Facial 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.
This 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