Facial Feminization: Upper Third of the Face

Facial feminization surgery (FFS) is a crucial intervention for transgender women. This article delves into comprehensive reconstruction of the upper third of the face, discussing anatomic differences between masculine and feminine features, and surgical considerations. Technical considerations, preoperative planning, procedural approaches, and postoperative care are described in detail. Patient-centered operative planning and execution ensure safety and efficacy in FFS and uphold its transformative effect on quality of life in appropriately selected surgical candidates.

Epidemiology of Gender Diversity

In the United States, approximately 1.6 million individuals identify as transgender and gender diverse (TGD), encompassing a wide range of identities and experiences. Despite progress in visibility and acceptance, TGD people continue to face health care and societal disparities, especially affecting racial minorities. Although legal advancements have been achieved, the key to addressing these persistent health care disparities lies in implementing comprehensive and culturally sensitive health care practices and supportive policies. With a growing number of TGD people seeking gender-affirming care, it is imperative that health care practitioners understand the unique challenges faced by this community and provide tailored services with sensitivity and expertise.

Preoperative Radiology and Virtual Surgical Planning

Virtual surgical planning enables precise surgical planning and translation of this planning into the operating room. Preoperative maxillofacial computed tomography scans are compared to a reference skull to identify desired surgical changes. In facial feminization surgery, these include forehead recontouring/frontal table setback, gonial angle reduction, and possible chin repositioning/reshaping, while in facial masculinization surgery, this includes forehead augmentation and gonial angle/chin augmentation. Cutting and recontouring guides as well as custom implants are then custom manufactured. Common guides include osteotomy guides, depth drilling guides, ostectomy guides, and guides for one/two-piece genioplasty or chin burring. Common implants include mandibular and chin implants.

Facial Feminization: Middle Third of the Face

Facial feminization surgery (FFS) as applied to the midfacial region targets modifications to the nasal and malar esthetic complexes. Although a global assessment is paramount in achieving desired functional results, most patients benefit from malar feminization in the form of bony and soft tissue augmentation, and nasal feminization in the form of reductive rhinoplasty. For patients with signs of aging, additional interventions in the form of rhytidectomy are powerful adjuncts to feminization. As with FFS techniques directed toward the upper and lower thirds, the overarching goal is to obtain complementary outcomes that enhance facial harmony and beauty.

Ethnic variation in lower face anthropometry on facial computed tomography scans for patients seeking facial feminization surgery

BACKGROUND

Facial feminization surgery (FFS) is the most common form of facial gender-affirming surgery. One of the current knowledge gaps is the understanding of differences among racial groups in baseline craniofacial norms for transgender and nonbinary patients.

METHODS

All patients who sought consultation for FFS and underwent craniofacial computed tomography (CT) scans at a single institution between 2018 and 2023 were included. Patients who underwent previous facial surgeries were excluded. Chart reviews were conducted for patient characteristics, including race, age, hormone therapy duration, and prior gender-affirming surgeries. Racial categorizations included White, Latinx, African American, or Asian. Patients with other or multiracial identities were excluded. Lower face measurements were derived from preoperative facial CT scans. Comparative analyses were performed on all measurements among the racial groups.

RESULTS

In this study, 204 patients were included with an average age of 32.0 ± 10.2 years and a median hormone therapy duration of 2.0 years. The notable differences among the racial groups were: 1. Zygomatic width was the largest in Asian patients (13.5 ± 0.6 cm) compared to all other racial groups (p = 0.03), 2. Nasolabial angle was the smallest in African American patients (82.5 ± 13.1 degrees, p < 0.001), 3. Lower face height was the largest in African American patients (6.9 ± 0.7 cm, p < 0.001), and 4. Lateral mandibular flare was the largest in African American patients (0.4 ± 0.1 cm) and the smallest in Latinx patients (0.2 ± 0.1 cm, p < 0.001).

CONCLUSIONS

Specific target areas of FFS should be carefully considered to account for possible baseline ethnic differences. Relative facial proportions may also be a more salient surgical planning tool in transgender and gender nonbinary patients rather than absolute measurements alone.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

Ambulatory facial feminization surgery: a comparative analysis of outcomes and complications

BACKGROUND

To date, there are no studies investigating the safety and outcomes of facial feminization surgery (FFS) as an outpatient procedure. This is the first study of its kind analyzing the outcomes of ambulatory FFS based on a comparison of complications, post-operative emergency department or urgent care (ED/UC) visits, and readmissions between patients who underwent FFS with admission versus same-day surgery.

