Quantitative Assessment of Forehead Morphology Following Facial Feminization Surgery

Feminization of the forehead is a standard component of gender-affirming surgery. The purpose of this study was to quantify the preoperative to postoperative changes in forehead morphology associated with facial feminization surgery (FFS) using computerized tomography (CT) imaging and a novel segmentation technique.

All patients underwent FFS at an academic medical center. Only patients who underwent upper third procedures and had preoperative and postoperative skull craniofacial CT imaging available were included. Measurements of forehead volume, surface area, frontonasal angle, and bossing angle were made with Mimics (Materialise, Leuven, Belgium). Three reviewers measured the scans independently, and intraclass coefficients were obtained to assess inter-rater reliability. Patient satisfaction was assessed preoperatively and postoperatively using the FACE-Q, a patient-reported outcome measure.

Twenty-two patients met the inclusion criteria. Average age at the time of surgery was 36 ± 11 years. All patients underwent frontal sinus setback, forehead contouring, and suprabrow contouring. On average, forehead volume decreased by 2,558 mm³ (p < 0.001), surface area decreased by 505 mm² (p < 0.001), frontonasal angle decreased by 9.6° (p < 0.001), and bossing angle decreased by 9.9° (p < 0.001). Intraclass coefficients ranged from 0.62 to 0.87. Patients reported significant improvement in satisfaction postsurgery across a majority of FACE-Q modules.

A measurable reduction of forehead dimensions, frontonasal angle, and bossing angle successfully aligns facial features with more feminine ideals, drawing attention to the critical role of FFS in facilitating gender transition for a patient and improving their overall quality of life.