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Archive for the ‘facial feminization surgery’ Category

Case Study – Transgender Vermilion Lip Advancements

Monday, December 11th, 2017


Background: The lips frame the mouth and are an important facial feature. What is seen on the lips is the dry vermilion with a little wet vermilion, known as the red part of the lips. The amount of vermilion seen determines the size of the lips. The junction of the vermilion and the skin, particularly the upper lip, determines their shape.

The lips are an important gender identifying feature. (even without makeup) As a general rule, desirable lips in women are fuller and have a more defined Cupid’s bow. It is not as important in men that lips necessarily be full. And most men do not have a well defined Cupid’s bow shape. While many women do have thin lips with little shape, often with aging, youthful feminine lips are associated with significant vermilion size and shape.

While there are many facial feminization surgery procedures, lip augmentation  is often a very important one. In achieving this change, a vermilion advancement is an effective and powerful procedure to do so. Changing the position of the vermilion-cutaneous junction through skin removal allows for much increased vermilion exposure. In the process the arc of the vermilion and the strength of the Cupid’s bow portion of the upper lip can be enhanced.

Case Study: This middle-aged male to female transgender patient was to undergo a fairly complete facial feminization procedure. The lips were thin (less than 7mms of exposed vermilion) and the mouth corners were turned down

As part of an overall nine hour facial feminization surgery, upper and lower lip advancements were performed. The size of the skin removed from the upper and lower lips was 3mms. The Cupid’s bow of the upper lip was sharpened. (stronger points) The two weeks result showed how dramatic such vermilion lip advancements can be.

Lip advancements may be a small in size facial feminization surgery procedure but its effects are significant. It does create a fine line scar at the vermilion-cutaneous junction but this heals extremely well particularly in genetic male facial skin that is naturally thicker with beard hairs.


1)The size and shape of the lips is a major feminine facial feature.

2) Vermilion advancements are the most powerful lip augmentation procedure because it can change both size and shape.

3) In the transgender male to female patient changing the mouth area with a surgical lip augmentation is a small but important facial change.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of Rhinoplasty in Facial Feminization Surgery

Sunday, December 18th, 2016


Facial feminization surgery changes the structure of the male face to appear more feminine. While procedures from the skull down to the trachea exist to make these modifications, nose reshaping is one of the mainstay operations. That is not only because it sits in the middle of the face but because it has distinct gender differences.

In the December issue of the journal JAMA Facial Plastic Surgery, an article entitled ‘Technical and Clinical Considerations for Facial Feminization Surgery With Rhinoplasty and Related Procedures’ was published. In this paper the authors reported on the role of rhinoplasty and other facial procedures procedures to feminize the nose to the forehead and lower face. A series of 200 consecutive male-to-female transgender patients were objectively evaluated. Frontonasal angles were measured as well as assessment by a five point nose feminization scale. In these 200 patients the mean frontonasal angle increased by a difference of 15 degrees from an average 133 degrees to an average 149 degrees. Patients considered their nose more feminine with a high satisfaction level. (4 out of 5 on the Nose Feminization Scale)

The authors also discussed how a feminizing rhinoplasty was also seen to be enhanced by changing adjacent facial structures as well with inferior lip lifts and superior brow bone reductions and forehead reshaping.

While facial feminization surgery is a compendium of a wide variety of procedures which together create an overall effect, certain of these procedures can be considered more important. Rhinoplasty and brow bone reduction/forehead reshaping would be considered the big two of facial feminization surgery given their central facial location.

frontonasal-angle-in-rhinoplastyThe difference between the male and female nose is more than just size alone. The female nose shape is more narrow, the tip is more refined and upturned (increased nasolabial angle) and the nostrils are smaller. In addition the frontonasal angle is larger and this is helped to be achieved by the effect of brow bone reduction above the radix of the nose to soften this angle. This frontonasal angle change is a critical element in a feminizing rhinoplasty.

