Facial feminization surgery

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Facial feminization surgery (FFS) refers to a series of surgical procedures that alter the human face to bring its features closer in shape and size to those of an average female human. Douglas Ousterhout pioneered what is now called FFS during the 1980s and 1990s in the U.S.A. There are a relatively small number of surgeons globally who specialise in FFS although many plastic and reconstructive surgeons are capable of performing the procedures.

Facial feminization surgery as the name implies is sought primarily by trans women although some cisgender women who feel that their faces are too masculine will also undergo procedures similar to it. Many of them feel that FFS is as important if not more important than sex reassignment surgery because it helps them integrate socially as women.

Surgical procedures

Below is a list of the surgical procedures most frequently performed during FFS and a short explanation. FFS includes various bony and soft tissue procedures derived from maxillofacial plastic and reconstructive surgery although is increasingly being expanded to suit the needs and desires of the client such as use of dermal (skin) fillers. FFS does not include facial hair removal being a non-surgical procedure.

Complications to FFS vary widely depending on the areas of the face that are changed and the skill of the surgeon. These complications can include but are not limited to: infection of the skin and bone, damage to nerve and muscle tissue, blood loss, undesired scar tissue formation, numbness from scar tissue, and post-op depression. Immediately post-op, FFS tends to be VERY painful and with significant swelling that may not subside until up to 6 months from the surgery date.

Hairline correction

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 forwards and given a more rounded shape either with a procedure called a “scalp advance]” where 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

Illustration of the difference between atypical male and female forehead and brow ridge.

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”. These 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 3 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 now 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 also often have various 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

Females tend to have higher eyebrows than males so a brow lift is often used to place the eyebrows in a more feminine position.


Males tend to have larger and wider noses than females. Also, if you look at a female nose from the side, the base often points slightly upwards while on males it tends to point more straight ahead or slightly downwards. Standard rhinoplasty procedures are generally used to feminise a masculine nose. Noses with a slightly concave “scooped” bridge are thought by many to look particularly feminine but this only holds true for certain ethnic groups. For example: women of Northern European descent often have the scooped bridge while women of Middle Eastern descent often have a more convex shape to the bridge.

Cheek implants

Females often have more forward projection in their cheekbones as well as fuller cheeks overall. Sometimes cheek (technically zygoma) implants are used to feminize 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 solid silicone implants but various other materials are also used.

Sometimes lipid (fat) transfer is done because of the availability of it in other parts of the body. The complications of fat transfer are similar to its transfer in breast augmentation and can include infection and blood supply issues.

Lip lift

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

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 recontouring

Illustration of the difference between atypical male and female lower jaw.

Males tend to have taller, more projected chins than females. Male chins also tend to have a flat base while female chins tend to be rounded. Sometimes liposuction is also used to remove some of the fat that some people have underneath the chin.

The chin can be reduced in height either by bone shaving or with a procedure called a sliding genioplasty, involves removing a horseshoe-shaped piece of the chin bone and sliding it either backwards or forwards, finally fixing it in place using titanium screws.[1] In general genioplasty refers to a reduction in the predominance of the chin while mentoplasty refers to increasing it with a solid silicon implant.

There is risk of lower tooth nerve damage with overly aggressive genioplasty.

Jaw recontouring

In addition to chin projection as explained above, male jaws tend to be wider and taller than female jaws and often have sharp angular corners at the back. This creates a squared off effect with the jaw in general with men.

The back corner can be rounded off in a procedure called “mandibular angle reduction”. This is done by shaving off bone 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.

Alteration to the jaw is often in conjunction with chin alteration because of the frequency of aesthetic issues of both areas.

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 females than many people realise. The Adam's apple can be reduced with a procedure called a “tracheal shave” or “thyroid chondroplasty”. 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

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 can be expensive too, often costing $12,000 to $40,000 USD (as of 2006) depending of course on which particular 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 and it may be several weeks before the patient can resume work.


  1. Genioplasty - Medscape

See also

Discussion groups

External links



*Some information provided in whole or in part by http://en.wikipedia.org/