Facial feminization surgery

Facial feminization surgery (FFS) refers to surgical procedures that alter the human face to bring its features closer in shape and size to those of an average female human. FFS includes various bony and soft tissue procedures (see below) though the term "FFS" is generally not regarded to include facial hair removal. 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.

FFS has become increasingly sought after by transsexual women and many feel that it is just as important or even more important for them than sex reassignment surgery (SRS) because it helps them integrate socially as women. 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 other transgender people such as cross-dressers and drag queens.

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 transplantation. 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
Males tend to have a horizontal ridge of bone running across the forehead at eyebrow level called the brow ridge or “brow bossing” while female foreheads tend to smoother and flatter and have little or no bossing. The outer segments of the bossing that the eyebrows sit on are called the “supraorbital rims”. These 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 and because it is hollow it can be more difficult to remove the bossing here. If the wall of bone sitting 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 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 where the wall of bone is taken apart, thinned, re-shaped and put back together in the new feminine position with titanium wires or titanium screws and microplates.

2. Some surgeons grind down the wall of bone as far as possible without breaking through and then build up the area around the remaining bossing with bone cement. The bone cement smooths out any visible step between the remaining bossing and the rest of the forehead to give a smooth and feminine appearance. In these cases some additional reduction in the bossing can also be made by thinning the soft tissues that sit over it.

There is a great deal of heated debate in 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 good 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 a reconstruction.

3. Some FFS surgeons now offer a compression technique in appropriate cases where the wall of bone is first 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 bone cement during surgery to smooth everything out.

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. 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 feminise 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.

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-Tex 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 liposuction 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 muscles) can also be reduced to make the jaw appear narrower.

Adam’s apple reduction
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 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.

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 “blepharoplasty” 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.

Limitations
FFS is a very powerful set of procedures but there are limits, for example: a wide jaw can be feminised 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 facial masculinites that can't be surgically feminised 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 $12,000 to $40,000 USD (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.

Discussion groups

 * http://groups.yahoo.com/group/ffs-support/
 * http://groups.yahoo.com/group/Trans-surgery/
 * http://groups.yahoo.com/group/dr_O_club/
 * http://groups.yahoo.com/group/dr_s_club/     Independent Support Group for patients and prospective patients of Dr Suporn