In conjunction with forehead reshaping, the refinement of the nose can significantly improve facial gender transition. A rhinoplasty contributes significantly to making the face appear softer and more feminine.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Feminization Surgery – Outcome Assessment

Monday, June 6th, 2016


Facial feminization surgery (FFS) is well recognized collection of hard and soft tissue reshaping procedures. While most commonly seen as a transgender procedure, it is also done for non-transgender females who have more masculine facial features. While it is unknown how many such FFS procedures are performed around the world, it is very clear that the numbers are increasing. This is sure to continue to increase as the internet makes awareness and access easier, more surgeons are performing the procedures and medical insurances are beginning to offer some coverage for them.

While various facial feminization surgery procedures exist, there are few studies that have been done that have assessed their outcomes. How successful is the change in the facial appearance, are patients satisfied and what is the rate of complications from this type of facial reshaping surgery.

In the June 2016 issue of the journal Plastic and Reconstructive Surgery, a paper appeared in print entitled ‘Facial Feminization: Systematic Review of the Literature’.  In this paper the authors performed a literature search and identified fifteen articles that were either case reports and clinical series. Of the over 1120 patients that were reviewed in these articles, seven (7) complications were reported. These complications were fluid collections in PMMA forehead augmentations (3), excessive mobility from bony nonunion from forehead contouring with brow bone reduction (3) and one rhinoplasty complication. Patient satisfaction was high although such determinations were not done using any method of quantified assessment.

facial feminization surgeryFacial feminization surgery consists of a collection of procedures of which the brow and forehead are the most recognized. It is well acknowledged that the upper third of the face is the most important in making for a female appearance. Alloplastic forehead augmentation, frontal bone narrowing, brow bone contouring using either burring or an osteoplastic bone flap setback method, and hairline lowering and browlifting create the potential for a major gender appearance change. While all of these procedures are effective at achieving these feminization goals, there are not without potential complications. Bony irregularities, visible scarring, supraorbital nerve injuries and infection from alloplastic materials are all possible.

The eyes play a critical role in determining sex and the female orbit. The shape of the orbital rims in females are higher, less rounded and appear larger creating a softer eye appearance. A wider palpebral fissure also leads to a more feminine appearance. This leads to the role of superior orbital contouring and lateral canthoplasties to affect these changes. Removal of upper eyelid skin can also be done to feminize the upper eyelid area.

Female faces are heart-shaped with prominent well defined cheeks. One element of the female cheek area is that the zygomas are wider than in men. Whether this is best done with a widening zygomatic osteotomy with interpositional graft, cheek implants or fat injections can be debated. But increasing the width of the zygomatic arch creates a rounder more female face. In my hands this is best done with silicone zygomatic arch implant that can go the whole back to just in front of the ear.

Feminizing the nose through an open rhinoplasty has several well known reshaping goals. A slight concavity to the dorsal profile with a supratip break, an increased and more open nasolabial angle and a thinner nose from the nasal bones down to the tip cartilages are all features that are more consistent with a female nose.

Lip augmentation for increased vermilion on both upper and lower lips with a more full cupid’s bow region are classic and desired female lip shapes. For many transgender patients this really require lip advancements and lip lifts to permanently increase the amount of vermilion show. Fat grafts or lip implants can be added for even more volume.

A smaller and more v-shaped jawline is an essential lower face contouring change for many FFS patients. Jaw angle reduction by burring and chin rehaping by a T-pattern ostectomy is an effective strategy for a softer jawline.

While the influence of the voice that emanates from the voicebox is more important in sexual recognition, a protruding laryngeal prominence is a male neck characteristic. Flattening the profile of the laryngeal prominence by direct excision (tracheal shave) can help flatten the neck profile in many transgender patients.

Facial feminization surgery can include a comprehensive facial reshaping from the top of the skull down to the neck. Whether one does a few or all of these FFS procedures depends on a variety of factors of which the cost of the surgery is a major consideration. But most FFS procedures are associated with few significant complications and appears to offer satisfactory facial appearance changes.

