Facial feminization surgery
Encyclopedia
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. FFS can include includes 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. "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."
For many transsexual women, FFS is medically necessary to treat gender dysphoria. 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. While most FFS patients are transsexual women, some non-transsexual women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressers
and drag queen
s.
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.
. 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.
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 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.
implants.
is also used to remove some of the fat that some people have underneath the chin.
s) can also be reduced to make the jaw appear narrower.
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 “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.
” 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 can be expensive too, often costing (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.
Surgeons specializing in transgender medicine
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include includes 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
Facial hair
Facial hair is a secondary sex characteristic of human males. Men often start developing facial hair in the later years of puberty or adolescence, approximately between 17–20 years of age, and most do not finish developing a fully adult beard until their early 20s or even later...
removal.
Faces contain secondary sex characteristics that make male and female faces readily distinguishable. "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."
For many transsexual women, FFS is medically necessary to treat gender dysphoria. It can be just as important or even more important than genital forms of sex reassignment surgery
Sex reassignment surgery
Sex reassignment surgery is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble...
(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. While most FFS patients are transsexual women, some non-transsexual women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressers
Cross-dressing
Cross-dressing is the wearing of clothing and other accoutrement commonly associated with a gender within a particular society that is seen as different than the one usually presented by the dresser...
and drag queen
Drag queen
A drag queen is a man who dresses, and usually acts, like a caricature woman often for the purpose of entertaining. There are many kinds of drag artists and they vary greatly, from professionals who have starred in films to people who just try it once. Drag queens also vary by class and culture and...
s.
FFS techniques are derived from maxillofacial
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
and reconstructive surgery as well as general plastic and cosmetic surgery. Douglas Ousterhout
Douglas Ousterhout
Douglas K. Ousterhout, MD, DDS, is a craniofacial surgeon with a practice in San Francisco, CA, USA. His specialty is facial feminization surgery for transsexual and transgender women, using a combination of procedures he developed in the 1990s...
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
Here is a list of the surgical procedures most frequently performed during FFS and the reasoning behind them: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 transplantationHair transplantation
Hair transplantation is a surgical technique that involves moving individual hair follicles from one part of the body to bald or balding parts . It is primarily used to treat male pattern baldness. It this case, grafts containing hair follicles that are genetically resistant to balding are...
. 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
The forehead is the facial region most important for sex identification. 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”.The supraorbital rims are usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the glabella
Glabella
The glabella, in humans, is the space between the eyebrows and above the nose. It is slightly elevated, and joins the two superciliary ridges.-Etymology:The term is derived from the Latin glabellus, meaning smooth, as this area is usually hairless....
) sits over a hollow area called the frontal sinus
Frontal sinus
Sinuses are mucosa-lined airspaces within the bones of the face and skull. The frontal sinuses, situated behind the superciliary arches, are absent at birth, but are generally fairly well developed between the seventh and eighth years, only reaching their full size after puberty...
. 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
Cranioplasty
Cranioplasty is a surgical repair of a defect or deformity of a skull. Cranioplasty is almost as ancient as trepanation. There is evidence that Incan surgeons were performing cranioplasty using precious metals and gourds...
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.Rhinoplasty
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. 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.Cheek implants
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
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-TexGore-Tex
Gore-Tex is a waterproof/breathable fabric, and a registered trademark of W. L. Gore and Associates. It was co-invented by Wilbert L. Gore, Rowena Taylor, and Gore's son, Robert W. Gore. Robert Gore was granted on April 27, 1976, for a porous form of polytetrafluoroethylene with a...
implants.
Chin recontouring
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 liposuctionLiposuction
Liposuction, also known as lipoplasty , liposculpture suction lipectomy or simply lipo is a cosmetic surgery operation that removes fat from many different sites on the human body...
is also used to remove some of the fat that some people have underneath the chin.
Jaw recontouring
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 muscleMasseter muscle
In human anatomy, the masseter is one of the muscles of mastication.In the animal kingdom, it is particularly powerful in herbivores to facilitate chewing of plant matter.-Origin and insertion of the two heads:...
s) can also be reduced to make the jaw appear narrower.
Adam’s apple reduction
Males tend to have a much more prominent Adam's appleAdam's apple
The laryngeal prominence—commonly known as the Adam's Apple—is a feature of the human neck. This lump, or protrusion, is formed by the angle of the thyroid cartilage surrounding the larynx...
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 “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 “blepharoplastyBlepharoplasty
Blepharoplasty is surgical modification of the eyelid. Excess tissue such as skin and fat are removed or repositioned, and surrounding muscles and tendons may be reinforced. It can be both a functional and cosmetic surgery.-Indications:...
” and many feminisation patients undergo a face and neck lift (rhytidectomy
Rhytidectomy
A facelift, technically known as a rhytidectomy , is a type of cosmetic surgery procedure used to give a more youthful appearance...
). 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.
Limitations
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 (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.
See also
Surgeons specializing in transgender medicine
External links
- Virtual FFS The Virtual Facial Feminisation Website
- Facial Feminization (FFS) Dr. Jeffrey Spiegel
- Lynn's Facial Feminization Surgery (FFS) Lynn Conway
- Facial Feminizing Surgery (FFS) Info and Links (with photo gallery)