Facial Feminization Surgery (FFS)
Authored by: Barry L. Eppley, MD, DMD
Facial feminization surgery (FFS) refers to a series of procedures used to achieve a softer, more feminine-looking face. The shape of the face has numerous features that give it a gender-specific appearance. Altering these facial features is an essential part of the transformation process for the male-to-female transgender patient.
Although most commonly associated with male-to-female transgender patients, FFS is also an option for women who feel their appearance is too masculine, or those who have a particular facial feature that is excessively strong for their appearance.
FFS is a collection of reshaping procedures targeting areas of the face from the skull to the neck. The three major facial thirds (upper face, midface and lower face) are analyzed, and a treatment plan is established for the optimal feminizing effect. Most FFS procedures involve bone reduction/reshaping, though a few of the changes involve soft tissue. Not all FFS patients need multiple procedures; however it’s extremely common for several procedures to be performed at the same time for a more transformative effect.
Preoperative Evaluation for FFS
The preoperative FFS consultation helps make sure that the patient and doctor are on the same page with regard to what can be achieved through treatment. Since most of the facial changes are irreversible, it’s critically important that the patient is aware as to what those changes may elicit.
A critical question to consider is whether the associated changes will produce the desired aesthetic outcome. Preoperative computer imaging allows the patient to see the effects the selected facial changes may create. Computer imaging is just an approximation but it provides an invaluable visual guide for the patient to determine the value of the surgery and what facial procedures would work the best for the desired outcome.
Facial feminization surgery is performed by board-certified plastic surgeons; many of whom have craniofacial surgical training and experience. Surgery may be performed in an outpatient surgery center or hospital depending upon what procedures are being done and whether they are covered by insurance. Time in surgery depends on the location and number of facial procedures involved in treatment. It could be as little as one hour, or take up to 8 to 10 hours to perform. FFS procedures are typically performed under general anesthesia. (Some of the procedures are minimally invasive and do not require general anesthesia.) You can discuss the appropriate type of anesthesia with your doctor and the anesthesiologist. Some FFS procedures are done on an outpatient basis, but more extensive facial reshaping procedures will require an overnight stay.
FFS procedures are divided into four zones of treatment: skull/forehead, midface, lower jaw and neck.
Brow Bone Reduction
The shape of the upper-third of the face is considered one of the cornerstones of FFS surgery. The elimination of protruding brows and altering the appearance of the forehead to a more convex shape with a straighter vertical angulation is considered more feminine.
Brow bone reduction is always done through a superior incisional approach (coronal or pretrichial incision). The bones are most commonly reduced through an osteoplastic bone flap technique. While burring may be effective for a small number of patients, it cannot create the more significant brow bone reduction often needed due to the presence of the underlying frontal sinus. Changing the frontonasal angle (lower radix height) can define the success of the brow bone reduction procedure.
Much of the focus is often placed on the center half of the brow bones, but it’s imperative that the outer half of the supraorbital rims not be forgotten. Laying outside of the frontal sinus cavities, the outer brows can be reshaped by burring to create a tail of the brow that sweeps more upward and opens up the outer eye. This is a distinct female feature that helps soften the appearance of the forehead.
The location of the frontal hairline can result in a long or high forehead, which creates a disproportionately large upper third of the face. Shortening of the upper facial third by hairline advancement (also called scalp advancement) is one form of forehead reduction that is very common in the male-to-female conversion patient. Some hairlines may not be candidates for scalp advancement due to hair density and location issues. But when possible, a pretrichial incision in front of the hairline permits a simultaneous brow bone and forehead reduction.
When scalp reduction is not an option, the other method for forehead reduction is to surgically reduce frontal bossing (bowed-out upper forehead area). While it is more common to build out the upper forehead to create a more feminine straight and convex forehead, there are situations where the bony projection of the upper forehead needs to be lessened to complement the changes associated with brow bone reduction.
While the brow bone projection can be reduced, the appearance of the upper face may still not appear fully feminized. The arch of the eyebrows plays an important role in producing a feminized effect, and a brow lift with any type of forehead surgery can have a substantial gender-confirming effect. For example, lifting the brows (particularly their tails) creates a distinctly feminine effect. It can be done with any brow bone reduction, either through a coronal or pretrichial incisional approach. The best browlift effects are created with the more direct pretrichial incision.
There are major gender differences in the nose. A straight or slightly concave dorsum (the latter being preferable) with a tip that is narrow and with a nasolabial angle that is more open (at least 110 degrees) is considered feminizing. An open rhinoplasty is usually needed to reliably achieve these changes. Getting the radix of the nose lowered (height of the nose between the eyes) is a key feature best achieved when done at the same time as a brow-bone reduction. Any functional breathing issues can be simultaneously managed with the cosmetic nasal changes.
Full cheeks — particularly those with fullness in the area on the front part of the cheekbone (“apple” area) — are considered a feminine trait. Cheek augmentation can be achieved using either standard or custom cheek implants, or through the use of fat injections. There are advantages and disadvantages to either technique, though choice can be influenced by the desired dimensional changes.
Buccal Lipectomies and Perioral Mound Liposuction
While not a classic FFS procedure, facial defatting can be a useful tool for people with rounder faces. Performed using small incisions inside the mouth, these areas of fat removal can be complementary to the overall facial reshaping effort.
