The “forceful” and macho look of prototypical man may not be unduly appealing to others whom he meets. this “forceful” look might not even appeal to the individual himself . in order to soften this appearance ,a series of operative procedures has been devised for use on the craniofacial skeleton .these surgical steps can be done in a single operation or as a series of multiple operative procedures .moreover , the needs of some patients may require that only special segments of these procedures be performed .
The surgical steps routinely performed are those that contour the forehead, orbits, malar eminence ,cheeks ,chin ,angle of the mandible , and larynx .
We meets generally three categories of patients: the female with a male face ; the male with a “forceful look” ; and the patient requesting a gender identity change . the psychosocial ,psychological , and behavioural problems leading to the decision for surgery will be the basis of final patient selection .
Gender identification of the adult male and female craniofacial skeleton is distinct each with certain structural characteristics that have been well studied by anthropologists and forensic scientists. These structural characteristics are basically due to the facial bones. There are also soft-tissue depth characteristics that can be used to match and contour the bony areas of the face. The basic role of skin and subcutaneous tissue is to drape the skeleton. Gradual changes in soft-tissue depth over many years give the individual aging and gender characteristics. The surgical changes as a result of bone contour surgery cause the soft tissue to recontour over one to two years. Previous experience in craniofacial surgery allows us today to use these principles in contouring the human face and in changing its inherent gender characteristics. If we include the accumulated knowledge and experience in aesthetic surgery in general, we find that we have reached a major concept or body of technique. This can be drawn upon for a select group of patients in order to produce the desired facial changes and to achieve acceptable and satisfactory results, provided that these patients have fundamentally realistic expectations.
THE BEST CANDIDATES FOR FEMINIZING THE FACE
We have categorized our patients into three groups. Not all patients seen and evaluated fit the criteria for a major change; some may be satisfied with minor alterations that ultimately lead to an acceptance of their new self-image.
Category I: the female with facial characteristics of a male such as bossing in the forehead, large supraorbial ridges, large nose, wide chin, and flared mandible. These patients on the whole are satisfied with their gender identity.
Category II: the male who has the “forceful” look, with exaggerated characteristics and flat cheeks in addition to some of the male characteristics or category I. These patients are satisfied with their gender identity. However, job pressure or various personality aspects may conflict with the physical appearance.
Category III: the patient who has all of the above characteristics and a long face. These patients feel more comfortable after a gender change. They are extremely difficult to treat and must be carefully selected.
To simplify our approach to craniofacial contouring, we have divided the face into nine regions, shown in figure 2. The areas that are contoured are shown in figure 3; these areas are the forehead, the supraorbital ridges, the supralateral orbital margins, the nose and cheeks, the malar prominence, the chin, the mandible, and the laryngeal prominence.
The procedure is done under general anaesthesia in a one-day surgery facility if feasible. All of the desired changes are done in one operation, or selected aspects of the contouring are performed to match the desires of the patient bases on preoperative evaluation and planning.
For changing the contour of the face, a small area of the hair is shaved to access the forehead flap. A bicoronal flap is raised in the avascular space to the supraorbital ridges. The pericranium is divided at the upper part of the forehead at the region that needs to be contoured so only small areas are denuded of the pericranium. The subperiosteal dissection is carried into the orbit, thus freeing the supraorbital neurovascular bundles and saving them and subsequently exposing the upper orbits, the nasion, and the supralateral orbital ridges.
If bone grafts are to be used, the same craniofacial principles and self sufficiency are used to harvest the autogenous bone from the skull. The temporalis muscle and its investing fascia are lifted up and by means of a thin osteotome and gentle tapping the outer table or the skull is removed to the diploic space. In adults, a good section of marrowlike bone graft can also be harvested. The amount of bone removed depends on the quantity needed, as determined by preoperative planning. The desired procedures and contouring on the exposed structures are done next. The edges of the temporalis muscle and its investing fascia are tacked with nonabsorbable sutures to cover the donor site. The forehead flap is lifted back to cover the region, and the pericranium is also taked with nonabsorbable sutures. The flap is closed in two layers. The gelea aponeurosa is closed with nylon sutures and the skin is stapled. Hemostatis is usually secured with electrocatery. The “Shaw” hot knife is used to open the skin and for dissection with minimal bleeding. Any ancillary procedure planned for the soft tissue can also be managed through this modus operandi. It is important to have a radiograph of the skull to delineate the anatomical landmarks and the location of the frontal sinus.
The oral approach is done via superior and inferior sulcus incisions. The superior sulcus incision allows for complete exposure of the upper maxilla. The dissection is done in subperiosteal fashion. The inferior region of the face is handled in a similar manner. Intraoral wounds are closed with absorbable sutures.
