Monthly Archives: June 2014

Feminization of the Forehead in a Transgender: Frontal Sinus Reshaping Combined with Brow Lift and Hairline Lowering – Review

This is a case study of facial feminization surgery on a 39 year-old patient.

The patient in this case had had previous FFS, but felt that her forehead was still masculine. The surgery and techniques used are described in detail.

The patient was satisfied with the results, the authors say the forehead looks more feminine now, and measurements confirmed that the forehead changed. Looking at the before and after pictures, I can see a difference in one set of pictures, but I am not sure I would have identified the before forehead as masculine. In addition, in one set of pictures the hair style is different and covers part of the forehead.

As in many studies, this is written by the people who did the surgery so there is a possible bias in favor of thinking they did a good job.

Original Article:

Feminization of the Forehead in a Transgender: Frontal Sinus Reshaping Combined with Brow Lift and Hairline Lowering by Sung-Woo Cho and Hong Ryul Jin, in Aesth Plast Surg (2012) 36:1207–1210.

Note – This article contains pictures of surgery.



Transgender Feminization of the Facial Skeleton – Review

This is a discussion of facial feminization surgeries performed on 35 trans women between 1992 and 1996. The surgeries seem to have been done at the Free University Hospital of Amsterdam. Based on the dates and the photos, this study includes the 16 individuals discussed in an earlier article.

Forty-six patients with GID were referred for possible surgery; of these “In 11 cases, patients’ expectations and surgical possibilities did not match,” so they did not have any surgery.

The authors provide in-depth information on the different surgeries they used and how they work.

As in the earlier study, the patients were happy and felt that the surgeries had made them appear more feminine, but the patients had also changed in other ways at the same time.

Once again, it is hard to judge from the before and after pictures because the patients often have different hair-dos, etc. In some cases, the patients look like they might pass before surgery.

The authors conclude:

there is a need for a more objective standardization of the differences in the facial features of the two sexes, to facilitate surgical treatment planning and more objectively assess the outcome of the facial surgery on psychosocial functioning and appearance, not only from the perspective of those treating, but also from the patient’s own point of view.

Original Article:

Transgender Feminization of the Facial Skeleton by Alfred G. Becking, MD, DDS, PhD,  D. Bram Tuinzing, DDS, PhD, J. Joris Hage, MD, PhD, Louis J.G. Gooren, MD, PhD

Note: This article contains photos of surgery.

Contouring the forehead and rhinoplasty in the feminization of the face in male-to-female transsexuals – Review

This is a case study of facial feminization surgery on a 26-year old trans woman who had already transitioned.

The article includes a good discussion of what FFS is and why it may be helpful. The authors also discuss some of the ways anthropologists tell male and female skulls apart; they use these differences to predict what surgeries may help trans women look more feminine. (This section of the article might cause dysphoria in some people.)

They believe that the patient looked more feminine after the surgery and the patient was happy with the results. It is hard to judge from the before and after pictures; it looks like the patient might have been able to pass before surgery. As with other studies, this one was done by the surgeons who performed the surgery. Thus, it may be biased towards belief that the surgery works well.

In addition, in a case study, the authors can focus on a successful surgery. A case study can not answer the question of whether or not FFS works for most people.

The authors discuss some of the challenges of FFS:

In most plastic facial surgery, the aim is to improve the appearance of individuals without changing who they are. Patients state they want to “look like themselves, only younger” or “look like myself, only better”. Patients seeking FFS wish to look dramatically different. They want a radical change to their appearance and frequently believe that FFS is their “ticket to a new life”.

It is important from the outset that the surgeon reduces any unrealistic expectations the patient may have. He must find out from the patient which features of the face are felt to represent the wrong sex and whether there are suitable procedures to change them to achieve the desired result. He must consider the risks and benefits of the proposed procedures in order to formulate a treatment plan in conjunction with the patient. It is important that the patient is psychologically prepared for the dramatic changes that are intended, and also that they have a realistic expectation of the outcome.

