Facial Feminization Surgery

Facial feminization surgery (FFS) encompasses a broad range of surgical procedures to feminize a face that are performed to alleviate gender dysphoria.  This dysphoria is due to a discrepancy between a person’s chosen gender and that person’s assigned sex at birth. By removing masculine features to create a softer and more feminine face, FFS helps transgender women align their external appearance with their gender identity.

Facial Feminization Surgery Overview

There are many procedures that can be done to feminize a face as many facial features reflect gender differences. Commonly best performed procedures include scalp advancement (hairline lowering), brow lift, forehead contouring, rhinoplasty, upper lip lift, jaw contouring, chin contouring, and tracheal chondroplasty (tracheal shave). The extent of surgery is customized and tailored to each individual patient’s goals.

FFS is one part of gender-affirming care that includes both medical treatment such as hormones and surgery on different parts of the body.  Many procedures can be done to feminize a face as many facial features reflect gender differences.  The extent of surgery is customized and tailored to each patient’s goals.

Who Might Need Facial Feminization Surgery?

Transgender women with persistent gender dysphoria due to masculine facial features can benefit from facial feminization surgery.  Often these patients have socially transitioned and are living as a woman and have been on hormone therapy.  FFS can also be appropriate for gender nonbinary people who are looking for a more feminine appearance.  Additionally, cisgender women who are bothered by certain masculine features can also benefit from FFS.

Who Shouldn’t Have Facial Feminization Surgery?

Poor candidates for FFS include those who have unrealistic expectations about surgery, those with poorly controlled mental health concerns, and those with significant medical conditions that preclude surgery such as heart disease, bleeding disorders, or problems with general anesthesia.  In general, patients should be at least over the age of 18.  FFS in transgender teenagers is highly controversial.

Is Facial Feminization Permanent?

FFS is permanent.  The changes to the different parts of the face should last a lifetime.  However, it is important to note that all faces, whether they have had surgery or not, go through changes with the aging process.  For instance, brow lift is a commonly performed procedure for FFS.  However, despite surgery, the brows still descend with aging.  The face also loses volume over time, so fat grafted to the cheeks may seem less prominent.  These changes will take many years to be manifest.

Who Performs Facial Feminization Surgery?

Facial feminization surgery falls under the umbrella of plastic surgery, referring to cosmetic and reconstructive procedures that can change one’s appearance or restore function to the body.  FFS is usually performed by a facial plastic surgeon, plastic surgeon, craniofacial surgeon, or oral maxillofacial surgeon.  Surgeons trained in these specialties have the knowledge and experience working with the bone and soft tissue of the face and understand its intricate anatomy.

What Are The Benefits Of Face Feminization Surgery?

Facial feminization surgery helps transgender women achieve a more feminine appearance that aligns with their chosen gender, alleviating gender dysphoria.  They can be their true authentic selves as they are seen as women and no longer misgendered.  This leads to increased confidence and better emotional, psychological, and social well-being.

What Are The Risks Of Facial Feminization Surgery?

As with any surgery, there are risks.  These include pain, bleeding, infection, poor healing or scarring, hair loss, nerve injury (numbness or weakness), asymmetry, need for revision, and risks associated with anesthesia.  Many of these risks can be minimized by having your surgery performed by a specialist in FFS.

How Much Does Facial Feminization Surgery Cost?

Facial feminization surgery may be covered by your health insurance plan.  When it is not covered, the cost of surgery will be an out-of-pocket expense.  The total cost depends on how many procedures are performed but it can be $50,000 or more.

What Does Facial Feminization Surgery Consist Of?

Facial feminization surgery involves addressing the different aspects of the face to remove masculine features and bring out feminine ones.

