Facial feminization surgery (FFS) for MtF transgender women

gender dysphoria transgender symbol

Facial feminization surgery (FFS) defines a broad range of procedures that modify the aesthetics of the face making it more feminine, as per the classic features of the biologic gender. It is sometimes referred to as Facial Gender Confirmation Surgery.

The procedures we will talk about in this blog post fall within the domain of cosmetic surgery when they are performed on cisgender women who are not satisfied with their facial traits sometimes defined as too masculine by themselves like often happens for the nose, chin or mandible; in this blog post though we are going to specifically cover the case of transgender women, in which case it is more appropriate to refer to these procedures as reconstructive surgeries or as surgical therapy for the treatment of gender dysphoria.

In most human interactions the face is the first part of the body that catches the eye. By looking at somebody’s face, we are able to extract important information about one another, such as age, gender or the emotional state. The first impression on someone is processed unconsciously within the first few seconds of meeting and is almost completely based on the analysis of the face and its expressions. The face reflects the personality of an individual as well as the emotions as communicates both verbally and non-verbally with the speakers.

For a transgender woman it is very important to look on the outside in a way that is congruent with their gender identity, reason for which the facial feminization surgeries are sought-after and increasing in popularity year by year, with a continuous improvement of surgical techniques.

Other parts of the body might be hidden or covered by clothes, but facial features generally are not: facial feminization surgeries might help in the correct identification of the gender by strangers and in creating harmony between the gender identity and the external look, improving the wellbeing of the individuals especially in social environments.

Facial Aesthetics: differences between male and female facial features

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Facial features differ between the two biologic genders as well as they vary based on ethnicity and age. The main differences in facial features among the two biologic genders, based on most of the experts’ consensus and authors, are the following:

  • Female faces are generally rounder with soft facial features, whilst male faces are more angular and squared.
  • The hairline in females is linear and gently curved, whilst in males it is higher and M shaped.
  • The forehead of a male is usually wider and higher, flat with a backward slope, a bony ridge across the forehead (brow bossing) and might present frontal bossing too. The female forehead is round shaped, smooth with no bossing and more vertical.
  • The eyebrows are thicker, straight shaped and positioned under the orbital rim in males; females have arched and thinner eyebrows positioned above the orbital rim.
  • Female eyes are bigger, while male ones look smaller and more nestled into the skull.
  • The nose has high variability like any phenotypical human trait, but in general and ideally the male nose is wider and longer, with a straight or convex nose bridge; the female nose is narrower and shorter, with a concave nose bridge. The tip of the nose is more projected (“far from the face”) in males than in females.
  • Cheeks are flatter, lower and squared in males. In females they are rounder, higher and more pronounced.
  • Male lips are thinner and straight with a greater distance between the base of the nose and the upper lip. Female lips are plumper, with the upper lip curved and slightly raised exposing the teeth.
  • Male chins are wider and protruding, while female chins are rounded or pointed and less protruding.
  • The male mandible is larger with hypertrophic masseter muscle.
  • The mandibular angle is close to 90°, giving them a squared face, while females have a greater mandibular angle which gives them a rounder and V-shaped face.
  • The thyroid cartilage, aka the Adam’s apple, is a typical male feature as it develops more in males due to androgen (testosterone) stimulation; it belongs to the secondary sexual characters that develop during puberty. In females this cartilage is less visible and less palpable to the touch. Although not being technically on the face, its modification is generally considered part of the facial feminization surgeries.

In general, single specific features extracted from a face are not objectively masculine or feminine; nor there are standard male or female facial measurements. The face has to be looked as a whole, looking at the harmony, symmetry and proportions between the different structures and regions of the face and in general looking at the entirety of the facial features.

The modification of the abovementioned features is possible uniquely by undergoing surgery.

Moreover, there are also quantitative and qualitative differences that give a different look to biologic male and female faces:

  • Males have more facial hair which tend to be thicker, longer and darker.
  • Males have thicker skin, which is also more elastic thanks to the dermal layer richer in elastin and collagen.
  • The stratum corneum (outermost layer) of the epidermis is thicker in males, making the skin look and feel rougher.
  • Male skin has a greater number of sebaceous glands, hence it is oilier than the female skin; sebum gives it more protection against environmental factors.
  • Sebum also has different biochemical characteristics; the sweat is different between females and males as well, and men sweat more as well.
  • Pores are present in higher numbers and are larger in male skin when compared to female skin.
  • When aging, male’s skin gets progressively thinner due to the loss of dermal proteins such as collagen, elastin and hyaluronic acid, while female skin stays almost the same until menopause, significantly getting thinner after that; hence, the two biological sexes age differently and express facial aging in a different way.

