Monthly Archives: July 2014

Feminization of the forehead: contour changing to improve female aesthetics – Brief Review

This is an early article by one of the pioneers of facial feminization surgery, Dr. Ousterhout. I was not able to find the full article.

The interesting thing about this article is that Dr. Ousterhout describes techniques used to make cis women look more typically feminine.

Original Abstract:

Feminization of the forehead: contour changing to improve female aesthetics by D. Ousterhout in Plast Reconstr Surg. 1987 May;79(5):701-13.

CT measurement of the frontal sinus – Gender differences and implications for frontal cranioplasty – Review

The authors used computed tomography (CT scan) to describe forehead and frontal sinus dimensions. In the past, descriptions have been based on facial surface measurements or plain film radiography. The new approach allows them to generate a three-dimensional image.

Understanding variations in frontal sinuses can help to guide surgery in the area. (There is a great variation in individuals’ sinuses.) In addition, knowledge about gender differences can help surgeons performing facial feminization surgeries.

The article includes a table summarizing sex differences in sinus size found in previous studies. As in other studies, the average differences are not large.

The authors confirmed previously observed sex differences in this area of the face. They also found:

However, it is interesting to note that despite this, the overall width and height of the frontal sinus was generally not greater in males compared to females (with the exception of height at 10 mm to the left and right of midline). Notably, statistically significant gender variations were only found at or close to midline, in the area identified as the glabella. Here, males clearly possessed a more prominent forehead features as measured by the greater thickness of the anterior table, deeper AP dimensions, and greater overall width of the glabella. Additionally, the glabella was discovered to be more anteriorly protruding in males. 

They conclude:

Using maxillofacial CT images in the axial, coronal, and sagittal planes, we report on anatomical measurements made at discrete points throughout the forehead and frontal sinus. Our measurements of forehead and frontal sinus dimensions may serve as a normative map of the surgical anatomy in this area. Specifically, this can be useful when the physician wishes to avoid opening of the sinus during surgical procedures involving the frontal bone. Additionally, gender variations in facial anatomy have been described. These gender variations demonstrate via CT the precise degree to which variation in frontal sinus anatomy exists between genders and the locations of greatest variation. This information can be useful to surgeons who perform forehead cranioplasty for gender confirming facial surgery.

Overall, the most pronounced differences in forehead and frontal sinus anatomy were found at or near midline. This corresponds to the area of the supraorbital ridge known as the glabella and its underlying frontal sinus, which is much more prominent in males. It is important to take into account these differences in pre-operative planning for and during surgery, as the anatomical dimensions in this region make this the most likely area for frontal sinus penetration, particularly in men.

This is an important study using new technology to better understand sex differences relevant to facial feminization surgery, It may be more useful to surgeons than patients, however.

Original Article:

CT measurement of the frontal sinus – gender differences and implications for frontal cranioplasty by Matthew K. Lee, Osamu Sakai, and Jeffrey H. Spiegel in Journal of Cranio-Maxillo-Facial Surgery, 2010-10-01, Volume 38, Issue 7, Pages 494-500.

Nasal Shapes and Related Differences in Nostril Forms: A Morphometric Analysis in Young Adults – Review

The authors of this study analyzed the nose and nostril shapes of 173 young white people. They studied the noses to find differences between male and female noses. Their goal was to make sure that during plastic surgery on the nose, men are not given noses that are too feminine.

The authors provide data on average differences between male and female noses that may be helpful to anyone preparing to get facial feminization surgery. Reading about the differences might cause dysphoria for some people.

It is interesting to note that there was no nostril type that was found only in males or only in females. In addition, the differences between the average measurements for males and for females is small. Noses do not fit into simple male and female categories.

The authors were not able to find all nose types that have been identified previously and they say this is a limitation to their data. Some of the subgroups of noses were smaller than others which might also limit their results.

The data was collected in Turkey and might not apply to populations in other countries. It is also limited by the fact that they only looked at white people.

Original Article:

Nasal Shapes and Related Differences in Nostril Forms: A Morphometric Analysis in Young Adults by Etöz, Betül Çam MD; Etöz, Abdullah MD; Ercan, Ilker PhD in Journal of Craniofacial Surgery Issue: Volume 19(5), September 2008, pp 1402-1408.




