applyparastyle "fig//caption/p[1]" parastyle "FigCapt" applyparastyle "fig" parastyle "Figure" F&R "Reprints and permission: [email protected]" (CopyrightLine) "Reprints and permission: ^njournals.permissions@ oup.com" (CopyrightLine) Facial Surgery Downloaded from https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaa430/6132321 by University of Pennsylvania Libraries user on 10 February 2021 Aesthetic Surgery Journal 2021, 1–10 Facial Hair Transplantation for Transgender © 2021 The Aesthetic Society. Reprints and permission: Patients: A Literature Review and Guidelines [email protected] DOI: 10.1093/asj/sjaa430 for Practice www.aestheticsurgeryjournal.com Viren Patel, BS ; Ian T Nolan, BM; Elizabeth Card, BS; Shane D Morrison, MD, MS; and Anthony Bared, MD Abstract Background: Facial hair transplantation has become an increasingly popular modality to create a more masculine appear- ance for transmasculine patients. Objectives: This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients. Methods: A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction. Results: We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations. Conclusions: Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testos- terone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a sec- ondary grafting procedure may be needed a year after initial transplant to achieve desired density. Level of Evidence: 4 Editorial Decision date: November 9, 2020; online publish-ahead-of-print February 10, 2021. Therapeutic USA. Dr Bared is an attending surgeon in private practice, Miami, Mr Patel and Ms Card are medical students, Division of Plastic FL, USA. Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. Mr Nolan is a medical Corresponding Author: student, Hansjörg Wyss Department of Plastic Surgery, New York Dr Shane D. Morrsion MD, MS, Division of Plastic and Reconstructive University Grossman School of Medicine, New York, NY, USA. Dr Surgery, Department of Surgery, Harborview Medical Center, 325 9th Morrison is a Resident, Division of Plastic Surgery, Department of Avenue, Mailstop #359796, Seattle, WA 98104, USA. Surgery, University of Washington School of Medicine, Seattle, WA, E-mail: [email protected]; Twitter: @ShaneMorrisonMD 2 Aesthetic Surgery Journal With the transgender population gaining more visibility, METHODS clinicians have been increasingly tasked with serving the needs of this patient population.1,2 In addition to the Search Strategy Downloaded from https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaa430/6132321 by University of Pennsylvania Libraries user on 10 February 2021 genitalia and torso, the face has become an area of in- This study was conducted in adherence with guidelines terest for providers caring for transgender patients be- set forth by the Preferred Reporting Items for Systematic cause masculine and feminine facial features are highly Reviews and Meta-Analyses statement (PRISMA).25 One of salient cues for signaling gender identity.3 Transgender the authors (V.P) undertook a systematic literature search individuals can experience significant facial gender dys- of the National Library of Medicine (PubMed), MEDLINE, phoria from facial features that do not match their identi- and Embase databases for studies published through April fied gender. Incongruous facial features may also result in 2020 that discussed facial hair transplant for transgender misgendering or being “outed” as transgender, which may or gender nonbinary individuals. Due to the heterogen- result in discrimination from others.2,4-7 eity of terminology used to describe both the transgender Gender-affirming therapies, including both surgical population and facial hair transplantation, an inclusive and medical modalities, have been shown to be effica- search query was developed to capture articles of interest, cious in treating the burden associated with facial gender including original articles describing facial hair transplant- dysphoria.8,9 Facial feminization surgery (FFS), which en- ation in the transmasculine population, in addition to case compasses a wide array of procedures, has become an reports, systematic reviews, book chapters, and editor- increasingly popular option for transfeminine individuals, ials (Table 1). Due to a lack of primary literature specific to with the goals of flattening the forehead, reducing the transmasculine patients, publications describing facial hair width of the nose, and creating a short and more pointed transplantation in cisgender patients were also included. chin.10-15 On the other hand, facial masculinization surgery No limits on dates or article type were set on the search. (FMS) aims to increase forehead width and supraorbital The resulting publication titles and abstracts were re- bossing, and to create an angled, rectangular chin and a viewed independently by 2 of the authors (V.P and E.C.) proportionately wide nose, which are generally accepted to determine relevance to this study’s objective, and all as masculine traits.3,13,16-18 disagreements between reviewers were resolved with Although not studied nearly as extensively as FFS, discussion and consensus. If consensus was not possible FMS has begun to appear in the surgical literature, mainly with case reports showing improvements in pa- tient satisfaction, but lacking the sample size to be able Table 1. Search Terms Used to Query Databases to generalize the findings.16-18 Although it is clear that more research about FMS is necessary, providers have Domain Search Terms Boolean Operator found alternative ways to “masculinize” patients’ faces, including fillers and fat grafting.19,20 One modality that Population “Transgender persons,” a “gender OR a could serve to augment FMS or as a standalone inter- of interest identity,” “transgender,” “gender nonconforming,” “gender vention is hair transplant to the face (mustache, beard, non-conforming,” “gender goatee) because the presence and density of facial hair variant,” “gender dysphoria,” contribute to a perception of masculinity.10,21 In early “gender identity,” “gender di- verse,” “transmen,” “trans men,” studies that determined which facial features were mas- “trans women,” “transwoman,” culine and which were feminine, all evidence of facial “transmasculine,” “transpersons,” hair was removed because this would be a give-away “trans persons,” “gender- affirming,” “gender reassign- 10,22,23 of a male face. Furthermore, recent studies have ment,” “gender-confirmation,” shown that increased facial hair is associated with in- “gender-confirming,” “gender creased perception of masculinity.24 minority,” “gender minorities,” “health services for trans- Acknowledging the importance of facial hair in cre- gender person,” a “non-binary,” ating a masculine appearance, providers have begun “nonbinary,” “nonconforming,” transplanting hair to the face of transmasculine patients, “non-conforming” with the hopes of providing a facial aesthetic that is more Intervention “Facial hair,” “beard,” “mous- OR in accordance with their gender identity. Despite this, tache,” “mustache,” “goatee,” “chin strap,” “hair regrowth,” there is no study describing the timing, technique, and “hair regrowths,” “alopecia,” utility of these procedures for transmasculine patients. “hair transplant,” “follicular unit The purpose of this study is to review the existing liter- transplant,” “follicular unit extrac- tion,” “hair restoration,” “beard ature regarding facial hair transplantation and develop restoration” guidelines for practitioners caring for transmasculine patients. aMeSH major topic; only for PubMed. Patel et al 3 between the reviewers, one of the senior authors (S.D.M.) beard transplantation have been described for a variety made a final decision. Duplicate studies and abstracts were of indications, including cosmesis, congenital abnor- excluded, as was any article not written in English. The full malities, posttraumatic injury, oncologic reconstruction, Downloaded from https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaa430/6132321 by University of Pennsylvania Libraries user on 10 February 2021 text of eligible studies was reviewed to extract all relevant and now for masculinization of the face27-36