ORIGINAL ARTICLE

The Upper Third in Facial Gender Confirmation Surgery:Forehead and Hairline

Luis Capitan, MD, PhD, Daniel Simon, DMD, Carlos Bailon, MD,Raul J. Bellinga, MD, FEBOMS, Javier Gutierrez-Santamarıa, MD, FEBOMS,

Thiago Tenorio, MD, and Fermın Capitan-Canadas, PhD

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproducti

From the FACIALTEAM Surgical Group, HC Marbella InternationalHospital, Marbella, Malaga, Spain.

Received March 29, 2019.Accepted for publication April 18, 2019.Address correspondence and reprint requests to Luis Capitan, MD, PhD,

FACIALTEAM Surgical Group, HC Marbella International Hospital,Ventura del Mar 11, 29660 Marbella, Malaga, Spain;E-mail: capitan@facialteam.eu

The authors report no conflicts of interest.Supplemental digital contents are available for this article. Direct URL

citations appear in the printed text and are provided in the HTML andPDF versions of this article on the journal’s Web site (www.jcraniofa-cialsurgery.com).

Copyright # 2019 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/SCS.0000000000005640

The Journal of Craniofacial Surgery � Volume 30, Number 5, July 2019

Abstract: The upper third of the face contains 2 features that areparticularly important for facial gender recognition: the frontona-soorbital region and the hairline. The supraorbital ridge, whichdetermines the position and exposure of the eyebrows, is almostinvariably more developed in the male than in the female. Surgicalmodification of the frontonasoorbital complex, considered a stan-dard procedure in facial feminization, is reliable and predictable,and also delivers satisfactory results that are stable over time.

A prototypical male hairline has an M-shaped pattern comparedto the more rounded shape often seen in female hairlines. Femini-zation of the hairline requires minimizing the temples as well asrounding out the overall shape, optimizing hair density, and occa-sionally changing the height of the hairline.

This article provides an update on our forehead reconstructiontechnique and our experience in the treatment of hairline redefini-tion.

Key Words: Facial feminization surgery, facial gender

confirmation surgery, forehead reconstruction, hairline, hairline

lowering surgery, simultaneous hair transplant

(J Craniofac Surg 2019;30: 1393–1398)

orehead recontouring or reconstruction is the surgical procedure

Fmost described in the scientific literature for Facial GenderConfirmation Surgery (FGCS).1–15 Over the past few decades, newdiagnostic tools have been introduced, such as computed tomogra-phy (CT) scan with 3D reconstruction, and numerous modificationshave been made to improve the technique: recontouring the areasadjacent to the supraorbital ridge (forehead surface, frontomalarbuttresses, orbital ridges, and frontonasal transition), the useof osteosynthesis materials (titanium screws, microplates, andmeshes), the use of anchor systems for the scalp, and the

introduction of new materials for use in cranioplasty (i.e., hydroxy-apatite, polyetheretherketone, etc).

However, and despite the importance of the hairline in therecognition of facial gender,16 few authors have studied the treat-ment of the frontonasoorbital complex and the hairline together. In2009, Shams and Motamedi described a surgical hairline loweringprocedure in a trans female patient for the first time.4 Since then,only 1 scientific publication has proposed an alternative hairlinetreatment technique: forehead reconstruction and simultaneous hairtransplant (SHT).17

This article provides an update on our forehead reconstructiontechnique.9 It also gives a bibliographic review of the evolution ofsurgical techniques to feminize the forehead and treat the hairline(See supplemental digital content, Table 1-SDC, http://links.lww.-com/SCS/A543), and compares surgical hairline lowering to ahair transplant.

METHODS

Study DesignBetween August 2008 and September 2018 (122 months), we

treated a total of 1049 trans female patients for forehead recon-struction, with the average patient age being 39.4 (range 18–73). Ofthese patients, 129 (12.30%) were only operated on for foreheadreconstruction. The remaining 920 patients (87.70%) also under-went 1 or several of the following surgical feminization procedures:SHT and/or deferred hair transplant (DHT), hairline loweringsurgery (HLS), rhinoplasty, malarplasty, lip lift, lower jaw contour-ing, or Adam’s apple contouring.

With specific regard to hairline treatment, 287 patients of thetotal number (27.36%) underwent SHT, 77 patients (7.34%) HLS,and 22 patients (2.09%) DHT.