Dr. Barry Eppley

Indianapolis, Indiana

Outcome Assessment of Facial Feminization Surgery

Thursday, February 4th, 2016


facial feminization surgeryFacial feminization surgery is a recognized collection of facial reshaping procedures that are primarily used in the treatment of gender dysphoria. Based on recognized anthropometric studies, the key craniofacial characteristic that separate a male from a female face is the shape of the forehead, the frontonasal junction and the shape of the chin. Thus, facial feminization surgery encompasses forehead recontouring/brow bone reduction, rhinoplasty, chin/jawline reduction/reshaping and tracheal shaves.

While facial feminization surgeries are becoming more commonly performed, an important question is how successful is this surgical process. Before and after surgery pictures can show either modest or significant changes, but how are the results perceived by the transgender patients on whom they are performed?

In the February 2016 issue of the journal Plastic and Reconstructive Surgery, the paper entitled ‘Full Facial Feminization Surgery: Patient Satisfaction Assessment Based on 180 Procedures Involving 33 Consecutive Patients’. In this study, an assessment of patient satisfaction after male to female FFS procedures that included outcome measurements after forehead and chin remodeling. Thirty-three (33) patients between the ages 19 and 49 years old over a ten year period were treated with a total of 180 facial procedures. The authors used a FFS flow chart that included two basic combined hard and soft tissue steps that are completed in six months. Step 1 is orthognathic surgery, rhinoplasty and chin/jaw reshaping (hard tissue) and/or facelift, blepharoplasty and structural fat grafting. Step 2 is forehead and orbital reshaping (hard tissue) and/or hairline lowering/browlift, tracheal shave and neck liposuction.

All treated patients showed excellent cosmetic results and were satisfied with their procedures. Photographs showed a successful loss of masculine features. Patient satisfaction after facial feminization surgery in this patient series was high. The facial physical improvements had significant psychological and social benefits that improved their quality of life.

This clinical FFS series is unique in several ways. First their approach to FFS surgery is somewhat different in that it introduces orthognathic surgery as part of the first stage. While there are some transgender patients that would benefit by this type of facial skeletal surgery, it would apply largely to younger patients who are more willing to commit to an investment in that effort. Most transgender patients I have seen and treat would have little interest in facial osteotomies unless they have a major malocclusion. Secondly, they treat the lower half of the face first, followed by a second stage attention to the upper face. For many transgender patients, the forehead is often a high priority and is often done first and there is no guarantee there will be another opportunity for additional procedures later.

Facial Feminization Surgery Indianapolis Dr Barry EppleyWhile it is clear there is no exact ‘formula’ for how to stage or even perform facial feminization surgery, various approaches can be used. When the procedures are done successfully, whether in a comprehensive single stage or in multiple stages, patient satisfaction surgery with FFS can be quite high.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization Surgical Techniques

Tuesday, September 15th, 2015


Forehead feminization Surgery Dr Barry Eppley IndianapolisOne of the many important areas to change in facial feminization surgery (FFS) is that of the forehead. The typical male forehead has a prominent brow bone, a visible brow bone break into the upper forehead and a central forehead area that is often flat or even slopes backward to some degree. This is a major phenotypic difference from that of a female forehead who has or desires a rounder smoother and more vertically oriented forehead.

The cornerstone of a male to female forehead shape change begins at the brow bones. While the brow bones can have variable thicknesses before entering the underlying frontal sinus, simple burring down of the brow bones is minimally effective and inadequate for many patients. It may be useful when there is little brow bone protrusion or the outer table of the frontal sinus is very thick. (thus the importance of preoperative x-rays)

Transgender Brow Bone Reduction technique intraop 2 Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction technique intraop 3 Dr Barry Eppley IndianapolisBut the most consistent and effective technique for brow bone reduction is that of the osteoplastic bone flap. Also known as the frontal sinus setback procedure the outer table of the frontal sinus (brow bone) is removed and reshaped. When the bone is replaced, which is necessary to cover the exposed frontal sinus cavity, it is put back so the brow bone contour is flatter. The much smaller segments of bone are usually best secured by small titanium microplates and screws. (1mm is thickness) The tail of the brow bones also needs to be reduced to create more of a lateral reduction and upward swoop. This can be done by bone burring since there is no underlying frontal sinus in this portion of the brow bone.