Forehead Contouring

The upper third of the face, comprising of the hairline, brows and upper eyelids, and the forehead and underlying frontal bone, shows the most gender differences.  As such, addressing this area is essential for feminization of the face.  Masculine features include excess prominence of the frontal bone and upper aspect of the orbit (eye socket).  This prominence acts as an awning over the eyes, keeping them more recessed and in shadow.  During surgery, this bony prominence is removed, and the orbits are reshaped to create a feminine shape.  This is usually done with a frontal sinus setback or type 3 cranioplasty procedure as well as shaving of the bone.  During the setback, the front wall of the frontal sinus is removed, reshaped, and replaced in a more posterior position to create a smooth and feminine forehead contour.

Scalp Advancement

The masculine hairline tends to have an “M” shape where there is recession near the temples.  The feminine hairline is typically rounded or assumes an upside-down “U” shape.  Scalp advancement is used to change the hairline into a more feminine shape and allows lowering of the hairline.

Brow Lift And Eyelid Lift

Masculine brows tend to sit lower and closer to the eyes and have a more horizontal shape while feminine brows sit higher above the eyes and peak laterally.  Lifting the brows and changing their orientation helps to feminize the face.  When combined with forehead contouring, the eyes are allowed to take center stage as they are no longer sitting in shadow and appear more open.  An eyelid lift or blepharoplasty can further make the eyes appear more youthful and feminine.

Nose Surgery For Facial Feminization

Nasal surgery for facial feminization primarily consists of a rhinoplasty.  During this procedure, the nose typically is made smaller, and the tip is made slightly upturned to give a more feminine appearance.  At the same time, anatomic issues that may affect breathing are usually corrected.  This includes straightening a deviated septum and reducing enlarged turbinates.  These surgeries are performed on the inside of the nose and do not affect the external appearance.  However, when combined with a rhinoplasty, the nose looks and functions its best.

Jaw Contouring And Chin Contouring

Like the forehead or frontal bone, the masculine jaw or mandible has extra bone that makes it appear wider and more square-like compared to the feminine jaw.  Feminine jaws tend to have more of a heart-shaped appearance.  The goal of jaw and chin contouring is to reduce the extra bone to create a more tapered and narrower jaw.  Genioplasty is another word for reshaping the chin.  Many different techniques can be used from just shaving the bone to adding a chin implant to making cuts in the bone to allow the excess bone to be removed.  These procedures are all done inside the mouth so there are no external scars.

After Jaw Or Chin Contouring For Facial Feminization

This area tends to have the most significant swelling and takes the longest to resolve as it is gravity-dependent and where all swelling will pool.  After surgery, a special dressing will be applied to help minimize swelling around the jaw.  It is advised to continue to wear a compression garment for the first month after surgery.  It typically takes 3-6 months before changes from surgery become apparent, and it will take at least a year to see the full results.  Right after surgery, you will be able to eat as nothing is done to the teeth, but it may be uncomfortable the first few days.  Most patients will start with liquids and soft foods at first, but within a few days can resume eating solid foods.

Tracheal Shave

This procedure, otherwise known as a tracheal chondroplasty or chondrolaryngoplasty, reduces the size and prominence of the Adam’s apple (thyroid cartilage).  In masculine necks, this cartilage is prominent and leads to a visible bulge.  During surgery, this prominence is reduced to achieve a smooth feminine neckline.

What Happens During Tracheal Shave

During surgery, an incision is made in a neck crease so that it will be more hidden.  The thyroid cartilage or Adam’s apple is exposed, and the prominence is removed to create a smooth neck contour.

Risks And Complications Of Tracheal Shave

It is important to know that the thyroid cartilage houses the larynx or voice box.  The voice box plays an important role in talking as well as swallowing.  Working in this area to remove excess cartilage can theoretically affect your voice, leading to hoarseness or other changes in the voice as well as swallowing difficulty.  These are usually temporary and resolve as swelling improves.  It is important to choose a surgeon who understands the anatomy in this area and has experience operating around the larynx to minimize the risk of any complications.

Recovering From A Tracheal Shave Procedure

Recovery after a tracheal shave is usually minimal.  There can be some mild pain and discomfort that typically resolves within a few days.  Some patients may find their voice is hoarse and experience some difficulty with swallowing solid foods initially, but this also tends to resolve quickly.  You can start with liquids or soft foods at first.

Fat Transfer

Fat transfer is where fat is harvested from one part of the body and used to add volume to another area.  Typically fat is harvested from the abdomen, thighs, or flanks.  Common areas in the face for fat transfer include the lower eyelids, cheeks, temples, and around the mouth.  The goal is to achieve a more feminine shape.  The fat that is transferred will be permanent but will gradually go away with the aging process.

Cheek Augmentation

FFS usually aims to reduce the size and shape in most areas of the face to remove masculine features.  However, the cheek tends to be more prominent in feminine faces.  Therefore, the goal of feminizing the cheek is augmentation.  This can be accomplished with fat transfer or implants.

Rhinoplasty

The male nose is typically larger in all dimensions compared to a female nose.  This includes the width of the nasal bones and the size of the tip.  The feminine nasal tip is also more turned up (rotated).  During feminizing rhinoplasty, the goal is to reduce the overall size and dimensions of the nose, narrow and rotate the tip, and create a nose that matches the rest of the face.  It is important to know that over-reducing the size of the nose can lead to difficulty breathing, and it is important to find a surgeon who understands the functional ramifications of surgery so that you get the best aesthetic result without compromising breathing.

Upper Lip lift

Through an incision hidden at the base of the nose, an upper lip lift removes a portion of the skin underneath the nose to shorten the distance between the nose and the upper lip.  With this procedure, the upper lip appears fuller, and there is increased tooth show which leads to a brighter smile.

Facelift And Neck Lift

The feminine face is typically more tapered and heart-shaped in the lower third while the masculine face is more square.  With aging, as the cheek tissues descend, there is more tissue that accumulates around the jaw and neck which further makes the lower part of the face appear wide.  Due to the prolonged swelling that occurs from jaw and chin contouring, the soft tissue around the jaw and neck also can become more stretched and redundant.  Facelift and neck lift can address all these issues and recreate the heart-shaped contours of a feminine face.

Nonsurgical Procedures For Facial Gender Affirmation

Fillers can be used for cheek and lip augmentation, hollowing of the lower eyelids, or to address volume loss and wrinkles in other areas of the face.  Unlike fat which tends to be permanent, fillers typically go away within 1-2 years; however, they do not require surgery or anesthesia.  Neuromodulators are useful to treat and prevent wrinkles and can help maintain the results of a brow lift.  Other procedures include hair removal and skin resurfacing.

First Assessment For FFS

At your consultation, your surgeon will get to know you, learn about your journey thus far, and discuss your specific goals for surgery.  Your surgeon will also review your medical history thoroughly, perform a complete examination of the head and neck, and take photographs.  After that, a comprehensive surgical plan is created.  You will also be referred for a CT scan to evaluate your facial anatomy.

Preparing For Facial Feminization Surgery

Before surgery, you will need preoperative clearance from your primary care physician and any preoperative tests and labs as needed.  This ensures that you are medically optimized for surgery and minimizes the risks of anesthesia.  Because surgery is extensive and the recovery long, you must be in optimal mental health to be able to go through all the ups and downs that come with having FFS.

Depending on how many procedures are planned, facial feminization surgery can be performed all at once or it may be staged over several procedures.  There are pros and cons of both approaches, and it’s best to discuss with your surgeon what is best for you.

During Your FFS Procedure: What Should I Expect From Facial Feminization Surgery?

Even as soon as one week after surgery, many of the changes in the upper third of the face and the nose can be seen, despite the swelling.  It can take a while for the swelling to subside, but once it does, a softer and more feminine you begins to emerge.  With this comes new confidence as your appearance matches your gender identity and others see you as feminine.  This leads to improved self-esteem, better quality of life, and can be life-changing.

What Happens After Facial Feminization Surgery?

