Q: Dr. Eppley, I am interested in facial feminization surgery but don’t know exactly what types of procedures I need. What are my options? Can they all be done at once> How much of a change to my face can they make?
A: Facial feminization surgery (FFS) involves a wide variety of bony and soft tissue changing procedures to create more of a feminine facial appearance. In a single surgery as few as one or two of these procedures can be done or as many as dozen or more . I have done as many as 15 procedures in a single patient. As a result FFS can produce subtle or major facial changes. Procedure options going from top to bottom of the craniofacial include: 1) skull augmentation, 2) hairline lowering (scalp advancement, forehead reduction), 3) forehead augmentation, 4) brow bone reduction, 5) lateral brow bone contouring, 6) browlift, 7) lateral canthopexy or corner of eye lift 8) rhinoplasty or nose reshaping, 9) cheek augmentation using either implants or fat injections, 10) lip lift or lip advancement, 11) corner of mouth lift, 12) lip augmentation with fat injections or Permalip implants, 13) chin reduction, 14) jawline/jaw angle reduction, 15) masseter muscle reduction by electrocautery or Botox injections, 16) submentoplasty (reshaping under the chin) and 17) adam’s apple reduction. (tracheal shave)
Dr. Barry Eppley
Q: Dr. Eppley, I am having facial feminization surgery by you in a few months. Is it possible for me to have breast augmentation at the time of my facial feminization surgery? Or will it need to be on a different day? How long after FFS would you recommend I wait to have it done?
A: The first thing to appreciate is That is too much surgery at one time. I don’t think you realize (understandably so) what is going to happen to your face and the recovery that is needed for that collection of facial procedures. Eight to ten hours of surgery is an extreme stress on both your face and body already. Adding breast augmentation to a facial feminization surgery can be done but let me give you several thoughts as to why that is not the best idea and how to think about staging it.
While a young person like yourself can undergo an extreme amount of stress (extensive surgery), there are numerous other issues that can develop from extensive surgeries that go well beyond 8 hours. Such potential medical issues such as blood clots (deep vein thrombosis) and the risk of infection increase significantly. With extensive facial surgeries that involve the nasal and oral cavities there is a bacteria load that is released into the blood stream from them. Placing a large synthetic implant at the same time becomes a great point of attachment for such bacteria floaring in the bloodstream and thus a potential source of implant infection.
When staging facial feminization surgery and breast augmentation there are numerous ways to do it. But the most practical one is to consider the risk of revisional surgery from the initial facial feminization surgery. While each procedure in a facial feminization surgery has its own inherent risks (mainly aesthetic outcomes) when all the procedures are put together that risk becomes additive or cumulative. So let’s say for example that each facial procedure has a 10% risk of revisional surgery, a combined ten procedures would then ensure a revisional surgery for at least one of them. Thus it is better to wait a few months to see the complete outcome of the facial feminization surgery and then combine breast augmentation with any revisional facial procedure if needed. This would be the prudent approach to lower the number of potential surgeries needed/desired.
Dr. Barry Eppley
Q: Dr. Eppley, I’m considering getting facial feminization surgery but I want to know the cost, recovery time and the amount of pain to be expected. I want to get the most change of my face that I can but am not sure how much I can really achieve. You are the facial feminization surgery expert so I would need your guidance as to what would be best for me.
A: Facial feminization surgery is a broad collection of hard and soft tissue procedures that are individually selected for each patient based on what has the best value to help change the shape of their face. There is no standard FFS surgery where everyone gets exactly the same procedures. I would need to see pictures of your face to make an assessment with computer imaging to see what works best for you before any cost quote can be given. Regardless of the exact procedures, FFS is always a compilation of numerous procedures that will cause a lot of swelling and takes about three weeks until one looks fairly normal and non-surgical…but really complete recovery from this type of facial reshaping surgery takes up to three months for everything to completely normalize.
Dr. Barry Eppley
Q: Dr. Eppley, Can I get a hair line lowering procedure, forehead contouring, and shaving of the brow browsing, lip lift, lip augmentation, corner lip lift and maybe jaw implants all during the same surgery? My goal is to feminize my forehead, the distance between my lips and nose is extremely far a lip lift would feminize my lips, and I’d like a heart shaped face and girls with heart shaped faces always have a nice feminine jawline.