The case study includes a good discussion of educating and working with a patient in order to get the desired results. Initially, the patient had a photo of a well-known actress she wished to look like; the surgeons then discussed more realistic possibilities.

The article concludes with a useful discussion of guidelines for doing FFS from the point of view of a surgeon.


FFS is not a well known area of surgical practice. If a surgeon begins to specialize in this area, he has to understand that, unlike in aesthetic surgery, patients are looking for surgery that will help to change their personality. Because of this the surgeon has a great responsibility to ensure that the patient has a realistic understanding of the scope and limitation of the possible surgical procedures. To ensure the surgeon can be confident he has fulfilled this responsibility we suggest the following approach:

Firstly, ensure that the patient meets the previously outlined definition of transsexualism according to the WHO.

Next the face of the patient must be analyzed carefully.

If this analysis shows one or more of the typically masculine features in a male-to-female transsexual, it is important to decide if there is a suitable feminizing surgical procedure available for the desired outcome. In feminization of the forehead, the patients can be divided into two groups.

Group I includes patients with only slight supraorbital bossing, thick skull bone over the frontal sinus and/or absence of the frontal sinus. In these cases, correction can be done by bony reduction alone using a burr without entering the frontal sinus.

Group II includes those individuals in whom the frontal bossing is combined with relatively thin bone over the frontal sinuses, the sinuses being of normal or large size. In these individuals, the frontal sinus must be opened through a frontal bone osteotomy and the entire anterior sinus wall and the associated supraorbital rim set back and secured in position. We had obtained familiarity with this technique in the correction of a pneumosinus dilatans ( Dempf et al., 2005 ).

Surgery in this group carries a higher risk than in Group 1 because of the potential for loss of the setback frontal bone. There are no reports in the literature of such loss following a FSS, but we know from experience in trauma that the loss of a frontal bone fragment is a rare complication.

In order to allocate the patients to one of the two groups and to plan the operation a CT scan is essential.

The nose is the central structure of the face and plays an important role in the perception of femininity and attractiveness ( Baudouin and Tiberghien, 2004 ). There is little information in the literature about the differences between the male and female nose information but there is general agreement that the linear dimensions and the bony framework of the female nose, are smaller than those of the male nose and that the nasofrontal and the nasolabial angle in female are higher than in male ( Habal, 1990Daniel and Farkas, 1994 Farkas et al., 1994 Hage et al., 1997 ).

Having analyzed these general characteristics, the wishes of the patient must be considered of before starting the detailed planning.

Finally, performing FFS at the end of the gender reassignment therapy helps to minimize the risk of failure.

Review by George Davis

(Bold added by G. Davis.)

Original Article:

Contouring the forehead and rhinoplasty in the feminization of the face in male-to-female transsexuals by R Dempf and AW Eckert, in J Craniomaxillofac Surg. 2010 Sep;38(6):416-22. doi: 10.1016/j.jcms.2009.11.003. Epub 2009 Dec 29.

Note: This article contains photos of surgery.

Facial Corrections in Male to Female Transsexuals: A Preliminary Report on I6 Patients – Review

This is an early study of facial feminization surgery (FFS) from 1996. At that time FFS was new and there were no standards or studies. The doctors at the Free University Hospital in the Netherlands had to devise surgeries they believed would make the trans women’s faces more feminine.

They conclude:

Without exception, all patients were convinced that their faces had become more feminine…it is impossible to consider this as the only reason for success. Make-up and hairdo were obviously changed over this period as well and, in time, most persons became more adapted to their life as a member of the opposite gender. 

Looking at the before and after pictures in the article, I would agree. In the after pictures, the patients are wearing make-up and jewelry and their hair styles have changed. It is hard to tell whether they look more feminine due to the surgery or the other changes.

