We read with great interest the letter to the editor in response to our article published in the Journal in March of 2017.1 Despite the fact that the focus of the argument in the letter is different from that of the cited publication, we agree with the authors regarding the importance of considering the nose as a key element in the identification of facial gender, as we argue in the publication included in the review made by the author.2 In addition, it is important to identify the other facial structures responsible for the visual identification of gender and that therefore must be approached when undertaking facial gender confirmation surgery. These elements include the frontonaso-orbital and mentomandibular complexes. These structural pillars, which can be surgically modified using facial feminization techniques, serve as supports for a series of secondary elements, including the hair and hairline, facial hair, skin texture, and the distribution and volume of facial fat.
These secondary elements also play a key role in the visual identification of the individual, and their analysis and treatment is a fundamental part of the transition process for patients as a complement to feminization bone surgery.3 As we show in our article,1 the approach to the upper third begins with an analysis of the bone structure of the frontonaso-orbital complex and an evaluation of the patient’s hair characteristics, including the hairline format. Based on the premise that there is a clear difference between male and female hairline formats,4 it is of the utmost importance to establish protocols that allow us to make a precise diagnosis of the transgender patient’s hair situation to be able to offer alternatives with predictable results that are natural, stable over time and, above all, feminine. Hair transplants, whether isolated or performed simultaneously with forehead reconstruction, provide a reasonable alternative that makes it possible to treat and modify the hairline of a transgender patient. Despite its being an a priori promising procedure, we must be aware that, like all new techniques, this one needs to be evaluated with a critical eye to be able to improve the technique and offer the best possible guarantee to our patients. Finally, it is important to mention the role that micropigmentation techniques5 and personalized hair systems are beginning to play for transgender patients, whether as a complement to hair transplants or as an alternative for patients with low hair density or severe alopecia.
The authors have no financial interest to declare in relation to the content of this communication or of the associated article.
Luis Capitán, M.D., Ph.D.Daniel Simon, D.D.S., M.Sc.Teresa Meyer, M.D.Antonio Alcaide, M.D.Alan Wells, M.D.Carlos Bailón, M.D.Raúl J. Bellinga, M.D.Thiago Tenório, M.D.Fermín Capitán-Cañadas, Ph.D.FACIALTEAM Surgical GroupHC Marbella International HospitalMálaga, Spain
1. Capitán L, Simon D, Meyer T, et al. Facial feminization surgery: Simultaneous hair transplant during forehead reconstruction. Plast Reconstr Surg. 2017;139:573584.
2. Bellinga RJ, Capitán L, Simon D, Tenório T. Technical and clinical considerations for facial feminization surgery with rhinoplasty and related procedures. JAMA Facial Plast Surg. 2017;19:175181.
3. Capitán L, Simon D. Salgado C, Monstrey S, Djordjevic M. Facial feminization surgery: A global approach. In: Gender Affirmation: Medical and Surgical Perspectives. 2016:New York: Thieme; 330.
4. Rassman WR, Pak JP, Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am. 2013;21:317324.
5. Rassman WR, Pak JP, Kim J, Estrin NF. Scalp micropigmentation: A concealer for hair and scalp deformities. J Clin Aesthet Dermatol. 2015;8:3542.