What is Facial Feminization Surgery (FFS)?

Facial feminization surgery—often abbreviated as FFS—is a gender affirming procedure commonly performed on transgender women. The surgery consists of a combination of facial procedures designed to take traditionally male-presenting features and make them look more female-presenting. This could include surgeries like a brow lift, chin reduction, lip lift, rhinoplasty, and several others.

No two facial feminization surgeries will look exactly alike. The best facial feminization surgery is customized to fit the patient and does not unnecessarily operate on areas that the patient is happy with or which already align well with their preferred gender.

In comparison to the lengthy history of other medical procedures and technologies, facial feminization surgery only began in the twentieth century. The earliest cases of gender affirming surgery took place largely in Germany at the Hirschfeld Institute or otherwise supervised by Dr. Hirschfeld—one of the first doctors to study gender and gender dysphoria.

World War II proved to be a setback in gender affirming care when much of Hirschfeld’s research and his facility were destroyed. Thankfully, hormone therapy became available and greatly benefited transgender people of the time. Gender affirming body surgeries began to take place in more places around the world including the United States.

In 1983, facial feminization surgery emerged in San Francisco. Dr. Douglas Ousterout—a craniofacial surgeon who specialized in plastic surgery—is considered the “father” of facial feminization surgery. Many of the techniques he developed are still used today.  It started with a forehead feminization procedure and slowly other procedures like hairline lowering and tracheal shave were added.

Since the 1980s, surgeons all around the world have continued to learn and improve upon FFS techniques. It is now a fairly common surgery for transgender women to seek out.

Reasons to Consider FFS

Transgender people seek gender affirming surgery like facial feminization because it can help treat and alleviate gender dysphoria. Gender dysphoria is a medical term that recognizes the mental anguish, anxiety, depression, and even suicidal thoughts that can come from feeling like their physical form is incorrect or incongruent with their gender assigned at birth.

The severity and degree to which a person may experience gender dysphoria will vary. Some experience no dysphoria, others may only feel it surrounding certain parts of the body, and, finally, some may experience a much more widespread gender incongruence.

Facial feminization takes traditionally masculine features and makes them appear more feminine. A few ways it may do this include narrowing the jaw, reducing the size of the chin, lowering the hairline, shortening and narrowing the nose, reducing the size of the forehead, creating a rounder-looking forehead, and addressing a noticeable Adam’s apple. Of course, there are other possible procedures or results that surgeons may perform to help a patient better align with their individual identity.

Benefits of Facial Feminization Surgery

Transgender women who undergo facial feminization surgeries often experience many possible benefits such as:

• Softer, rounder facial features

• Smaller facial features and structure

• More of a rounded hairline

• Reduces gender dysphoria

• Allows the patient to more easily present as female publicly

• Can help improve symptoms of mental health issues such as anxiety, depression, etc.

• Improved confidence

• Helps boost self-esteem

• Patient is able to see a more accurate self-image in the mirror

• Permanent results

• Customized to fit the specific needs of the patient and their unique anatomy

What Does Facial Feminization Surgery Change?

The exact changes that a specific FFS procedure makes will differ between patients. Though, FFS can address almost every facial structure and feature:

• Hairline: Male hairlines often sit higher up on the skull, begin receding early, and take on more of an M shape. FFS can lower the hairline via hairline lowering surgery, and it can reshape the hairline through hair transplants.

• Forehead: A male forehead protrudes more prominently than a female one. They also tend to have a straighter profile and are larger. FFS helps reduce the projection of the forehead and may subtly reshape it so it takes on a more curved profile.

• Brows: Like the forehead, the male brow bone is much larger and protrudes noticeably. A surgeon may set the brow bone further back and also may shave down the orbital rims which contribute to the appearance of the brows.

• Nose: Female noses tend to be smaller, narrower, and often straighter. FFS commonly helps slim the nose and adjusts the size to better suit a female appearance.

• Midface: Female cheeks may be rounder and include higher cheekbones. While it is rare to get cheek implants, it is not unheard of. Many patients opt for non-surgical enhancements such as hyaluronic acid filler to address the cheeks.

• Lips: The distance between the bottom of the nose and the top lip is shorter in women. A lip lift can help shorten this distance as well as subtly create a more feminine lip appearance. For increased plumpness, many patients choose to get lip filler. However, lip implants are also an option.

• Chin: The female chin tends to be smaller and more rounded. This can be achieved through chin reduction surgery. In rare cases, a patient may benefit from a chin implant in addition to or instead of chin reduction surgery.

• Jaw: The jawline is often shaved to create a slimmer and rounder chin contour.

• Neck: Women do not have as prominent of an Adam’s apple so a tracheal shave can help reduce its projection.

Not every patient will have all of the features addressed. The best facial feminization surgery is custom tailored to meet a patient’s specific goals and needs.

Duration of FFS Results

For the most part, the results of FFS are considered permanent. For example, rhinoplasty, tracheal shave, and any shaving procedure are reliably permanent. Brow lifts and similar procedures may occasionally need touch-ups as a person ages. Additionally, any non-surgical procedures a patient may have done as part of FFS will need regular treatments to maintain results.

Complications of FFS

All surgeries have the potential for complications. As a usually long surgery that addresses multiple areas, FFS can have elevated risks for some patients. Possible complications include infection, visible or raised scarring, asymmetry, unsatisfactory results, and prolonged side effects.

Surgeons who perform the best facial feminization surgeon take steps to minimize and prevent complications:

• Thorough patient screening at the consultation and before surgery

• Patient may stay overnight for monitoring

• Hair transplant performed under local anesthesia to prevent too much time under general anesthesia

• Detailed post-operative instructions

• Regular follow-up appointments

• Starting or ceasing certain prescription medications before or after surgery

• Provide the patient with a realistic idea of recovery and results

Pain and Recovery After FFS

After surgery, it is normal to experience post-operative pain. The face does tend to swell and this can cause discomfort. Surgeons usually prescribe a pain medication and antibiotics. Patients may also take certain supplements to minimize and prevent bruising. However, patients should know that FFS can involve an intense recovery.

Patients will see side effects and pain subside significantly over the first two weeks. Residual swelling can last for months. Patients can usually return to work in two to three weeks. It can take two to three months for patients to get back to their full range of activities.

Recovery Timeline for FFS Surgery

In the initial days following FFS surgery, patients can expect to rest and focus purely on recovering. Patients often need to follow a liquid diet for at least a few days. After a week or so, most bandages can be removed and patients can become more active at home. Patients tend to discontinue prescription medication within a week.

After two to three weeks, patients can return to work and basic activities. However, they should continue to avoid exercise or anything strenuous. Swelling should have gone down significantly and patients should be much more comfortable than they were immediately after surgery.

Two to three months after surgery, patients can return to all of their activities. Some residual swelling may still be present, but largely unnoticeable. Patients can use makeup to hide scarring and should continue to protect their scars with clothing or strong sun protection.

Conclusion

The best facial feminization surgery allows patients more freedom and agency within their lives. It helps to alleviate gender dysphoria and can have other mental health benefits. However, there are drawbacks and risks that patients should be aware of before undergoing the surgery. Meet with a few surgeons, research, and go into FFS making an informed decision. This lets patients feel more confident and often happier with their procedure.