Facial Feminization

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Facial Feminization Surgery (FFS)

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Facial feminization surgery (FFS) refers to surgical procedures that alter the human face to bring its features closer in shape and size to those of an average female human. FFS includes various bony and soft tissue procedures (see below) though the term "FFS" is generally not regarded to include facial hair removal. FFS techniques are derived from maxillofacial and reconstructive surgery as well as general plastic and cosmetic surgery.

FFS has become increasingly sought after by transsexual women and many feel that it is just as important or even more important for them than sex reassignment surgery (SRS) because it helps them integrate socially as women. While most FFS patients are transsexual women, some non-transsexual women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressers and drag queens.

FFS Procedures Include:

Best Candidates for Facial Feminization Surgery

Transsexual women are common candidates for this surgical procedure, although drag performers and other individuals may also consider facial feminization surgery, for a variety of reasons. A number of procedures for the face are available.

As with most other forms of surgery, it is recommended that you're healthy, with no significant heart or circulatory problems and are mentally stable. You can learn specific details on what is involved for a procedure by meeting with your general practitioner and gaining a referral to a specialized plastic surgeon.

Most transsexual women go through transition after adolescence and thus transition with a male facial structure. High levels of masculine hormones cause significant changes to the facial appearance, including making the forehead heavier and more pronounced, altering the structure of the nose, and creating a more pronounced chin and jaw. The Adam's apple may also develop a protruding appearance. Women may choose facial feminization surgery because they are concerned about facial aesthetics.

Preparing for FFS

Before facial feminization surgery, patients will meet with their surgeons to discuss their options. Many surgeons use samples of before and after images to help women see how specific procedures work and to give them ideas for reshaping their own faces. The surgeon will work with the patient to develop an appropriate plan so she can feel confident going into surgery.

Depending on the amount of work a patient decides to request, multiple surgical procedures may be necessary. The patient is placed under general anesthesia so the surgeon can do things like shaving down bone to change the shape and structure of the face, inserting implants into the cheeks, reshaping the nose, and moving the hairline. In the days immediately following surgery, the patient will have significant swelling and bruising. As these go down, her new face will emerge and the surgeon can remove any stitches.

FFS Surgery Overview

Bony work will have a far more dramatic effect on the shape of a face. In frontal view most important goal is to change the overall square form of most masculin faces to the more oval shape of a women's face.

This bony work is often combined with soft tissue procedures to achieve an aesthetic result. Soft tissue work may be necessary to get the full result of bony work for some patients

Hairline correction

In males the hairline is often higher than in females and usually has receded corners above the temples that give it an "M" shape. The hairline can be moved forwards and given a more rounded shape either with a procedure called a "scalp advance" where the scalp is lifted and repositioned or with hair transplantation. Hair transplants can also be used to thicken up hair that has been thinned by male pattern baldness. If too much hair has been lost, it will not be possible to correct hairline problems.

Forehead Recontouring

Males tend to have a horizontal ridge of bone running across the forehead just above eyebrow level called the brow ridge or "brow bossing" while female foreheads tend to be smoother, flatter and have less bossing, or bossing that project just below eyebrow level. The outer segments of the bossing that the eyebrows sit on are called the "supraorbital rims". These are usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the glabella) sits over a hollow area called the frontal sinus. Because the frontal sinus is hollow it can be more difficult to remove bossing there. If the bone over the frontal sinus is thick enough the bossing can be removed by simply grinding down the bone, however if the wall of bone is too thin it may not be possible to grind the bossing away completely without breaking through the wall into the frontal sinus. FFS surgeons have taken 3 main approaches to resolving this problem:

  1. Most FFS surgeons can perform a procedure called a forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled, in the new feminine position with small titanium wires or titanium microplates and screws.

  2. Some surgeons grind down the wall of bone as far as possible without breaking through and then build up the area around any remaining bossing with hydroxyapatite bone cement if necessary. The hydroxyapatite bone cement, commercially available as BoneSource, can smooth out any visible step between remaining bossing and the rest of the forehead to provider a smoother, more feminine appearance. In these cases some additional reduction in the bossing can sometimes be achieved by thinning the soft tissues that sit over it.

    There is a debate within FFS circles about whether it is best to remove the bossing with a reconstruction or to use the build-up method to disguise it. Some feel that a reconstruction is too invasive and that disguising the bossing is just as effective as removing it. Others feel that disguising the bossing is an unacceptable compromise and that it can sometimes leave the forehead with an unnatural bulge - these patients would rather have the bossing completely removed with the reconstruction technique.

  3. Some FFS surgeons now offer a compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.

Male foreheads also often have various indented areas. For example, the centre of the forehead is often slightly indented. These areas can be filled with hydroxyapatite during surgery to smooth them.

