COSMETIC

Facial Feminization Surgery: The Forehead.

Surgical Techniques and Analysis of Results
Luis Capitán, M.D., Ph.D.
Daniel Simon, D.D.S.
Kai Kaye, M.D.
Thiago Tenorio, M.D.
Marbella, Málaga, Spain
Background: Facial feminization surgery encompasses a series of surgical
techniques derived from plastic and craniomaxillofacial surgery to soften
facial features that are generally perceived as being more masculine, main-
ly in patients diagnosed with gender dysphoria. This article describes the
main surgical techniques used in feminization of the forehead complex,
sequences the different steps in forehead reconstruction, evaluates results
obtained using cephalometric analysis, and includes the level of patient
satisfaction.
Methods: Between January of 2008 and December of 2012, the authors per-
formed a total of 172 forehead operations. The postsurgical results were
analyzed using postoperative cephalometric studies that were compared with
preoperative teleradiographies. The patients’ level of satisfaction was also eval-
uated using a satisfaction questionnaire that they filled out after a 6-month
postoperative period.
Results: Along with an evaluation of patient satisfaction and clinical and
cephalometric results where significant setback of the frontal bossing was
observed, the authors present the sequencing of frontonasal-orbital recon-
struction/recontouring with systematic osteotomy of the anterior wall of
the frontal sinus in addition to developing a modification of the standard
coronal approach.
Conclusions: By treating the forehead region with the different surgical pro-
cedures described in this article, masculine facial features of the upper third
can be modified with predictable and satisfactory results. Facial feminization
surgery must be considered part of the process of treating patients with gen-
der dysphoria, because the modification and elimination of masculine facial
features allows these patients to adapt more easily to the workplace and social
and family environments. (Plast. Reconstr. Surg. 134: 609, 2014.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