Hair transplants were performed using the follicular unit (FU)strip surgery technique in either simultaneous or deferred trans-plants.18 All of the patients who received a hair transplant hadclinical alopecic stabilization resulting from the hormone treatmentassociated with their gender transition beginning at least 1 yearbefore their operation.19 As previously described,17 a modifiedcoronal approach at the temporoparietal level (anterior) was thetechnique of choice for patients with Hamilton-Norwood type I, II,and III, good hair density (>60 FU/cm2), and a clinical and der-matoscopic absence of miniaturization. A modified coronalapproach at the temporoparietooccipital level (posterior) was thetechnique of choice for patients with Hamilton-Norwood type IIIand IV, temporoparietal hair density below 50 FU/cm2, and theclinical or dermatoscopic presence of miniaturization in thetemporoparietal region.

From August 2008 to October 2014, all patients underwentpreoperative and postoperative teleradiography and a cephalometricstudy. Since November 2014, all patients have undergone a preop-erative and postoperative CT scan with 3D reconstruction (SOMA-TOM Emotion CT, Siemens, Munich, Germany). Pre-, intra- and

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FIGURE 1. Forehead reconstruction approaches. (Left) Modified coronalapproach at the temporoparietal level (anterior). (Right) Modified coronalapproach at the temporoparietooccipital level (posterior).

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postoperative imaging was obtained for each patient, always usingthe same camera (Canon EOS 550D EF-S, Canon, Tokyo, Japan)and following the same protocol and parameters. In September2016, 3D photography (VECTRA H1 3D Imaging System, CanfieldScientific, NJ) was incorporated. 3D photographs were taken duringboth the pre- and post-operative period.

In all cases, general anesthesia was used, and surgeries that alsoincluded jaw procedures used nasotracheal intubation at that time.

The results and images that appear in this article belong topatients who have given their express consent for their image to bepublished in scientific publications in compliance with currentpersonal data protection regulations.

ANATOMICAL AND CLINICALCONSIDERATIONS

When approaching the upper facial third in trans female patients,both the anatomy of the frontonasoorbital region and the overallcondition of the hairline—format, height and hair density— shouldbe considered as a unit.17

The frontonasoorbital region encompasses the forehead surface,the frontal bossing (the most prominent region of the frontal area)and the supraorbital ridge, the frontomalar buttresses, the temporalridges, and the frontonasal transition. The supraorbital ridge, whichdetermines the position of the eyebrows, is almost invariably moredeveloped in the male than in the female.20 Typically, all of theareas are more pronounced and have greater bone volume in themale than in the female skeleton.

Regardless of gender, the hairline has a series of intrinsiccharacteristics:

� T

Cop

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he first 2 or 3 rows of hair that comprise the hairline aremade up of FUs with only 1 hair, followed by FUs with 2hairs. This makes the hairline unique with respect to the restof the hair.21

� T

he hairline itself is naturally irregular, with randomlydistributed hairs.22

� T

here is vast variability in the format of the hairline,23 whichis, moreover, usually conditioned by hormone phenomenarelated to gender.24 In the absence of these phenomena, thehairline is usually stable over time. However, changes in hairmorphology, density, and the like can appear over the years asa natural consequence of the physiological phenomenaof aging.

In terms of gender, the male hairline tends to have an M-shapedpattern with recessions at the temples.25 The hairline of womenusually has a rounded shape,26 their hair is not normally affected byalopecia and, proportionally, the hairline implantation is higher inthe center than with men.17

FOREHEAD RECONSTRUCTIONAND HAIRLINE REDEFINITION

Forehead Reconstruction Surgical TechniqueForehead reconstruction is one of the key procedures in facial

feminization. It completely modifies the frontonasoorbital anatomyand helps to soften and feminize the patient’s expression. Thesurgical plan is devised to open the frontonasal angle; achieve anadequate backward position of the entire forehead, including theanterior wall of the frontal sinus, while maintaining a harmonicrounded shape; recontour the superior part of the orbit; and obtain aproper position of the eyebrows in relation to the new supraorbitalridge.

This article describes new developments with regard to thetechnique published by our group in 2014.9 At this time, a modified

yright © 2019 Mutaz B. Habal, MD. Unautho

coronal approach (anterior or posterior) is used in approximately93% of our patients (Fig. 1), regardless of whether or not theyreceive an SHT. The design of the pericranial flap and its carefuldetachment, preventing tears or perforations, is fundamental toguarantee the correct isolation of the entire surgical site, especiallyin the reconstructed sinus area. It is essential to identify and exposethe key anatomical areas, which will serve as a reference point whenthe time comes to plan the bone remodeling and subsequentreconstruction. The working field is exposed, taking into accountthe identification and preservation of the supraorbital arteries,veins, and nerves.

