ORIGINAL ARTICLE The Upper Third in Facial Gender Confirmation Surgery: Forehead and Hairline Luis Capita´n, MD, PhD, Daniel Simon, DMD, Carlos Bailo´n, MD, Rau´l J. Bellinga, MD, FEBOMS, Javier Gutie´rrez-Santamarı´a, MD, FEBOMS, Thiago Teno´rio, MD, and Fermı´n Capita´n-Can˜adas, PhD introduction of new materials for use in cranioplasty (i.e., hydroxy- Abstract: The upper third of the face contains 2 features that are apatite, polyetheretherketone, etc). particularly important for facial gender recognition: the frontona- However, and despite the importance of the hairline in the soorbital region and the hairline. The supraorbital ridge, which recognition of facial gender,16 few authors have studied the treat- determines the position and exposure of the eyebrows, is almost ment of the frontonasoorbital complex and the hairline together. In invariably more developed in the male than in the female. Surgical 2009, Shams and Motamedi described a surgical hairline lowering 4 modification of the frontonasoorbital complex, considered a stan- procedure in a trans female patient for the first time. Since then, dard procedure in facial feminization, is reliable and predictable, only 1 scientific publication has proposed an alternative hairline treatment technique: forehead reconstruction and simultaneous hair and also delivers satisfactory results that are stable over time. transplant (SHT).17 A prototypical male hairline has an M-shaped pattern compared This article provides an update on our forehead reconstruction to the more rounded shape often seen in female hairlines. Femini- technique.9 It also gives a bibliographic review of the evolution of zation of the hairline requires minimizing the temples as well as surgical techniques to feminize the forehead and treat the hairline rounding out the overall shape, optimizing hair density, and occa- (See supplemental digital content, Table 1-SDC, http://links.lww.- sionally changing the height of the hairline. com/SCS/A543), and compares surgical hairline lowering to a This article provides an update on our forehead reconstruction hair transplant. technique and our experience in the treatment of hairline redefini- tion. METHODS Key Words: Facial feminization surgery, facial gender Study Design Between August 2008 and September 2018 (122 months), we confirmation surgery, forehead reconstruction, hairline, hairline treated a total of 1049 trans female patients for forehead recon- lowering surgery, simultaneous hair transplant struction, with the average patient age being 39.4 (range 18–73). Of (J Craniofac Surg 2019;30: 1393–1398) these patients, 129 (12.30%) were only operated on for forehead reconstruction. The remaining 920 patients (87.70%) also under- orehead recontouring or reconstruction is the surgical procedure went 1 or several of the following surgical feminization procedures: F most described in the scientific literature for Facial Gender SHT and/or deferred hair transplant (DHT), hairline lowering Confirmation Surgery (FGCS).1–15 Over the past few decades, new surgery (HLS), rhinoplasty, malarplasty, lip lift, lower jaw contour- diagnostic tools have been introduced, such as computed tomogra- ing, or Adam’s apple contouring. phy (CT) scan with 3D reconstruction, and numerous modifications With specific regard to hairline treatment, 287 patients of the have been made to improve the technique: recontouring the areas total number (27.36%) underwent SHT, 77 patients (7.34%) HLS, adjacent to the supraorbital ridge (forehead surface, frontomalar and 22 patients (2.09%) DHT. buttresses, orbital ridges, and frontonasal transition), the use Hair transplants were performed using the follicular unit (FU) strip surgery technique in either simultaneous or deferred trans- of osteosynthesis materials (titanium screws, microplates, and 18 meshes), the use of anchor systems for the scalp, and the plants. All of the patients who received a hair transplant had clinical alopecic stabilization resulting from the hormone treatment associated with their gender transition beginning at least 1 year before their operation.19 As previously described,17 a modified From the FACIALTEAM Surgical Group, HC Marbella International coronal approach at the temporoparietal level (anterior) was the Hospital, Marbella, Ma´laga, Spain. technique of choice for patients with Hamilton-Norwood type I, II, Received March 29, 2019. 