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A Novel Application of Virtual Surgical Planning to Facial Feminization Surgery

Mandelbaum, Max BS*; Lakhiani, Chrisovalantis MD; Chao, Jerry W. MD*

doi: 10.1097/SCS.0000000000005090
Original Articles

Feminization of the frontonasal-orbital complex is a critical aspect in surgical management of gender dysphoria. Here, we describe our utilization of a prefabricated cutting guide to facilitate frontal sinus setback.

*The George Washington University School of Medicine and Health

Georgetown University School of Medicine, Washington, DC.

Address correspondence and reprint requests to Jerry W. Chao, MD, Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, The George Washington University School of Medicine and Health Sciences, The George Washington University Medical Faculty Associates, 2300 M St NW, Washington, DC 20037; E-mail:

Received 9 May, 2018

Accepted 3 September, 2018

The authors report no conflicts of interest.

With the introduction of the Patient Protection and Affordable Care Act, healthcare for sex dysphoric individuals has expanded. With sex dysphoria no longer classified as a preexistent condition, there has been an increase in the demand for sex-affirming surgery. Facial feminization surgery (FFS) provides significant improvements in transgender women's physical, mental, and psychosocial quality of life that may approach that of the general female population.1

FFS is not in the standard curriculum of many plastic surgery training programs, resulting in a significant learning gap among plastic surgeons, and potential failures to provide the new standard of care to this community. A critical determiner of facial masculinity/femininity is the frontonasal-orbital complex, as illustrated by Douglas Ousterhout.2 The male forehead has increased supraorbital bossing, heavier lower-set brows, deeper orbits, an M-shaped hairline, and a flattened surface when compared to the average female forehead.3,4 Feminization of supraorbital bossing in individuals with a thin anterior table of the frontal sinus requires complete osteotomy, re-contouring, and bony setback to achieve an optimal result.3,4

Virtual surgical planning (VSP) has been demonstrated in craniofacial applications to reduce operating room times and improve reconstructive outcomes.5 Generation of prefabricated cutting guides allows for rapid design and precise execution of osteotomies. In an effort to curtail the learning curve in FFS of the frontonasal-orbital and forehead regions, we have utilized VSP for preoperative planning and production of an intraoperative cutting guide. We universally perform pre-operative computed tomography (CT) scanning before facial feminization to delineate skeletal and sinus anatomy.

During a brief planning session, (3D systems, Littleton, CO) reformatted images from the CT scan are used to generate a 3D skeletal model. On the coronal view, the frontal sinus borders can be visualized and outlined. We typically will ask the VSP engineer to inset the borders of the cutting guide 2 mm from the sinus border, which takes into account the width of a marking pen or drill tip. The engineer is then instructed to add short extensions into the superior-medial orbits (Fig. 1), which facilitates rapid positioning of the cutting guide during surgery. At the time of this session, we do not plan the actual degree movement or “setback” of the bone—in our opinion, this is more readily done intraoperatively, as soft-tissue response to bony reduction must be taken into account for the final aesthetic result. Rather, the value of VSP in this case is ensuring a precise and accurate osteotomy.



Intraoperatively, exposure is obtained via a standard coronal approach, with release of the supraorbital neurovascular bundles and limited subperiosteal dissection into the superior orbit. At this point, the cutting guide is positioned—the orbital extensions of the guide allow for a “hand in glove” fit. Frontal sinus osteotomy is then performed by making perforating drill holes around the cutting guide borders using a drill with a 5 mm stop, and the osteotomy is completed using an osteotome. Using this technique, the underlying sinus mucosa typically has minimal trauma or disruption (Fig. 1). The remaining supraorbital bar is contoured using a bur to feminized proportions. Ex vivo, the anterior table is also contoured and reshaped (to a softer/flatter curvature), then rigidly fixated to the resulting bony defect. We typically perform concurrent scalp advancement and/or brow lift according to the patient's needs.

In our opinion, precise osteotomy at the borders of the frontal sinus facilitates contouring of the remainder of the forehead, reduces intracranial injury risk, allows maximal bone preservation, and permits rapid repositioning and fixation of the anterior table. This osteotomy may be readily aided by the use of a prefabricated cutting guide. Alternatives include preoperative measurements from an x-ray or CT scan, or use of intraoperative stealth navigation (requiring specialized equipment). The obvious disadvantage to our described technique is the inherent additional cost. Nevertheless, the benefits of faster operative time, technical ease, and reliability to a novice facial feminizing surgeon may obviate this cost.

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1. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res 2010; 19:1019–1024.
2. Capitán L, Simon D, Meyer T, et al. Facial feminization surgery: simultaneous hair transplant during forehead reconstruction. Plast Reconstr Surg 2017; 139:573–584.
3. Ousterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 1987; 79:701–713.
4. Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: systematic review of the literature. Plast Reconstr Surg 2016; 137:1759–1770.
5. Khechoyan DY, Saber NR, Burge J, et al. Surgical outcomes in craniosynostosis reconstruction: the use of prefabricated templates in cranial vault remodeling. J Plast Reconstr Surg 2014; 67:9–16.

Cutting guide; facial feminization; frontal sinus setback; gender dysphoria; virtual surgical planning; VSP

© 2019 by Mutaz B. Habal, MD.