The abovementioned features are influenced by hormones, so they can’t be modified with plastic surgery. Feminizing hormone replacement therapy instead is capable of gradually modifying these features of human skin, with effects that vary based on the specific characteristics of each individual.

Lastly, to complete the facial aesthetics also the lights are important: by creating shades based on the concavities and convexities of the face they alter our image. For this reason, by altering the perception of lights and shades, make-up is very effective in changing our image and is capable of making it, in this case, more feminine without resorting to plastic surgery.

So how many facial feminization surgeries do I need??

Reading the long list of differences between a biological male and female face you might be thinking that in order to feminize the face dozens of surgical procedures are required; which would also translate into long recoveries, high expenses, lot of pain, and a long time period before achieving the desired results.

First off it is good to remind that no surgical procedure is mandatory. It is up to each own individual to accept their own image or to evaluate the need for a surgical intervention. No one should be judged for their choice, whether it is to resort to plastic surgery or to not undergo any procedure. What it is important is to not suffer from gender dysphoria and if someone is able to do that without any surgery, avoiding risks, costs and times related to them, even better.

Once someone decides to undergo facial feminization procedures it is of utmost importance to turn to a specialist: a surgeon with specific studies and experience in such procedures. A surgeon who is specialized in facial feminization surgeries for the MtF transgender and with specific training in maxillofacial surgery and craniofacial surgery. Most of plastic surgeons are trained to perform procedures on soft tissues in any region of the body; however, for a long lasting and satisfactory result in FFS it is often needed to perform modifications of the bone structure underlying the soft tissues. Moreover, specific knowledge and experience are still not enough to guarantee success: for these procedures you also have to be an artist, having eye for detail, understanding of proportions and face harmony, aesthetic sense and awareness also of the most subtle details that make a difference in the aesthetic of the two biologic genders.

The choice of the surgeon, when undergoing facial feminization procedures, is fundamental in order to achieve satisfactory post-op results that meet the expectations of the patient.

As stated before, once someone decides to undergo FFS they won’t actually require dozens of procedures as there is no need to change every single aspect and structure of the face. A great surgeon is able to understand and advise on what procedures will have great impact in the overall aesthetics and what procedures actually aren’t needed. For example, a research paper published by Dr. Spiegel MD – FACS determined that the upper third of the face, which is the forehead, has great effect on our perception of gender: in his study, 6 out of 7 patients who underwent just forehead feminization were later correctly identified with their gender identity.

Criteria for facial feminization surgery and pre-op procedures

facial feminization surgery

During the consultation the surgeon will ask questions to understand the details and features of one’s face that the patient doesn’t like and wants to modify.

As for any other surgical procedure, the surgeon will then collect family and personal medical history (anamnesis), will order blood lab tests, electrophysiological examinations (EKG), and imaging studies (such as head CT). The surgeon will look into your immunizations, might prescribe screening exams based on age and gender, will ask about tobacco, alcohol and drug use, will check for STDs. Then the anesthesiologic consultation will be scheduled to get the green light for surgery.

Once notes on the features that would like to be changed are taken, the surgeon will analyze the face. To do that he will take high resolution pictures of the face from different angles. He will measure angles, widths, lengths, projections, proportions and relations between the different facial features. Once the facial analysis is completed the surgeon will be able to advise on one or more procedures needed to achieve the results desired by the patient as well as he will help the patient in having realistic expectations and will explain the risks related to each surgery. Some surgeons might also be able to show a 3D simulation of how the final look might be, to help better understand the possible results.

According to the Standards of Care 7th edition of the World Professional Association for Transgender Health (WPATH), there are no prerequisites for FFS unlike hormone replacement therapy or sex reassignment surgery.

The only requirement is to sign the informed consent once the surgeon will have explained the nature of the surgery, expected results, risks and possible alternate treatments. However, some surgeons might ask for a psychiatric consult to better understand the reason why the patient resorts to such invasive procedures. The mental health professional will try to understand whether or not the patient suffers from gender dysphoria, the consequences it has on their mental health and on their social life, the subsistence of other mental or behavioral issues, the tendency to risky behavior, the presence of family or friends support, the expectations about this surgery and the further goals of the patient in the treatment of gender dysphoria. The coexistence of other medical or psychiatric issues does not necessarily exclude the patient from FFS: if well managed and controlled and they do not pose a risk to the health and wellbeing of the patient the surgeries will be possible, nonetheless.

