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• W2697861896 abstract "Sir: First, our surgical group would like to express our gratitude for having the opportunity to respond to Dr. Ousterhout, whom we greatly admire for his professional activity and scientific work. We would also like to clarify that the aim of this letter is to respond to the technical and scientific points made by Dr. Ousterhout; it does not delve into unverified personal considerations that have little value for the scientific community. Facial feminization surgery, which has its origins in plastic and craniofacial surgery and began to advance after Dr. Ousterhout’s article was published in 1987,1 is, contrary to Dr. Ousterhout’s assertions, a relatively recent discipline, with little scientific basis, as evidenced by the scarcely 20 bibliographic citations indexed in PubMed using the keyword phrase “facial feminization surgery,” most of which provide level IV or V evidence. However, this should not be interpreted as a negative assessment, but should serve as an incentive to further develop the discipline and build solid foundations in this exciting field. In an attempt to explain the underdevelopment of facial feminization surgery in recent years, we need to examine the population most likely to receive this treatment, a group that faces, at best, limited social acceptance, and, at worst, misunderstanding and rejection. Fortunately, the transgender community is constantly breaking new ground for visibility in society and, as a result, the medical disciplines that cater to it are quickly evolving, gaining recognition and consolidation from medical and social points of view, and taking their rightful place. Returning to the subject at issue, the 172 cases included in our article are consecutive,2 noting that we have performed 423 consecutive forehead reconstructions to date (January of 2008 to April of 2015), all following the protocol defined in our article (forehead recontouring with osteotomy of the anterior wall of the frontal sinus). Dr. Ousterhout, in his letter, is assuming that every specialist follows his classification system and method, which we do not, because it is based on applying his particular surgical techniques in each specific anatomical case. We agree with the author regarding the existence of patients without a frontal sinus, a situation that must be evaluated through presurgical imaging tests, whether teleradiography or computed tomography. Even in patients with complete or partial agenesis of the frontal sinus (the literature varies somewhat on this point, but generally speaking, the average for the two phenomena is between 5 and 8 percent),3 we recommend using the same technique described in our article for the following reasons: (1) to maintain the anatomical integrity of the anterior frontal region, because excessive burring could weaken the external bony cortex or cause it to disappear, excessively exposing the bone marrow; (2) insufficient control with isolated burring over the internal cortex; and (3) the possibility of obtaining poor results at the level of the frontonasal transition. To date, we have had the opportunity to work with only four patients with complete agenesis of the frontal sinus (1 percent) and five with unilateral agenesis (1.2 percent), all of whom were treated using the same reconstruction dynamic (Fig. 1).Fig. 1: Forehead reconstruction in a patient with complete agenesis of the frontal sinus. (Above and center) Presurgical and postsurgical sequence with sagittal and three-dimensional computed tomographic reconstruction images. (Below) Intrasurgical before and after images of forehead reconstruction with osteotomy of the frontal sinus area. Note the bone fixation method.With regard to filling materials in facial feminization surgery, in our experience, regardless of the bony anatomy, optimal results can be obtained by directly reconstructing and sculpting the patient’s frontal region, with no need to add volume. We can confidently say that, as of today, rigid fixation osteosynthesis with titanium is the most substantiated fixation mechanism in adult craniofacial bone surgery.4,5 This mechanism guarantees stability and prevents micromovements that could result in bad bone healing, with all the potential associated problems and complications. With 100 percent of the patients we have operated on to date needing some type of rigid bone fixation, high-quality medical titanium osteosynthesis is used in many of the versions made available today by modern osteosynthesis (mesh, plates, and monocortical and bicortical screws). Finally, and with regard to evaluating patient satisfaction, we used a questionnaire that attempted to create this index on an individual basis. Of course, the parameters in this method are subjective and possibly disputable, but unfortunately, at this time, the question of the objective measurement of postsurgical satisfaction in the field of craniofacial cosmetic surgery has yet to be resolved. In conclusion, we would once again like to express our appreciation for Dr. Ousterhout’s criticism of our work and thank the Journal for giving us the opportunity to respond to it. We fully believe in applying a multidisciplinary approach to facial feminization surgery and invite anyone interested in learning about our working methodology to visit us at our facilities in Marbella (Spain). From here, we encourage specialists in facial feminization surgery to share and publish their experiences, following the example of figures such as Ousterhout and Spiegel, and to work to help make this exciting surgery a recognized and established discipline in the clinical and scientific fields. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Luis Capitán, M.D., Ph.D. Daniel Simon, D.D.S. Kai Kaye, M.D. Thiago Tenório, M.D. FACIALTEAM Surgical Group MHC International Hospital Marbella, Málaga, Spain" @default.
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