Plastic and Reconstructive Surgery • February 2022

Table 1.  CPT Codes Used for Correctional Procedures of the Mandible*
Isolated
Procedure
Median Isolated
CPT Overall Isolated Operative wRVUs/
Procedure Name Code Frequency Frequency† Time (min) wRVUs Hr
Open treatment of mandibular fracture; with interdental fixation 21462 1044 723 104 11.0 6.4
Open treatment of complicated mandibular fracture by multiple 21470 620 416 137 17.5 7.7
surgical approaches including internal fixation, interdental
fixation, and/or wiring of dentures or splints
Open treatment of mandibular fracture; without interdental fixation 21461 346 173 85 9.3 6.6
Open treatment of mandibular condylar fracture 21465 88 41 89 13.1 8.8
Open treatment of mandibular fracture with external fixation 21454 57 34 123 7.4 3.6
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/14/2022

wRVUs, work relative value units.

*The following procedures were excluded from the table because of an isolated procedure frequency <30: closed treatment of mandibular
fracture with interdental fixation (CPT code 21453); open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
(CPT code 21445); percutaneous treatment of mandibular fracture, with external fixation (CPT code 21452); closed treatment of mandibular
or maxillary alveolar ridge fracture (separate procedure) (CPT code 21440); closed treatment of mandibular fracture, with manipulation (CPT
code 21451); and closed treatment of mandibular fracture, without manipulation (CPT code 21450).
†Isolated frequency refers to surgical cases wherein only one CPT code was used.

reinforce the notion that increased representation sebastian.winocour@bcm.edu

of craniofacial surgeons in leadership positions
is needed.
DOI: 10.1097/PRS.0000000000008734
Andrew M. Ferry, B.S.
Han Zhuang Beh, M.D.
R. Michael Reul, Jr., B.S.
Rami P. Dibbs, B.A.
Division of Plastic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, and
Division of Plastic Surgery
Department of Surgery
Texas Children’s Hospital
Christopher J. Conlon, M.D.
Rebecca C. O’Neill, M.D.
Division of Plastic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Edward P. Buchanan, M.D.
Edward M. Reece, M.D., M.B.A.
Division of Plastic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, and
Division of Plastic Surgery
Department of Surgery
Texas Children’s Hospital
Twitter: @WinocourMD
DISCLOSURE
The authors have no financial interest to declare in
relation to the content of this article. No funding was
received for this work.
REFERENCES
1. Pickrell BB, Serebrakian AT, Maricevich RS. Mandible frac-
tures. Semin Plast Surg. 2017;31:100–107.
2. Koshy JC, Feldman EM, Chike-Obi CJ, Bullocks JM. Pearls of man-
dibular trauma management. Semin Plast Surg. 2010;24:357–374.
3. American College of Surgeons. ACS NSQIP participant
use data file (2011-2018). Available at: https://www.facs.
org/quality-programs/acs-nsqip/participant-use. Accessed
February 1, 2021.
4. Dotson P. CPT codes: What are they, why are they necessary,
and how are they developed? Adv Wound Care (New Rochelle)
2013;2:583–587.
5. Kazi AA, Lee TS, Vincent A, Sokoya M, Sheen D, Ducic Y.
The role of external fixation in trauma and reconstruction
of the mandible in the age of rigid fixation. Facial Plast Surg.
2019;35:614–622.
Objectification of Transgender Female Patients
in Surgical Goals of Facial Feminization Surgery

Sebastian J. Winocour, M.D., M.Sc.

Division of Plastic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Houston, Texas
Correspondence to Dr. Winocour
Division of Plastic Surgery
Baylor College of Medicine
Jamail Specialty Care Center, Suite E6.100
Houston, Texas 77030
I n popular culture, transgender women are often
presented as hyperfeminine and hypersexualized
in a way that reaffirms binarized gender stereotypes
and objectification.1 Transgender females are women
who were assigned male at birth, but who identify as
female. Objectification is defined as a common social
experience of vulnerability in individuals with a physi-
ologically matured female body,2 through experiences,
such as unsolicited comments about their physical
appearance. Psychological literature on objectification
have shown that when women consider preferences
related to potential romantic partners, and are aware