Surgical procedures for facial feminization

Scalp advancement

Scalp advancement, also known as hairline advancement, is a procedure that aims at modifying the hairline shape and lowering it to reduce the distance between the hairline and the eyebrows.

Typically, biologic males have wider and taller foreheads with an M shaped hairline, which also recedes with aging and based on the genetic profile.

This surgery is performed by making an incision hidden in the hair, at the hairline level or even lower. A strip of skin is then excised causing the advancement of the hairline and its modification depending on the shape of the cut.

This procedure can be coupled with a hair transplant to further modify or to refine some details of the hairline.

FUE Hair Transplant

The FUE hair transplant technique is a valid alternative to hairline advancement surgery. In the case of facial feminization, it is aimed at the patients that due to androgen hormones and their genetic profile had the hairline rising, or had some hair thinning, or a receding hairline with the classic M shape.

The only requisite for this surgery is to have a donor area capable of donating the needed number of follicular units to perform the surgery and obtaining the expected result.

Forehead reshaping and contouring

When talking about facial feminization surgery, intended as a set of procedures performed on the same patient, forehead reshaping is a cranio-facial surgery that is often included in that. This is because the forehead makes up to 30-40% of the facial surface, hence its reshaping produces a pronounced change in facial aesthetics. There are several surgical techniques to perform forehead contouring, some of which are proprietary meaning they have been developed and are performed exclusively by one surgeon or clinic.

Forehead reshaping might involve the grinding or reduction of frontal bossing; the surgical fracturing of the frontal bone and its repositioning with or without reshaping it; or the removal of part of the frontal bone and the grinding of the underlying bony structure at the level of the paranasal sinuses and then repositioning the frontal bone and firmly attaching it in place with a titanium plate and screws. These are just some of the most common interventions, but there are more and sometimes they are referred to as forehead reconstruction.

This surgical procedure is often coupled to the superior orbital rim reshaping in order to obtain a harmonious result of the whole upper third of the face.

Superior orbital rim reshaping

The superior orbital rim reshaping procedure has the goal of modifying a typical biological male facial feature, which is the brow bossing or horizontal bony ridge at the level of the eyebrows. Brow bossing is often more prominent and clearer than the frontal bossing.

To perform this procedure and feminize this feature, the surgeon performs an osteotomy, the surgical cut of the bone tissue, followed by some grinding to improve the result and create a smooth continuous profile with the forehead.

The superior orbital rim reshaping by itself can greatly change the overall appearance, like the forehead reconstruction, and highly feminize the face.

Brow lift

The brow lift, also known as the forehead lift, is a very common procedure with over 40,000 surgeries per year performed just in the USA.

Its usual goal is rejuvenating the forehead by reducing wrinkles and lines by pulling forehead skin upwards, which also raises the eyebrows in a more youthful position or in the case of the transgender women in a more feminine position. Moreover, it can correct the ptosis of the eyebrow over the eyelid in older individuals.

The eyebrows can not only be raised in a more youthful and feminine position, which is above the superior orbital rim, but can also be shaped with the typical arched eyebrow shape of the biologic female, with its peak located right over the lateral canthus (corner) of the eye.

The surgical approach can vary greatly with an incision right over the eyebrow, or on the upper eyelid as per a blepharoplasty, or along the hairline, or with a coronal incision which is an incision 2-3cm behind the hairline.

The brow lift does not reduce the distance between the eyebrows and the hairline; on the contrary, it might lengthen it by slightly raising the hairline. For this reason, it is sometimes coupled with the scalp advancement procedure aforementioned.

Malarplasty: cheek augmentation and reshaping

Male cheeks are flatter and lack projection when compared to female ones, meaning they are not as prominent.

To create the elevation typical of biologic females, implants are usually placed by an incision within the oral cavity. Sometimes this can be done with less invasive procedures such as autologous fat graft or a filler injection. To accentuate even more the cheekbones, sometimes the Bichat’s fat pads (aka buccal fat pad) are excised. These fat pads are located right under the cheekbone in the cheek. This makes the cheeks hollower accentuating the cheekbones.

Rhinoplasty

Feminizing rhinoplasty has the goal of addressing the differences between the biologic male and female anatomy as described in the previous paragraphs. The procedure is not different from a common rhinoplasty performed on a cisgender male or female, besides one detail: if the surgeon is going to perform more than one procedure as a set of facial feminization surgeries, he will have to take into consideration all of the changes in order to respect the proportions and create a nose balanced and harmonious with the other newly shaped facial features.

