Perception of femininity and attractiveness in Facial Feminization Surgery

Introduction

Gender-affirming surgeries (GAS) are a set of genital and non-genital surgeries that are essential in the multidisciplinary healthcare provision for the transgender community (1). The World Professional Association for Transgender Health (WPATH) has defined gender-affirming interventions, treatments, and surgical procedures as beneficial and effective in the treatment of gender dysphoria and distress caused by the discrepancy between a transgender person’s gender identity and sex assigned at birth (2). WPATH acknowledges that non-genital GAS, including Facial Feminization Surgery (FFS), are often of greater practical significance in the patient’s daily life than reconstruction of the genitals (3).

FFS is a collection of procedures that alters bone and soft tissue, to feminize facial features to aid social identification of transgender females (individuals assigned male at birth) who self-identify with the female gender. The historical basis of FFS is sexual dimorphism, in which the sexes have different biological phenotypes, including facial features (4). FFS alters a transgender female’s, typically “male” facial features, to fit a more female phenotype. Through understanding the anatomic differences between the male and female face one may develop impressions of masculinity and femininity. Some FFS surgeons strive to achieve the “metrics of normal skeletal form” of a female face, based on quantitative measurements and statistical analysis of sexual differences of the skull (4). However, other surgeons achieve femininity through physical attractiveness, rather than an average of the quantitative norm (5).

This study aims to better understand the goals of transgender female individuals, who present for FFS, their personal perceptions of femininity, attractiveness and their preferences for ideal surgical outcomes. This study was carried out through a survey in which respondents evaluate standardized, virtual-modified images of three facial features, the nasal tip width, supratip angle break, and the mandibular gonial angle. Additionally, a composite of the above facial features, was assessed in an individual who was assigned as male at birth. These anatomic features were chosen because they are often asked to be modified in our clinic during consultation for FFS. However, what contributes to attractiveness and what is consistently needed for femininity is unclear in the presently available literature. Hence, features such as dorsal nasal hump, frontal bone ridge, and thyroid cartilage prominence with consistent trends of ideal surgical outcome were not chosen (6,7).

In addition, we compared the responses of transgender females, to non-transgender females, and plastic surgeons who perform FFS. With challenges in communication between transgender individuals and healthcare professionals (8), this study aims to facilitate the communication between transgender female patients and plastic surgeons. By understanding possible differences in perceptions, one may improve management of expectations.

Methods

This study was granted exemption by the Yale University Institutional Human Investigation Committee (HIC: 2000024657) and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-3376). Informed consent was taken from all individual participants. We presented progressive degrees of change of the nasal tip width, nasal supratip angle, and gonial angle of the mandible to respondents. The facial features were studied first in isolation, in which respondents were asked to choose the most “feminine” and most “attractive” option out of 5 variations. In addition, transgender female and plastic surgeon respondents were asked to choose their ideal surgical outcome, for themselves and for their patients respectively. Subsequently, the facial features were studied in combination in which respondents ranked the 9 composites images, from the least to most feminine, in order to explore the relative importance of nose and mandible in determining femininity.

Creation of photographs

The photographs of this study were created using VECTRA 3D software. The modifications were made to the facial features on a 3D photograph of a male Caucasian individual, aged 28 years, without any hormone therapy or craniofacial surgery. The photographs were reviewed by senior plastic surgeons (AJF, MA, and JP). Written consent to alter and distribute photos for the purposes of this study was provided. The digital changes made to the photographs, representing variations of possible surgical outcomes, were guided by objective measures consistent with published literature and historical quantitative measurements on sexual dimorphism (6,7,9-12).

The three altered features are the nasal width, angle of the supratip break, and gonial angle (Figures 1-3). Five variations for each feature were labelled 1 to 5 and presented on a spectrum: 1 being the option expected to be most feminine, and 5 being the altered option expected to be least feminine in accordance to published literature on typical measures of feminine and masculine facial features. The literature suggests a more accented and smaller nasal tip, a more acute supratip angle, and a softer, more obtuse gonial angle, are considered more feminine. The interval in measurements used between options are equal, and are changed progressively per option; for the nasal tip width: 2 mm, supratip break: 5°, and mandibular gonial angle: 6°.