T
he concept of facial feminization has been
presented in the scientific literature by vari-
ous authors1–4 over the past few years. Facial
feminization surgery embraces a range of surgical
techniques, the objective of which is to soften and
harmonize the different aesthetic sectors of the
face, bringing features that are usually identified
as male more in line with female features. This
surgical discipline is particularly important for
patients with gender dysphoria or gender identity
disorder, a diagnosis included in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition5
and classified in the International Classification of
From the MHC International Hospital, Facial Team
­Surgical Group.
Received for publication August 3, 2013; accepted January
28, 2014.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000545
Diseases, Tenth Revision, with a prevalence that can
vary from one in 12,000 to one in 50,000 accord-
ing to different studies.6,7 The disorder requires
a multidisciplinary approach following a strict
protocol, in which the alteration of the facial fea-
tures leads to an improvement in the patient’s
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Supplemental digital content is available for
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www.PRSJournal.com 609
 Plastic and Reconstructive Surgery • October 2014
self-esteem and successful integration into the
workplace, society, and family, all contributing
to a significant improvement in quality of life.8,9
The principal differences between masculine and
feminine facial features are related to the bone
structure,3,10 although other important differenti-
ating characteristics also exist, such as skin type,
distribution of facial hair and fat, type of hair and
hairline shape,11,12 the prominence of the thyroid
cartilage or Adam’s apple, and differentiating
characteristics in the soft tissues, among others.3,13
We describe our experience with facial femini-
zation during the period between January of 2008
and December of 2012, reviewing the different
procedures and the surgical techniques used in
the treatment of the forehead that allow the fron-
tonasal-orbital complex to be retropositioned,
which were later analyzed using preoperative and
postoperative cephalometries. The patient satis-
faction level was also evaluated using postopera-
tive questionnaires. Finally, the most important
results obtained are presented here.
PATIENTS AND METHODS
Between January of 2008 and December of
2012 (60 months), we performed 214 facial femi-
nization operations. All of the patients that we
operated on had been previously diagnosed with
gender dysphoria (International Classification of
Diseases, Tenth Revision code F-64). The average
age of the patients was 39 years (range, 18 to 61
years). Postoperative follow-up ranged from 6 to
65 months. The facial feminization procedures
performed break down as follows: 172 frontona-
sal-orbital recontouring procedures with oste-
otomy of the anterior wall of the frontal sinus,
of which 110 used a modified coronal approach
and 62 used a hairline approach; 99 mentoplas-
ties with osteotomy, bone sculpture using shaving,
or both; and 63 jaw recontouring procedures with
bone sculpture using shaving and 42 mandibular
angle osteotomies. All of the results and images
that appear in this article belong to patients who
have given their express consent for their images
to be published in scientific publications in com-
pliance with current personal data protection
regulations.
Clinical Evaluation and Surgical Techniques
When evaluating the facial feminization needs
of a patient, we choose to follow the classic evalua-
tion technique of dividing the face into thirds and
focusing on the key areas. In the upper third, the
key areas to evaluate are the frontonasal-orbital
610
region, the nasoglabellar angle, the supercili-
ary and supraorbital ridge, the protrusion of the
anterior wall of the frontal sinus, the frontoma-
lar suture, the forehead bone shape, the distance
between the nasal root and the beginning of the
hairline, the hairline shape, the type of hair and
skin, and the expressive areas and established
wrinkles. In the middle third, the focus is on the
shape of the nose, the projection of the malar
region, and the length of the upper lip (the point
between the columella and the vermilion border).
In the lower third, attention is focused on the chin,
its shape and position, and the mandibular body
and angles. The following sections describe exclu-
sively what we consider to be the most important
techniques being used in the field of facial femini-
zation of the forehead.
FOREHEAD RECONTOURING AND
RECONSTRUCTION
Frontonasal-orbital recontouring includes
bone sculpture along with osteotomy, recon-
touring, repositioning and, finally, securing the
anterior wall of the frontal sinus. (See Video,
Supplemental Digital Content 1, which is a three-
dimensional animation of the forehead recon-
struction technique. This video demonstrates the
steps of the forehead operation through a surgi-
cal animation in which the areas approached are
visible and the technique is described in detail,
Video. Supplemental Digital Content 1, which is a three-dimen-
sional animation of the forehead reconstruction technique. This
video demonstrates the steps of the forehead operation through
a surgical animation in which the areas approached are visible
and the technique is described in detail, available in the “Related
Videos” section of the full-text article on PRSJournal.com or, for
Ovid users, available at http://links.lww.com/PRS/B74.
Volume 134, Number 4 • Facial Feminization Surgery
available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, available at http://links.lww.com/PRS/B74.)
Two possible approaches exist that vary depend-
ing on whether or not the vertical dimension of
the forehead (the distance between the nasal
