Facial feminization surgery

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This is a remake of a facial geometric sexual dimorphism diagram from Valenzano, D. R. et al. (2006). The horizontal axis indicates geometric facial femininity, and the vertical axis indicates proportion of the population. The blue bell curve on the left represents the male faces, and the pink bell curve on the right represents the female faces. The purple area in the center represents the overlap of the two bell curves where the feminine male faces cannot be distinguished from the masculine female faces. The bell curves show that the proportion of female faces that are more feminine than the most feminine male faces is much greater than the proportion of male faces that are more masculine than the most masculine female faces.[1]

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.[2][3] 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.[4][5] "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."[6]

For many transgender women, FFS is medically necessary to treat gender dysphoria.[7][8] 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.[2] While most FFS patients are transgender 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.

Surgical procedures[edit]

Here is a list of the surgical procedures most frequently performed during FFS and the reasoning behind them:

Hairline correction[edit]

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.

Forehead recontouring[edit]

The forehead is the facial region most important for sex identification.[4] 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.[9] 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:

  1. 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.
  2. 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.
  3. 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.

Brow lift[edit]

Men tend to have lower eyebrows relative to the position of their brow ridges when compared to women. Men's eyebrows tend to be below their brow ridges while women's eyebrows tend to be above their brow ridges. Accordingly, FFS to raise the eyebrows results in a face with a more womanly appearance.[10]


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.[9][11] 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.[9][11][12]

Cheek implants[edit]

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.

Lip lift[edit]

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.

Lip filling[edit]

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.

Chin contouring[edit]

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.

Jaw contouring[edit]

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[edit]

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.

Associated procedures[edit]

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)($50,000 or even more in the US) 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.

Surgeon qualifications[edit]

The best facial feminization surgeons have formal training in maxillofacial and craniofacial surgery.[10]

Completion of skull growth[edit]

FFS candidates should wait until the bones of their skull have stopped growing before undergoing FFS. The way to determine if the bones of the skull have stopped growing is to take successive radiographs of the mandible and wrist bones to make sure that bone growth has stopped.[10]

See also[edit]


  1. ^ Valenzano D. R.; et al. (2006). "Shape analysis of female facial attractiveness". Vision Research 46: 1282–1291. doi:10.1016/j.visres.2005.10.024. 
  2. ^ a b Ainsworth, TA; Spiegel, JH (2010). "Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery". Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 19 (7): 1019–24. doi:10.1007/s11136-010-9668-7. PMID 20461468. 
  3. ^ Shams, MG; Motamedi, MH (2009). "Case report: Feminizing the male face". Eplasty 9: e2. PMC 2627308. PMID 19198644. 
  4. ^ a b Spiegel, JH (2011). "Facial determinants of female gender and feminizing forehead cranioplasty". The Laryngoscope 121 (2): 250–61. doi:10.1002/lary.21187. PMID 21271570. 
  5. ^ Hage, JJ; Becking, AG; De Graaf, FH; Tuinzing, DB (1997). "Gender-confirming facial surgery: Considerations on the masculinity and femininity of faces". Plastic and Reconstructive Surgery 99 (7): 1799–807. doi:10.1097/00006534-199706000-00001. PMID 9180702. 
  6. ^ Stan Monstrey, Gennaro Selvaggi and Peter Ceulemans. Surgery: Male-to-Female Patient, Principles of Transgender Medicine and Surgery 105, 111 (Randi Ettner, et al. eds., 2007)
  7. ^ World Professional Association for Transgender Health. WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. (2008).
  8. ^ World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7. pg. 58 (2011).
  9. ^ a b c Dempf, R; Eckert, AW (2010). "Contouring the forehead and rhinoplasty in the feminization of the face in male-to-female transsexuals". Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery 38 (6): 416–22. doi:10.1016/j.jcms.2009.11.003. PMID 20036572. 
  10. ^ a b c Ousterhout, D.K. (2009). Facial Feminization Surgery: A Guide for the Transgendered Woman. Omaha, Nebraska: Addicus Books, Inc. pp. 11, 15 & 22. ISBN 978-1-886039-93-3
  11. ^ a b Hage, JJ; Vossen, M; Becking, AG (1997). "Rhinoplasty as part of gender-confirming surgery in male transsexuals: Basic considerations and clinical experience". Annals of plastic surgery 39 (3): 266–71. doi:10.1097/00000637-199709000-00008. PMID 9326707. 
  12. ^ Noureai, SA; Randhawa, P; Andrews, PJ; Saleh, HA (2007). "The role of nasal feminization rhinoplasty in male-to-female gender reassignment". Archives of facial plastic surgery : official publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies 9 (5): 318–20. doi:10.1001/archfaci.9.5.318. PMID 17875823. 

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