Male foreheads differ from female foreheads by having a bony prominence (supra-orbital ridge or brow bossing) over the eyebrows. In other words, the bone over the eye sockets projects farther forward than the bone in female foreheads. Additionally, the forehead above this prominence is usually flatter or occasionally tilted backwards compared to the female forehead, which is usually more vertical or even slightly rounded or convex. Located behind these ridges are the frontal sinuses. However, they are absent in 5% of the population and only on one side in 15%. To reduce the brow bossing, an incision is made in the scalp which allows the forehead skin to be elevated for access to this area. It is then burred down with an electric drill. In patients with very flat or posteriorly directed foreheads, a synthetic material (methyl methacrylate) is occasionally used to produce the more feminine, rounded contour. And, finally, if the frontal sinuses are very enlarged, the anterior wall may, at times, have to be set back.
The female eyebrow is arched compared to the flat eyebrow in the male. The ends of the eyebrow (the club and the tail) are at the same level, and the highpoint of the arch is between the outside of the iris (lateral limbus) and the corner of the eye (lateral canthus). Since many MtF TS patients have their supra-orbital ridges reduced, the eyebrows can be elevated at the same time by pulling the forehead skin upward in this “open” approach. On the other hand, if brow bossing is not an issue, endoscopic (closed) browlifting or even brow elevation through an upper eyelid incision can be performed. This latter technique would be a good approach if upper eyelid surgery was also being performed and most of the elevation that was needed was on the outside or lateral aspect of the eyebrow without significant drooping of the inside or medial aspect of the eyebrow.
It has always been my impression that a good looking, balanced face is more of a square than an oval. This necessitates having well developed cheeks and angles to the jaw. For a face to look more feminine, the cheeks are stronger than the angles. And vice versa for a face to be more masculine. To this end, we usually place cheek implants in MtF patients. Though there are many synthetic materials used, as well as a person’s own fat, I have been very happy using the silicone variety and stabilizing them in place with a tiny titanium steel screw. The approach is under the upper lip, and I usually use implants that either just enhance the cheek area (malar implants) or those that enhance both the cheek and sub-cheek area (combined implants).
Being centrally located, the nose should blend harmoniously with the other facial features and not draw attention to itself.
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The operation consists of correcting areas of asymmetry and deformity resulting from a prior surgery.
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The eyes are the first features noted when people meet. And having puffy, sagging or wrinkled eyelids can convey a false image of being tired, sad or old.
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Having revised thousands of rhinoplasties, I have noticed certain features common to all.
Even a structurally symmetric, aesthetically pleasing nose can be a poor result if it is out of proportion with the other facial features by being too small or too large. However, the real clues to a poor result are the asymmetries, malpositions, disproportions and decreased function that are seen. We can see collapse of the side walls and/or nostrils producing a “pinched look” or asymmetry between the two sides. The bridge can be too low or too high, and the tip can be overly rotated or not rotated enough. There can be too much “nostril show” from aggressive cartilage resection causing upward migration of the nostril rims. Or too much nostril show from failure to raise the columella (area between the nostrils). Also, irregularities or distortions in the nasal tip can occur which can present technical challenges to the revision surgeon. There can be deflections or angulations of the tip or the entire nose. As mentioned above, nostril asymmetries are particularly common with one nostril appearing higher or wider than its companion. Finally, there can be a worsening of breathing , especially if a reductive rhinoplasty was performed. Making a nose smaller has to be accompanied, many times, by measures to assure that the airflow is not compromised. This means correcting any septal deviations and/or turbinate enlargement, as well as maintaining adequate openings through the nostrils and the areas above called the internal valves. I’ve included photos of a nose showing most of these deformities with the subsequent post-operative results, after I corrected them.
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