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Posts Tagged ‘facial feminization surgery’

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

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

Case Study: Tracheal Shave in the Transgender Patient

Saturday, August 13th, 2011

Background:The central prominence of the neck is well recognized as the adam’s apple. It is largely a male feature although it can be prominent in some women as well. It is composed of paired cartilages which surround the larynx and is designed to protect the delicate voicebox from injuries. While often referred to as the thyroid cartilages, a more accurate name would be the larynx cartilages as that is what it actually guards.

The name adam’s apple is often believed to be a reference to the observation that it looks like a chunk of apple stuck in the throat, relating to the biblical story of Adam and the fruit from the Tree of Knowledge. More likely, however, it is the result of a mistranslation of the Hebrew words, tappuach ha adam, which means ‘male bump’.

Those patients who seek adam’s apple reduction generally fall into two categories, transgender conversion from male to female and males who simply desire less of a central neck prominence. It is widely believed that most tracheal reductions are done in the transgender patient but this has not been my experience. I find it to be about a 50:50 ratio. The aesthetic neck goals for each group are slightly different. The transgender patient would prefer a completely flat neck profile which is more feminizing. The male patient can live with some reduction and a visible remaining small neck bump is still acceptable.

Case Study: This 53 year-old male-to-female transgender patient wanted her thyroid cartilage eliminated if possible. It had an approximate 2 cm central profile and was located unusually low in the neck with a very obtuse cervicomental angle.

Under general anesthesia, it was approached through a 2.5 cm horizontal incision located directly over the prominence. After going through the strap muscles, the thyroid cartilage was identified and all soft tissues dissected off of it including the perichondrium. A scalpel was used to shave the wings of the thyroid cartilage down. At the anterior V of the thyroid cartilages, shaving was done until the cartilage became hard. A handpiece and burr was then used to thin out the central prominence done along the central box of the cartilages. The thyroid cartilages became thin In some areas but no complete through and through defects were created. The strap muscles were closed over the reduced areas but with minimal tension so as to not bunch up the muscles over the reduced area. The skin was closed with small dissolveable sutures. The difference in the neck profile was both immediate and dramatic. The incision was covered only with glue and tapes.

She could shower the next day and there were no restrictions from any activity. She reported minimal discomfort and swelling. By six weeks after surgery, most of the swelling had subsided. The scar already was very fine and nearly indiscernible.

Thyroid cartilage reduction is a simple but effective neck contouring procedure. While it is important to reduce the cartilage prominence as much as possible, it is critical to not destabilize the thyroid cartilage to avoid the risk of voice change due to alteration of the tension on the vocal cords. There is no exact way to know how much cartilage can be safely removed before this occurs so when in doubt, conservative reduction is best.

Case Highlights:

1) Tracheal shaves are done through a small horizontal neck incision with minimal recovery and discomfort.

2) Complete elimination of the thyroid cartilage profile is not always possible. The limiting factor is the thickness of the cartilage and the location of the vocal cords internally.

3) Adam apple reduction is largely done by cartilage shaving but more firm areas of cartilage may require mechanical burring reduction.

Dr. Barry Eppley

Indianapolis, Indiana

The Concepts of Facial Feminization Surgery

Wednesday, July 15th, 2009

Facial feminization surgery (FFS) is an assortment of plastic surgery procedures that changes a genetically male face to bring its features closer in shape to that of a female. FFS is sought after largely by transsexual women and psychologically it is often more important than sex reassignment for social integration. FFS works on both the bone and the overlying soft tissues and, as a result, has much of its origins from craniomaxillofacial surgery as well as traditional cosmetic plastic surgery. For this reason, those few plastic surgeons who perform FFS usually have such backgrounds.

 I like to think of FFS as three potential zones of change… upper, middle, and lower face. Within these zones, the primary plastic surgery procedures include frontal hairline alteration/brow lift, forehead/brow recontouring, rhinoplasty, cheek/submalar augmentation, upper lip enhancement, jaw/chin modification, and thyroid cartilage reduction. To no surprise, many of these changes deal with facial prominences ….lessening the amount of bony and cartilage convexities. Each patient usually has one primary zone for change and two others for some modification. In essence, every patient has at least one dominant facial feature which must be changed onto which other procedures are complementary. While it is true that it takes many changes to create a  more convincing change of appearance, one or two of the procedures usually has a dominant effect.

FFS, philosophically, consists of a combination of reconstructive and cosmetic plastic surgery procedures. Changing the bony prominences, or changing the skeletal foundation of the face, is based more on the reconstructive heritage of the procedures. Modifying or lifting of soft tissues of the face encompasses more standard cosmetic procedures used for a primary anti-aging or more youthful effect.

Every FFS procedure has differing levels of difficulty and degrees of change. Some are easy to go through, while others are more extensive with prolonged swelling and social recovery. The procedures of tracheal shave, upper lip lift and cheek implants are very effective and relatively simple with little downside or complications. More difficult procedures are forehead contouring and brow reduction and the alteration of the chin and jawline. These have issues of surgical access and bone manipulation, of which makes for more swelling. Rhinoplasty and standard plastic surgery procedures such as facelift, blepharoplasty or browlift, falls between the two with a few weeks of relatively easy recovery.

The key to a successful FFS outcome is to plan a combination of facial procedures that can most effectively soften one’s appearance and make for a convincing change. There is no one standard set of procedures that will work for every patient. While some patients need just three or four, others may benefit by twice that many. Most patients have a good feel for what they think will be effective and a careful discussion and computer imaging is essential to create a reasonable working list of procedures. While some patients may want the most change possible by number of procedures, it is important to have a realistic outcome and work within one’s budget for maximal facial change.

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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