Journal Logo


Facial Feminization Surgery

The Forehead. Surgical Techniques and Analysis of Results

Ousterhout, Douglas K. M.D., D.D.S.

Author Information
Plastic and Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 560e-561e
doi: 10.1097/PRS.0000000000001425
  • Free


The article “Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results” by Capitán et al. was published in the Cosmetic section as a review of the authors’ experience in 172 forehead feminizing operations. (They do not say whether these are consecutive cases or selected from their experience.) There are a number of errors in this article, only a few of which I am addressing. They imply that all of these cases are type III (see the fifth paragraph in their discussion), meaning that all of their patients had a frontal sinus. It is well known that only 95 percent of people have a frontal sinus. Obviously, this method would not work in those 5 percent without a sinus. It is unlikely that they did not have at least one patient without a frontal sinus. If in fact they did not, they did need to be prepared for the event. Furthermore, they criticize (1) bony contouring alone, type I in my classification,1 as one can wrongly enter the frontal sinus when in fact this is the method indicated when there is not one, 9.3 percent of my forehead feminizations; and (2) type II, again in my classification,1 the use of prosthetic material. The issue with type II is that the projection of the orbital rim is desired but the forehead contour is masculine, and the depression superior to the orbital rims needs to be filled. These occur in 7.5 percent of my forehead feminizations. The authors attempt to support their argument with the last article they reference, an article by me, which was not for feminization, at the time that the article was published, but for forehead augmentation, saying that prosthetic materials are contraindicated. In later years, in a few cases, I did use this method for a particular issue in forehead feminization, 1 percent of my forehead feminizations, type IV in my classification.1 The point is that they criticize any other approach than the method they use for forehead feminization using inappropriate arguments.

Based on the articles they have referenced, they perhaps can state that their approach is based on their knowledge. But that is not true either. First of all, they were fully aware of my text, Facial Feminization Surgery: A Guide for the Transgender Woman, published in 2009 and available through, because they told me personally how much they used the book; and second, they have been to several of my lectures at the Southern Comfort Conference in Atlanta. We have had coffee together. They know fully well of the 36 articles that I have published relating to facial feminization, several of which are specifically related to the forehead. They are listed in my book. They know that I have completed well over 1300, partial or complete, facial feminizations. I have feminized somewhere around 1100 foreheads; 913 are listed in my book published in 2009.

There are many other issues in this article with which I disagree. They have had complications I have not seen. The method of bony fixation is not satisfactory in my mind. Also, their method of evaluating their success is seriously flawed.

Therefore, I have major issue with this article having been published. First of all, as a contribution to the literature, they have not only made glaring mistakes in the forehead feminization procedures but failed to recognize an appropriate and published classification system. Second, they have failed to give an adequate review of the literature, basically implying that nothing much else has been published, other than what they have referenced. In fact, there are many articles that are not referenced. In addition, there is my book reviewing the entire subject, with a discussion on my classification system, a system that seems to be generally accepted. Therefore, this article does not contribute to our knowledge of the subject, it is not innovative, and it is not academic.

I have one more issue. When this article was received by the Editorial Board of this Journal, it seems that they obviously passed it on for review to someone that was totally unaware of what has been previously published and with little knowledge about the subject. This information not only has been published before but has also been presented several times by me at national meetings, the last being at the 86th Annual Meeting of the American Association of Plastic Surgeons annual meeting in Coeur d’Alene, Idaho, in May of 2007. I am not an unknown in the world of facial feminization, nor am I an unknown in the world of craniomaxillofacial surgery. As my name is seen several times in their article, they could not have missed my involvement. I do not understand why I was not asked to at least see the article before it was published. Yes, my pride is a little bit dinged as I have been very responsible for developing the procedures generally used in facial feminization. There will of course be new articles in the future but I would hope that they would have value. That is not the case here. Few will read this letter even if it is published. However, sometime in the future, this misleading article will be referenced as an important article from an important journal supporting the new article. This is not the first time I have seen this problem in the Journal but it is the first time I have commented about it. The Editorial Board seems to know very little about the issues of aesthetic contouring of the craniofacial skeleton.


The author has no financial interest to declare in relation to the content of this communication.

Douglas K. Ousterhout, M.D., D.D.S.

2640 Steiner Street

San Francisco, Calif. 94115


1. Ousterhout DK Facial Feminization Surgery: A Guide for the Transgendered Woman. 2009 Omaha, Neb Addicus Books


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2015American Society of Plastic Surgeons