This past year has created national awareness of the term, Facial Feminization Surgery. Although this surgical subspecialty of plastic surgery has been around for decades, the Caitlyn Jenner story documenting former Olympic champion Bruce Jenner’s transition from male to female has brought its awareness to the entire American public and even that of the world. From her appearance on the cover of Vanity Fair to the new reality TV show, “I am Cait”, Jenner has helped make Facial Feminization Surgery a recognized concept. No pun intended, she literally has become the ‘face’ of Facial Feminization Surgery. As a result, more transgender patients than ever before are presenting to have this type of facial surgery.
Facial feminization surgery, known as FFS, is a broad collection of facial procedures that are done to change a genotypic male face into one that has a softer and more feminine appearance. The vast majority of FFS procedures are done for those making an overall male to female change, but there are some women with stronger facial features that want a softened appearance as well. Facial feminization surgery has become an important part of the transformation process in transexuals who may be undergoing part or all of sexual reassignment surgery.
While one’s facial appearance is important to everyone it is even more so in the transgender patient. The face provides the first visual and a constant social interpretation of the sex of a person. While body parts may be hidden by clothes or artificially augmented or tucked, there are no non-surgical means to alter the face in any appreciable way.
Facial feminization surgery includes changes to both the bone and soft tissues of the face and neck. The list of available procedures is a collection of more traditional aesthetic facial procedures combined with less commonly done craniofacial and maxillofacial procedures. Such a diverse collection of facial procedures is often done by a board-certified plastic surgeon with craniofacial surgery and experience to be able to adequately perform all of them.
A very important understanding in FFS is the appreciation of the differences between male and female faces. Male foreheads have brow bossing and tend to slope backward, while females have no brow bossing and are more vertical and convex-shaped. A female’s eyes are bigger and more open due to a less prominent overlying brow bone and more recessed and tapering lateral orbital rim. The female nose is shorter, smaller, has a lower dorsal profile and has more of an upturned tip than men. Female chin are more narrow and tapered while the male chin is broader and squarer. Similarly, the male jawline is broader and has more prominent angles while the female jawline is narrower and has a convex curve from back to front. The Adam’s apple in men juts out while a female neckline is smooth without a bump or at least a minimal one.
Besides these general trends is the realization that no one particular facial feature makes one look female or male. Rather it is the integration of multiple facial features that creates the gestalt or overall impression of facial gender. It is this artistic part of FFS that helps make up the best treatment planning and surgical execution of any patient’s facial transformation.
Facial feminization surgery can include changes in the scalp hairline, skull, forehead, brow bones, temples, eyelids, nose, cheeks, lips, chin, jawline and Adam’s apple. The collection of available FFS procedures includes the following:
- Scalp/Hairline Advancement
- Hair Transplantation
- Browlift/Temporal Lift
- Skull Reshaping/Narrowing
- Brow Bone Reduction
- Orbital Rim Reshaping
- Temporal Augmentation
- Blepharoplasty/Eyelid Surgery
- Cheek Implant Augmentation/Osteotomy Reduction
- Paranasal-Premaxillary Augmentation
- Lip Augmentation/Lifts/Advancements
- Chin Narrowing/Reshaping/Sliding Genioplasty
- Jawline/Jaw Angle Reduction and Narrowing
- Submental/Neck Liposuction
- Tracheal Shave/Adam’s Apple Reduction (thyrochondroplasty)
Facial Feminization – Before Surgery
A thorough assessment of the face by plastic surgeon Dr. Barry Eppley, with the use of computer imaging is a necessary first step to determine what exact procedure(s) would be beneficial and which ones would have the greatest impact on facial change. In some cases, all selected procedures may be done at once and in other cases, usually due to the length of recovery and economics, it may be needed to a staged approach.
Physical health is an important issue before and in some cases (older than 45 years of age), preoperative blood tests may be needed. For skull and forehead/brow bone surgery, x-rays are usually needed as part of the preoperative assessment.
Facial Feminization – The Operation
All FFS procedures are done under general anesthesia and most patients will require an overnight stay in the facility if more than three skull/facial areas are being simultaneously treated. These procedures are not performed in a hospital but in a private surgery center for economy efficiency, comfort and utmost discretion.
Each FFS procedure has its own unique methods of being performed. But, in general, dissolvable sutures are used as opposed to those that need to be taken out. Drains are used for skull and forehead procedures which are removed the next day. Rhinoplasties are taped and splinted. Most cheek, chin and jawline procedures are done from incisions inside the mouth and a compression wrap is applied right after to help manage swelling.
Facial Feminization Recovery
Once of the unique features of FFS surgery is the multiple number of procedures usually performed throughout the face. This leads to an expected large amount of facial swelling and some bruising that, for the unprepared, can be frightening as it manifests to its fullest extent by the second day of surgery when it peaks. While pain is not usually much of an issue, despite the multiple operated areas, it can take a good three weeks for one to look normal again and feel completely comfortable being in public. A good rule to remember is that big changes require big surgery which means there will be a big recovery. For smaller number of procedures this may be so drastic so each patient must be considered individually in this regard.
Facial Feminization – The Cost
Due to the number and complexity of the procedures, each patients needs to be individually treatment planned and costs determined.