Transgender Brow Bone Reduction Forehead Augmentation intraop 1 Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction Forehead Augmentation intraop 2 Dr Barry Eppley IndianapolisBut reduction of the brow bones alone is often insufficient to create a more optimal female forehead shape. The central portion of the forehead also needs to be augmented to create a more vertical forehead inclination and a rounder shape from side to side between the temporal lines. Various bone cements can be used and both PMMA and hydroxyapatite compositions are effective. The optimal choice is, however, hydroxyapatite cement due to direct bonding to the bone without a scar interface due to its calcium phosphate composition.

Combining flattening of the inner half of the prominent brow bones, reduction of the outer or tail of the brow bones and increasing the convexity and vertical slop of the forehead are all important forehead feminization techniques. In some cases a hairline advancement to shorten a vertically long forehead can also be done at the same time tio provide the most complete forehead shape change.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques and Outcomes in Forehead and Brow Feminization

Sunday, September 28th, 2014


Forehead feminization Surgery Dr Barry Eppley IndianapolisFacial feminization surgery is a relatively recent plastic surgery procedure that has only been done since the late 1980s. It has been developed to address the need to modify masculine facial features for those with gender dysphoria who need to change their facial identity. As a result it is a well known need for the transgender patient. Certain facial features can have very specific male and female characteristics. Specifically the forehead and the jawline are especially important in facial gender identification.

In the October 2014 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Facial Feminization Surgery: The Forehead. Surgical Technique and Analysis of Results’. Over a four year period, the authors performed 172 forehead reshaping procedures. The results were assessed by cephalometric x-rays and a six month after surgery survey. The specific techniques discussed were incisional access and how the bone areas are specifically reshaped. Incisional access was done through either a hairline (pretrichial) or modified coronal based on the vertical length of the forehead and whether hairline lowering was simultaneously needed. The bone was reshaped through sequencing of frontonasal-orbital reconstruction/recontouring with osteotomy and setback of the anterior wall of the frontal sinus.

No serious complications were observed in this forehead feminization patient series. No hematomas, seromas or infections occurred. There were no complications related to osteotomizing the anterior wall of the frontal sinus such as sinus dysfunction, sinusitis, mucoceles, or air leaks. One patient did develop a cerebrospinal fluid leak from the posterior wall of the frontal sinus that resolved spontaneously within days after surgery by posture measures. Most patients had some degree of forehead numbness with complete recovery starting three months after surgery. No permanent injury to the frontal branch of the facial nerve occurred although some patients  had some weakness which fully recovered weeks after surgery. The average level of patient satisfaction by the after surgery survey was between satisfied and completely satisfied.

Brow Bone Reduction - Bone Flap Technique Dr Barry Eppley IndianapolisThis article highlights several technical aspects of the procedure that one learns by doing this type of surgery over the years. Where to place the incision and how to access the brow area must be initially considered. Whether to place the incision at or behind the hairline depends on how long the forehead is and the natural shape of the frontal hairline. Brow bone reshaping almost always requires removing the anterior wall of the frontal sinus, reshaping it and repositioning it further back into the frontal sinus. (burring reduction is inadequate and the anterior wall of the frontal sinus permits little reduction to be achieved) With the anterior wall of the frontal sinus removed, the nasal root and glabellar region must be reduced to create a more feminine frontnasal junction. Reduction/rehaping of the superolateral brow bone down along the lateral orbital wall must not be forgotten as a more comprehensive approach to the fronto-orbital recontouring.