The nasal incisions for contouring and closure are done in a fashion similar to that used in aesthetic rhinoplasty.
Laryngeal cartilage shaving is done via an external incision in the crease line. At the end of the procedure the patient receives 1g of methylprednisolone to reduce facial edema and the appropriate antibiotics for prophylaxis against infection.
The surgical contouring procedures used are based on the evaluation of the anthropological differences between the male and the female skeleton and the desired changes. In the older-age group, soft tissue alterations can enhance the skeletal changes even though the soft tissue drapes the skeleton. We divide the management of the surgical procedures into the following steps:
- All of the incisions used in facial contouring are concealed, namely, the coronal incision with degloving of the upper face; the superior and inferior sulcus incisions in the oral cavity that provide access to upper and lower parts of the facial skeleton; the intranasal incisions that provide complete exposure for the correction of the nasal deformity .
- In the process of feminizing the face, detail the anthropological characteristics as deficiencies or excesses between the male and the female
These two steps form the basis of the contouring procedures. For building up or adding to an area, autogenous bone graft is used, and for contouring, bone is removed by means of power equipment with a “burr” these are the methods of choice. Some of the areas that are contoured are as follows:
- the forehead in the male has bossing and is overly prominent in the frontal bone. The forehead skin is usually wrinkled and there is the sinister look on the heavy frown lines.
- In the female the orbits are closer and the opening of the orbital bones is smaller.
- The cheek bones are flat and even depressed in the male (flat look), while in the female the cheek bones are prominent.
- The nose is large and the nasolabial angle is less than 90° in the male.
- The mandible is wide at the angles and shorter in height.
- The chin is pointed and small in the female; it is wide, large, and may be bifid in the male.
If we take all these skeletal differences, and the operative steps to change them into consideration, we find that augmentation or reduction is the basis of total contouring and will produce the optimum results described by the patient.
- the third step in the management of the contouring procedure comprises the following steps:
1. The forehead bossing is shaved. The outer table of the skull is contoured and then flattened. To avoid opening the frontal sinus, a radiograph of the face is done prior to surgery and an outline of the sinus is followed during the contouring phase. The forehead is contoured by means of a small bone burr using power equipment .
2. From the same exposure, bone grafts are harvested from the outer table of the skull on the non-dominant side. Bone is harvested as large units of corticocancellous bone, bone paste, and concellous bone .
It is then contoured with bone-contouring forceps , following the preoperative plan .
3. The upper part of the supraorbital ridges is reduced to decrease the ridge prominence. This is also done by a power “burr”. The anterior-lateral orbital ridges are then shaved and osteotomized by gentle tapping via an osteotome to produce a wider opening of the orbits. This is a feminine face.
4. The cheek bones are then exposed via a small superior sulcus incision. The contoured bone graft is placed over the malar eminence to produce fullness and prominence as it contours the maxilla .
5. The nose is treated with a classical reduction rhinoplasty that changes the nasolabial angle to 105° and the nasofrontal angle to a more defined one .
6. The lower mandible is contoured with a power burr to reduce the flaring at the mandibular angles. Additionally, the vertical height at the mandibular angle is reduced .
7. The chin is then reduced by a double osteotomy, i.e., made shorter and pointed to correspond with the softening effect at the tip—a characteristic of the feminizing process. The vertical height of the chin is reduced and prominence is obviated. The chin accordingly blends into the reduced and softened look of the face . The soft tissues in the chin are altered to drape the new contour.
8. The laryngeal prominence is reduced by a small incision over the laryngeal cartilage, and shaving the cartilage to flatten it . This complements the softening effect one the face and further feminizes the look.
9. Ancillary skin procedures, such as frontalis flattening, frown line removal by resecting the procerus muscle, and eyelid plasty, can be done when indicated during the same procedure or in a separate procedure particularly in the older patient.
YOUR NEW LOOK
Facial contour surgery can be performed on patients who desire the changes. In general, patients in our three categories outlined above have satisfactory and pleasing results. The changes in the facial contour are reasonable if all the procedures discussed here are properly performed. It is important to stress, however, that these patients should have realistic expectations of the outcome. In category I patients the changes produce a definite and positive difference in the patients’ outlook. In category II, in keeping with patients’ desires, we will not show any photos, however, the outcome is satisfactory. Category III patients show a drastic physiognomic changes and a more acceptable, well-adapted self-image, in accordance with the gender changes desired by the patient.
The major complications noted so far have been excessive bleeding and postoperative oedema. The bleeding was obviated by the use of electrosurgical equipment during all phases of dissection. Postoperative oedema has been obviated by means of large doses of steroids given at the termination of the procedure.
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