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Facial feminization is an increasingly sought after cosmetic surgery. With huge implications and esthetic expectation for minute facial features, the operating surgeon faces tremendous stress. A successful facial feminization begins with a proper interview through which the surgeon estimates and understands the expectation of a patient. Although many of them would be feasible, some of their expectations would be unrealistic. This unrealistic expectation could be related to complex craniofacial anatomy, the issues with occlusal harmony, interplay of oral musculatures, and may be even related to facial hair nature.[1,2,3]
The most common request would be altering the hairline. The male pattern baldness would be a challenging one, and the patients would pose to advance the hairline to make their appearance more feminine one. Although the hairline could be extended and the forehead length reduced, it comes with the stretching of the scalp which has its own disadvantages including tearing of the scalp owing to extensive stretching. The surgeon would need to balance the anatomical/physiological factors of stretching of scalp with that of patient's expectation. Reduction of frontal bossing is another challenge. If the patient consents for use of titanium mesh for covering the frontal sinus, surgeon is not handicapped. If not, reduction of the frontal bossing would be very challenging owing to anatomical constraints. The typical Asian nose differs from the nose of other races. There is sufficient literature on the outcomes of the feminization of the nose. If properly planned and performed, nose feminization is never a challenge. Similarly, pullback of the prominent ears can be performed. Correcting wide zygoma/arch to give the desired facial contour is also performed with ease.
The challenges emanate from temporalis muscle reduction. The bulk of the muscle can be only reduced with compromise in function, which results from fibrosis after healing. The tricky part will be to remove incomplete fascicles so that fibrosis does not set in. The major challenge is from the gonial/masseter complex as well as chin. These two areas give the face a more masculine appearance by virtue of its prominence. Reduction of gonial angle and masseter is possible to an extent. Violating the complex regional anatomy to satisfy patient's expectation would result in severe anatomical and physiological issues of muscle including tenderness, trismus, and abnormal postsurgical contraction. The chin is another area where potential problems could arise. Reducing the chin through genioplasty is an accepted surgical procedure. The problem is with unrealistic expectation that compromises the occlusal architecture. Reduction of lower jaw needs to be harmonious with upper jaw. The occlusion is also another factor that needs to be considered. In addition, the relation of jaw to other oral structures such as tongue, muscular attachments, in normal and parafunction needs to be factored in. Yielding to patient's unrealistic demands could result in disastrous results.
A surgeon needs to understand the expectation of his/her patients, the complexity of the locoregional anatomy, his/her surgical dexterity, and match the same with the reality. This would fetch him/her with a satisfied patient with a reasonable result.