Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management

The 1960s and 1970s were an important time for craniofacial surgery because of the work of Paul Tessier and Hugo Obwegeser, both mentored by Sir Harold Gillies, along with many other important monumental minds. During this era, the birth of craniofacial surgery occurred and represented a new discrete specialty within plastic surgery. In the 1980s distraction of the facial skeleton became an indispensable tool in the arsenal of the craniofacial surgeon, based on initial cases in Italy, and rigorous research by McCarthy, Grayson, and others. In more recent times, from 2000 onward, craniofacial surgery has benefitted from the advent and refinement of techniques using computer-aided planning for procedures, spring distraction, as well as the widespread use of fat grafting as part of facial reconstruction. In the last decade, innovations based on the fusion of microsurgical procedures with craniofacial procedures for face allotransplantation and improvements in safety regarding separation of craniopagus infants have been observed. The author thinks it is worth mentioning and conferring praise upon the anesthesia colleagues for improvements in anesthesia which have led to vastly decreased mortality in the infant population undergoing complex procedures. The common theme among these achievements is that they were quickly adopted by the subspecialty community. However, in the hindsight of history, the author thinks it is now understood that during this time another great achievement, long overlooked, occurred in craniofacial surgery. In the 1980s the author's associate and mentor, Douglas Ousterhout, adapted techniques of craniofacial surgery to change the lives of transgender patients. This new and powerful surgery had the potential to change the course of someone's life just as profoundly as the correction of congenital craniofacial anomalies. This quality of life improvement for trans patients undergoing facial feminization has been evaluated and found to be quite significant. However, it was essentially ignored by the specialty community, and the author and his colleagues were slow to adopt this surgery. In this study, the author will give an overview of the procedures required to feminize or masculinize a face. The history of surgery is fascinating, and the author hopes that the origins of facial gender confirmation surgery (facial feminization and masculinization), which may be found in the forward to this journal, are fascinating to the readers as well.