Figure 1 Image options of variations of nasal tip width provided to respondents. The options of 1 to 5 are with increasing widths of nasal tip with 2 mm intervals.

Figure 2 Image options of variations of supratip break provided to respondents. The options of 1 to 5 are with increasing supratip break angle with 5° intervals.

Figure 3 Image options of variations of mandibular gonial angle provided to respondents. The options of 1 to 5 are with decreasing gonial angle with 6° intervals.

In the second part of this study, options 1, 3, 5 for each of the three facial features were combined, to create 9 composite images (Figure 4). Options A to C, D to F, G to I have the gonial angle of the mandible in options 1, 3, 5 respectively. Options A, D, G, options B, E, H, options C, F, I have the supratip break and width of nasal tip of options 1, 3, 5 respectively.

Figure 4 Image options of the combinations of nasal width, supratip break and mandibular gonial angle provided to respondents. Options 1, 3 and 5 of each of the three facial features were combined, to create 9 varying composites images. (A,B,C,D,E,F,G,H,I) refers to images in Figure 4. Options A to C, D to F, and G to I, have the same mandibular gonial angle as in options 1, 3 and 5, respectively. Options A,D,G, options B,E,H, and options C,F,I, have the same supratip break and width of nasal tip as in the options of 1, 3 and 5, respectively.

Survey questions

The survey was hosted on Qualtrics, a secure survey hosting website. It collected basic demographic information, including age, ethnicity, country of residence, education level, household income, employment, and gender(s) to which respondents experience romantic or sexual attraction. Transgender female respondents were asked the age at which they began hormone therapy, transition history (social, legal, medical, and/or surgical). They were also asked what gender-affirming procedures (facial bony surgical, face and neck soft tissue surgical, facial non-surgical, body surgery, top surgery and bottom surgery) they have accessed, are interested in accessing in the future, or have health insurance coverage. Non-transgender female respondents were asked for their gender identities, and whether they had rhinoplasty or orthognathic surgery performed for either reconstructive or cosmetic purposes. Plastic surgeons were asked how many FFS that have involved rhinoplasty or orthognathic surgery they have performed in the past 10 years.

Distribution of survey

The survey was distributed to individuals who self-identify as transgender females through regional and national organizations, medical schools, engagement with social media platforms, including Facebook groups with members interested in FFS. Respondents were encouraged to share the study with other potentially interested individuals. The study was shared on Reddit (13), a social news aggregation website, with community specific discussion boards, by a member of the public. The response rate is incalculable because there is no sampling frame.

The distribution to non-transgender female respondents was initiated through Facebook advertisements, and Qualtrics panel, to target respondents, with similar demographics distribution after responses from at least 100 transgender female individuals were received.

Plastic surgeons involved academically or clinically in FFS were first contacted by email in May, and a subsequent follow-up email was sent in June 2019.

Statistical analysis

Test of normality was produced using Shapiro-Wilk test (SPSS, v.24.0, IBM Corp., Armonk, NY). Independent T tests were used when there were 2 categorical variables, and ANOVA test if there were more than 2 categorical variables. Pearson correlation was used to calculate correlation between 2 values with a normal distribution. The r value of more than 0.6 considered as strong correlation. The P value of less than 0.05 was considered statistically significant.

Results

There were 319 respondents in total and there are three main groups in this study for comparison. One hundred and four transgender female respondents, 192 non-transgender female respondents which include cisgender female (n=93), cisgender male (n=88), transgender male (n=4), and non-binary (n=4) individual respondents, and plastic surgeons who perform FFS (n=23, survey response rate: 35.1%). Transgender female and non-transgender female groups collectively have a survey completion rate is 48.4%. The demographics are presented in Tables 1-3.