root and the beginning of the hairline) needs
to be modified. When some modification of this
distance is required to reduce it, the approach is
made through the hairline, where the remaining
cutaneous fragment is eliminated to modify this
vertical dimension (Fig. 1). The second access
route is the modified coronal approach (Fig. 2).
This modification includes the elimination of an
elliptical fragment of the scalp, making it pos-
sible to eliminate the excess skin after the bone
recontouring and allowing for better attachment
of the edges of the wound, a discrete lifting effect
on the forehead and, when necessary, the use of
the follicular units in this fragment for immedi-
ate transplant in the hairline and the temporary
recesses. For both types of approaches, hairline
Fig. 1. Detail of the hairline approach. The marked cutaneous area will be eliminated during surgery.
Fig. 2. Detail of the modified coronal approach. Front and side views.
and coronal, we recommend an oblique cutane-
ous incision with a 35- to 45-degree scalpel incli-
nation, which will help to preserve the follicular
units and, after a suitable scarring period, pro-
duce hair growth through the scar itself. Once
the approach route is chosen, detachment is per-
formed in layers to prevent injury to the frontal
branch of the facial nerve, and the frontoorbital
region is exposed, including the nasal bones. In
both cases, it is important to identify the supra-
orbital nerves and detach them correctly, which
may require osteotomy of the bony septum that
separates the orbital cavity. The next step is oste-
otomy of the anterior wall of the frontal sinus,
which is removed and meticulously sculpted,
always taking care to prevent any perforations.
With access to the sinus secured, the permeability
of both frontonasal ducts is ascertained and the
undamaged sinus mucous preserved (Fig. 3). The
forehead region, frontomalar transition, super-
ciliary and supraorbital ridge, and nasoglabellar
transition are sculpted at the same time. Once all
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 Plastic and Reconstructive Surgery • October 2014
Fig. 3. Osteotomy of the anterior wall of the frontal sinus. The
integrity of the sinus structure is checked, as is the permeability
of both frontonasal ducts.
of the recontouring is finished, the anterior wall
of the now sculpted frontal sinus is secured using
1.2 osteosynthesis material, either screws or mini-
plates, depending on the requirements (Fig. 4). It
is important at this point to eliminate any possible
interferences and inspect the transition zones.
Then, the area is closed, paying special attention
to the galeal-pericranial flap suture. In the event
that a coronal approach is used, when reposition-
ing the scalp flap, two resorbable fixation devices
(Endotine Forehead Fixation Device 3.0; Coapt
Systems, Inc., Palo Alto, Calif.) are placed to
ensure that the flap is secured correctly and help
to position the eyebrows over the new bone shape.
With the hairline approach, a meticulous cutane-
ous suture is made that guarantees accurate posi-
tioning, with no tension in the beveled cutaneous
edges and the best possible scarring. The use of
Fig. 4. Stable fixation of the anterior wall of the frontal sinus
with osteosynthesis (1.2-mm miniscrews) after sculpting the
entire frontonasal-orbital complex.
612
magnifying optical instruments is recommended
to obtain optimal results with this closure. When-
ever a coronal access is used, a drainage device
is placed that is removed 24 to 48 hours after
surgery. During the preoperative and immedi-
ate postoperative periods, teleradiography con-
trol radiographs are obtained to obtain an initial
evaluation of the surgery performed (Fig. 5).
­Figure 6 provides a step-by-step description of the
frontonasal-orbital recontouring-reconstruction
technique.
RESULTS
The average medical follow-up for patients
was 28 months, with the interval ranging from 6
to 65 months. The demographic distribution of
patients is shown in Figure 7. No serious complica-
tions were observed and no new emergency surgi-
cal operations were required. It was not necessary
to drain any postsurgical seromas or hematomas.
It was possible to remove all of the drains placed
in the coronal approaches between 24 and 48
hours after surgery. One patient had a cerebrospi-
nal fluid fistula along a linear cut in the posterior
wall of the frontal sinus that resolved spontane-
ously 72 hours after surgery with the assistance of
posture measures. There were no complications
related to the approach to the frontal sinus such
as sinus dysfunction, sinusitis, or mucocele or any
fractures in the anterior wall of the frontal sinus.
All of the patients received preoperative and post-
operative lateral teleradiography x-ray examina-
tions. Both hairline and coronal scarring showed
positive development, with hair growth in the
scar beginning 8 to 12 weeks after surgery. Most
of the patients reported light to moderate pares-
thesia, with complete recovery starting 3 months
after surgery in the supraorbital, forehead, and
scalp regions. No injury was reported to the fore-
head branch of the facial nerve, although a slight
degree of paresis occurred in some cases, with
complete recovery a few weeks after surgery. Most
of the patients had low to moderate postsurgical
edema that responded very well to hilotherapy.
No complications associated with any of the com-
plementary procedures related to the operations
were reported. Preoperative, intraoperative, and
postoperative imaging was performed on all of
the patients operated on during this period. The
average level of patient satisfaction, assessed using
postsurgical questionnaires, was between satisfied
and completely satisfied, with an average over-
all satisfaction level of 4.5 in the questionnaire
filled out 6 months after surgery (Table 1 shows
Volume 134, Number 4 • Facial Feminization Surgery

