Facial Gender-Affirming Surgery: Frontal Bossing Surgical Techniques, Outcomes and Safety

Background Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250-261, 2011). This article describes the author's three main surgical techniques used in forehead feminization and reports on the results. Methods The type of surgery performed is based on the patient's anatomy. Type one FGAS consists of buffing the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes buffing and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing. Results We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout's methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome. Conclusions FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate.