Facial Masculinization Surgery (FMS)

Authored by: Barry L. Eppley, MD, DMD

Facial masculinization surgery (FMS) refers to a group of cosmetic treatments aimed at making feminine features appear more masculine. Like facial feminization surgery(FFS), the treatments are often associated with transgender patients. FMS is also sought by men seeking stronger and more defined facial features.

An FMS surgeon analyzes the three major facial thirds (upper, mid and lower) to develop a cus-tom treatment plan to elicit the maximum masculinizing effect. Most FMS procedures involve some form of bone or hard tissue augmentation.

There are many FMS procedures available, and while most patients do not choose to undergo all of them, it’s extremely common to undergo more than one procedure at once to save time and get the best transformative (or enhancing) effect.

Preoperative Evaluation for FMS

The preoperative FMS process allows doctor and patient to get on the same page in terms of goals and treatment options. Considering that many of the facial procedures performed as part of FMS create irreversible changes, it is essential that patients are aware of the magnitude of the modifications that these procedures create. As such, preoperative computer imaging helps better set and manage patient expectation. No patient should undergo FMS without some sort of pre-dictive tool aiding the decision process.

Although computer imaging is an essential component of the preoperative process, it’s merely representative of an approximation of the facial changes that may occur.

Facial Masculinization Surgery Procedures

Facial masculinization procedures are broken down into four categories based on the associated zones of treatment: skull/forehead, midface, lower jaw and neck. Depending on the number of procedures involved, FMS may be performed in an outpatient surgery center or at a hospital. Treatment time may be as little as one hour, or it may take considerably longer for complex cases with multiple procedures. For such cases, the doctor may recommend keeping the patient over-night to monitor initial recovery. (You will get a clearer understanding of treatment time during your consult.)

All FMS procedures are performed under general anesthesia by board-certified plastic surgeons, many of who specialize in facial masculinization procedures, and have additional training and experience with craniofacial surgery.

FMS procedures include:

FOREHEAD/BROW BONES

Brow Bone Augmentation

Strong brow bones with a brow bone break are the hallmark of a masculine upper third face. In the past, the typical approach has been the application of bone cements through an open coronal incision across the head. However, a more contemporary approach is to use a custom brow bone implant made from a 3D CT scan. The design process allows for the pre-surgical determination of the exact degree of increased brow bone protrusion as well as how far it extends down along the lateral orbital rim. This type of forehead implant can be placed using an endoscopic approach through a small scalp incision and sometimes via upper eyelid incisions.

Forehead Augmentation/Reshaping

The shape of the male forehead is less rounded and vertically inclined than that of the female. Achieving a broader forehead that is flatter and squarer is best done with a custom forehead im-plant in those lacking adequate projection. In some cases, a combined forehead-brow bone im-plant is the best approach to create a more masculine appearance to the upper third of the face.

MIDFACE

Rhinoplasty

Rhinoplasty is a common FMS procedure given that there are major gender differences in the shape of the nose. A masculine nose boasts a straight or even slightly convex dorsal line. A nasal tip that is not too narrow and has nasolabial angle that is at 95 degrees or less is preferred. An open rhinoplasty is usually needed to achieve adequate changes and often times, cartilage grafts or implants will be needed. Functional breathing issues can be taken care of at the same time as the cosmetic nasal changes.

Cheek Augmentation

Ideally, male cheeks have more fullness higher on the cheeks and back along the cheekbone for more defined and angular cheek highlights. Cheek implants are usually not sufficient in FMS. Specially designed cheek implants are used to create this uniquely male/model cheek look.

Some cases of cheek augmentation can also be done using autologous fat injections. There are advantages and disadvantages to both of these cheek augmentation approaches. Your surgeon can help guide the process after a frank discussion about your aesthetic goals that take your anat-omy into account.

Buccal Lipectomies and Perioral Mound Liposuction

Many men seek a more angular facial shape. To achieve this (or “de-round” the face) as much as possible, the removal of selective areas of facial fat can complement other facial augmentation procedures. Besides the neck, the only areas of the face where fat can be removed is the buccal pads, and subcutaneous fat around the mouth and back (which age the jawline). These select are-as of fat can be removed via small incisions inside the mouth. Such facial fat removal produces more modest reduction changes between the cheeks and jawline.

