The information on this page is designed to provide an outline of the most common procedures required to feminize masculine facial features. However, it is not comprehensive and should you wish to discuss a specific procedure, please do not hesitate to ask for further information. Each procedure mentioned here will carry certain risks and these are outlined in more detail both at consultation and in Mr. Musgrove’s letter, following the consultation.
The difference between male and female faces: It is helpful to understand what facial features distinguish a female from a male face. Clearly there is a spectrum of facial characteristics in both genders and some males can look quite effeminate but essentially the changes that occur to the adolescent face happen around puberty when the male face has a growth spurt, and the face becomes much larger compared to the female. The forehead grows forwards, the face becomes longer and the bones heavier. In particular the nose and the lower face including the jaw become more dominant in the face. These changes, often referred to as secondary sex characteristics, together with facial hair, coarse skin and a higher hairline, are the features which we subconsciously help us to identify a male from a female.
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. This is because the bossing is caused by frontal sinuses, which are hollow bony cavities in the bone above the eyes, and these tend to be larger in the male compared to the female. Also the bone is thicker in the male than in the female and this bone is particularly thick in the male along the supraorbital rim (the upper edge of the eye socket). The resulting heavy looking brow is a male characteristic and considered a “gender cue”. The section of bossing between the eyebrows is often referred to as the glabellum and the hollow area behind it is 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:
- Most FFS surgeons can perform a procedure called a forehead reconstruction or cranioplasty where the glabellum 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.
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 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. Any irregularities can be evened out with hydroxyapatite bone cement.
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.
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 can usually be done at the same time as a brow recontour.
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 feminize 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.
Females often have more forward projection in their cheekbones as well as fuller cheeks overall. Sometimes cheek 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. The implants are usually Medpore, Silicone, Gore-Tex, or Hydroxyapatite cement. An alternative approach is to use a fat transfer technique where fat is removed from another part of the body and injected into the cheeks to make them fuller.
It is also possible to construct customized implants which are constructed on 3-D models of the individual patient’s facial skeleton. This requires a CT Scan of the face.
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 feminize 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 feminization. There are many methods of lip filling from injecting fat into them to Gore-Tex implants. Some patients prefer to try temporary (approximately 6months) fillers firstly, to gain an idea of how their lips would look and feel when fuller. Restylane, Perlane, etc are all effective fillers and may be administered by a nurse practitioner who works with a plastic surgeon, or by the surgeon himself.
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 the prominence of the lower jaw.
The lower face is longer and more prominent in the male compared to the female and in a small proportion of patients it may be appropriate to use a specialized technique called orthognathic surgery to reduce the size of the lower face. This often involves a combination of orthodontic treatment and surgery to move the position of the jaws to reduce the height of the lower face and the prominence of the chin. It is often combined with a genioplasty.
Adam’s apple reduction/Tracheal Shave
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 realize. 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.
Beautification and rejuvenation procedures are often performed at the same time as facial feminization. For example, it is common for eye bags and sagging eyelids to be corrected with a procedure called “blepharoplasty” and many feminization 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 an attempt to minimize male facial characteristics to help the transgender patient pass more readily as a female in public. It is not an exact science and employs a variety of surgical techniques to achieve it aim. Individual patients are understandably anxious to know what level of success can be achieved in their quest to look feminine. This depends on many factors, most importantly how severe their masculine features are at the start of treatment, their choice of operations and most importantly the skills of the surgeon they ask to treat them. The surgery often requires bone and soft tissue surgery and it is important to choose a surgeon who has a wide range of operations in his repertoire and can advise on the appropriate combination to achieve the optimum result.
It is vitally important that any patient deciding to undergo facial feminization has realistic expectations. Most FFS patients undergo hormone therapy for some time prior to surgery, which will help to soften certain features somewhat and alter the skin’s appearance over a period of time. Many patients will have the support of a psychiatrist or counselor during their transition. A good consultant will write to the patient’s specialist(s) and also their GP and will liaise with other medical personnel if necessary.
Any decision to have elective surgery should not be taken lightly and a full and frank consultation(s) is needed to be able to fully assess the correct procedures needed and to enable the patient to arrive at a fully informed decision. There are of course risks to any surgery and each procedure carries its own specific risks. Fortunately most of these are infrequent or minor.
It will be some weeks before the average patient can return to work and normal activities, and during the recuperation period it is important to have support from relatives, friends, GP and access to advice from the consultant surgeon or his staff. Every individual is unique and their capacity to heal will differ. It should be noted that just because one person heals well and quickly following a certain procedure, it will not necessarily follow that the next patient will heal in the same manner. This is not only dependent on the surgeon’s skill but on many other factors such as a patient’s general health, hereditary factors, skin type and thickness etc, medication and medical history.
FFS can be expensive too, often costing from £1,900 for a tracheal shave for example up to £14 - 20,000, for multiple procedures, 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 staff or the patients own GP and local nursing support where appropriate, may be required during the immediate post-operative period and it may be several weeks before the patient can resume work.
Finally, most FFS patients are very pleased with the results of their surgery and report that they are able to live their lives as they had hoped for, in the female role, without too many difficulties. Having FFS is not the complete answer of course and with other kinds of support, either professional or from family and friends, most Transgender patients find a way to achieve a satisfying life. Those who view having FF surgery as one of the steps towards this end and NOT as the answer to all the challenges they face with their transition, are usually the most satisfied.
For more information, please ring Pat or Annie on 01625 505412 / 406