Table 1 Demographics of transgender female, and non-transgender female respondents
Full table

Table 2 Profile of transgender female respondents
Full table

Table 3 Demographics of plastic surgeon respondents
Full table

Perception of “femininity”, “attractiveness”, and “ideal surgical outcome”

There are statistically significant differences of means in options chosen as the most feminine and most attractive between transgender female, non-transgender female and plastic surgeon respondents, depending on the facial feature (Table 4). Transgender female respondents considered a more acute supratip break [2.6±1.0 vs. 3.0±1.1, P=0.003, (mean ± SD)], (3.0±0.7 vs. 3.4±0.8. P=0.003) and a more obtuse gonial angle (2.0±1.1 vs. 2.2±1.4, P=0.023) (2.1±1.1 vs. 2.5±1.2, P=0.020) to be both more feminine and attractive than non-transgender female respondents. Transgender females considered a narrower nasal tip (2.2±0.9 vs. 2.7±1.1, P≤0.001) as more attractive than non-transgender female respondents. Differences in mean of the supratip break and nasal tip (0.4 to 0.5) between the two respondents groups in perceptions of femininity and attractiveness are larger than the corresponding differences in means of the gonial angle (0.2 to 0.4) between transgender females and non-transgender female respondents. The perceptions between plastic surgeons and transgender female respondents were mostly similar (Table 5) except plastic surgeons considered a more obtuse gonial angle as more feminine and a more ideal surgical outcome than transgender female respondents (2.0±1.1 vs. 1.4±0.6, P=0.007; 2.1±1.1 vs. 1.7±0.8, P=0.046).

Table 4 Mean value of options being chosen as the most feminine, the most attractive and the ideal surgical outcome, of nasal tip width, supratip break, and mandibular gonial angle, in transgender female, non-transgender female, and plastic surgeons
Full table

Table 5 Relative impact of lower mean of more expectedly feminine option indicating narrower nasal tip width, more acute supratip break, more obtuse gonial angle chosen on femininity, attractiveness and ideal surgical outcome by transgender female, non-transgender female, plastic surgeon respondents
Full table

Ranking of composite photographs in determining femininity

Non-transgender females consistently ranked composite images that have more obtuse gonial angles as more feminine. The mean rank of options chosen by non-transgender female respondents decreased from 5.7 (±3.0, SD) for option A to 3.8 (±3.2) for option I, option A to I of increasingly obtuse mandibular gonial angles. The relationship between increasingly obtuse gonial angles and increasing femininity is linear (Figure 5). In contrast, the mean rank of options chosen by transgender female respondents ranged narrowly from 4.7 (±2.5) to 5.3 (±1.8) with no clear trend. The differences in mean rank for options between transgender and non-transgender female respondents were only statistically significant for the most obtuse gonial angle, i.e., options A, B and C (P=0.036, P=0.013, and P=0.001, respectively), and the most acute gonial angle, i.e., options I (P=0.022) (Table 6).

Figure 5 Graphically depicted difference in mean ranks of femininity of composite images between transgender and non-transgender respondents. The options A-I refer to images in Figure 4. As the scale of 1 to 9, 1 is the least feminine, and 9 is the most. *, P<0.05.

Table 6 Mean ranking of composite images by respondent groups, difference in mean rank and P value of difference in mean rank between transgender and non-transgender female respondents
Full table

However, in options with the most acute gonial angle (options G, H and I) both transgender and non-transgender females evaluated the options with a more acute supratip break and narrower nasal tip width only, as more feminine (5.1±2.2, 4.9±2.9, 4.7±3.5 in transgender group; and 4.6±2.4, 4.3±2.6, 3.8±3.2 in non-transgender females, respectively).

Effect of demographics, sexual attraction, transition on transgender females’ perception of femininity of the mandible

Given the difference in perception of femininity of mandible between transgender and non-transgender individuals and plastic surgeon respondents, we analyzed possible factors that influence perception of femininity in transgender respondents, including demographic features, romantic/sexual attraction to various gender identities, and insurance status.