Brow Lift

Females tend to have higher eyebrows than males so a brow lift is often used to place the eyebrows in a more feminine position.

Rhinoplasty

Males tend to have larger and wider noses than females, and the base of the female nose will often visibly point slightly upwards when compared to a male. Standard rhinoplasty procedures are generally used to feminise a masculine nose. Noses with a slightly concave "scooped" bridge are thought by many to look particularly feminine but this only holds true for certain ethnic groups. For example: women of Northern European descent often have the scooped bridge while women of Middle Eastern descent often have a more convex shape to the bridge.

Cheek Implants

Females often have more forward projection in their cheekbones as well as fuller cheeks overall. Sometimes cheek implants are used to feminise cheeks. They come in different sizes and can be placed in different positions depending on the needs of the patient. Sometimes bone cement (hydroxyapatite cement) is used instead of silicone implants but various other materials are also used. Another possibility is a fat transfer where fat is removed from another part of the body and injected into the cheeks to make them fuller.

Lip Lift

The distance between the opening of the mouth and the base of the nose tends to be longer in males than in females and when a female mouth is open and relaxed the upper incisors are often exposed by a few millimeters. To feminise a mouth an incision is usually made just under the base of the nose and a section of skin is removed. When the gap is closed it has the effect of lifting the top lip, placing it in a more feminine position and often exposing a little of the upper incisors. The surgeon can also use a lip lift to roll the top lip out a little making it appear fuller.

Lip Filling

Females often have fuller lips than males so lip filling is often used in feminisation. There are many methods of lip filling from injecting fat into them to Gore-Tex implants.

Chin Recontouring

Males tend to have taller chins than females and while female chins tend to be rounded, male chins tend to be square with a flat base and two corners. The chin can be reduced in height either by bone shaving or with a procedure called a "sliding genioplasty" where a section of bone is removed. The square corners can usually be shaved down. Sometimes liposuction is also used to remove some of the fat that some people have underneath the chin.

Jaw Recontouring

Males' jaws tend to be wider and taller than female jaws and often have a sharp corner at the back. The back corner can be rounded off in a procedure called "mandibular angle reduction"; bone can also be shaved off along the lower edge of the jaw to reduce width and height and the chewing muscles (masseter muscles) can also be reduced to make the jaw appear narrower.

Adam's Apple Reduction

Males tend to have a much more prominent Adam's apple than females although small Adam's apples are more common in males than many people realise. The Adam's apple can be reduced with a procedure called a "tracheal shave" or "thyroid chondroplasty". It is not always possible to make a large Adam's apple invisible with this procedure, rather the intent is to change it from the masculine 90 degree angle to the feminine 120 degree angle.

Associated Procedures

Beautification and rejuvenation procedures are often performed at the same time as facial feminisation. For example, it is common for eye bags and sagging eyelids to be corrected with a procedure called "blepharoplasty" and many feminisation patients undergo a face and neck lift (rhytidectomy). It is often necessary for older patients to have a lower face-lift after jaw and chin surgery because the reduction in bone and the effects of swelling can leave sagging skin.

Facial Feminization Surgery Results

This type of surgery yields very dramatic results that are permanent and irreversable. Any person considering such a combination of procedures, should be certain that they want to permanently present as female.

The results from this portion of the surgery are generally very dramatic, and offer tremendous psychological support. With a greatly improved femenine appearance, the transwoman will find greater social acceptance, and have much improved self-confidence.

Recovery After Facial Feminization

This surgery is generally completed on an inpatient basis, and most patients will spend one night in the hospital following surgery. A dressing is placed around the forehead after surgery, and left in place during the first night. It can be removed the day following surgery.

After removal of the dressing, showering and gentle washing of the hair is completed daily for a few days. If chin surgery has been completed at the same time, there will be a tape supporting dressing. This must stay dry, in which case the hair will need to be washed by someone else while lying down.

There will be some pain for a few days, which will require pain medications. While infections are extremely rare, antibiotics are utilized to avoid any potential infection. Swelling and any black and blueness that occurs around the eye will generally be gone within 10-12 days following the surgery. There may be some forehead numbness lasting several weeks to possibly years. Other nerve injuries that might rarely occur will be discussed by your doctor during consultation.

FFS Post Operative Care

Many patients are able to go back to work at their usual activities (especially if they can work at home) within 2-4 days following surgery. It is not advisable to do anything that would require exertion sufficient to cause you to sweat or to have a rise in pulse or blood pressure for 8 days following surgery. The sutures and staples utilized to close the scalp incisions are generally removed by 9 days following surgery.