A: What you are referring to is known as facial feminization surgery and in the classic use of that plastic surgery term refers to a type of transgender surgery. By your inquiry it does not appear that you are a transgender patient. But the concept is really the same and there is nothing unique or different in terms of the number of facial reshaping procedures that can be done on a male to female or a female patient. It is very common to perform up to a dozen or more different facial operations during facial feminization surgery. These are perfectly safe and are well tolerated to be done all at the same time. It does create the need for significant recovery, however, as the more facial procedures you do the more swelling that occurs as you might imagine.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in facial feminization surgery but for different reasons that the typical facial feminization surgery patient. I am a 27 year-old female but my features have been destroyed by acromegaly making me unable to recognize myself. I want the frontal bossing removed and the overall size of my nose reduced. Have you ever worked on an acromegaly patient before? Do you think these two (generally speaking) procedures will improve my features or will I need a reduction in chin, etc? I had my pituitary tumor removed four years ago and my IGF-1 levels are controlled by medication. I have attached pictures of me both and before the acromegaly developed.
A: You are correct in that you desire/need for facial feminization surgery is rare. I have worked on a few acromegaly patients in my career and making significant changes can be challenging based on how much their face has become ‘overgrown’. You appear to have a favorable starting point where some changes (e.g., frontal bossing, chin and jawline reduction) can be visibly improved given that they result from excessive bony deposition and the bone is likely thicker than normal. There are limits in rhinoplasty because there is often as much skin thickening over the nose as there is bone and cartilage excess. As in any rhinoplasty patient the limits of what can be seen on the outside is partially controlled by how much the skin will shrink over a reduced osseocartilaginous framework. Based on just a frontal view alone, it is hard to assess his much nasal changes can occur. (as well as other areas of the face)
Since your pituitary tumor has been removed and your IGF-1 levels are being monitored/controlled, facial surgery would be reasonable to do as the risk of causing an excessive healing response to tissue manipulations (i.e., overgrowth) has been eliminated. It would be important to get an assessment of your facial skeletal features with a 3D CT scan so bone size/thicknesses can be assessed preoperatively. That can be ordered by me to any imaging facility that you choose where you live. Also please send some cur6rent picture from different angles (non-smiling) for my further assessment.
Dr. Barry Eppley
Q: Dr. Eppley, Do you have experience with facial feminization surgery? Particularly with forehead recontouring, rhinoplasty, adam’s apple shaving, and hair line lowering?
A: I have considerable experience with facial feminization surgery (FFS) procedures, particularly the four that you have mentioned which are some of the most common FFS operations. All can make very successful feminizing effects. The key to the hairline lowering is the density of the frontal hairline where the incision has to be made. If this is adequate then the hairline can usually be lowered in a single stage of up to 2 cms based on one’s natural scalp laxity. Combining forehead/brow bone contouring with hairline lowering is particularly convenient since the pretrichial incision provides direct access to the entire forehead. Adam’s apple reduction (aka tracheal shave) is the simplest of the procedure and how much is can be reduced is dependent on what incisional access is used. (directly over it or the more remote submental incision) Reshaping the nose through a rhinoplasty to create a smoother and less prominent nose result depends on the thickness of the overlying skin. The thicker the skin the less it will contract and the size of the nose will reduce less.
Please send me some pictures of your face for my assessment and computer imaging to see what changes may be possible for you.
Dr. Barry Eppley
Q: Dr. Eppley, I am sending you some pictures for consideration for facial feminization surgery. (FFS) I am a 25 year-old transgender who wants to really make the change and be accepted for who I really am on the inside. What FFS procedures do you think I need and how successful will the change be in your opinion?
A: In assessing your pictures, I can see where the following procedures would be very help in achieving your goal of softening and feminizing your face and I would place them in the following order of importance:
1) Forehead Augmentation/Brow Reduction/Browlift (the issue here is whether a hairline advancement can be done with any appreciable forehead reduction of vertical skin length from the hairline to the brows) But reducing the brow prominence, getting rid of the brow break and increasing the convexity of the forehead are key elements of your facial appearance change.
2) Jawline/Chin Reshaping/Tapering (reduce jaw angles and square chin in the frontal view) The horizontal chin projection as it is now is perfect for a female as you naturally have a convex facial profile due to your chin position)
Lip Advancements (increase vermilion exposure and cupid’s bow enhancement) While injectable fillers or fat injections could also work on your lips, if you are undergoing surgery for other facial procedures then it makes sense to take this opportunity for a permanent lip enhancement change.