In cases where there is some projection of the upper foreheadregion, an upper forehead setback procedure can be done before theosteotomy of the anterior wall of the frontal sinus. The aim is tomake this area as leveled as possible with the insertion of the nasalbones into the forehead. After the bone shaving, the retropositioningneeded across the entire frontoorbital ridge will become quiteevident (Fig. 2).

The sequence continues designing the osteotomy of the anteriorwall of the frontal sinus. This must take into consideration theanterior wall’s maximum projection, its thickness, the sinus length(cranial-caudal and lateral), the location and characteristics of theposterior wall of the sinus, the frontonasal angle, the location of theorbits with respect to the sinus, the intrasinus clinical situation, andthe possible absence of a sinus. Most of these anatomical andfunctional considerations must be analyzed before surgery using aCT study (Fig. 3).

After the osteotomy, the next step is recontouring and setback ofthe frontoorbital region, using the following reference points for thebone shaving: the 2 frontomalar buttresses, the insertion of the nasalbones into the forehead, the orbital ridges, both temporal ridges, andthe upper forehead region (with or without prior setback). Withforeheads that are especially square-shaped or have marked tem-poral ridges, correct exposure and shaving is essential in these areas.If a rhinoplasty is included in the treatment plan and when the noseinsertion to the forehead is too high or projected, a conical burr isused to lower the frontonasal transition to the optimal and desiredposition, which will mark the level of the osteotomy or rasping ofthe new bony nasal dorsum during the subsequent rhinoplasty.27

After completing the bone recontouring, work begins on repo-sitioning the anterior wall of the sinus and fixing it using osteo-synthesis material. This may vary substantially from 1 case toanother according to the sinus characteristics (Fig. 4 and Fig. 5).During this surgical step, properly sealing the sinus is of particular

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# 2019 Mutaz B. Habal, MD

FIGURE 4. Before and after surgical photos of a forehead reconstruction. Upperviews. (Above) Reconstruction with micro screws and plates. (Below)Reconstruction with micro screws and titanium mesh.

FIGURE 2. Upper forehead setback. (Above) Pre-setback. (Center) Transitiondetail between the area with and without setback, delineated by a black line.Note that the upper setback should not be carried out over the frontal sinus.(Below) Post-setback.

The Journal of Craniofacial Surgery � Volume 30, Number 5, July 2019 Facial Gender Confirmation Surgery

concern, especially in the lower region or closer to the nasoorbitalridge, as is using the correct material to reinforce all the areas withobvious bone gaps, which have become excessively weakened aftershaving or perforated.

The final surgical steps include suturing the pericranial flap,placing the anchor devices (Endotine Forehead-mini device, CoaptSystems Inc., Palo Alto, CA) to reposition the eyebrows in caseswhere this is required, and closing the surgical approach.

The sequence in Figure 6 gives a step-by-step description of theforehead reconstruction technique proposed by our team.

Copyright © 2019 Mutaz B. Habal, MD. Unautho

FIGURE 3. Diagnostic tool for preoperative planning: CT study with 3Dreconstruction. Note the cranial-caudal and lateral length of the frontal sinus.

# 2019 Mutaz B. Habal, MD

Simultaneous Hair Transplant TechniqueThis technique consists of taking advantage of the strip of scalp

obtained during the modified coronal approach (anterior or poste-rior) used to access the frontal region, harvesting the hair folliclesfrom the strip, and grafting them after the forehead reconstruction isdone.17

Since it was published in 2017, the technique has undergonevery few changes. Choosing the correct donor site based on hairdensity and absence of the phenomena of androgenetic alopecia andfollicular miniaturization continues to be especially important.Additionally, attention must be paid to the transplant design inthe hairline region in terms of the areas to cover and the drawing ofthe new hairline. This design must be marked before the foreheadsurgery so that it is not distorted by surgical manipulation.

RESULTSThe average follow-up time with the patients included in thispublication was 58 months, with the interval ranging from 6 to122 months.

Forehead ReconstructionAll the drainage devices could be removed between 24 and

48 hours after surgery.The vast majority of the patients reported slight to moderate

paresthesia in the forehead and scalp region, with spontaneousresolution beginning 3 months after surgery. A total of 43 patients(4.10%) required surgical drainage of a coronal hematoma in thefirst 24 hours after surgery. One patient had a cerebrospinal fluid

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FIGURE 5. Before and after surgical photos of a forehead reconstruction. Lateralviews. (Above) Reconstruction with micro screws and plates. (Below)Reconstruction with micro screws and titanium mesh.