2 Accepted for publication April 18, 2019. and III, good hair density (>60 FU/cm ), and a clinical and der- Address correspondence and reprint requests to Luis Capita´n, MD, PhD, matoscopic absence of miniaturization. A modified coronal FACIALTEAM Surgical Group, HC Marbella International Hospital, approach at the temporoparietooccipital level (posterior) was the Ventura del Mar 11, 29660 Marbella, Ma´laga, Spain; technique of choice for patients with Hamilton-Norwood type III E-mail: [email protected] and IV, temporoparietal hair density below 50 FU/cm2, and the The authors report no conflicts of interest. clinical or dermatoscopic presence of miniaturization in the Supplemental digital contents are available for this article. Direct URL temporoparietal region. citations appear in the printed text and are provided in the HTML and From August 2008 to October 2014, all patients underwent PDF versions of this article on the journal’s Web site (www.jcraniofa- preoperative and postoperative teleradiography and a cephalometric cialsurgery.com). Copyright # 2019 by Mutaz B. Habal, MD study. Since November 2014, all patients have undergone a preop- ISSN: 1049-2275 erative and postoperative CT scan with 3D reconstruction (SOMA- DOI: 10.1097/SCS.0000000000005640 TOM Emotion CT, Siemens, Munich, Germany). Pre-, intra- and The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 1393 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Capita´netal The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 postoperative imaging was obtained for each patient, always using the same camera (Canon EOS 550D EF-S, Canon, Tokyo, Japan) and following the same protocol and parameters. In September 2016, 3D photography (VECTRA H1 3D Imaging System, Canfield Scientific, NJ) was incorporated. 3D photographs were taken during both the pre- and post-operative period. In all cases, general anesthesia was used, and surgeries that also included jaw procedures used nasotracheal intubation at that time. The results and images that appear in this article belong to patients who have given their express consent for their image to be published in scientific publications in compliance with current personal data protection regulations. ANATOMICAL AND CLINICAL CONSIDERATIONS When approaching the upper facial third in trans female patients, both the anatomy of the frontonasoorbital region and the overall FIGURE 1. Forehead reconstruction approaches. (Left) Modified coronal condition of the hairline—format, height and hair density— should approach at the temporoparietal level (anterior). (Right) Modified coronal be considered as a unit.17 approach at the temporoparietooccipital level (posterior). The frontonasoorbital region encompasses the forehead surface, the frontal bossing (the most prominent region of the frontal area) coronal approach (anterior or posterior) is used in approximately and the supraorbital ridge, the frontomalar buttresses, the temporal 93% of our patients (Fig. 1), regardless of whether or not they ridges, and the frontonasal transition. The supraorbital ridge, which receive an SHT. The design of the pericranial flap and its careful determines the position of the eyebrows, is almost invariably more 20 detachment, preventing tears or perforations, is fundamental to developed in the male than in the female. Typically, all of the guarantee the correct isolation of the entire surgical site, especially areas are more pronounced and have greater bone volume in the in the reconstructed sinus area. It is essential to identify and expose male than in the female skeleton. the key anatomical areas, which will serve as a reference point when Regardless of gender, the hairline has a series of intrinsic the time comes to plan the bone remodeling and subsequent characteristics: reconstruction. The working field is exposed, taking into account The first 2 or 3 rows of hair that comprise the hairline are the identification and preservation of the supraorbital arteries, made up of FUs with only 1 hair, followed by FUs with 2 veins, and nerves. hairs. This makes the hairline unique with respect to the rest In cases where there is some projection of the upper forehead of the hair.21 region, an upper forehead setback procedure can be done before the The hairline itself is naturally irregular, with randomly osteotomy of the anterior wall of the frontal sinus. The aim is to distributed hairs.22 make this area as leveled as possible with the insertion of the nasal There is vast variability in the format of the hairline,23 which bones into the forehead. After the bone shaving, the retropositioning is, moreover, usually conditioned by hormone phenomena needed across the entire frontoorbital ridge will become quite related to gender.24 In the absence of these phenomena, the evident (Fig. 2). hairline is usually stable over time. However, changes in hair The sequence continues designing the osteotomy of the anterior morphology, density, and the like can appear over the years as wall of the frontal sinus. This must take into consideration the a natural consequence