Volume 138, Number 4 • Letters
6. Iblher N, Manegold S, Porzelius C, Stark GB. Morphomet-
ric long-term evaluation and comparison of brow position
and shape after endoscopic forehead lift and transpalpebral
browpexy. Plast Reconstr Surg. 2012;130:830e–840e.
7. Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic
Plast Surg. 1994;18:269–274.
8. Vasconez LO, Core GB, Gamboa-Bobadilla M, Guzman G,
Askren C, Yamamoto Y. Endoscopic techniques in coronal
brow lifting. Plast Reconstr Surg. 1994;94:788–793.
9. Matarasso A. Endoscopically assisted forehead-brow rhytido-
plasty: Theory and practice. Aesthetic Plast Surg. 1995;19:141–147.
10. Ramirez OM. The anchor subperiosteal forehead lift. Plast
Reconstr Surg. 1995;95:993–1003; discussion 1004.
Reply: Does the Eyebrow Sag with Aging? An
Anthropometric Study of 95 Caucasians from
20 to 79 Years of Age
Sir:
We thank Drs. van der Lei and Fechner for their
interest in our work1 and the relevance of their remarks.
As they point out, our publication does not mention
the evolution with age of the extreme lateral part of the
eyebrow. This omission is deliberate, as our preclinical
study showed a lack of reliability in the measurements
observed at this level.
Several reasons can account for this. First, the
upper edge of the eyebrow is difficult to define in this
area because of a diminished hair density. Second, our
protocol is valid only in the frontal plane, at the level of
the metric ruler taped horizontally onto the glabellar
region just above the eyebrows, which allows calibra-
tion measurements.
The eyebrow does not evolve in a single plane, but
in three dimensions. The medial third and the middle
third can be evaluated in the frontal plane and are the
subject of our work. The lateral third, however, oper-
ates in a plane whose orientation is oblique, posterior,
and exterior, corresponding to the temporal region.
In our study, two-dimensional portraits show the
extreme lateral part of the eyebrow tangentially, in a
remote plane to our reference. Therefore, a height
measurement at this level could not be precise or be
extrapolated for analysis.
Our study protocol was validated in a frontal plane
tangential to the eyebrow, thus affording reliable mea-
surements to avoid bias. It does not allow rigorous
evaluation of the extreme lateral eyebrow. The study of
this region requires an appropriate methodology with
demonstrated reliability and validity.
We read with particular interest their statement on
aesthetic surgery of the upper face. It underlines the
importance of rejuvenating the forehead, or the eyelids,
without distorting the eyebrow. This is a major point for
a natural aesthetic result: rejuvenation techniques to be
successful must respect the physiology of facial aging.
DOI: 10.1097/PRS.0000000000002579
Stéphane Bruneau, M.D.
Jean-Marc Foletti, M.D.
North University Hospital
Marseille, France
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Correspondnece to Dr. Bruneau
Service de Chirurgie Maxillo-Faciale, Chirurgie Plastique, et
Réparatrice
Pavillon Etoile, 2ème Etage
Chemin des Bourelly
13015 Marseille, France
stephane.bruneau@ap-hm.fr
disclosure
Neither author has a financial interest to declare in rela-
tion to the content of this communication.
acknowledgment
The authors thank Eileen Benz.
reference
1. Bruneau S, Foletti JM, Muller S, Vercasson C, Lauwers F,
Guyot L. Does the eyebrow sag with aging? An anthropomet-
ric study of 95 Caucasians from 20 to 79 years of age. Plast
Reconstr Surg. 2016;137:305e–312e.
Full Facial Feminization Surgery: Patient
Satisfaction Assessment Based on 180 Procedures
Involving 33 Consecutive Patients
Sir:
W e read with great interest the article by Raffaini
et al.1 concerning facial feminization surgery sat-
isfaction assessment. Despite our personal high resis-
tance in operating on transgender patients who want
to undergo facial feminization, we feel that in some
cases such operations are an unavoidable choice. The
principle of not changing easily nature’s selection on a
person’s gender and gender characteristics can often
protect him or her from secondary surgery–based
problems that might arise.2–4
Because of psychological imbalance and instability,
which are probably not going to improve in such surgi-
cal cases, we feel that exclusion criteria should be strict
and precise; otherwise, studies will lead to biased results
of dubious or decreased scientific significance. In similar
cases where psychological issues need to be ruled out,
we have used the Rosenberg Self-Esteem Scale5 question-
naire or a similar instrument to confirm the homogene-
ity and increase the reliability of our patient sample.
We feel that, given the complication rate, the cur-
rently increasing trend of gender reassignment sur-
gery followed by appearance change surgery has to
follow rules.6 It cannot hide behind the alibi of wishes
of “making his or her body as congruent as possible
with the preferred sex through surgery.” Plastic sur-
gery indications must be preserved. Limitations based
on indications define rules and limits within which
plastic surgery can function freely and safely.
DOI: 10.1097/PRS.0000000000002580
Leonidas Pavlidis, M.D., Ph.D.