METHODS

A retrospective analysis was conducted on all patients who underwent FFS in a single integrated healthcare system. Patient charts were reviewed for operative details, complications, post-operative ED/UC visits, readmission, and demographic factors. Major outcomes including complications, readmissions, and ED/UC visits were compared between groups with same-day discharge and post-operative hospital admission.

RESULTS

Of 242 patients included in the study, ED/UC visits were comparable between patients discharged same-day (18.2%) and patients admitted post-operatively (21.6%, p = 0.52). Logistic regression showed no significant difference in the composite outcomes of minor complications, major complications, and readmissions (15.6% for ambulatory versus 19.3% for admission, p = 0.46). Temporary nerve palsy, infection, and hematoma were the most common post-operative complications. However, covariates of a lower face procedure and operative time were shown to have significant differences in the composite complication outcome (p = 0.04 and p = 0.045, respectively).

CONCLUSION

Ambulatory FFS is a safe practice with no associated increase in adverse outcomes including complications, ED/UC visits, and readmission when compared to post-operative admission. Adoption of same-day FFS should be considered by high-volume gender health centers to potentially benefit from increased scheduling flexibility and efficiency, increased access to care, and lower healthcare costs.

Assessing Preferences of Facial Appearance in Transgender and Gender Nonbinary Patients

BACKGROUND

We designed a survey to evaluate preferences of facial appearance in transgender male (TM), transgender female (TF) and gender nonbinary patients to better inform goals of facial gender affirming surgery (FGAS) in gender nonbinary patients.

METHODS

TM/TF and nonbinary patients > 18 years old were identified via retrospective chart review and distributed an anonymized survey via email from October 3 to December 31, 2022. To assess facial preferences, AI-generated and open-source portraits were edited to create five image sets with a range of features from masculine to feminine for the forehead, mandible/chin and hairline. Data were analyzed using Fisher's exact tests and ANOVA in R-Studio.

RESULTS

Survey response rate was 32% (180 patients identified via chart review, 58 respondents; TM = 5, TF = 39, nonbinary = 14). TM and TF patients as well as TF and nonbinary patients had significantly different preferences for all regions (p < 0.005; all series), while TM and nonbinary patients did not (p => 0.05; all series). TF patients consistently selected 4s with neutral or more feminine features. TM and nonbinary patients, however, demonstrated no consistent preference for either male or female features but rather a range of responses spanning extremes of both masculine and feminine options. When stratified by sex assigned at birth, nonbinary patients consistently identified preferences opposite to their assigned gender.

CONCLUSION

Gender nonbinary and TM patients appear to have uniquely individual preferences regarding facial appearance that do not fit into classically masculine or feminine patterns/phenotypes. As a result, we recommend individualized preoperative planning for FGAS to achieve the optimal result in these patient populations.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay

BACKGROUND

Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery.

METHODS

A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes.

RESULTS

Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery.

CONCLUSIONS

The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

Risk Factors for Postsurgical Infections in Facial Feminization Surgery

BACKGROUND

Facial feminization surgical procedures are involving several surgical disciplines in multiple surgical sites and therefore may carry the risk of developing infections. Data on the development of postsurgical infection (PSI) and contributing factors in male-to-female transgender people (transwomen) undergoing facial feminization surgery are scarce. The aim of this study was to investigate the contributing factors to develop PSIs in facial feminization surgical procedures.

METHODS

Data from the medical records of 40 transwomen who underwent facial feminization surgeries in our institution between 2019 and 2021 were analyzed. The independent variables included demographic parameters (weight, body mass index, medical comorbidities and age), details of the surgical procedure (type, duration and whether another procedure had been performed concomitantly), type, dosage and route of administration of postoperative antibiotics and steroids, length of hospitalization and follow-up duration. Postsurgical infection was designated a dependent variable.

RESULTS

Five out of 40 patients (12.5%) developed PSI. The surgery of those with PSIs involved more sites, and the duration of nasal tamponade was more than four times longer than for patients who did not develop a PSI.

CONCLUSIONS

The current study revealed higher postsurgical infections rates after lengthy surgeries or when it involves several surgical facial feminization procedures. Multicenter clinical trial on a big cohort may enable better evidence-based results.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p < 0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

Gender Facial Affirmation Surgery: Cheek Augmentation

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.

