LAUSR

‘‘A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy’’ [1] is an article with three main aims. According to the authors, their goal is to characterize the masculine and feminine hand, to describe established gender affirming procedures for the hand and to adapt current aesthetic hand procedures for gender affirming care. They achieve the goals in the first objective and do their best to describe the current state of the art for the last two objectives. They are to be congratulated on their very comprehensive review. In the opening sections, they give a good recap on what defines the masculine versus feminine hand. The average male hand is around 25% larger than the female hand when controlled for patient height. The male hand also appears more square and muscular, while the female hand is more slender. Surveys of hand attractiveness find masculine hands with decreased dorsal fat have been found to be more attractive, while less prominent vasculature is preferred in feminine hands. Compared to masculine hands, the feminine hand is characterized by more subcutaneous adiposity and by tendons that are noticeable only during flexion and extension, and not at rest as they are in masculine hands. Nails are also considered quite important to the perception of a feminine hand [2, 3]. In both masculine and feminine hands, youthfulness is preferred [4]. The next part of the paper tries to establish known feminizing and masculinizing techniques for the hand and adapt them to gender-specific tasks. The problem is that there really is a dearth of literature specifically addressing these techniques in the context of gender affirmation. This is especially true with regard to hand and finger masculinization. The authors move on to feminization techniques, and again there is very little literature that specifically addresses feminization techniques as opposed to rejuvenation techniques. Fat grafting, filler injection, vein ablation and hair removal are all described as feminizing techniques, but of course these methods were originally developed as general rejuvenation, anti-aging techniques as opposed to specific feminization techniques. Fortunately, there is much overlap and it is understood that a softer appearing hand with less visible show of veins and tendons is more feminine. The most common technique used by gender patients is the administration of crossgender hormone therapy. Estrogen and testosterone are powerful hormones and have separate effects on the appearance of the upper extremity. Specifically, estrogen can increase the amount of body fat in the upper extremity and testosterone can increase upper extremity musculature and hair growth [5–7]. Both of these outcomes will have some modest benefit in the goal of feminizing or masculinizing the hand. The authors to be thorough briefly touch upon hand lift and arthrodesis techniques, but it is clear that these are not wide spread techniques for gender patients (or any aesthetic patients) and indeed should not be. It is clear from the authors’ comprehensive review that there have been very few studies specifically addressing hand aesthetics in the transgender community. In the & Daniel A. Medalie [email protected]