The authors conclude that the results thus far are promising and call for more research:

More research is needed on several aspects of the subject. There is a need for a more objective standardization of the differences in the facial features of the two sexes, thus facilitating the process of planning facial corrections. Objective follow-up on the appreciation and the effects of the facial surgery on psychosocial functioning also needs to be carried out. Finally, the long-term effect of these surgical interventions, with regard to function and cosmetics, await

The authors of the study talk about the importance of facial features for passing in public as a member of the opposite sex, but they also state that not everyone will need FFS:

Facial esthetic surgery of the soft tissues or the bone is not indicated in many patients. Make-up, changing the hairdo, and using depilating procedures usually give satisfying cosmetic results. Occasionally, additional surgery in the head and neck region is carried out. Blepharoplasty, rhinoplasty, and chondrolaryngoplasty may be of help.

This is a good early report on reasons and potential strategies for FFS.

Original Article:

Facial Corrections in Male to Female Transsexuals: A Preliminary Report on I6 Patients, by ALFRED G. BECKING, DDS, D. BRAM TUINZING, DDS, PHD, J. JORIS HAGE, MD, PHD,AND LOUIS J.G. GOOREN, MD, PHD, published in J Oral Mzdlofac Surg, 54:413-418, 1996.

Note: This study includes photos of surgery.

Frontal Bone Remodeling for Gender Reassignment of the Male Forehead: A Gender-Reassignment Surgery – Review

This study describes a surgical technique for making a more feminine forehead.

Twenty-one male-to-female patients were given the surgery. The results of the surgery were independently evaluated one year later using a four-point scale (excellent to poor).

“The aesthetic results were considered good to excellent in 15 cases and satisfactory in two cases. The contour results were stable in long-term follow-up evaluations.”

The study does not say what the results were for the remaining four patients; presumably they were poor. This would give results of 71% good or excellent; 10% satisfactory; and 19% poor.

The study does not break down how many of the surgeries were rated excellent vs. how many were rated good.

The study includes before-and-after photographs for three patients. For two of the three patients, I could not see why the after pictures were more feminine. I thought they would have been able to pass before the surgery.

The patients were followed for 18 months and there were no complications.

The paper is by one of the people who developed the surgical technique. This creates a potential for bias, although the use of an independent evaluation counteracts the bias.

On the other hand, the author of the study sidesteps an important issue: were 19% of the results poor?

The study would be improved by an evaluation of whether or not photographs of the patients were perceived as women more often after the surgery.

Original Article:

Frontal Bone Remodeling for Gender Reassignment of the Male Forehead: A Gender-Reassignment Surgery by Johannes Franz Hoenig, in Aesth Plast Surg (2011) 35:1043–1049.

Note: This study includes photos of surgery.

Appendix to Orgasm after Vaginoplasty

Further information on the studies used in the article Orgasm after Vaginoplasty.

Lawrence, 2005 (USA):

Surgeries were performed between 1994-2000, all by the same surgeon (Dr. Meltzer).

232 trans women returned an anonymous questionnaire by mail; 227 answered the question on orgasm by masturbation.

Follow-up time after surgery was a minimum of one year.

32% of the eligible participants returned the survey.

The technique used was described as “penile-inversion vaginoplasty and clitoroplasty using a portion of the glans penis on a dorsal neurovascular pedicle.”

18% were never able to achieve orgasm by masturbation; 15% were not able to orgasm from any sexual activity. 

Imbimbo et al., 2009 (Italy):

Surgeries were performed between 1992-2006 at the same institution.

139 trans women participated, 93 completed questionnaires at the clinic, 46 had phone interviews. 33 women answered the question on masturbation.

Follow up-time after surgery was 12-18 months.

85% of eligible participants took part in the study.

Three different techniques were used, 34% of the trans women had penile skin inversion, 61% had peno-scrotal flap, and 5% had an enterovaginoplasty.

18% of the trans women were never able to orgasm by masturbation; 14% of the trans women complained of anorgasmia

Buncamper et al., 2015 (the Netherlands):

Surgeries were performed between 2007-2010 VUmc in Amsterdam.

49 trans women completed questionnaires at their clinic.

Follow-up time after surgery was 1.9-5.8 years (average = 4.1 years).