Transgender female respondents who started hormone therapy at an older age or have never been treated with hormone therapy chose a mandible with a more acute gonial angle as more feminine (P=0.033). Respondents who have undergone social-legal and medical-surgical transitions, chose a mandible with a more obtuse gonial angle as more feminine, compared to individuals who have either made social-legal changes or undergone medical gender-affirming interventions alone (P=0.022) (Table S1).

Transgender female respondents who are romantically/sexually attracted to cisgender men and other transgender female individuals prefer a more obtuse gonial angle, as more feminine, and an ideal surgical outcome as compared to the transgender females who did not share those romantic/sexual attractions (1.80±0.90 vs. 2.27±1.30, P=0.034; 1.84±0.90 vs. 2.28±1.35, P=0.047) (Figure S1). Having accessed, planned or insurance coverage for various gender-affirming procedures had no statistical significance on perception of femininity of the mandible (Table S2).

Correlations between femininity, attractiveness and ideal surgical outcome

The correlation between femininity and attractiveness is stronger among transgender female respondents (r=0.5–0.8, all P<0.001), compared to non-transgender respondents (r=0.3–0.5, all P<0.001). In plastic surgeons, the correlation between femininity and ideal surgical outcome (r=0.7, 0.8, all P<0.001) is stronger than the correlation between attractiveness and ideal surgical outcome (r=0.8, 0.9, all P<0.001) (Table 7).

Table 7 Pearson correlation and 95% confidence interval of the most feminine, the most attractive, the most feminine facial features, and ideal surgical outcome, in transgender female, non-transgender female and plastic surgeon respondents
Full table

Discussion

The WPATH Standards of Care (SOC) recommends criteria for initiation of chest and all genital gender-affirming surgical treatments for gender dysphoria. However, clear surgical guidelines for FFS have not been delineated (2). The WPATH SOC acknowledges that while most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures, including FFS, can be considered purely reconstructive. The surgical interventions, like FFS, can have a “radical and permanent” influence on the quality of life and therefore it is medically necessary for individuals with gender dysphoria (3). Studies in neural networks highlight the gender-affirming power of being socially identified in congruence with the gender with which one self-identifies (14). In fact, some social scientists view FFS as enacting a far more “profound change” than genital reconstruction surgery. FFS has been reported to be either attained or desired in 45% of transgender females (15), and shown to be highly effectively in alleviating related gender dysphoria and improving quality of life (16). Yet, only an estimated 3–8% of transgender individuals have access to FFS (17).

This study demonstrates the difference in perceptions of femininity and attractiveness, between transgender females and non-transgender females. Transgender female respondents perceive a smaller nasal tip width, more acute supratip angle, and more obtuse gonial angles are more “feminine” and “attractive” compared to non-transgender female respondents. Plastic surgeon are more likely to choose a relatively more obtuse gonial angle as more feminine and as ideal surgical outcome compared to transgender females. This suggests the mandible is a more effective indicator of femininity in non-transgender female compared to transgender female respondents. However, in options with the most acute gonial angle, options with a more a narrower nasal tip, and a more acute supratip break seems to assume importance in indicating femininity.

This study also demonstrates that both transgender females and plastic surgeons chose features which are expected to be more feminine as the ideal surgical outcome than non-transgender female respondents. Some surgeons have argued that it is beneficial to achieve extremes of femininity through FFS to decrease a transfeminine individual’s chances of being identified by the public as a gender with which they do not identify (9). This choice by transgender females could reflect societal pressures transgender female individuals face to be hyperfeminine (18), and detract the consideration of FFS as a highly individualized set of procedures, serving individual patients with an individualized goal based on what is realistic.

The choice to attractiveness and femininity reflects critiques by social scientists who argue FFS is a tool for cope with stigma, rather than redirecting efforts to the social discrimination (19). Bioethicists suggest that stating FFS as medically necessary, in achieving binary expectations of gender identification could limit the access of individuals who are deemed to be “feminine enough” to FFS (20). Additionally, the principal goal of FFS is to attain a specific type or amount of femininity could unintentionally socially delegitimize non-binary individuals or transfeminine individuals, who are most comfortable with a gender expression that is not necessarily consistent with historical measures of femininity (21). Due to the potential of FFS in restricting expression of transgender-females, social scientists have suggested for FFS to be considered as medically useful, rather than medically necessary (18,22).

