Facial feminization surgery

Key points

• The male skull is longer and broader compared with the female skull, whereas the female skull has a more pointed chin and tapered jaw.

• Frontal bossing of the male skull generally extends from the region of the nasion medially to the supraorbital region extending laterally to the zygomaticofrontal suture of the lateral orbital wall on each side.

• From an anatomical perspective, the forehead and thyroid cartilage are the two most “masculine” characteristics of the male face.

• Approximately 20% of the female population demonstrates a mild to moderate degree of midforehead bossing (MFB) while approximately 50% of the male population demonstrates midforehead bossing in addition to supraorbital bossing (SOB).

• With many transgender patients presenting in their 50s and 60s, rejuvenation procedures contribute as much to the feminization process as do FFS procedures.

• Narrowing of the chin in the transverse plane by T-osteotomy genioplasty can dramatically change the angularity of the lower face creating a desirable V-line configuration.

• The T-osteotomy genioplasty advancement (TOGA) procedure permits narrowing of the chin in the transverse plane as well as advancement of a retruded chin.

• Feminizing a strong male chin often requires reducing the height of the chin and narrowing the width of the chin with a sliding genioplasty.

• In most transgender women, a successful transformation and the ability to “pass” are dependent on reduction of the thyroid cartilage–chondrolaryngoplasty.

• Care must be taken during thyroid cartilage resection to avoid injury to the adjacent vocal cords which could result in permanent voice changes and hoarseness.

Introduction

Almost 40 years ago, Dr. Douglas Ousterhout pioneered the field of facial feminization surgery (FFS) when, in 1982, Dr. Darrell Pratt, a plastic surgeon who performed gender reassignment surgery (GRS), conveyed the request of a male-to-female transgender patient who wished to have more feminine facial features as people still reacted to her as though she were a man despite her GRS. That request opened the door to a new world in which techniques of transforming the larger, more angular male features to smaller, softer, more feminine female features evolved and progressed with the goal of matching one’s external appearance with the internal perception of oneself.

Bony differences

Numerous anthropologic and anthropometric studies have defined the characteristics that distinguish male skulls from female skulls. In general, the male skull is longer and broader compared with the female skull, whereas the female skull has a more pointed chin and tapered jaw ( Fig. 40.1 ). Frontal bossing of the male skull generally extends from the region of the nasion medially to the supraorbital region extending laterally to the zygomaticofrontal suture of the lateral orbital wall on each side. Perhaps the most prominent component of frontal bossing overlies the frontal sinus and extends laterally as a ridge of varying thickness ( Fig. 40.2 ). The female forehead demonstrates a much more consistently convex contour, with minimal supraorbital ridging or bossing. However, approximately 20% of the female population demonstrates a mild to moderate degree of midforehead prominence or bossing, and approximately 50% of the male population demonstrates midforehead bossing of varying degrees in addition to supraorbital ridging. In general, broader more prominent nasal bones will translate to larger noses in the male, although this is clearly not always the case.

Fig. 40.1, Male versus female skulls. The male skull is more rectangular and has a vertically longer chin, whereas the female skull is more oval in shape and has a more pointed chin. The male skull also has a wider, fuller jaw. The male skull has a pronounced brow ridge, whereas the female skull has a more rounded, smooth forehead that does not project over the eyes. The male also has a taller, angular jawbone; the female has a shorter, tapered jawbone.

Fig. 40.2, Supraorbital frontal bossing. This well-known television character, Herman Munster, demonstrates significant supraorbital bossing and frontal bone ridging due to pronounced frontal sinus formation.

Soft tissue differences

Typical differences in soft tissue characteristics between the male and female faces include skin thickness, especially with respect to the lower third of the nose, presence of the male beard, position of the eyebrows and hairline, temporal hair density, and upper lip length. The male eyebrow rests at or slightly below the supraorbital rim and bony ridge, whereas the female eyebrow rests above the supraorbital rim and bony ridge. As a result, women have a shorter distance between the hairline and eyebrows. The average distance from the hairline to the eyebrow at the midpupillary line is approximately 3 inches in the male and 2 inches in the female. This distance increases as the hairline recedes in the male, especially with loss of hair in the temporal and midforehead regions. The upper lip of the male tends to be longer and flatter than that of the female with less tooth show demonstrated.

Goals of facial feminization surgery

Although the desire to “pass” may be the most commonly stated goal of FFS, lifelong internal struggles with the paradox of improper gender embodiment ultimately cause trans women to strive to feel comfortable in their own skin. Certainly, the importance of external gender perception by others matching one’s own perception of self cannot be understated. Many patients present in their 20s, but some present even in their 60s and beyond, often married and with grown children, indicating they finally have the means, resolution, and support to move forward with what they had contemplated and yearned to do their entire lives. Assimilation and integration into the workplace, family, and social situations are also important goals of FFS. Keith Haring’s vision of a genderless society where equality reigns independent of gender ( Fig. 40.3 ) represents a type of utopia sought by many. Gender equality or “gender blurring” has been symbolically depicted by the transgender community to represent that journey. The transgender symbol links the internationally accepted symbols for male and female together with a new entity that is a combination of the two ( Fig. 40.4 A) and is increasingly seen in public venues and businesses (see Fig. 40.4 B).

Fig. 40.3, Keith Haring’s vision of a genderless society.

Fig. 40.4, Transgender symbol. (A) The transgender symbol links the internationally accepted symbols for male and female together with a new entity that is a combination of the two. (B) Actual sign outside a restroom at The Second City in Chicago, IL.

Managing patient expectations

As with every plastic surgery patient, the patients’ expectations and the surgeons’ vision must be aligned to achieve a successful outcome and a satisfied patient. The transgender patient is no different. A whole world of additional psychology is involved in working with the transgender community, but at the end of the day, the patient and the surgeon must be on the same page before any surgery is undertaken. ^, Realistic expectations must be met with realistic reassurances. It is often hard to say to the transgender patient, or any patient, “I’m a physician, not a magician.” If the surgeon feels that only a magician would be able to deliver the desired result, then it must be conveyed to the patient that the surgeon will not be able to meet their expectations and that rather than displeasing the patient, the surgeon would prefer that the patient meet with another Board-certified plastic surgeon who might be better able to achieve the result sought. There is no shame in being honest and direct. To the contrary, the patient will be appreciative and potentially adjust his or her expectations as a result. Choosing to find another surgeon will likely do a favor to oneself and the surgeon.

Principles of facial feminization surgery

First do no harm

With FFS, as with all surgeries, including aesthetic surgery, the first principle is derived from the Hippocratic Oath: First do no harm. This especially applies to FFS where some patients may wish to undergo “full facial feminization” in one stage, and some surgeons may be tempted to comply. Conversely, some surgeons may seek the opportunity to combine an excessive number of procedures. The corollary to this principle, of course, is “Safety first.”

The primary goal of FFS is to produce a happy, live transitioned patient. Therefore procedures should be combined only when it is safe and feasible to do so. With some patients, it is certainly feasible to address all concerns in one sitting and achieve “full facial feminization.” With others, however, it simply is not, and overambitious 14-hour procedures should generally be avoided if the first principle of FFS is adhered to and the primary goal of FFS and the surgeons’ goal are the same.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here