Georgia Alexandra Spyropoulou
765e
 Plastic and Reconstructive Surgery • October 2016
Dimitris Dionyssiou
Efterpi Demiri
Aristotle University of Thessaloniki
Thessaloniki, Greece
Correspondence to Dr. Pavlidis
Mikroulea 25
55132 Thessaloniki, Greece
leopavlidis@gmail.com
disclosure
The authors have no financial interest to declare in
­relation to the content of this communication.
references
1. Raffaini M, Magri AS, Agostini T. Full facial feminization
surgery: Patient satisfaction assessment based on 180 proce-
dures involving 33 consecutive patients. Plast Reconstr Surg.
2016;137:438–448.
2. Lehavot K, Simpson TL, Shipherd JC. Factors associated with
suicidality among a national sample of transgender veterans.
Suicide Life Threat Behav. E-published ahead of print February
15, 2016.
3. Haas AP, Lane A; Working Group for Postmortem Identifi-
cation of SO/GI. Collecting sexual orientation and gender
identity data in suicide and other violent deaths: A step
towards identifying and addressing LGBT mortality dispari-
ties. LGBT Health 2015;2:84–87.
4. Rood BA, Puckett JA, Pantalone DW, Bradford JB. Predic-
tors of suicidal ideation in a statewide sample of transgender
individuals. LGBT Health 2015;2:270–275.
5. Duchesne AP, Dion J, Lalande D, et al. Body dissatisfaction
and psychological distress in adolescents: Is self-esteem a
mediator? Health Psychol. E-published ahead of print Febru-
ary 29, 2016.
6. Sohn MH, Hatzinger M, Wirsam K. Genital reassignment
surgery in male-to-female transsexuals: Do we have guide-
lines or standards? (in German). Handchir Mikrochir Plast
Chir. 2013;45:207–210.
Reply: Full Facial Feminization Surgery:
Patient Satisfaction Assessment Based on 180
Procedures Involving 33 Consecutive Patients
Sir:
We would like to thank you for the possibility of
further discussing our article published in the February
issue of Plastic and Reconstructive Surgery.1 Pavlidis et al.
refer to “high resistance” to perform facial feminization
procedures, reserving these procedures for selected
cases to respect human nature. According to this
principle, all cosmetic procedures would be affected
because they influence patients lifelong; this “working”
principle cannot guide surgeons to indicate surgical
procedures to avoid possible reoperative surgery. Psy-
chological imbalance affects all patients undergoing
cosmetic surgery, not only transgender patients. On this
principle, we fully agree that there is a possible increase
of bias that could be corrected by proper preoperative
evaluation by specialized medical or paramedical staff,
766e
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
but certainly not by the same surgeon who will perform
surgery (conflict of interest). Rules to engage patients
undergoing transgender surgery have been widely dis-
cussed and accepted, but guidelines to identify diseases
such as body dysmorphic disorder have not been devel-
oped.1,2 Body dysmorphic disorder, in particular, is a
well-established psychiatric disorder characterized by
an excessive concern with a nonexisting or slight defect
in physical appearance, and diagnosing it during a pre-
operative consultation remains challenging. Body dys-
morphic disorder is usually associated with poor quality
of life, extremely high rates of suicide and, following
cosmetic surgery, high rates of dissatisfaction, occasion-
ally manifesting as aggressiveness.3,4 As further proof
of an emerging point of discussion, it is notable how
four epidemiologic studies have examined mortality
among women with cosmetic silicone gel–filled breast
implants and have found that risk of death from sui-
cide is twofold to threefold higher in this group than
among women of comparable age in the general popu-
lation.5–7 The same authors, pending further investiga-
tions, suggest supporting patients undergoing cosmetic
surgery by psychiatric consultation, which is the only
means, in this difficult field, of making the proper diag-
nosis.4 Furthermore, de Brito et al. analyzed the level
of body dissatisfaction and prevalence of body dysmor-
phic disorder in patients seeking abdominoplasty (n =
90), rhinoplasty (n = 151), and rhytidectomy (n = 59),
based on the Body Dysmorphic Disorder Examination,
which was administered preoperatively. The authors
conclude that abdominoplasty candidates showed the
highest prevalence; rhytidectomy candidates exhibited
the highest percentage of severe cases, and rhinoplasty
candidates had the lowest percentage of severe cases.6
On these considerations, transgender patients
should receive proper psychiatric and psychological
support with respect to the other patients undergo-
ing cosmetic procedures because they are involved in
proper referral centers. As further support, we would
like to emphasize that our patients met specific crite-
ria for facial feminization surgery (we did not record
any suicides), 16 (48.4 percent) had undergone previ-
ous breast augmentation, and six (18.1 percent) had
undergone surgery of the genitalia.1
DOI: 10.1097/PRS.0000000000002581
Mirco Raffaini, M.D., D.D.S.
Department of Maxillofacial Surgery
University of Florence
Florence, Italy
Face Surgery Center
Parma, Italy
Alice Sara Magri, M.D.
Face Surgery Center
Parma, Italy
Tommaso Agostini, M.D.
Department of Maxillofacial Surgery
University of Florence
Florence, Italy