Possible FFS Risks

It's important to remember that facial feminization surgery is elective and permanent. Facial feminization surgery, like any surgery, has its risks. Below is a list of possible risks to consider when exploring facial feminization surgery:

Severe Risks of Facial Feminization Surgery

Blood loss - Patients rarely hemorrhage after surgery, but donor blood could carry infectious diseases. To avoid this stop all drugs that affect clotting.

Blood clots - These can lead to heart attack or stroke. Ask your endocrinologist if you should stop taking drugs and hormones, and stop smoking to avoid this risk.

Infection – Improper surgical procedure or post-op care can lead to infections and affect recovery time, surgical outcome, and, in extreme cases, cause death.

Pneumonia - Fluid in the lungs can build up after surgery. The best way to avoid this is to quit smoking, get in shape, use an incentive respirator, or walk or sit up as much as possible after surgery.

Necrosis - Death of tissue can be caused by infection, tissue rejection or loss of blood supply to tissue.

Paralysis – A severed nerve or stroke or blood clot can cause mild to moderate effects on muscles around the mouth, usually on one side or the other.

Allergic reaction - Reactions from anesthesia or certain drugs like penicillin can close air passages or send a patient into shock. Non-fatal reactions include rashes and hives. Inform the doctor of all allergies drugs taken in the month prior to surgery.

Visual changes - Some patients have reported visual problems because of tightened tissue and swelling. Double vision or distortion in one or both eyes may also occur. Blindness could also occur, but is extremely rare.

Speech changes – Patients have reported slight to noticeable slurring or lisping following facial feminization surgery, especially chin work. Sometimes facial feminization surgery can affect control of the lower lip. Pronouncing "s" can also be difficult.

Less Serious Risks of Facial Feminization Surgery

Weakness and Fatigue - Mental and physical activities can be more difficult for many months after facial feminization surgery. Getting in shape prior to surgery, quitting smoking and avoiding overexertion will help with a quicker recovery.

Numbness - Numbness in some or all areas the face may occur after facial feminization surgery. This can make it difficult to notice saliva or food on the face. Less sensitivity to hot or cold items can also be dangerous.

Pain - Permanent pain may occur as a result of a severed nerve or other mistake.

Hypersensitivity – Some areas may be permanently too sensitive to be touched.

Bleeding - Mild bleeding may occur as incisions heal, especially during facial feminization surgery involving the noses and mouth.

Sore throat - Breathing tubes put in during general anesthesia may cause a sore throat, making it difficult to eat or drink Eat soft foods around room temperature to help.

Shocks - Tiny nerves that have been cut or disturbed during facial feminization surgery may send out tiny electric shocks to the face as they regenerate and heal. This can be painful and last for as long as a three months.

Swelling and Bruising - Expected after surgery, but very greatly by individual. The bruising looks worse than it feels.

Nausea - Post-surgical nausea from anesthesia can occur ranging from loss of appetite to severe vomiting.

Skin problems - Rashes or bedsores can occur from not moving around after facial feminization surgery.

Cosmetic Risks of Facial Feminization Surgery

Scarring - Surgery will cause scars. Depending on skin type, the surgeon's skill, and post-op maintenance, scars can be unnoticeable or prominent. Show your surgeon incisions or scars before facial feminization surgery so they can understand the skin's healing process. Follow the surgeon's post-op instructions diligently, and ask about vitamin E oil, silicone sheets, oral vitamin B1, cortisone creams or other topical preparations.

Grafts – Scarring may occur at the donor site as well as the graft site.

Keloids - Raised, dark scars may occur on certain skin types, but are more common on dark or black skin.

Shape - Unsatisfactory cosmetic results may occur including too much or too little change, or a disproportionate looking face, which can make it look like work has been done.

Positioning – Since a face is asymmetrical, improper work can make adjustments more noticeable. Brows may look too high, skin too tight, lips too high or low, or a nose or mouth can look off-center

Psychological Risks of Facial Feminization Surgery

Depression - Almost every patient can suffer some level of post-surgical depression because of the event's build-up before surgery. Some people rely on facial feminization surgery as a solution for problems the surgery cannot solve. Keep realistic expectations of the recovery and outcome of facial feminization surgery.

Anxiety - Anxiousness and worried feelings can occur as patients heal. Immediately after facial feminization surgery, patients may feel they look horrible and worry they'll never look normal again. As the bruising and swelling subsides, anxiety should also decrease. Thoroughly researching the procedure and the surgeon will often help.

Regret - Some patients feel they made a poor choice of surgeons or wish they had not had the facial feminization surgery. This is especially true when complications or poor cosmetic results occur. It's best to have realistic expectations of recovery and outcome.

Remember that a good surgeon will rarely have complications and will honestly discuss the likelihood of risks during your consultation. A Surgeon at a University medical center will often be able to provide the safest and best surgical procedures.