Cheek Augmentation (this is not on your list and may be surprising to you but I actually rate it as more important than the rhinoplasty) The flatness/gaunt appearance of your midface would benefit by some voluminization to create more of an ‘apple cheek’ effect. It not only would look more feminine but also creates a ore healthy appearance as well.
Rhinoplasty Very slight changes to your nose is all that is needed. Some tip narrowing and slight rotation upward would change your already thin nose to a more feminine one.
I think your face is a very good ‘canvas’ to work with to become very feminine and with a few of these changes can become so. Not every patient that undergoes even extensive facial feminization surgery can always become highly feminine in their facial appearance.
Dr. Barry Eppley
Q: Dr. Eppley, I am seeking Facial Feminization Surgery (Rhinoplasty, Lip Lift, Chin Implant, Trachea shave, Brow shave). Please let me know if I am a good candidate. I am very serious/committed to doing this. What is the lead time between consultation and scheduled operation typically?
A: My definition of an ideal candidate for Facial Feminization Surgery (FFS) is a male who has the greatest chance of making a successful gender transformation based on their existing facial features. I would say you are about as ideal as it gets because you have a soft small thin face with a less distinct facial skeletal structure. With a few changes you would look quite feminine. The procedures you have chosen are the ones that I would agree are the only ones you need to make for a very successful FFS result. I will work on some computer imaging of these changes and get them back to you tomorrow.
As a general rule, I try and get patients into surgery as soon as they would like to have the procedure.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in facial feminization surgery. I specifically want: 1. lower forehead and brow ridge bone contouring, 2. forehead and eyebrow lift, 3. hairline restoration by scalp advancement and hair transplantation, 4. upper forehead bone augmentation, 5. frown line and crow’s feet surgical correction, 6. feminizing rhinoplasty, 7. cheek (malar or submalar) augmentation, 8. lip lifting, 9. chin contouring (reduction) & sliding genioplasty or chin augmentation by implant 10. jaw contouring (reduction). I also would like to know if possible can i have all these procedures done at the same time ?
A: All of the procedures you have listed are very common and often part of an overall facial feminization surgery (FFS) approach. When it comes to FFS surgery, most of them can be done all at the same time although some work against the others and are best deferred for a second surgery if needed.
Brow bone reduction/reshaping, upper forehead augmentation and scalp (hairline) advancement can all be combined and would need to be due to the same incision used for all of them. At the same time, a rhinoplasty, cheek implants and chin/jawline recontouring can be done.
There is no specific surgery for crow’s feet or frown lines. When doing an open rhinoplasty, a lip lift can not be done at the same time due to blood supply concerns of the intervening columellar skin.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 35 year-old transgendered woman who is interested in more of a feminine face. I do believe that my jawline and chin is what needs to be changed and would be the most beneficial to me. I have been living full-time as a woman since my gender transition eight years ago. At this time, other than having two teeth extracted and dental work, I have no other facial surgery or injuries. As a woman, I do have occasional passability problems. I feel that my face currently absolutely needs improvement and will boost my self-esteem and self-worth.
A: In looking at your pictures, I do agree that your jawline from the chin back to the jaw angles, is the most masculine appearing part of your face. Softening your jawline would be a beneficial step towards your aesthetic facial goals and is a potential part of many facial feminization surgeries. Reducing the entire jawline is never as easy as making it bigger but there are procedures that can help your its prominence. The jawline angle can be reduced by angular ostectomies where the sharpness and prominence of the angles are reduced along with some width reduction. This is done through an intraoral approach where a saw is used to removed the bony jaw angles (makes them less square) and taking the outer cortex of the mandibular ramus to make it thinner as well. Your chin needs to be vertically reduced and narrowed combined with lateral prejowl ostectomies to make the whole front part of the jaw more narrow. This also is done from inside the mouth where the chin bone is downfractured, shortened and narrowed and put back together. Then behind the chin osteotomy the body of the jaw is then narrowed by outer corticotomies. I have attached some predictive imaging of those potential jawline reduction results.
Dr. Barry Eppley
Q: I am interested in facial feminization surgery. I will be starting hormone replacement therapy in the next few months and as part of this I would like to know which surgical procedures I can benefit from. f you could list them in priority would be greatly appreciated. I need to prioritize my surgeries based on finances and benefit. Thank you so very much for providing this service, it will be such a stress reliever and I am looking forward to your recommendations. I have attached a front and side view picture of me to review.
A: Thank you for sending your pictures. In looking at your pictures, I would recommend the following facial feminization surgery procedures and would place them in the following order of importance and value.