Mandibular angle reduction and jaw contouring

The jaw has an important role in gender identification. Face width is determined not only by the mandibular bone, but also by the masseter muscle; moreover, the mandibular angle and shape of the chin are all gender indicators. Even though as already stated previously there are no exactly defined measurements pertaining to the two biological genders, men tend to have a large and squared lower third of the face, while women tend to have it more round and pointy and when paired with the cheekbones it gives them a heart-shaped face.

To modify these features, the surgeon makes an incision within the oral cavity, on the side and posteriorly to the teeth, from where he will have access to the mandibular angle. Depending upon the case, he might grind it down or proceed with an osteotomy, the surgical cut of the bone, for a marked modification. Part of the masseter muscle might be excised as well, contributing to slimming the lower third of the face, which is a common procedure among Asian cisgender females too.

Genioplasty: chin reshaping

The chin is generally squared, bigger and more projected in biological males, while being pointy, rounded, smaller in biological females. It can be modified with surgery both by direct intervention on the bone or, in some cases, with implants.

The surgeon makes an incision within the oral cavity, between the lower lip and the gum, to get access to the mandible. Then proceeds with the excision and/or cut of part of the bone and to rearrange the bone segments to achieve the desired shape.

It is of utmost importance to have proper knowledge of jaw anatomy: there are blood vessels and nerves coming out of it in close proximity to the chin which could easily get damaged and cause loss or reduced sensitivity not only to the chin, but also to the lower lip and the roots of the teeth.

It is also important to properly fix the bone segments or the implant in place in order to avoid migration and a change of shape of the chin post-op.

Pre-op it is important to understand if there is any malocclusion which might require orthognathic surgery or special care during the procedure.

Cheiloplasty: lip surgery

Cheiloplasty is a generic term indicating any type of lip surgery. In the specific case of facial feminization procedures this could indicate an upper lip lift, a lip reshaping and/or lip augmentation. All of these procedures contribute to a more feminine look of the face.

Upper lip lift reduces the distance between the alar base of the nose and the upper lip; it also produces a slight opening of the mouth with partial exposure of the upper teeth, which is a typical female feature. Upper lip lift can be achieved with small incisions at the base of the nose or along the upper border of the lip and then excising a strip of tissue.

Lip augmentation can be achieved by a filler injection such as hyaluronic acid or with an autologous fat injection (fat graft).

Lip reshaping is achieved by placing strategic stitches and removing parts of tissue and is aimed at providing the typical sinuosity of the upper lip (Cupid’s bow) and at exposing further the vermilion. The mouth corner lift can be realized by small incisions of the corner of the mouth, excision of part of the tissue and placing of stitches; this last procedure also fixes a common aesthetic defect that comes from aging or which is sometimes congenital: the ptosis of the corners of the mouth which cause a down turned “sad” appearance to the mouth.

Chondrolaryngoplasty: Adam’s apple reduction surgery

Also known as tracheal shaving, the chondrolaryngoplasty aims at reducing the typical male prominence on the anterior part of the neck, which develops more in male during puberty due to its androgen sensitivity and which is a clear and widely known gender indicator. For this reason, Adam’s apple reduction is a common procedure in male to female transition.

The surgeon performs a small incision horizontally as high as possible so that the resulting scar will be hidden when healed. Soft tissues are dissected to expose the thyroid cartilage which is then reduced in volume by exciding a portion in its upper part, above the attachment of the vocal folds to preserve their function.

 

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Minimally invasive techniques in facial feminization surgery: fillers and botox

Besides the invasive surgical techniques, there are also non-invasive or minimally invasive options for the feminization of the face: the injection of biologic fillers (we always recommend not to use permanent or alloplastic fillers) such as hyaluronic acid or autologous fat injections and the use of neuromodulators such as Botox.

It is always of utmost importance to consult with a medical professional who is qualified and expert in such techniques. The knowledge of facial anatomy, the course of blood vessels and nerves, is very important in order to avoid issues and lower the possible risks of these techniques to the minimum. Experience in such techniques and artistical and aesthetic sense are required to obtain a result coherent with the patient’s expectations.

The results obtained this way are temporary and require recurring treatment. Besides a general rejuvenation of the face, it is possible to modify facial features by augmenting the nose, forehead, lips, eyes, jaw, cheeks and chin with a filler injection which can produce varying results, from subtle to more obvious ones.

Botox too can modify facial features and its use is not limited to rejuvenation: from non-surgical eyebrow lift to the masseter muscle reduction with slimming of the jaw.

