elective.” Notably, this study was based in Connecticut, which offers coverage for a majority of facial feminization procedures, in addition to genital and breast surgery requests.32 With patients in our cohort pursuing FFS before other gender affirming surgeries, it could be argued that FFS is of equal importance to other gender affirming surgeries and should have equivalent insurance coverage.
Over the years, there have been improvements in expanding insurance coverage for FFS, affording patients better access to care.2 With increases in coverage, patients may have the opportunity to obtain GAS sooner. The finding that shorter wait times before FFS and younger age at procedure are associated with overall satisfaction underscores the importance of providing timely access to care. Importantly, the length of time a patient spent living openly in their gender before surgery did not influence satisfaction.
Although many patients utilize their health care providers (e.g., mental health provider, craniofacial surgeon), as sources of information for FFS, nearly half of patients also utilized social media as a resource. With the rise of new social media platforms over the past several years, many medical professionals have joined these platforms, reasoning that social media can be used to improve accessibility for patients.33 However, for facial feminization, research is needed to determine what information is being presented to patients online and its impact on patient expectations and satisfaction after their procedure.
Limitations
There are several limitations to this study that deserve consideration. First, while the FACE-Q is a standardized method for assessing facial procedures, it primarily assesses satisfaction with facial appearance. The FACE-Q was calibrated to a cis population and does not have trans-specific questions, and validation of the survey was completed with a younger patient population. Improved gender congruence may be a greater motivator for patients to pursue FFS than esthetic improvements. A specific standardized survey to assess impact on gender dysphoria and satisfaction in patients undergoing GAS is underway and needed for the transgender population. Second, the results of this study are dependent on whether patients returned the survey, resulting in the possibility of selection/nonresponse bias.
In addition, this study was limited to postoperative satisfaction. Our conclusions are therefore limited to overall satisfaction with facial appearance of patients who have undergone FFS rather than the effects of FFS on satisfaction. Finally, the comparison population of HRT only FACE-Q scores was younger than our cohort, with a median age of 29 (interquartile range 22–32) compared to a mean age of 39.1±13.0 years for our cohort. However, previous studies have shown no difference in FACE-Q scores of the subscale “Satisfaction with overall facial appearance” based on age.34 More research is needed to better assess how subscale scores of the FACE-Q change with FFS, including psychological and social function.
Conclusions
In conclusion, transgender patients who underwent FFS reported high overall satisfaction with their facial appearance compared to transgender patients with HRT alone or cisgender patients following esthetic surgery. Personal acquaintances, surgeons, and social media are particularly important sources of information for patients considering FFS. However, insurance coverage remains one of the greatest challenges to receiving surgery.
Abbreviations Used
- FFS
facial feminization surgery
- GAS
gender-affirming surgery
- HRT
hormone replacement therapy
- PROMs
patient-reported outcome measures
- SD
standard deviation
Authors' Contributions
M.N.A.: investigation (equal), formal analysis (equal), writing—original draft (equal). A.S.L.: conceptualization (equal), methodology (equal), Investigation (equal), writing—original draft (equal). A.H.J.: conceptualization (equal), methodology (equal), investigation (equal). J.C.R.: methodology (equal), investigation (equal). S.C.H.: formal analysis (equal). D.P.A.: writing—original draft (equal). J.Z.G.: writing—original draft (equal). M.C.G.W.: writing—original draft (equal). J.A.P.: writing—review and editing (equal), supervision (equal). M.A.: writing—review and editing (equal), supervision (equal).
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Supplementary Material
Cite this article as: Almeida MN, Long AS, Junn AH, Rivera JC, Hauc SC, Alper DP, Glahn JZ, Williams MCG, Persing JA, Alperovich M (2023) FACE-Q satisfaction ratings are higher after facial feminization surgery than hormone replacement therapy alone, Transgender Health 9:5, 436–443, DOI: 10.1089/trgh.2022.0209.
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