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.