Lasers, radiofrequency (RF), intense pulsed light (IPL), chemical peels, …

Lastly, there are also other minimally invasive treatments such as laser therapy, radiofrequency, intense pulsed light and chemical peels to cite a few common ones; these medical treatments can improve the look of the skin, its elasticity, its color, treat pigmentation issues or scars, rejuvenate and overall help achieve a neater and more feminine appearance.

Besides the laser or IPL hair removal, they are not feminizing treatments per se, but are able to contribute and assist in conjunction with other medical or surgical treatments in achieving the goal set by the individual.

Risks and complications of facial feminization procedures

Any medical or surgical intervention carries risks.

For what concerns general anesthesia, there is the anesthesiologic risk, generally minimal in healthy individuals, but still present. Among the side effects of anesthesia there are nausea, vomit, headache, dry mouth, sore throat, and drowsiness. Some of these can be treated with medications, but anyway they are all temporary side effects.

Some of the above-mentioned surgeries and procedures can be performed under local anesthesia, which reduces both the risks and the side effects.

There is also the intrinsic surgical risk of any surgery, which can be divided into generic surgical risk and specific risk based on the procedure, on the technique and on the materials used. Among the generic surgical risks there are patient dissatisfaction with the results, asymmetries when performing surgery on symmetrical features, scarring, hemorrhage, swelling, seromas, bruises, pain, infections, wound healing complications, nerve damage with sensitivity issues, allergic reactions and tissue necrosis.

FAQs – Frequently asked questions on facial feminization surgery

How long after surgery will the results be visible?

Stable and definitive results might require up to one year after surgery. During this period of time, you will have scheduled visits with your surgeon and will stay in touch with him to monitor the changes or talk about any doubt or complication that might arise.

Is it possible to preview the results with the aid of modern technologies?

This service can be provided by digital elaboration of the photographic images or with 3D simulation, but it depends from the surgeon and the clinic. It is not just because you need instruments and software to provide this service, but also because sometimes these previews lead the patient to unrealistic expectations and post-op dissatisfaction; for this reason, some surgeons don’t offer this service.

How long before I can go back to work?

It depends from the procedure you underwent. In general, the recovery varies between 2 and 4 weeks. Those who work from home might be able to get back to work few days after surgery, while those who wish to wait until total recovery might have to wait 4 weeks.

Is it possible to feminize any face?

It is possible to modify traits and facial features of any face and make them more feminine. The only cases when this is not possible are those who have contraindications to surgical procedures due to the risks for the patient.

Is facial feminization painful?

It depends from the procedure. In general, during surgery you will be under general or local anesthesia so no pain can be felt. After surgery you will receive pain medications to mitigate pain and you should just feel discomfort.

Will face feminization surgery make me unrecognizable?

No, the goal of the surgeon is to feminize your facial features, not to completely alter them.

Some modifications are subtle, other more obvious, but it will still be you, recognized by family and friends, but with a more feminine look which is congruent with your gender identity. If you choose a good surgeon, the general physiognomy of your face will stay the same.

Is facial feminization surgery only for transgender women?

No, these surgeries are often sought after by biologic women who feel they have masculine facial features and want to change them. Moreover, some men desire a more androgynous look, so they undergo some of these procedures as well.


Sources:
  • Lesbian, Gay, Bisexual, and Transgender Healthcare. A Clinical Guide to Preventive, Primary, and Specialist Care.
    KL Eckstrand, JM Ehrenfeld – Springer, 2016
  • Surgical Management of the Transgender Patient
    LS Schechter – Elsevier, 2017
  • Principles of Transgender Medicine and Surgery – 2nd edition
    Ettner R, Monstrey S, Coleman E – Routledge 2016
  • Transgender Medicine – A multidisciplinary Approach
    Poretsky L, Hembree WC – Springer 2019
  • Facial determinants of female gender and feminizing forehead cranioplasty.
    JH Spiegel – Laryngoscope, 2011
  • Male versus female skin: What dermatologists and cosmeticians should know.
    Rahrovan S, Fanian F, Mehryan P, Humbert P, Firooz A – Int J Womens Dermatol, Giu 2018
  • Facial feminization surgery: a guide for the transgendered woman.
    Ousterhout DK – Omaha, Nebraska: Addicus Books; 2009
  • Facial feminization surgery: current state of the art.
    Altman K – International Journal of Oral and Maxillofacial Surgery, 2012
  • The American Society of Plastic Surgeons (ASPS)

 

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