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 149, Number 2 • Viewpoints
of objectification, it can lead to in-depth self-analysis,
wherein they consider themselves to be objects to be
critically evaluated.3
Despite growing literature on facial feminization
surgery, including social perceptions of transgender
women and correct identification of transgender
women as their chosen gender identity, little is known
about the experiences of transgender women in their
self-perception in their social environment. With
the goal of clarifying the experience of transgender
women, and possibly improving self perceptions, we
investigated features of femininity and attractiveness
by transgender female individuals. This was addressed
by ranking of images of potential surgical outcomes
of three facial features—nasal tip width, supratip
break angle, and mandibular gonial angle—both in
isolation and in combination.4 Potential options were
presented in order of degrees of perceived feminin-
ity based on published literature. Results showed that
transgender women similarly selected the options that
were expected to be more feminine and attractive, as
in published literature.5 Plastic surgeons performing
facial feminization surgery had similar perceptions
of ideal surgical outcome as transgender women.
Interestingly, cisgender female patients, and especially
younger cis female patients, had perceptions of femi-
ninity that were more consistent with expectations
based on sexual dimorphism than cisgender men.
Most importantly, perceptions of attractiveness of
transgender female patients by cisgender individuals
did not coincide with hyperfemininity. In the rank-
ing of isolated features, options of facial features that
were ranked as more feminine were significantly dif-
ferent from options that were ranked as attractive. The
facial profile, with the combination of the most femi-
nine facial features, when viewed in isolation was not
ranked as the most attractive by either cisgender men
or cisgender women. Thus, even though transgender
female patients are objectified in popular culture, this
objectified appearance might not translate into reality
as perceived attractiveness.
Femininity and attractiveness are likely to be more
complex than by sheer definitions of sexual dimor-
phism. Treating plastic surgeons therefore should be
cognizant of the social phenomenon of objectification
in discussion of surgical goals in consultations with
transgender female patients presenting for facial femi-
nization surgery, which optimally should be based on
individual goals and social environments.
DOI: 10.1097/PRS.0000000000008738
Ann Hui Ching, M.B.B.S.
Division of Plastic Surgery
Yale School of Medicine
New Haven, Conn.
Yong Loo Lin School of Medicine
National University of Singapore
Singapore
John A. Persing, M.D.
Division of Plastic Surgery
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Yale School of Medicine
New Haven, Conn.
Correspondence to Dr. Persing
Division of Plastic and Reconstructive Surgery
Yale School of Medicine
330 Cedar Street
Boardman Building, 3rd Floor
New Haven, Conn. 06510
john.persing@yale.edu
@yaleplasticsurgery
DISCLOSURE
Neither author has a financial interest in relation to
the content of this article. No funding was received for
this article.
REFERENCES
1. Tsai WH, Wan-Hsiu Sunny T. Assimilating the queers:
Representations of lesbians, gay men, bisexual, and trans-
gender people in mainstream advertising. Advertising Soc Q.
2010;11.
2. Fredrickson B, Roberts TA. Objectification theory: Toward
understanding women’s lived experiences and mental health
risks. Psychol Women Q. 1997;21:173–206.
3. Sanchez DT, Broccoli TL. The romance of self-objectification:
Does priming romantic relationships induce states of self-
objectification among women? Sex Roles 2008;59:545–554.
4. Ching AH, Hirschman A, Lu X, et al. Perception of femi-
ninity and attractiveness in facial feminization surgery. Ann
Transl Med. 2021;9:602.
5. Morrison SD, Vyas KS, Motakef S, et al. Facial feminiza-
tion: Systematic review of the literature. Plast Reconstr Surg.
2016;137:1759–1770.
Patient-Specific Three-Dimensional Planning for
Head and Neck Reconstruction: Paradigm Shift
and Refuted Myths
P atient-specific planning and three-dimensional
printing have revolutionized head and neck
reconstruction.1 Tumor resection/flap harvesting are
guided by laboratory-made guides using the patient’s
scan data. This leads to the downfall of many surgical
myths.
Myth 1: Extensive mandibular resections are com-
mon. A fibula flap has been the gold standard, because
of bone length. However, the fibula is of low height,
which makes placement/rehabilitation of dental
implants challenging. Cosmesis, contour/profile, and
the reliability/pliability/flexibility of the skin paddle
are questioned.
Using patient-specific planning/three-dimen-
sional printing, we realized that chimeric scapula
flaps work in these defects. The average angle-to-angle
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version of the article on www.PRSJournal.com.
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