While aesthetic facial surgery performed for reasons of undesired facial masculinity or femininity has had some attention in the literature, there is a lack of information on gender-confirming facial surgery as part of an overall surgical sex reassignment program. In this paper we try to capture some of the sex differences, respectively, of skeleton, musculature and other subcutaneous soft tissues, integument and frame of the face. From this, we come to a description of some general differences of facial appearance between the sexes. In restructuring the skeletal architecture and facial proportions to match the desired gender, these factors should be taken into account.

Until April 1991, 31 phalloplasties were performed in 28 patients at our hospital. Operative techniques and results of the use of the superficial inferior epigastric pedicled skin flap, rectus abdominis myocutaneous pedicled flap and radial forearm free flap for phalloplasty are presented and discussed. Functionally and cosmetically, the microsurgical free flap phalloplasty techniques lead to the best results. In all cases of free flap phalloplasty in our series tactile sensitivity recurred in the neophallus. However, erogenous sensibility should not be expected. We regard use of the infraumbilical flap to be a technique with few indications and it should not be applied to obese patients. Use of the rectus abdominis myocutaneous pedicled flap is a reliable technique. Primary connection of the pars fixa and pars pendulans urethrae often leads to formation of fistulas at the level of the anastomosis. Genital reassignment surgery in female-to-male transsexuals can seldom be achieved in 1 stage and this should be made clear to the patient before any form of surgery is done.

Ideally, in phalloplasty one should aim at 1) a one-stage procedure that can be predictably reproduced, 2) creation of a competent neo-urethra to allow for voiding while standing, 3) return of both tactile and erogenous sensibility, 4) enough bulk to tolerate the insertion of a prosthetic stiffener, and 5) a result that is aesthetically acceptable to the patient. We consider 6) minimal scarring or disfigurement, and 7) no functional loss in the donor area further requirements for any ideal procedure. Thanks to ongoing refinements, microsurgical free flap phalloplasty techniques lead to the best results, both functionally and cosmetically. These refinements are presented and discussed, as are our experiences applying them.

Cutaneous meningiomas are extremely rare tumours and their diagnosis is dif cult. We describe the case of a patient who developed a paranasal swelling after head trauma and associated fractures in the same region years before. Histopathological examination of an incisional biopsy revealed the diagnosis of cutaneous meningioma. After one and a half years' follow up, surgical excision was performed because of progressive growth of the tumour and associated aesthetic problems. Extracranial meningiomas can develop probably secondary to trapping of meningeal tissue after trauma. If there is no intracranial connection surgical removal can be considered.