Facial feminization surgery
Facial feminization surgery (FFS) is a set of reconstructive surgical procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue procedures such as brow lift, rhinoplasty, cheek implantation, and lip augmentation though the term "FFS" is generally not regarded to include facial hair removal.
Faces contain secondary sex characteristics that make male and female faces readily distinguishable. "Typically, females have a more pointed chin and less nasal prominence than males. Additionally, females have a less angular nasal tip.... The forehead is quite different in males from females, particularly the areas of the brows and the mid-forehead, and the shape of the skull affects the drape and contour of the skin. Changing the shape of the skull will assist in changing one feature from distinctly male to female."
For many transgender women, FFS is medically necessary to treat gender dysphoria. It can be just as important or even more important than genital forms of sex reassignment surgery (SRS) in reducing gender dysphoria and helping trans women integrate socially as women. Studies have shown that the mental health-related quality of life for trans women who have had FFS is significantly higher than for trans women who have not had FFS. While most FFS patients are transsexual women, some cisgender women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressers and drag queens.
FFS techniques are derived from maxillofacial and reconstructive surgery as well as general plastic and cosmetic surgery. Douglas Ousterhout pioneered what is now called FFS during the 1980s and 1990s in the U.S.A. There are only a small number of surgeons globally who specialise in FFS.
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Here is a list of the surgical procedures most frequently performed during FFS and the reasoning behind them:
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 forward and given a more rounded shape either with a procedure called a “scalp advance” wherein 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.
The forehead is the facial region most important for sex identification. 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”.
The supraorbital rims 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 three main approaches to resolving this problem:
- 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.
- 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.
- Some FFS surgeons 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 often have 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.
Females tend to have higher eyebrows than males so a brow lift is often used to place the eyebrows in a more feminine position. This makes the patient look more feminine with higher eyebrow lines which aids to the female appearance.
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 successfully feminise a masculine nose. Rhinoplasty is effective in achieving female facial profiles in patients undergoing male-to-female sex reassignment.
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.
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.
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.
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.
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 “Chondrolaryngoplasty”. 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.
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.
FFS is a very powerful set of procedures, but there are limits. For example, a wide jaw can be feminized by surgical narrowing but it may not be physically possible to narrow a very wide jaw enough to make it fully female. There are also some masculine facial features that can't be surgically feminized at all like the relative size of the eyes to the skull (females tend to have proportionately larger eyes).
FFS is also quite expensive, often costing upwards of £10,500 (as of 2015) depending of course of procedures the patient undergoes and which surgeon they go to. Although many patients do not spend much time hospitalized, specialized expertise by the surgeons' support staffs may be required during the immediate post-operative period. It may be several weeks before the patient can resume work.
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