Despite the rather invasive nature of this type of forehead surgery, complications are remarkably few and significant improvement is always seen. There can be issues that may require secondary revision such as the smoothness of the brow region. This article does not address whether any revisions were required but some low percent can be expected. (3% to 5%)

Brow bone reshaping and associated hairline modifications can effectively alter masculine facial features in the transgender patient with a very low incidence of negative side effects. To really change the forehead/brow area a comprehensive bone and soft tissue approach is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Transgender Brow Bone Reduction/Reshaping

Tuesday, July 15th, 2014


Background: The shape of the forehead is very gender specific and these differences are well known. The male forehead has prominent brow ridges, a brow bone break and a forehead that has a slight backward slope. The female forehead has no visible brow ridging or break and a more convex shape as it extends upward into the frontal hairline. These forehead shape differences are driven largely by the influence of testosterone on the development of the frontal sinuses and the frontal bone.

Forehead feminization Surgery Dr Barry Eppley IndianapolisIn facial feminization surgery (FFS), forehead recontouring is an important one-third of the facial changes needed. This is usually perceived as ‘burring of the brow bone’ but this is an overly simplistic understanding of how to reshape the entire superior orbital rim. Because of the thinness of the outer cortex of the brow bone with a large underlying frontal sinus air space, simple burring of the frontal bone can only make a limited change. Most brow bone reductions of any significance require an osteoplastic bone flap technique in which the entire outer cortex is removed, reshaped and replaced.

But the brow bone reduction is often not enough to get a definitive gender change in the FFS patient. As part of the brow recontouring, the lateral or tail of the brow bone must be reduced to allow a more upward sweep to the tail of the eyebrow. In some cases, the orbital rim reduction may need to be carried around to the side to help with greater orbital exposure. (opening of the eye) Also, the frontal hairline may benefit from being advanced or lowered. If access to the brow bone reduction is done through a hairline or pretrichial approach, then vertical forehead reduction/hairline repositioning can be done at the same time as the brow bone reduction.

Case Study: This 35 year-old patient was undergoing a variety of facial feminization surgeries from the forehead down to the adam’s apple. The concerns on the forehead was that the brow bones were too strong but the upper forehead was adequately shaped/projected. The hairline was also in good place (not too high) with reasonable hair density.

Osteoplastic Brow Bone Reduction Technique front view Dr Barry Eppley IndianapolisOsteoplastic Brow Bone Reduction Technique side view Dr Barry Eppley IndianapolisUnder general anesthesia, a pretrichial or frontal hairline incision was made in an irregular fashion paralleling the direction of the hair shafts. The forehead flap was turned down and the brow bones exposed, protecting the supraorbital nerves. A reciprocating saw was used to take off the outer brow bones at the levels of the surrounding forehead. The two pieces were reshaped and put back with resorbable sutures. The tail of the brow bones were the frontal sinus cavities did not exist was burred done to reduce its prominence. The forehead flap was put back in a two layer closure with small sutures for the skin.

Transgender Brow Bone Reduction result side view Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction result oblique view Dr Barry Eppley IndianapolisBrow bone reduction is usually more than just simple burring, particularly with the goal of changing a prominent masculine brow shape to a flatter more feminine one.  The osteoplastic bone flap technique is needed with the potential for additional procedures of lateral orbital rim contouring, forehead augmentation and hairline advancement done at the same time.

Case Highlights:

1) Brow reduction is an important part of many facial feminization surgeries.

2) Brow reduction can be done by burring but usually needs a more aggressive approach with an osteoplastic bone flap to create a more feminine brow shape.

3) Many FFS brow bone reductions can be done through a hairline or pretrichial incision which allows for a simultaneous hairline advancement if desired.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Transgender Tracheal Shave

Sunday, June 15th, 2014


Background: The bulge in the center of just about any neck is the result of the laryngeal prominences. These are two large plates of paired cartilages who have a primary function to provide protection of the very important vocal cords from injury The size or prominence of these cartilages is highly influenced by hormones which is why men have larger laryngeal cartilages than women. As a secondary sexual characteristic, its presence is highly associated with being a male feature.

