Narrative review of facial gender surgery: approaches and techniques for the frontal sinus and upper third of the face

Facial gender confirmation surgery (FGCS) is a series of procedures which seek to harmonize a patient's face with his/her self-image and gender identity. Originally described in San Francisco in the 1980s, FGCS has evolved to encompass all elements of the craniofacial skeleton and facial soft tissue. This field in plastic and reconstructive surgery has quickly gained more attention in the past decade due to the pioneering work of groups around the world along with increased social acceptance and medical care of the transgender community. This narrative review focuses on the upper third of the face. Key differences in the forehead and the hairline of cis men and women are discussed which inform pharmacologic and surgical interventions. Hairline modifying therapies including pharmacotherapy and hair transplantation are explained. Virtual surgical planning (VSP), a tool broadly used in surgical fields, has a special role in FGCS and we offer advice in using VSP when addressing the frontal sinus. Use of VSP allows the surgeon to provide reproducible and accurate results. We then discuss the history of the frontal sinus setback and offer our algorithmic approach to recontouring the forehead with detailed description of the operative steps and decision making. Finally, postoperative care and complications considered.