Fig. 5. Preoperative and postoperative teleradiography and cephalometric study. Note the
clinical modification of the frontal bossing after surgery. Setback of the frontal bossing can be
determined by measuring the distance from the point corresponding to the frontal prominence
landmark (PF) to the gonion (Go) and to the sella (S). For the case in the figure, preoperative mea-
surements include the following: frontal prominence landmark to sella, 81.17 mm; and frontal
prominence landmark to gonion, 121.15 mm. Postoperative measurements include the following:
frontal prominence landmark to sella, 72.66 mm; and frontal prominence landmark to gonion,
112.42 mm. A setback of 8.51 mm from frontal prominence landmark to sella and a setback of
8.73 mm from frontal prominence landmark to gonion can be observed.

the satisfaction questionnaire and Table 2 shows
the average satisfaction level, calculated using the
average of all of the answers obtained from each
questionnaire and patient). Figures 8 through 12
show different intraoperative, radiologic, cepha-
lometric, and clinical presurgical and postsurgical
results. Table 3 shows the average preoperative
and postoperative cephalometric measurements
where setback of the frontal bossing is determined
by measuring the distance from the point corre-
sponding to the frontal prominence landmark to
the gonion and to the sella before surgery and
after surgery. A statistically significant difference
can be observed between preoperative and post-
operative measurements (Table 3).
DISCUSSION
The concept of facial feminization surgery
was first introduced by Douglas Ousterhout in
1987.1 Since then, several authors have published
accounts of their experiences in this surgical dis-
cipline.4,6,14,15 Facial feminization results from the
need to modify masculine features in patients
with gender dysphoria who are in the process of
adapting their identity9 or patients with overly pro-
nounced facial features.16 Facial gender identity is
a field of interest because certain areas of the face
are easily recognizable as masculine or feminine.3
The frontonasal-orbital region and jaw are espe-
cially important areas in the visual identification
of facial gender.17 In contrast to studies by Brown
and Perrett, Spiegel attaches particular impor-
tance to the nose as an isolated element in facial
gender identification.4 For Becking et al., the
zygomaticomalar complex also plays an important
role in differentiating facial gender.6
The modification of masculine facial features is
increasingly important in the framework of gender
reassignment for patients with gender dysphoria.9,18
Emphasis has been placed on the significance of
this treatment for the patient’s self-esteem and
confidence, and their ability to incorporate and
adapt to their new role in the workplace, society,
and family.8 Some authors advocate—and we fully
agree with this line of thinking—that facial femini-
zation is a key element in the treatment of gender
dysphoria and that it can be more important from
the patient’s psychological point of view, in terms
of their psychosocial adaptation, than the sexual
reassignment itself, which is related more to the
patient’s personal life.19
When evaluating patients who are requesting
facial feminization surgery, decisions are based on

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Fig. 6. Forehead reconstruction technique sequence. (Above, left) Patient’s profile before surgery. (Above,
center) Modified coronal approach, with elimination of the scalp strip. (Above, right) Coronal flap, preserving
the frontal branch of the facial nerve. (Second row, left) Pericranial flap until frontonasal-orbital ridge and
both frontomalar apophyses are reached. (Second row, center) Skull profile; note the protrusion of the frontal
bossing. (Second row, right) Osteotomy of the anterior wall of the frontal sinus using a saw. (Third row, left)
Access to the frontal sinus. The anterior wall is preserved in saline solution until shaving and repositioning.
(Third row, center) Sculpture of the entire frontonasal-orbital complex, paying special attention to the fronto-
nasal transition. (Third row, right) Sculpture of the anterior wall of the frontal sinus. (Below, left) Stable fixation
of the anterior wall of the frontal sinus with osteosynthesis. (Below, center) Meticulous closure of the pericra-
nial flap and placement of the resorbable anchors (Endotine Forehead Fixation Device) to achieve the correct
repositioning of the eyebrows over the new bone structure. (Below, right) Patient’s profile after surgery.

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Fig. 7. Demographic distribution of patients (n = 172).