As an aside, the neck laryngeal prominence is commonly called the ‘Adam’s Apple. It is a commonly held belief that this term comes from a piece of forbidden fruit embedded in the first man’s (Adam ) throat. This sounds somewhat logical but there is no mention of any such reference of it happening in the Bible. It is postulated that a far more likely explanation are translation errors. Latin translation from Hebrew confuses the word ‘bump’ to be ‘apple’ and the word ‘man’ to be ‘Adam’. Hence ‘man bump’ has become ‘Adam’s Apple’.

Adam's Apple Surgery Dr Barry Eppley IndianapolisBecause the Adam’s Apple is a highly recognized male feature, it has become an important area of treatment in facial feminization surgery. Getting rid of an obvious and prominent neck bulge and creating a smooth more feminine neck line is a small but important change. Known more commonly as a tracheal shave, technically a reduction chondrolaryngoplasty, it is a fairly simple and uncomplicated procedure.

While a tracheal shave is most commonly recognized as a transgender facial feminization surgery procedure, it is done just about as often in non-transgender men. The difference in treating these two patient populations for tracheal shave reduction is a matter of degree. In facial feminization patients, an aggressive and maximal reduction of the neck bulge is needed to achieve a flat and smooth as neckline as possible. The reduction needs to be less aggressive in other men who still want to leave some semblence of an identifiable male neck bulge.

Case Study: This 36 year-old transgender female wanted to reduce a very prominent Adam’s apple. Her overall face and neck was very thin with little subcutaneous fat but was strongly skeletonized with prominent bone and cartilage structures. As part of numerous other facial feminization procedures, a tracheal shave reduction was comboned with brow bone reduction and rhinoplasty surgery.

Transgender Tracheal Shave Surgery Dr Barry Eppley IndianapolisUnder general anesthesia, a 2.5 cm skin incision was made over the height of the larygneal prominence in a natural skin fold. The strap muscles were split vertically and the laryngeal cartilages exposed. The prominent cartilages were reduced by shaving them down with a scalpel until the inner lining mucosa was seen on the inside of each one. Because of the stiffness of the paired cartilages in the middle, a handpiece and burr was used to take down this area for maximal reduction. The strap muscles were sewn back together and the skin closed. A clear glue dressing was applied.

Transgender Tracheal Shave result side view Dr Barry Eppley IndianapolisRecovery from a tracheal shave is uncomplicated. The wound requires no care and the swelling is fairly minimal. Patients report only mild discomfort for a few days that is most evident on swallowing. The skin incision heals quite well and is rarely noticeable.

Transgender Tracheal Shave result oblique view Dr Barry Eppley IndianapolisThe tracheal shave can be done through either a direct skin incision over it or from a more remote submental incision under the chin. While the submental incision offers a hidden scar, it does not afford as much visualization of the cartilages and may compromise the amount of reduction obtained. Some surgeons prefer to do the procedure under local anesthesia and to visualize the vocal cords by laryngoscopy while doing the reduction to prevent injury to the vocal cords. While this approach offers theoretical benefits, it has not been necessary in my experience to have an uncomplicated tracheal shave outcome.

Case Highlights:

1) A tracheal shave can be done successfully and discretely through a small incision directly over the laryngeal prominence.

2) Significant tracheal reduction can be done without voce changes under general anesthesia.

3) Tracheal shave reduction is one of many facial feminization surgery procedures for transgender patients that can be combined with any number of other procedures.

Dr. Barry Eppley

Indianapolis, Indiana

The Emergence of Facial Feminization Surgery

Monday, January 27th, 2014


Facial feminization surgery (FFS) in the transgender patient has come a long way in the past two decades. As societal and political changes have occurred, greater patient acceptance and awareness of the need for such external physical changes has become mainstream procedures for those plastic surgeons experienced in doing them. With roughly a 1/4% to 1/2% of the population being transexual, the number of patients desiring FFS is steadily increasing.

The key factor in transgender patients finding qualified and experienced plastic surgeons to address their needs is the internet. Like everything else in life, the internet has made finding FFS surgeons as easy as the click of a mouse. Having discussions by e-mails and online video chats enables patients to gather a tremendous amount of information without travel or office visit expenses. Patients can literally search amongst the available facial feminization surgeons to see whom they feel the most comfortable.