The results of this study show that FFS could allow transgender female individuals to simultaneously achieve both femininity and attractiveness. The correlation between femininity and attractiveness is stronger in transgender female and plastic surgeon than in non-transgender female respondents.

However, managing the expectations of patients presenting for FFS is challenging for plastic surgeons (8). Plastic surgeons and transgender female respondents have different perceptions of “femininity”, “attractiveness” and ideal surgical outcome of the mandible, although their opinion on the nose shape are similar. This is helpful for plastic surgeons in interpreting the actual preferences and expectations of transgender female individuals presenting for surgery. Some strategies suggested in the existing literature include using photographs of female family members as a discussion point and asking individuals presenting for surgery to point out their favorite features of the face, so as to start the discussion between surgeons and transgender females on a positive note (11).

Transgender female individuals seeking FFS do not have homogenous perception of femininity (11). Age at which medical hormonal therapy was initiated, transition history, and romantic/sexual attractions are all influencing factors that impact the perceptions of “femininity”. Medical hormonal therapy affects facial structures and could explain different goals among transgender females, depending on whether or not, and for how long they have been treated with hormone therapy, and when the hormone therapy was initiated. Standardized anti-androgen and estradiol therapy has been shown to induce the increased volume of soft tissue in cheek and decrease soft tissue around jaw (23). Hence, earlier and increasing access to medical intervention with puberty blockers and age-appropriate feminizing hormone replacement therapy, could impact future goals of FFS in gender-affirming care.

Respondents who have undergone more extensive gender-affirming interventions, were more likely to choose options with more obtuse gonial angle as the most feminine than those who had limited or partial transition. However, previous gender-affirming procedures, interests in future GAS, and insurance access, do not affect the perceptions of femininity, attractiveness or ideal surgical outcome in facial structures.

There are several limitations to this study. The individual depicted in our study was Caucasian, and 80.6% of transgender female respondents identified as white. Although the analysis of demographics show no difference in perception of femininity, attractiveness, and ideal surgical outcome between ethnicities, the inclusion of faces from different ethnicities may alter the results in future studies (24-26). The sample size of plastic surgeons is small, despite our outreach efforts. Commonly, more than one FFS procedure is performed in the same operative setting (27). However, the upper third of the face was not included this study, hence we were unable to evaluate its effect on facial harmony. Finally, although this study shows correlation between various groups and desired outcomes, it does not fully explain the intentions and motivations of those seeking changes.

Conclusions

Transgender female perceptions of facial femininity and attractiveness differ from non-transgender females, but are similar to plastic surgeons, except for the mandible. Transgender female respondents chose options that are expected to be the most feminine and attractive, and as their ideal surgical outcome, compared to non-transgender respondents. In the analysis of composite images, non-transgender females considered options with more obtuse mandibular gonial angle as more feminine, while transgender females did not. Acknowledging differences of these perceptions could impact FFS planning, and result in clearer expectations and outcomes for both transgender females and plastic surgeons.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Dr. Oscar J. Manrique, Dr. John A. Persing, and Dr. Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-3376