Feminization Rhinoplasty

This article provides a brief cross-cultural history of transgender, nonbinary, and other diverse gender identities, before exploring the background of gender-affirming care and facial feminization surgery in the United States. A variety of techniques for feminization rhinoplasty are discussed in detail. The authors provide insight into assessment and counseling of this unique patient population, timing of surgery, functional nasal considerations, and performing rhinoplasty in the context of other facial feminization procedures. Finally, complications of feminization rhinoplasty are identified and methods to prevent and treat such complications are enumerated.

Gender Facial Affirmation Surgery; Techniques for Feminizing the Chin

The shape and size of the chin are very important in feminizing the lower third of the face, and osseous genioplasty is commonly used in FFS. Different variations of the osseous genioplasty can be used to feminize the chin. The 1-piece genioplasty reduces the size and rounds the chin. 2-piece genioplasty reduces or increases the projection of the chin, but retains the same shape. 3-piece genioplasty also reduces or increases the projection, but has the additional benefit of narrowing the chin. This narrowing helps to create the "V" shaped lower face that is often desired by patients seeking facial feminization. Protection of the mental nerve and resuspension of the mentalis muscle is essential to prevent permanent lower lip numbness and ptosis respectively.

Approach to the Transgender Patient: Preoperative Counseling, Setting Expectations, Avoiding Potential Postoperative Pitfalls

An increasing number of transgender patients are seeking gender-affirming facial surgery, also known as facial feminization surgery. Physicians offering these services must be well versed in how to compassionately care for this patient population. We recommend having a well-informed staff that is knowledgeable about proper verbiage, use of pronouns, and preferred names for transgender patients. We also recommend helping patients to manage expectations and seek realistic goals from the first consultation. A frank discussion about the limits of facial feminization is essential. Discussing the prolonged recovery and expected outcome is of paramount importance preoperatively to avoid postoperative disappointment.

Jaw Reduction Surgery

Facial feminization surgery (FFS) combines a series of facial bone and soft tissue surgeries to feminize the masculine appearance of the face in a transgender female patient. Jaw reduction surgery is an extremely critical component of FFS and is generally performed in combination with genioplasty. Our technique of jaw reduction involves sagittal resection of the mandible from the angle of the jaw to the mental nerve region. This creates a smooth transition from the ramus to the chin and also retains the integrity of the inner portion of the mandible. We discuss our techniques of jaw reduction surgery in this article.

Feminization Rhinoplasty

Facial gender affirmation surgery is currently growing worldwide and is an important treatment for gender dysphoria that will improve quality of life. The most frequently sought modifications by transgender women are forehead and supraorbital ridge reduction, cheek augmentation, upper lip surgery (lip lift), laryngeal chondroplasty, jaw reduction, and rhinoplasty. Rhinoplasty for transgender women uses the same techniques as rhinoplasty for a cisgender patient. However, knowledge of transgender care is necessary and must be widely adapted to all health professionals. This article intends to explain the author's personal approach to feminization rhinoplasty.

Sex-Related Characteristics of the Face

The face is central to individual identity and gender presentation. Sex-based differences are seen at nearly every component of the face, from craniofacial structure to skin and soft tissue distribution. This article provides a framework for identification and analysis of sex-based differences in facial anatomy. This can then be used to guide individualized approaches to surgical planning to create greater congruence between patients' existing physical features and goals for gender expression.

3D Sliding Genioplasty and Its Role in Facial Feminization Surgery

The chin is a key element of the lower third of the face and plays the main role as a gender indicator. Since its introduction, genioplasty has become very popular and highly established for the treatment of various conditions. Additional procedures, such as mini V-line, V-line surgery, lateral cortex ostectomy, or mandible angle resection round out the result. (i) The 3D sliding genioplasty is a very effective feminizing procedure (ii) It enables the surgeon to modify the size, form, height, and position of the chin in all dimensions. (iii) We discuss our approach to sliding genioplasty.

forehead, orbits, eyebrows, eyes, and nose

Facial feminization surgery (FFS) incorporates aesthetic and craniofacial surgical principles and techniques to feminize masculine facial features and facilitate gender transitioning. A detailed understanding of the defining male and female facial characteristics is essential for success. In this first part of a two-part series, we discuss key aspects of the general preoperative consultation that should be considered when evaluating the prospective facial feminization patient. Assessment of the forehead, orbits, hairline, eyebrows, eyes, and nose and the associated procedures, including scalp advancement, supraorbital rim reduction, setback of the anterior table of the frontal sinus, rhinoplasty, and soft tissue modifications of the upper and midface are discussed. In the second part of this series, bony manipulation of the midface, mandible, and chin, as well as soft tissue modification of the nasolabial complex and chondrolaryngoplasty are discussed. Finally, a review of the literature on patient-reported outcomes in this population following FFS is provided.