1) Forehead Contouring/Brow Reduction and Brow Lift – This is almost always one of the most important areas as you have a classic male forehead and appearance with a low horizontal brow shape, mildly prominent brow bones and a dip in the forehead shape. A more feminine appearance comes from smoothing donw the brow bones with a lateral wing effect, cranioplasty to make the forehead more convex, and a browlift to create an arch to the eyerows with a lateral swoop. This can dramatically change the way the eye and forehead area looks, creating a very softening effect. Because this has to be done through an open scalp incision, you will need to consider potential hair transplantation later. But this may have been on your list anyway at some point.
You would also benefit from an upper blepharoplasty to get rid of the extra skin and create a better eyelid shape to go with the forehead/brow reshaping.
2) Rhinoplasty – The thick skin and shape of your nose needs substantial refinement. That is a challenge with your thick nasal skin and underlying cartilages but significant improvement can still be obtained.
3) Chin Contouring – Tapering the chin bone to make it less square would provide a softening effect.
4) Necklift – Tucking up the loose neck skin would help the chin and the neck angle to be more defined.
As outlined above, the Forehead, Brow and Nose are really important in our case and would be the first set of procedures you should do. I have attached some rough computer imaging which gives a general idea but would probably look better in real life as there are limits to what moving image pixels around can do.
Dr. Barry Eppley
What Are Some Of the Procedure Considerations That I Need To Know for Facial Feminization Surgery (FFS)?
Q: I am interested in Female Feminization Surgery which would encompass brow bossing reduction, hairline lowering, rhinoplasty, chin and jaw shaving and breast augmentation. I am considering doing the FFS either all at once or in two parts. I am male to female transgender. Can you provide me some details or specifics about what I need to consider for each of these procedures.
A: All of those Facial Feminization Surgery (FFS) procedures certainly can all be done as a single procedure and are not too excessive for one operation. If you were to do them in stages, I would separate them into the facial procedures as one set of procedure and the breast augmentation as a separate procedure.
A few comments about your proposed FFS procedures:
Hairline lowering – Whether that is possible would depend on your hairline now and where it is located. Some FFS patients have to consider hair transplants instead if their hair density is very thin or too far back.
Brow Bone Bossing – There are two methods based on the degree of bossing, burring reduction (tail of brow only) or frontal sinus wall setback (if the whole brow is very prominent) It is impossible to know which is best for you without seeing a picture. The relevance to this difference is prinarily a cost issue. Frontal sinus wall setback requires some tiny plates and screws to hold the reshaped bone and takes a little longer to do.
Rhinoplasty – There are two different types of rhinoplasty, limited and full. The full rhinoplasty requires more work and is almost always needed when there is a hump reduction needed. Limited rhinoplasty is where only the tip is manipulated/changed.
Chin and Jaw Shaving – For most FFS patients, this is largely burring reduction or saw shaving of the inferior border although sometimes the chin bone may need to be shortened vertically as well as setback.
Adam’s Apple – Any issues here? I am supposing not since you didn’t mention it.
Breast Augmentation – The only issue here is saline vs silicone gel breast implants. That is just a cost difference issue
Dr. Barry Eppley
Q: I am a transgender patient and I am looking for information regarding facial feminization surgery. I am interested in getting some work done. I think I may need full facial feminization surgery.
A: One of the most important transformations that a transgender patient needs to make is in facial appearance. The potential to be seen and accepted socially as a female is of major physical importance. There are numerous facial changes that can be done, most prominently brow reshaping, rhinoplasty, cheek enhancement, and jawline contouring. These are changes in the support structure of the face that can change the gestalt of sexual orientation. Soft tissues changes such as blepharoplasty, canthoplasty, lip augmentation and shaping, and facelifting are complements to structure changes but, in and of themselves, are not primary facial feminization changes. The prominent adam’s apple (thyroid cartilages) is the lone non-facial feature whose reduction makes for a softer more feminine neck profile.
In considering facial feminization surgery (FFS), there is no standard set of procedures that works for everyone. The total face must be taken into consideration and changes selected that will make for the greatest improvement in appearance. Some patients may benefit by only two or three while others may get half a dozen or more. In considering what changes may work, computer imaging can be very helpful. Such imaging is not a guarantee of outcome but a method of communication and education about useful possibilities.
Whatever changes are selected, it is best to do the whole package in a single operation. The recovery may be longer but a one-time commitment for ‘changing face’ is better psychologically.
Dr. Barry Eppley