Data Sharing Statement: Available at http://dx.doi.org/10.21037/atm-20-3376

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-3376). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. XNL and JAP served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was granted exemption by the Yale University Institutional Human Investigation Committee (HIC: 2000024657) and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Pan S, Honig SC. Gender-Affirming Surgery: Current Concepts. Current Urology Reports 2018;19:62. [Crossref] [PubMed]
2. WPATH. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. 2012.
3. WPATH. Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A 2016.
4. Plemons ED. Description of sex difference as prescription for sex change: on the origins of facial feminization surgery. Soc Stud Sci 2014;44:657-79. [Crossref] [PubMed]
5. Plemons E. Formations of femininity: science and aesthetics in facial feminization surgery. Med Anthropol 2017;36:629-41. [Crossref] [PubMed]
6. Springer IN, Zernial O, Nolke F, et al. Gender and nasal shape: measures for rhinoplasty. Plast Reconstr Surg 2008;121:629-37. [Crossref] [PubMed]
7. Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope 2011;121:250-61. [Crossref] [PubMed]
8. Eyssel J, Koehler A, Dekker A, et al. Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey. PLoS One 2017;12:e0183014 [Crossref] [PubMed]
9. Spiegel JH. Rhinoplasty as a Significant Component of Facial Feminization and Beautification. JAMA Facial Plast Surg 2017;19:181-2. [Crossref] [PubMed]
10. Bellinga RJ, Capitan L, Simon D, et al. Technical and clinical considerations for facial feminization surgery with rhinoplasty and related procedures. JAMA Facial Plast Surg 2017;19:175-81. [Crossref] [PubMed]
11. Berli JU, Loyo M. Gender-confirming Rhinoplasty. Facial Plast Surg Clin North Am 2019;27:251-60. [Crossref] [PubMed]
12. Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature. Plast Reconstr Surg 2016;137:1759-70. [Crossref] [PubMed]
13. Reddit, Inc., Reddit. Available online: https://reddit.com/, accessed 10 April 2019.
14. Chen K, Lu SM, Cheng R, et al. Facial recognition neural networks confirm success of facial feminization surgery. Plast Reconstr Surg 2020;145:203-9. [Crossref] [PubMed]
15. Van Boerum MS, Salibian AA, Bluebond-Langner R, et al. Chest and facial surgery for the transgender patient. Transl Androl Urol 2019;8:219-27. [Crossref] [PubMed]
16. Satterwhite T, Morrison SD, Ludwig DC, et al. Abstract: Prospective Quality of Life Outcomes after Facial Feminization Surgery. Plast Reconstr Surg Glob Open 2017;5:204-5. [Crossref]
17. Nolan IT, Kuhner CJ, Dy GW. Demographic and temporal trends in transgender identities and gender confirming surgery. Transl Androl Urol 2019;8:184-90. [Crossref] [PubMed]
18. Grzanka PR, DeVore E, Gonzalez KA, et al. The Biopolitics of Passing and the Possibility of Radically Inclusive Transgender Health Care. Am J Bioeth 2018;18:17-9. [Crossref] [PubMed]
19. Richie C. A queer, feminist bioethics critique of facial feminization surgery. Am J Bioeth 2018;18:33-5. [Crossref] [PubMed]
20. Antommaria AHM. Accepting things at face value: insurance coverage for transgender health care. Am J Bioeth 2018;18:21-3. [Crossref] [PubMed]
21. Ashley F, Ells C. In favor of covering ethically important cosmetic surgeries: facial feminization surgery for transgender people. Am J Bioeth 2018;18:23-5. [Crossref] [PubMed]
22. Notini L, Gillam L, Pang KC. Facial feminization surgery: privacy, personal identity, compensatory justice, and resource allocation. Am J Bioeth 2018;18:12-5. [Crossref] [PubMed]
23. Tebbens M, Nota NM, Liberton N, et al. Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures. J Sex Med 2019;16:746-54. [Crossref] [PubMed]
24. Darrach H, Ishii LE, Liao D, et al. Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty. JAMA Facial Plast Surg 2019;21:96-102. [Crossref] [PubMed]
25. Cho DY, Massie JP, Morrison SD. Ethnic considerations for rhinoplasty in facial feminization. JAMA Facial Plast Surg 2017;19:243. [Crossref] [PubMed]
26. Balaji SM. Facial feminization - Surgical modification for Indian, European and African faces. Ann Maxillofac Surg 2016;6:210-13. [Crossref] [PubMed]
27. Raffaini M, Perello R, Tremolada C, et al. Evolution of full facial feminization surgery: creating the gendered face with an all-in-one procedure. J Craniofac Surg 2019;30:1419-24. [Crossref] [PubMed]