Reprint of: Breaking the binary: The identification of trans-women in forensic anthropology

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Breaking the binary: The identification of trans-women in forensic anthropology

In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Gender-confirming Rhinoplasty

Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

Forehead and Orbital Rim Remodeling

Facial features remodeling surgery is performed to obtain feminization of the face that corresponds to the gender perceived by patients. This includes techniques and findings to remodel the forehead and orbital rim to change the expression of the eyes, correction of the frontonasal angle in relation to rhinoplasty, hairline feminization, and eyebrow lift to correct the position and aesthetic dissatisfaction or the effects of aging.

Midfacial Bony Remodeling

Craniofacial procedures to the midface in conjunction with work to the upper face and skull, and if needed the lower jaw, are a permanent and effective way to achieve feminization of the face in transgender patients. Although the surgery is more complex than other procedures, it should be considered for select patients. Further improvement of cosmesis may be considered a separate surgical entity and is not limited in scope or time by having undergone midface osteotomies. When carefully planned, bony surgery to the midface is safe and results in long-term predictive results and a favorable appearance as the patient ages."

Facial Gender Confirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery

Facial feminization surgery was pioneered in the 1980s to provide options for trans women who were having difficulty with their outward appearance. This process presented a novel application of craniofacial surgery at the time. This text outlines the basic differences between male and female facial morphology, as well as the procedures we use to feminize the face.

Fronto-orbital feminization technique. A surgical strategy using fronto-orbital burring with or without eggshell technique to optimize the risk/benefit ratio

The demand for facial feminization is increasing in transsexual patients. Masculine foreheads present extensive supraorbital bossing with a more acute glabellar angle, whereas female foreheads show softer features. The aim of this article is to describe our surgical technique for fronto-orbital feminization. The mask-lift technique is an upper face-lift. It provides rejuvenation by correcting collapsed features, and fronto-orbital feminization through burring of orbital rims and lateral canthopexies. Depending on the size of the frontal sinus and the thickness of its anterior wall, frontal remodeling is achieved using simple burring or by means of the eggshell technique. Orbital remodeling comprises a superolateral orbital opening, a reduction of ridges and a trough at the lateral orbital rim to support the lateral canthopexy. Frontal, corrugator and procerus myectomies, plus minimal scalp excision, complete the surgery. Our technique results in significant, natural-looking feminization. No complications were observed in our series of patients. The eggshell technique is an alternative to bone flap on over-pneumatized sinus. Fronto-orbital feminization fits into a wider surgical strategy. It can be associated to rhinoplasty, genioplasty, mandibular angle remodeling, face lift and laryngoplasty. Achieving facial feminization in 2 or 3 stages improves psychological and physiological tolerance.

Formations of Femininity: Science and Aesthetics in Facial Feminization Surgery

Facial feminization surgery (FFS) is a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of trans- women in order to make their identities as women recognizable to others. In this article, I explore how the identification of facial femininity was negotiated in two FFS surgeons' practices. One committed to the metrics of normal skeletal form and the other to aspirational aesthetics of individual optimization; I argue that surgeons' competing clinical approaches illustrate a constitutive tension in the proliferating therapeutic logics of trans- medicine. The growing popularity of surgical practices like FFS demonstrates a shift in American trans- therapeutics away from a singular focus on the genitalia as the location of bodily sex and toward understandings of sex as a product of social recognition.

Aesthetic Correction of a Protrusive Forehead through Repositioning of the Anterior Wall of the Frontal Sinus

Facial skeletal remodeling was revolutionized more than 30 years ago, by the work of Tessier and other craniofacial surgeons. However, the need to correct the skeleton in the upper third of the face is not frequently diagnosed or treated in aesthetic facial surgery. Here, we report on the aesthetic correction of a protrusive forehead. A patient visited our hospital for aesthetic contouring with a prominent forehead. The anterior wall of the frontal sinus was removed with a craniotome via the bicoronal approach. After the excised bone was repositioned, it was fixed with a titanium mesh plate and screws. An electric burr was used to contour the supraorbital rim and frontal bone. Once the desired shape was achieved, the periosteum was replaced, and the wound was closed in layers. When performed properly, frontal sinus contouring could significantly improve the appearance in patients with a prominent forehead. Plastic surgeons must carefully evaluate patients with a prominent forehead for skeletal remodeling that involves the accurate and safe repositioning of the anterior wall of the frontal sinus.