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FIGURE 6. Step-by-step sequence of forehead reconstruction. (A) Modifiedcoronal approach, with elimination of the strip of scalp. (B) Pericranial flapuntil the supraorbital ridge and both frontomalar buttresses are reached. (C)Upper forehead setback. (D) Osteotomy of the anterior wall of the frontal sinus.The anterior wall is preserved in saline solution during skull recontouring. (E)Sculpture of the entire frontonasoorbital complex. (F) Readaptation of the frontalsinus ridges for subsequent attachment of the osteotomized anterior wall.(G) Stable fixation of the anterior wall of the frontal sinus. (H) Orbital opening.(I) Pericranial flap suture and placement of resorbable anchors (EndotineForehead-mini device, Coapt Systems Inc., Palo Alto, CA) to correctly repositionthe eyebrows over the new bone structure. (J) Surgical approach closure.

FIGURE 7. Clinical case before and after facial gender confirmation surgery.Procedures done: forehead reconstruction and simultaneous hair transplant;rhinoplasty; lower jaw contouring; Adam’s apple contouring.

FIGURE 8. Clinical case before and after facial gender confirmation surgery.Procedures done: forehead reconstruction and simultaneous hair transplant;rhinoplasty.

Capitan et al The Journal of Craniofacial Surgery � Volume 30, Number 5, July 2019

fistula that resolved spontaneously after applying posture measures.One patient developed sinus problems 2 months after surgery thatdid not respond to conservative measures, antibiotherapy, or endo-scopic treatment, requiring open surgery to clean the sinus andrepermeabilize the frontonasal duct. One patient required a secondoperation to repair reabsorption in the orbitofrontal region that left aclinically visible defect.

Simultaneous Hair TransplantOf the 287 patients who underwent forehead reconstruction

and SHT procedures, an anterior coronal approach was used with

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FIGURE 9. Clinical case before and after facial gender confirmation surgery.Procedures done: forehead reconstruction and simultaneous hair transplant;lower jaw contouring; Adam’s apple contouring.

The Journal of Craniofacial Surgery � Volume 30, Number 5, July 2019 Facial Gender Confirmation Surgery

174 (60.63%), and a posterior coronal approach was used with 113(39.37%).

The average number of FUs per strip was 1508� 300, or some3468 hairs. Clinical evaluation 12 months after surgery showedadequate density in the transplanted site (45 to 50 FU/cm2 onaverage) and in the donor site (70 to 80 FU/cm2 on average).

The most commonly seen complications were the presence ofexcessive scabbing in the recipient site (due to poorly hydratedgrafts or because the patient had a condition like seborrheicdermatitis), light bleeding, or folliculitis. 5 patients developed skinnecrosis in a small part of the recipient site, resulting in poortransplant growth in the affected area.

Figures 7–9 show different preoperative and postoperativeresults.

DISCUSSIONThe forehead reconstruction technique has been widely described inthe scientific literature and it is the FGCS surgical procedure withthe highest number of publications to date. In 2016, Morrison et aldid a comprehensive literature search of the Medline, PubMed, andEMBASE databases for studies published through October 2014with multiple search terms related to facial feminization.28 Specifi-cally, regarding forehead reconstruction, they reviewed the devel-opment of the technique from the publication by Ousterhout in 1987to the article published by our surgical group in 2014.1,9

Since 2014, several authors have published articles about theirexperience with forehead reconstruction, presenting modificationsto the technique. Bachelet et al use a piezoelectric scalpel for theosteotomy of the anterior wall of the frontal sinus.10 We believe thatthe vast majority of osteotomy cases can be safely and predictablydone using a standard reciprocating saw. The use of piezosurgery ishighly indicated for osteotomies on solid sinuses to preventunwanted fractures or perforations in the posterior sinus wall.Likewise, its use might be of interest when freeing the supraorbitalnerve in the event that its emergence is very high or when it has a

Copyright © 2019 Mutaz B. Habal, MD. Unautho

# 2019 Mutaz B. Habal, MD

thick bony septum. Raffaini et al include a brow lift and lateralcanthal upper repositioning.12 With particular regard to reposition-ing the eyebrows, we agree with the author that a coronal approachprovides greater predictability and correct handling of the symme-try. This allows for precise, simultaneous control in the placementof both eyebrows and also respects their natural arch. Controllingthe eyebrows through a hairline approach can be less predictableand more subject to possible asymmetries since the positioning ofeach eyebrow is done separately. Moreover, as sutures are required,the result may be some loss of the eyebrow arch and/or unnatural,unharmonious formats.