61% of eligible participants took part in the study.

A penile skin inversion technique was used.

10% had not had orgasm after surgery.

Selvaggi et al., 2007 (Belgium):

Surgeries were performed between 1986-2001 at Ghent University Hospital.

30 trans women were personally interviewed by a team of experts:*

Follow-up time after surgery was a minimum of one year.

51% of eligible participants took part in the study. (All French patients were excluded from consideration for the study; 24% of all patients participated.)

Technique was described as “vaginoclitoroplasties with the penoscrotal inverted skin flap modified and dorsal glans pedicled flap,” however there may have been some earlier patients with a different technique; this is unclear.

15% had not experienced orgasm after surgery during any sexual practice.

Giraldo et al., 2004  (Spain):

Surgeries were performed “during the last two years” by the same surgeon (Giraldo)

16 trans women were given structured interviews at follow-up visits.

Follow-up time is unclear.

100% of eligible participants took part in the study.

The new technique is described as a “corona glans clitoroplasty with urethropreputial vestibuloplasty.”

0% had problems – all the women reported the ability to achieve orgasm

Note: This study is about a modification to the technique for creating a clitoris.

Hess et al., 2014 (Germany):

Surgeries were performed between 2004-2010 at the Essen University Hospital’s Department of Urology.

119 trans women returned anonymous questionnaires by mail, 91 answered the question “How easy it is for you to achieve orgasm?”

Follow up time was 1-7 years.

47% of eligible participants took part in the study.

The technique used was a penile inversion vaginoplasty with sensitive clitoroplasty; they did it in a two-step process.

18% said they never achieve orgasm; however it is unclear if they were sexually active or not.

Perovic et al., 2000 (Yugoslavia):

Surgeries were performed between 1994-1999.

89 trans women were interviewed.

Follow-up time was 0.25-6 years (mean = 4 years).

100% of eligible participants took part in the study.

The technique used was a penile inversion with penile skin and urethral flap and a clitoris from the glans.

It looks like 18% had not experienced orgasm during vaginal sex, but it is possible that some of the women were not sexually active.

Goddard et al., 2007 (United Kingdom):

Surgeries were performed between 1994-2004 in Leicester.

70 trans women were interviewed by a telephone questionnaire; 64 of them had had a clitoroplasty:

Follow-up time was 9-96 months (median = 3 years).

30% of eligible participants took part in the study.

233 patients had penectomy, urethroplasty, and labiaplasty, 202 had skin-lined vaginas. A penoscrotal flap was preferentially used. 207 had neoclitorises created. A sensate clitoris was made with a proximal dorsal triangle of the glans penis maintained on its neurovascular bundle.

It looks like 52% of the women with clitorses were not able to achieve clitoral orgasm, but again it is not clear if they were sexually active.

Wagner et al., 2010, (Germany):

Surgeries were performed between 2001-2008 at Martin Luther University in Halle by a single surgeon with extensive surgical experience.

50 trans women completed a questionnaire.

Follow-up time is unclear, but the mean was 3 years.

100% of eligible participants took part in the study.

A penile-inversion technique was used with a neoclitoris made from the glans cap.

It looks like between 17% and 30% were not able to achieve clitoral orgasm, depending on whether or not the patients were sexually active.

Salvador et al., 2012 (Brazil):

Surgeries were performed between 2000-2004 at the Hospital de Clínicas de Porto Alegre.

52 trans women participated in the study. It is unclear how they were surveyed, but based on this earlier study, it could have been a combination of a questionnaire and interview.

Follow-up time was a minimum of two years.

75% of eligible participants took part in the study.

The study gives no information on the surgical technique used.

8% did not consider vaginal sex pleasurable, however, only one woman said sexual intercourse was unsatisfactory (2%).


*The exact number of the participants is unclear because this study is one of a pair using the same participants. The other study by de Cuypere et al. did in-depth interviews with 32 trans women while this one focused on testing the sensitivity of the genitals for 30 trans women.