Table 1. Questionnaire 6 Months after Surgery

Evaluate the following aspects and mark on a scale of 1 to 5, with 1 being ­completely dissatisfied, 2 being dissatisfied, 3 being
satisfied, 4 being very satisfied, and 5 being completely satisfied.
1. Response to questions and problem solving during the postoperative period 1 2 3 4 5
2. Indicate your level of satisfaction regarding the following clinical aspects:
 2.1. Transition between the nose and forehead 1 2 3 4 5
 2.2. Eye socket openings/appearance of the eyes 1 2 3 4 5
 2.3. Eyebrow position 1 2 3 4 5
 2.4. General forehead appearance 1 2 3 4 5
3. Degree to which the results met your expectations 1 2 3 4 5
4. Level of satisfaction with the surgical team 1 2 3 4 5
5. Level of overall satisfaction with your treatment 1 2 3 4 5

Table 2. Questionnaire Results* Ousterhout classifies forehead treatment into

Satisfaction Index Points No. of Patients (%)
Completely dissatisfied 1 0 (0)
Dissatisfied 2 1 (0.6)
Satisfied 3 14 (8.1)
Very satisfied 4 45 (26.2)
Completely satisfied 5 112 (65.1)
*n = 172 patients.
the classic evaluation technique that divides the
face into thirds,20 which makes it easier to identify
the treatment needs. This article focuses on one
of the facial regions whose modification results in
a more significant change in terms of the identifi-
cation of facial gender: the forehead.
Forehead reconstruction has been widely
discussed in the scientific literature with a basi-
cally craniofacial focus. In his publication in
1991, Ortiz Monasterio proposed reconstructing
the forehead region from an aesthetic point of
view.16 From the perspective of facial feminiza-
tion, treatment of the forehead and, in general,
the frontonasal-orbital complex, receives the
most attention in the scientific literature.1,2,4,6,15
three types according to the technique used: type
I, recontouring using a burr; type II, reconstruc-
tion of the forehead complex using methacry-
late; and type III, setting the anterior wall of the
forehead sinus back.1 Lee et al. have based their
research on the importance of treating the fron-
tonasal-orbital region, a key area in the identifica-
tion of facial gender, according to the authors.21
In his 2011 publication, Spiegel presents a series
of 168 treatments of the forehead region using
the burring technique alone, osteotomy and set-
back, or the “island” technique, developed by the
author himself according to the characteristics of
the forehead area being treated.4 Franz Hoenig
supports this theory and has presented his expe-
rience performing frontonasal-orbital recontour-
ing on 21 patients using hydroxyapatite.15 In his
2012 analysis of surgical feminization procedures,
Altman provides an exhaustive review of the vari-
ous techniques associated with forehead surgery,
emphasizing the different possibilities for han-
dling the frontal sinus—using a standard coronal
or hairline approach when the hairline must be

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 Plastic and Reconstructive Surgery • October 2014

Fig. 8. Intraoperative pre- and post-profiles. Reconstruction of the frontonasal-orbital complex and repositioning
of the anterior wall of the frontal sinus.

Fig. 9. Preoperative and postoperative three-dimensional computed tomographic scans demon-

strating forehead reconstruction (three-quarters left view).

modified—and the position of the eyebrows.18
From our experience, we can fully corroborate
what these authors have described regarding the
importance of treating the frontonasal-orbital
complex and its impact on facial gender identifi-
cation. After evaluating a series of 172 foreheads
with recontouring and reconstruction, we believe
that it is not only essential to treat the forehead
region and the supraorbital ridge, but that the
recontouring must include the frontomalar
apophyses, the upper-outer region of the orbital
ridge, the supraorbital ridge on the level of the
orbital cavity, the entire frontal wall, and the naso-
glabellar junction. The last of these constitutes
a key point in the treatment of the entire fore-
head region, because it conditions the transition
between the nose and forehead and, therefore,
the angle between both areas, which clearly dif-
ferentiates the female from the male face. With
regard to the surgical technique, we believe that
the best way to achieve a true recontouring of the
forehead is through sculpture of the anatomical
regions, as discussed above, together with osteot-
omy and retropositioning, or setback, of the ante-
rior wall of the frontal sinus.
Regarding the approach to the forehead
region, most of the literature supports the stan-
dard coronal access22,23 or an approach through
the hairline.24 In our experience, a modified cor-
onal approach allows for excellent access to the
frontonasal-orbital region, prevents excess second-
ary skin on the bone recontouring, and makes it
easier to reposition the soft tissues, helping us to
achieve a discrete effect with the eyebrow elevation.

