Airway Events in Transgender Women During Facial Feminization Surgery

Transgender individuals commonly undergo hormone therapy as part of their gender-affirming care. Given the lack of clinical data regarding the impact of these exogenous hormones on airway management as well as the limited knowledge of transgender health, we examined the prevalence of airway events in transgender women undergoing facial feminization procedures.

Retrospective chart reviews were performed on 282 transgender women, ages 14-75, who underwent facial feminization surgeries between 2014 and 2020. Our control group consisted of 375 age-matched, cisgender patients undergoing rhinoplasty procedures during the same time period. Airway events, defined as desaturations (oxygen saturation ≤92%) within 45 minutes of induction and/or ≥ two attempts required for endotracheal intubation, were stratified based on severity. Statistical analysis was performed using multinomial logistic regression.

Compared to our cisgender men and cisgender women control cohorts, the total rate of airway events in transgender women was higher (14.2% vs. 7.5% and 3.6%). Within the transgender women cohort, 57.5% of airway events were considered mild, 35.0% moderate, and 7.5% severe. In a subgroup analysis, transgender women undergoing voice feminization or tracheal shaving experienced significantly more airway events. There were no statistically significant associations between airway events and the studied variables, including age, body mass index, and Mallampati scores.

Transgender women may face a higher risk of airway events during facial feminization surgery influenced by various factors including previous surgeries, hormonal therapies, and comorbid conditions. Anesthesiologists should consider these variables along with the procedure type to preempt potential airway difficulties in their transgender patients.