Dr. Paul Tessier and Facial Skeletal Masculinization – Review

The article is partly a tribute to Dr. Paul Tessier who trained Dr. Ousterhout and mostly a description of techniques use to masculinize the face. So far, the author has only performed facial masculinization on six men, but he has performed some of the individual techniques involved many times.

The article discusses the various techniques used and some of the possible complications. There are good before and after photos – the person is posed the same way. I can easily see the differences in the faces. The faces are more masculine after surgery, but they were also clearly men’s faces before surgery.

Chin masculinization has sometimes resulted in facial numbness that is usually temporary, but there have been cases where it was not. The author says he has reduced this problem over time.

As in most of this research, the study is written by the person who performed the operations and might therefore be biased in favor of the work.

Original Article:

Dr. Paul Tessier and Facial Skeletal Masculinization by Ousterhout, Douglas K. MD, DDS, in Annals of Plastic Surgery Issue: Volume 67(6), December 2011, p S10–S15.


Forehead Augmentation with a Methyl Methacrylate Onlay Implant Using an Injection-Molding Technique – Brief Review

This is a technique for augmenting the forehead that is used to make the forehead more attractive. Most of the patients in this study were cis women, but a few were men. It is not clear if the men were trying to feminize their foreheads.

The authors were surgeons who used the procedure on 547 patients over a 13 year period; 516 of them were included in the study (the others did not return for the three-month follow-up). 45 of the patients were male, 471 were female.

Most of the patients were satisfied with the procedure and there were no major complications. 60 patients (12%) were not satisfied with the result, 28 people (5%) returned for a reoperation to fix things. The authors use the reoperation rate to evaluate the procedure. The authors modified their technique over time and the reoperation rate in 2008-2011 was lower than the rate in 1999-2002.

The article does not say if the people who were dissatisfied with the operation were female or male.

As in many studies, the authors of the paper are the surgeons who performed the operations. They may be biased in favor of their own work.

Original Article:

Forehead Augmentation with a Methyl Methacrylate Onlay Implant Using an Injectin-Molding Technique by Dong Kwon Park, Ingook Song, Jin Hyo Lee, and Young June You in Arch Plast Surg. Sep 2013; 40(5): 597–602..

Surgical modifications of forehead and orbital area in facial feminization – Brief Review

This is an abstract of an oral paper. They presented clinical cases and seem to have discussed surgical techniques.

Original Article:

Surgical modifications of forehead and orbital area in facial feminization by A. Lemaitre, W. Waskiewicz, S. Medin Rey, S. Duvigneaud, M. Shahla, K. Keiani in International Journal of Oral & Maxillofacial Surgery, Volume 40, Issue 10 , Page 1084, October 2011.


Case Report: Feminizing the Male Face – Review

This is a study of facial feminization surgery given to ten Iranian trans women during the years 1990-2007. It provides a good description of the various procedures they used to feminize the face, although not all of the patients needed all of the possible surgeries.

The authors talk about the importance of having standards for FFS. They present a staged surgical protocol and parameters to consider before surgery.

The study includes a table summarizing some facial differences between males and females. It is interesting to note that the differences are measured in millimeters. This may be why some people can pass without surgery.

The authors mention the importance of cephalometeric radiography (this may refer to X-rays) and tracing in planning the surgery.

The authors make the interesting observation that the changes needed to feminize the face will vary by ethnicity and society.

The average age of the trans women in this study was only 23 (range 20-32). This is younger than in many of the other studies.

The before pictures are in black and white while the after pictures are in color. Nevertheless, it is easy to see that the face in the after pictures is much rounder. The after picture was taken four years after the operation, so there might have been other causes for the change (hormones or weight gain).

As in other studies, the authors are the surgeons who performed the surgery, thus they may have a bias to want to believe that the surgery was successful.

The article includes an interesting discussion of transgender history. Prior to 1991, there was no medical treatment for transgender people in Iran. In 1991 a religious decree was issued saying that transition was a permitted therapeutic procedure.

The authors conclude with an endorsement of further research:

Although our patients were satisfied with their improvement in appearance with these standard set of operations, conclusions as to these effects cannot be drawn. Even if feminization is considerable, the degree of improvement these procedures have on lifestyle remains to be assessed.

Original Article:

Case Report: Feminizing the Male Face by Mohammad Ghasem Shams, DMDa and Mohammad Hosein Kalantar Motamedi, DDSb in the Open Access Journal of Plastic Surgery, Eplasty. 2009; 9: e2.