ORIGINAL ARTICLE Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management Jordan C. Deschamps-Braly, MD, FACS origins of facial gender confirmation surgery (facial feminization Abstract: The 1960s and 1970s were an important time for and masculinization), which may be found in the forward to this craniofacial surgery because of the work of Paul Tessier and Hugo journal, are fascinating to the readers as well. Obwegeser, both mentored by Sir Harold Gillies, along with many other important monumental minds. During this era, the birth of craniofacial surgery occurred and represented a new discrete spe- Key Words: Chin feminization, chin reduction, facial cialty within plastic surgery. In the 1980s distraction of the facial feminization surgery, facial masculinization surgery, feminizing skeleton became an indispensable tool in the arsenal of the cranio- rhinoplasty, facial gender confirmation surgery, forehead facial surgeon, based on initial cases in Italy, and rigorous research contouring, forehead feminization, genioplasty, jaw contouring by McCarthy, Grayson, and others. In more recent times, from 2000 (J Craniofac Surg 2019;30: 1352–1358) onward, craniofacial surgery has benefitted from the advent and refinement of techniques using computer-aided planning for pro- cedures, spring distraction, as well as the widespread use of fat grafting as part of facial reconstruction. In the last decade, innova- BACKGROUND tions based on the fusion of microsurgical procedures with cranio- he 1960s and 1970s were an important time for craniofacial facial procedures for face allotransplantation and improvements in T surgery because of the work of Paul Tessier and Hugo Obwe- geser, both mentored by Sir Harold Gillies, along with many other safety regarding separation of craniopagus infants have been important monumental minds. During this era, the birth of cranio- observed. The author thinks it is worth mentioning and conferring facial surgery occurred and represented a new discrete specialty praise upon the anesthesia colleagues for improvements in anesthe- within plastic surgery. In the 1980s distraction of the facial skeleton sia which have led to vastly decreased mortality in the infant became an indispensable tool in the arsenal of the craniofacial population undergoing complex procedures. surgeon, based on initial cases in Italy, and rigorous research by The common theme among these achievements is that they were McCarthy, Grayson, and others. In more recent times, from 2000 quickly adopted by the subspecialty community. However, in the onward, craniofacial surgery has benefitted from the advent and hindsight of history, the author thinks it is now understood that refinement of techniques using computer-aided planning for pro- during this time another great achievement, long overlooked, cedures, spring distraction, as well as the widespread use of fat occurred in craniofacial surgery. In the 1980s the author’s associate grafting as part of facial reconstruction. In the last decade, we have seen innovations based on the fusion of microsurgical procedures and mentor, Douglas Ousterhout, adapted techniques of craniofacial with craniofacial procedures for face allotransplantation and surgery to change the lives of transgender patients. This new and improvements in safety regarding separation of craniopagus infants. powerful surgery had the potential to change the course of some- I think it is worth mentioning and conferring praise upon our one’s life just as profoundly as the correction of congenital cranio- anesthesia colleagues for improvements in anesthesia that have facial anomalies. This quality of life improvement for trans patients led to vastly decreased mortality in the infant population undergo- undergoing facial feminization has been evaluated and found to be ing complex procedures. quite significant. However, it was essentially ignored by the spe- The common theme among these achievements is that they were cialty community, and the author and his colleagues were slow to quickly adopted by our subspecialty community. However, in the adopt this surgery. In this study, the author will give an overview of hindsight of history, I think it is now understood that during this the procedures required to feminize or masculinize a face. The time another great achievement, long overlooked, occurred in craniofacial surgery. In the 1980s my associate and mentor, Dou- history of surgery is fascinating, and the author hopes that the glas Ousterhout, adapted techniques of craniofacial surgery to change the lives of transgender patients.1 This new and powerful From the Deschamps-Braly Clinic of Plastic & Craniofacial Surgery, San surgery had the potential to change the course of someone’s life just Francisco, CA. as profoundly as the correction of congenital craniofacial anoma- Received January 4, 2019. lies. This quality of life improvement for trans patients undergoing Accepted for publication January 14, 2019. facial feminization has been evaluated and found to be quite Address correspondence and reprint requests to Jordan C. Deschamps- significant.2,3 However, it was essentially ignored by our specialty Braly, MD, FACS, c/o Deschamps-Braly Clinic of Plastic & and we were slow to adopt this surgery. Within the following pages, Craniofacial Surgery, 450 Sutter St, Suite 1520, San Francisco, CA I will give an overview of the procedures required to feminize or 94108; E-mail: [email protected] masculinize a face. The history of surgery is fascinating, and I hope The author reports no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD that the origins of facial gender confirmation surgery (facial ISSN: 1049-2275 feminization and masculinization), which may be found in the DOI: 10.1097/SCS.0000000000005391 forward to this journal, are fascinating to you as well. 1352 The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 FFS and FMS PREREQUISITE EXPERIENCE predict the exact outcome of these operations. It is crucial to pick What experience does one need to perform facial feminization patients who are psychologically flexible in their expectations. One surgery (FFS) and facial masculinization surgery (FMS)? This is an cannot defer this decision to a mental health provider. One cannot important question that requires an answer. Let us begin by what is assume that a patient is a good candidate because they carry a letter not needed. Microsurgery is not a relevant skill set necessary to do from a therapist stating that a patient has gender dysphoria and is a this surgery. Yet extensive experience in the remainder of both candidate for whatever surgery they are seeking. This is a decision craniofacial and maxillofacial surgeries is imperative. One without that only the plastic surgeon interviewing the patient can make. If the other will not suffice. The reason I even bother to mention this is one is wrong and operates upon a patient who is not fit for surgery, it that not all craniofacial training is the same. Many practitioners who will not be the psychologists’ responsibility. It will be the surgeon’s do large numbers of cranial vault operations per year may not have responsibility. Thus, I suggest taking your time and talking with performed a sliding genioplasty in years. Many maxillofacial your patients at length. surgeons who have done vast numbers of sliding genioplasties The age of the patient must be considered when evaluating and orthognathic operations may not have harvested a cranial bone someone for surgery. The patient must be skeletally mature at the graft or repaired a cranial defect in years, if ever. Often surgeons in time of surgery. A patient with a growing craniofacial skeleton is a the situations I just described may have limited experience poor candidate for surgery of the facial skeleton, because the bone is in rhinoplasty. often soft and the precise movements that need to be made could be My journey to doing this surgery was necessarily protracted. compromised by operating too early. There is no particular age limit After being well trained by great mentors in the United States, Paris, for this type of surgery. I have performed this surgery even on and Zurich, there was still a large leap I needed to take to perform elderly patients, with the eldest being 72 years of age. The patient these operations. It became apparent that the approach of ‘‘see one, should be medically fit and able to tolerate a lengthy operation. do one, teach one’’ was not sufficient for these operations. They were not even ‘‘see ten, do ten, teach ten’’ operations. I worked with THE HAIRLINE Douglas Ousterhout for a number of years before the operations felt Altering the hairline is of significant importance in feminizing the intuitive and my ability to visualize an end result prior to starting the face. Female hairlines fall between 5.5 and 5.8 cm above the brows operation came naturally. The other relevant issue is operative time. in females and significantly higher in males.4 The type of hairline Even if a patient may be able to tolerate a 14- to 16-hour surgery, one sees while consulting with male-to-female patients is changing, this operative time is not ideal. The more comfortable and efficient however, since patients start hormone treatment at a younger age. one is with the operations, the more likely