LOWER FACE

Chin Augmentation

Chin augmentation is the single most important lower-face procedure in FMS. (A prominent chin is a wholly distinct male feature) Chin augmentation is often perceived only in the profile, ignor-ing the appearance from the front view, so it’s important to consider chin width and squareness as well. An augmented chin that appears more masculine often has a squarer shape to it.

Chin augmentation can be done through an intraoral or submental skin approach. The most effec-tive technique is submental where the risks of infection are lower and better implant position can be assured.

Jawline Augmentation

One of the key features of the male face is the jawline. Technically this means the angles of the jaw, but often means the entire jawline from the chin to the jaw angles. Having more defined jaw angles together with a prominent chin creates a lower third of the face that defines masculinity. This can be achieved with standard chin and jaw angles implants, or with a custom one-piece jawline implant made from the patient’s 3D CT scan.

NECK Tracheal Augmentation

A prominent Adam’s apple or thyroid cartilage creates a central neck bulge that is a distinctively male trait. It can be created for FMS by a special implant designed to create a more prominent v-shaped thyroid prominence that is placed through a small overlying skin incision.

Facial Masculinization Surgery Recovery

The FMS recovery process largely revolves around the amount of swelling that occurs during treatment. Fortunately, the swelling is more of an aesthetic issue rather than a functional issue, meaning that patients recovering from FMS shouldn’t experience any functional limitations.

The amount of swelling that occurs is largely down to the type and number of procedures per-formed as part of FMS. That said, there are general postoperative guidelines that can help to es-timate the amount of swelling to expect after treatment. Approximately 50 percent of facial swelling should subside within 10 to 14 days of FMS. Close to 65 percent should subside within three weeks of treatment, and virtually all swelling should be gone by six weeks after surgery.

The reality is that it takes longer for facial swelling and bruising to go away than most patients realize. Being out in public or returning to work is more of a personal decision tied to how a pa-tient feels about their facial appearance. The results of any facial surgery cannot be fully assessed until at least three months after treatment, at which point swelling has subsided and the overlying soft tissues have contracted back down over the reshaped facial framework.

Complications and Risks

FMS procedures are generally very safe with high success rates. However, as with any medical procedure, there is the potential for complications. These can be viewed as medical and aesthetic complications.

The most significant medical risks are that of infection, and permanent numbness of nerves close to the implanted facial areas. These complications are not very common.

The aesthetic risks of FMS surgery are usually of greater relevance and are how the facial out-come appears and how it is perceived by the patient. For example, scarring from the procedure may be more pronounced than the patient expected. There is always the risk of the need for revision of the procedures to optimize their aesthetic outcomes.

Facial Masculinization Surgery Cost & Insurance Coverage

The only way to get a true sense of the cost of FMS is to schedule a consultation with a board-certified plastic surgeon regarding the scope of treatment. The cost can vary greatly depending on the number of procedures performed as part of FMS, the cost of the implants used (if any), the operative time required for the surgery, the location at which it is performed, etc.

The cost of FMS may be covered by insurance in cases of documented female-to-male transgender surgery. However, for the more common instances of men seeking to improve their natural genetic appearance, the treatment is viewed as purely cosmetic and therefore not covered.

Consult a Qualified Plastic Surgeon

Most patients have a number of surgeons practicing in and around their general area, so it’s important to know what to look for when selecting one for FMS. Your surgeon should be board-certified by the American Board of Plastic Surgery with extensive experience in facial reshaping procedures (specifically facial masculinization surgery). Although it’s a good indicator, keep in mind that board certification may not always guarantee good results or a good experience.

Here are some additional points to consider when choosing a plastic surgeon for FMS:

• Evaluate surgeon’s credentials, education, training, certifications, and experience with the procedures in question.
• View before-and-after photos of other FMS patients.
• Compile a list of the aesthetic changes you are most focused on to discuss with your surgeon.
• Ask questions about the procedure, such as where the surgery will be performed, its extent, and the potential risks and complications.
• How long it will take to recover from surgery and when you can return to normal activities.

About the Reviewer of This Article

Barry L. Eppley, MD, DMD is a licensed phyisican and dentist board-certified in the specialties of plastic and reconstructive surgery, and oral and maxillofacial surgery. This diverse combination of specialties gives Dr. Eppley a unique degree of experience and perspective in helping patients with a wide range of issues ranging from cranio and maxillofacial, to breast augmentation, face lift, body contouring and other aesthetic procedures. To learn more about Dr. Eppley, visit his practice webiste: https://www.eppleyplasticsurgery.com/