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Fig. 10. Preoperative and 2-month postoperative left medium profile clinical images. Forehead
reconstruction was performed by means of the hairline approach with lowering of the hairline.

Fig. 11. Preoperative and 6-month postoperative front clinical images. Forehead reconstruc-
tion was performed by means of the modified coronal approach.

We believe that only in specific cases is it neces-
sary to approach through the hairline, because the
concept of hairline lowering is increasingly being
replaced by redesigning the hairline with follicu-
lar transplants,12,25 with excellent natural results
and no significant scarring in a very visible area.
We use hairline approaches only in select cases
after considering the following parameters: type of
hair, hairline shape and capillary volume at that
point, the shape and amount of any hairline reces-
sion, the distance from the nasal root to the begin-
ning of the hairline in the most advanced central
point and, finally, the angle of the forehead slant.
In both cases—modified coronal approach and
hairline approach—we, like other authors, recom-
mend oblique cutaneous incisions that preserve
the greatest quantity of follicular units, resulting
in better postoperative hair recovery in the scar.18,26
This retropositioning technique mentioned
makes it possible to modify the nasoglabellar
angle. In our opinion, isolated burring of the fore-
head region has two drawbacks. First, it can perfo-
rate the anterior wall of the frontal sinus because
of the weak control over the thickness of this

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 Plastic and Reconstructive Surgery • October 2014

Fig. 12. Preoperative and 6-month postoperative right profile clinical images. Forehead recon-
struction was performed by means of the modified coronal approach.

Table 3. Preoperative and Postoperative Measurements and Setback Average

Cephalometric ­Measurements
(n = 172 patients) Preoperative (mm)* Postoperative (mm)* Setback (mm)* p†
PF-S 85.94 ± 2.67 77.26 ± 2.15 8.68 ± 1.42 <0.001
PF-Go 144.22 ± 8.20 135.33 ± 8.15 8.89 ± 1.43 <0.001
PF, frontal prominence landmark; S, sella; Go, gonion.
*Mean ± SD.
†t test for paired samples.

wall, with subsequent sinus exposure. Second, it
does not allow for the correct modification of the
nasoglabellar transition, which can determine the
result to a large extent. Recontouring using het-
erologous reconstruction material, as proposed
by some authors,15,27 creates a similar problem,
because the transition cannot be modified cor-
rectly and there is a risk of artificial results caused
by excessive overcorrection of the forehead.
CONCLUSIONS
Feminization surgery of the forehead makes
it possible to modify specific facial features that
are usually identified as masculine, using differ-
ent surgical procedures based on plastic and
craniomaxillofacial techniques. The frontonasal-
orbital complex is one of the main facial areas
that determine the identification of facial gender
and which, therefore, is a prime target for modi-
fication in facial feminization surgery. By treating
these regions with the different surgical proce-
dures described in this article, masculine facial
features can be modified with predictable and
satisfactory results. Facial feminization surgery
must be considered part of the process of treating
patients with gender dysphoria, because the modi-
fication and elimination of masculine facial fea-
tures allows these patients to adapt more easily to
the workplace and social and family environments.
Luis Capitán, M.D.
MHC International Hospital
Facial Team Surgical Group
Marbella, Málaga, Spain
ACKNOWLEDGMENTS
The authors thank everyone who made this project
possible: Mili, Lilia, Ana, and Fernanda for their con-
tribution to the project; Carlos Bailón, M.D., for invalu-
able assistance and for recently joining our team; Drs.
Andrés Merlo, M.D., and Alan Wells, M.D., for their
professionalism and excellent results; Alexandra Hamer
for sharing her knowledge and incredible results with
us; Michel Lipiec for assistance with the cephalometric
measurements; Dr. Fernando Monsalve, M.D., for help
with the statistical analysis; Grassyt for her compassion
and experience; Marcos Nascimento for his marvelous

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Volume 134, Number 4 • Facial Feminization Surgery
illustrations; Pamela Lalonde for her professionalism;
our mothers and fathers for their example and con-
tinuous assistance; and our families for their love and
patience, in particular Ino, Camila, Javier, Carolina,
Lara, and Felipe.
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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