FFS surgery is a well known collection of bone and soft tissues procedures that extend from hairline lowering and forehead/brow reshaping all the way down the face to a tracheal shave reduction. What all these procedures share is that the objective is to soften or feminize one’s facial appearance…and it does that by reducing bony prominences and volumizing the overlying soft tissues. Hence fuller cheeks but a smaller jawline for example.

One of the most important changes in the transgender face to make is that of the eye or orbital area. This is because the eyes create the visual focus in conversation and almost every human interaction. Specifically, the prominence of the brow bones and how the eyebrows sit on top of them are the key structural changes to make. Softening the brow bones can be as simple as burring or may require an osteoplastic bone flap for the inner half of the brow bone which is often the most prominent part. The tail of the brow bone can always be burred as there is no frontal sinus beneath it. The brow bone tail is reduced and contoured upward so the overlying brow will develop a lateral swoop towards the temples. This can also be helped by a browlift which is often done by a pretrichial incision so the frontal hairline can be lowered at the same time.

While almost all trasngender patients rate the forehead/eye area as one of the most important, most do not stop there. It is very common to accompany that with a rhinoplasty, jawline reshaping and tracheal shave. In older FFS patients, blepharoplasties and a facelift are often also done.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization with Combined Brow Bone Reduction, Browlift and Hairline Lowering

Sunday, April 21st, 2013


There are numerous surgical procedures to feminize a masculine facial appearance. They include jawline reshaping (chin and mandibular angle reduction), rhinoplasty, cheek reduction, tracheal shave and forehead reduction/reshaping. While every transgender patient’s face is different and may need just a few or all of these facial feminization procedures, the forehead is one of the top considerations for most patients. The female forehead has a very distinct shape with a rounded contour from the brows up to the hairline with no obvious bone break.

Forehead reshaping incorporates reduction of the prominence of the central glabellar region as well as the projection of the brow bones. The brow bones must not only be deprojected but should also have the tail of them near the lateral orbit reshaped to have more of a sweeping effect up and towards the temples. Since this procedure requires an open scalp approach, this creates the oportunity to lower the frontal hairline as well. Together this type of foreheadplasty has a significant impact on the gender identification of the face.

The prominent glabella and brow bones are always due to the pneumatization of the front sinus. In cases of minor protrusion, the outer table of the frontal sinus can be simply burred down. Unfortunately this rarely can be successfully done due to the thin bone thickness overlying the frontal sinus. A few millimeters of change is rarely enough to make a noticeable external change. Most patients require the anterior wall of the bone to be removed, reshaped and repositioned back into place with resorbable sutures or metal microplates and screws. This method sets back the bulging bony prominence while preserving sinus function. The outer brow bone areas that lie outside of the sinuses can be reshaped as desired by burring.

When significant brow bone reduction is done (flattening of the bone), there is the potential for an excess of overlying skin. Loose skin on the brows can result in sagging or overlying brow ptosis. This can be easily addressed at the time of the brow bone reduction by a comcomitant browlift using the transcoronal or hairline incision made for access to the brow bones. An alternative approach is a direct browpexy from the galea below the eyebrows to underlying bone holes or the fixation plates (if used) above the reshaped brow bones.

A final component of the feminizing foreheadplasty procedure is the potential to simultaneously lower the frontal hairline. A long forehead (> than 6.5 to 7 cms between the brow and hairline) is unaesthetic for any gender but is particularly so in the male to female transgender patient. If a hairline approach (trichophytic) is used, a simultaneous scalp advancement can be done by securing the galea of the advanced scalp by sutures to bone holes in the outer table of the skull. By bringing the scalp forward, the lifted forehead skin will need to be trimmed creating a combined forehead skin reduction and browlift.

Ultimate feminization of the forehead can be done by simultaneous brow bone reduction, browlift and hairline lowering.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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