Enhancing the shape and size of the upper and lower lips can make a big difference in appearance for patients interested in FFS. Though small in size, lips’ impact on gender identification is significant.
A variety of lip augmentation procedures exist from subnasal lip lifts, vermilion advancements, corner of mouth lifts, and augmentations by filler, fat or implants. While all have a role to play in enhancing the lips, the most powerful procedures are those that involve surgical excision of skin to create their effects, lip lifts and vermilion advancements. Lip advancements that change the location and shape of the vermilion border creates the most effective and permanent method to enhance the size of the lips, create a more pronounced Cupid’s bow of the upper lip, and lift up the mouth corners as well.
A large or prominent chin is a distinct male feature and is the most important change to make for a more feminine lower face. The chin often needs to be reduced in all three dimensions (horizontally, vertically and by width). Depending on the dimensional changes needed, chin reduction can be done through an intraoral or submental skin approach. The most effective technique is submental, which allows all three dimensions of the chin to be reduced in addition to any excess soft tissue as well.
Jawline reduction specifically refers to reduction of the back of the jaw at the jaw angles. Reducing their width or flare eliminates the more angular jawline appearance associated with men, in addition to slimming the appearance of the jawline from the front view. This softens the jawline for a more feminine lower facial appearance. Jawline reduction is most commonly done through an intraoral approach with rare exceptions to preforming it from an external skin incision in the neck or behind the ear.
A prominent Adam’s apple or thyroid cartilage disrupts the profile of the neck and is probably the most obvious facial trait associated with men. It is reduced by a procedure called a tracheal shave. This is often the first procedure in a series of facial feminization surgeries. The prominent union of the two halves of the thyroid cartilage is shaved down through either a direct skin incision or from a more camouflaged skin incision up under the chin. It is the simplest of all the FFS procedures, but it’s also incredibly effective in making the neck look more feminine.
Older FFS patients may have a laxity of the soft tissue along the jawline as well as in the neck. While a lower facelift may not be considered a classic FFS procedure, many older male-to-female transgender patients benefit by this jawline-neck reshaping procedure. It is both a rejuvenating and feminizing procedure with an improved sweep up along the jawline into the ear area.
Recovery from any facial surgery is more appearance-related than it is of functional limitations.
The recovery period will be highly influenced by the number of FFS procedures that are performed. While there are some patients who only have one or two procedures that take a few hours of surgery, it is far more common that multiple facial procedures are done that can involve 8 to 10 hours of surgery.
As a general guideline, 50 percent of the facial swelling subsides within 10 to 14 days after surgery. Approximately two-thirds is gone by three weeks after surgery and it takes up to six weeks before most of the swelling is fully gone.
There are no physical restrictions after surgery. Patients are free to shower and wash their hair within 48 hours. The results of any facial surgery cannot be fully assessed until three months or so after treatment, once the swelling has subsided and the overlying soft tissues have contracted back down. Despite this somewhat long recovery period, most FFS patients can see the positive changes early on.
Complications and Risks
The potential complications from FFS surgery can be divided into medical and aesthetic risks. The most significant medical risks are that of infection and permanent numbness of the target areas. Fortunately such side effects are rare.
The aesthetic risks of FFS surgery are more common and are fundamentally about how the facial appearance has turned out in terms of degree of change, symmetry and smoothness of the results. (Scarring may also be an issue.) There is always some risk of the need for revision of the procedures to optimize their aesthetic outcomes.
There are few non-surgical alternatives to the changes created by FFS procedures. With the exception of lip and cheek augmentations by injectable fillers, facial feminization can only be achieved fully through surgery.
Facial Feminization Surgery Cost
The cost for FFS surgery varies widely and depends on the number of procedures being done and the amount of time it takes to do them. Fully customized treatment plans are established and agreed upon during the initial consultation/evaluation period. Such evaluations today can be done by a virtual consultation process. Once a treatment plan is agreed, the exact cost estimate can be provided to the patient.
In some cases, FFS surgery may be covered by insurance. This is established by a preoperative insurance predetermination process, a written submission by the plastic surgeon which contains all pertinent information for the insurance company to evaluate and make a coverage decision.
Although more insurance companies are providing coverage for transgender procedures than ever before, many still don’t.
Consult a Qualified Plastic Surgeon
It’s important to choose a board-certified plastic surgeon from the American Board of Plastic Surgery with extensive experience in facial reshaping procedures — specifically facial feminization surgery. Board certification may not always guarantee good results. Some FFS plastic surgeons have a craniofacial background although not all do.
Here are some tips to consider when consulting a plastic surgeon about FFS:
- Review credentials, education, training, type of certification held, and number of times the procedure has been performed in the practice.
- View before-and-after photos of patients who received different types of FFS surgical procedures.
- Create a list of the facial changes you think would be most helpful for the best transformation to discuss with your plastic surgeon. This will help the surgeon understand your expectations and develop a treatment plan.
- Ask where the surgery will be performed, the extent of the procedure and the potential risks and complications.
- The recovery period and your activities after surgery should be explained to you as well.
During your consultation, the doctor will complete a medical evaluation. The doctor will also provide a list of instructions to follow before and after the procedure. Instructions might include no eating or drinking after midnight, an antibiotic for both before and after the procedure, stopping the use of certain medications, and having someone drive you home after the procedure.
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/