Altman carries out the 3 techniques proposed by Ousterhout; thedifference lies in the use of bone cement instead of methylmetha-crylate onlay implants for the augmentation cranioplasty (Group IIpatients).13 However, alloplastic reconstruction in any area of thebody can produce complications, including infection, fractures, orthe formation of a seroma.28 Salgado et al do an endoscopic browreduction in patients with an anterior table thickness greater than5 mm when HLS is not needed.14 In our point of view, an endo-scopic approach is significantly limited with regard to being able toexpose and work on the entire forehead complex, especially in someof the key anatomical areas cited, which can generate suboptimalresults. Additionally, in the event of perforation or excessiveweakening of the anterior wall of the sinus, this approach leavesno option to seal the sinus or reconstruct it using osteosynthesismaterial. Villepelet et al, the last group to date to describe theirsurgical technique, propose performing the forehead remodelingwith simple burring or with an eggshell technique, where theanterior wall is weakened by burring and then caved, preservingthe integrity of the mucosa.15 They also perform a lateral cantho-pexy. In our opinion, with techniques that involve the sinus, one ofthe objectives should be to respect its functionality, guaranteeingcorrect sealing in the region whenever possible. In more complexcases where the anterior wall of the sinus cannot be completelysealed after bone recontouring, we advocate the use of reconstruc-tion material to guarantee the anatomical preservation of the sinusregion. In secondary cases where the anterior wall is completelymissing due to reabsorption, the use of autologous bone grafts isof interest.

Focusing on the hairline, in 2009, Shams and Motamedi arguedthat it could be lowered to give a more feminine appearance,describing the first HLS in a trans female patient.4 In his 2011work, Spiegel concludes that the shape of the hairline plays asignificant role in determining gender: ‘‘A receding or thinninghairline is distinctly masculine and may serve to skew observers tojudging the area as masculine even in the face of feminine eye-brows and glabellar bone shape.’’6 His technique consists ofadvancing (when necessary) and feminizing the hairline withreduction of the temporal recession typical of the male pattern.Cho and Jin reach the frontonasoorbital region through a coronalapproach with a trichophytic incision 4 to 5 mm posterior to thehairline, following the natural undulations and slightly beveled(458), so that the hair would grow through the distal flap.8 Table 1(SDC, http://links.lww.com/SCS/A543) describes the evolution ofthe forehead reconstruction technique and hairline treatment inthe bibliography.

In 2017, we published a forehead reconstruction and SHTtechnique as the only alternative to HLS at that time.17 In ourexperience, HLS, which has been proposed by several authors, has aseries of disadvantages compared to hair transplantation. As noted,there is a significant difference between the general format of themale (M-shaped) and female (rounded) hairlines. Using differenttechniques, surgical lowering can try to eliminate alopecic areaslike recessions, but the consequence—something frequentlyobserved by our group in redoing patients—is the presence of

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Capitan et al The Journal of Craniofacial Surgery � Volume 30, Number 5, July 2019

visible scar tissue and the complete loss of the naturalness ofthe hairline.

Based on the classification of hairline types in trans womendescribed in 2017,17 we believe that HLS is contraindicated forpatients with normal height and rounded format hairlines (Type I,22%). In hairlines with normal height and receding side temples(Type II, 43%), HLS usually achieves greater lowering in thecentral portion, since the side areas, which have a different degreeof recession, do not descend to the same level. As a result, there issome risk that the forehead will be excessively short in the middleregion after surgical lowering. For patients with rounded andnaturally high hairlines (Type III, 4%), HLS may be indicated.HLS and SHT can be considered for high hairlines with recedingside temples (Type IV, 21%), which can be complemented with aDHT in a second session. Finally, for hairlines that are undefineddue to advanced alopecia (Type V, 10%), we prefer SHT followedby a DHT or to leave it untreated.

One of the main risks associated with HLS is the possibility thatit will leave a visible scar in a highly exposed location.29 At times, ifthe surgical wound was closed with tension, the scar can beconsiderably wide.30

In conclusion, we believe that the forehead region and hairlineare key elements in the feminization of the upper facial third.Frontonasoorbital recontouring with frontal sinus osteotomy andsetback offers satisfactory and safe results regardless of the anat-omy of the frontal region, even in patients with complete agenesisof the frontal sinus.31 Furthermore, SHT is a safe and effectivealternative for treating the hairline.

ACKNOWLEDGMENTS

The authors thank their team, families, and patients.

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