In the short term, there will be significant bruising and swelling, and even some bleeding.  It can take several weeks for enough of this swelling to go down so that you start seeing the changes.  For the lower third of the face, the swelling can take up to a year to completely go away.  Many patients start to enjoy the newfound confidence of seeing their true selves emerge about a month after surgery.

FFS Recovery

The recovery course varies from patient to patient and with the number and type of procedures.  Depending on what was performed, many patients can go home to recover while some may need to be admitted to the hospital or an outpatient recovery center.

Immediately after surgery, there will be pain, bruising, and swelling.  The face is bandaged for the first few days, and you will not be able to shower until this comes off.  After this, you should wear a compression garment for the neck and lower face for at least 8 hours a day for the first month.  Sutures and splints are removed one week after surgery.  You are allowed to resume exercise two weeks after surgery.

While many patients start to enjoy their new appearance within the first month after surgery, swelling will continue to improve for many months.  Final results are usually seen one year after surgery.

How Much Discomfort Follows After FFS?

After any surgical procedure, there is expected to be some degree of pain and discomfort.  Your pain will vary depending on how many procedures are performed during your surgery.  For patients who have multiple procedures on the entire face, there is expected to be a moderate amount of pain.  Typically, this is well controlled with medication.  Most patients need to take narcotics only for the first 4-5 days after surgery.  After that, Advil and Tylenol will suffice.  For patients that have fewer procedures, Advil and Tylenol are usually all that is needed.

How Long Does Facial Feminization Surgery Take To Heal?

After surgery, there are cellular changes that continue to take place for a year or more.  Practically speaking, however, incisions will be fully closed within a week or so.  There will be swelling and possibly bruising, and both will gradually improve.  Most bruising will resolve within the first 2 weeks of surgery as long as you follow postoperative instructions and apply ice and limit your physical activity.  Swelling can take as long as a year to completely go away.

Patients often start to enjoy their new appearance within the first month after surgery, and things will only continue to improve over time.  Final results are usually seen one year after surgery.  As a result, revision surgery is usually not performed until 12 months have passed.

When To Call The Doctor

Patients should contact their surgeon if they experience signs of infection such as fevers, increased pain, swelling, or drainage as well as any chest pain, shortness of breath, or changes in mental status.  They should also call for any persistent bleeding from incisions that do not resolve.

A Note From Henry Chen

Facial feminization surgery is a permanent, life-changing, and integral part of your transition.  FFS helps you attain a more feminine face that matches your gender identity.  Choosing to undergo FFS is a deeply personal and emotional decision, and Dr. Chen wants you to feel confident and supported throughout the process.  Dr. Chen aims to listen to your goals and work with you to create a highly individualized surgical plan to achieve them.  He will make sure you are fully prepared for surgery and recovery and that all of your questions are answered.  After surgery, he will be there step-by-step through the recovery process to make sure you heal as well as possible.

Book an appointment now or visit us in Beverly Hills, Los Angeles.

Frequently Asked Questions

How Long Does Facial Feminization Surgery Last?

The length of surgery depends on how many procedures are planned.  If a comprehensive surgery is planned to address the entire face, it can take up to 12 hours.  This results in a more intensive recovery process.  For that reason, it oftentimes is better to stage them into two or three separate surgeries.  This allows you to recover faster and will be less disruptive to your schedule than an extended surgery and recovery.

How Do I Pay For FFS?

Facial feminization surgery may be covered by your health insurance plan.  It is important to note that the approval process may be long and arduous, and in the end, the coverage may only be for a portion of the total cost.  In cases where your insurance does not cover FFS, the cost of surgery will be an out-of-pocket expense.  There are financing options available such as CareCredit that can allow you to pay for the cost of surgery over time.

Does Facial Feminization Surgery Hurt?

During surgery, you are under general anesthesia and will feel no pain.  After surgery, there will be some pain and discomfort.  Often patients describe pressure and headaches due to swelling and inflammation in addition to some sensitivity inside the mouth.  A combination of Advil, Tylenol, and narcotic pain medication help relieve the pain which improves within the first 4-5 days of surgery.

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