An Overview of Facial Feminization Surgery

There are dozens of measurements on the human face that differ systematically by gender. These differences are the result of hormone exposure during various phases of development. The study of these differences is known as facial anthropometry. Facial feminization surgery (FFS) is a series of surgical interventions designed to make the face appear more feminine. These changes address the gendered differences in facial structure that occur due to testosterone exposure during various phases of development.

Facial feminization surgery may alter both the hard tissues and soft tissues of the face. It involves adding material to some places and removing material from others. Facial feminization surgery can be performed as a single procedure or multiple procedures.

Transgender Community

Transgender individuals, those whose gender identity differs from their assigned sex at birth, are often very aware of the subtle structural differences and facial cues that affect how their gender is perceived by others. Testosterone is reasonably effective at masculinizing the faces of transgender men (those whose sex at birth is female). However, spironolactone and estrogen treatment are not nearly as effective at feminizing the faces of transgender women. In large part, this is due to the fact that they cannot fully undo the work of testosterone.

Some transgender women (those whose sex at birth is male) feel uncomfortable with the gendered structures of their faces. They may also perceive that their facial structure makes it more likely that they will be misgendered in casual interactions.

For such women, facial feminization surgery may be a reasonable option. Unfortunately, facial feminization surgery is not consistently covered by insurance. Even insurance companies that pay for other gender-affirming surgeries will not always pay for facial feminization surgery.

Fortunately, there has been a growing movement among transgender health professionals to advocate for increased coverage of facial feminization surgery.

Although the face is not necessarily considered to be as gendered as the chest or genitals, it may have far more of an impact on a person's ability to feel comfortable moving through the world. After all, a person's face is often the first and sometimes the only part of the body that other people see. Even infants as young as one year are often capable of distinguishing a person's sex by looking at a picture of their face.

Which Parts of the Face Are Altered?

Facial feminization surgery actually refers to multiple plastic surgery and craniofacial procedures. These procedures can be staged over time. They can also be performed all at the same time. The choice depends on the expertise and preferences of the surgeon as well as the needs of the patient.

Facial feminization is not simply soft-tissue surgery. It also alters the bones of the face. Bone may be added or removed to different areas in order to fundamentally reshape the skull. This reshaping is done to make the measurements of the skull follow the proportions that are associated with estrogen (feminine proportions) rather than testosterone (masculine proportions).

Areas of the face that may be altered in facial feminization surgery include the:

  • Forehead and eyes: Reshaping the forehead and eye sockets can be one of the most significant components of facial feminization surgery. This may involve moving the forehead back. The place where the nose meets the forehead may also be made smaller. Prominent eyebrow ridges may be shaved down.
  • Nose: The bridge of the nose may be made smaller, and also the tip. The nose may be more generally reshaped.
  • Mandibles/jaw: The squareness/flaring at the back of the jaw may be reduced. The bone beneath the bottom teeth may be shaved down. The height of the chin may be lowered.
  • Soft tissue: The top lip may be raised/shortened. Cheek implants may be added. There may be a brow lift.
  • Hairline: Hair transplantation can be used to reshape the hairline to provide a more feminine appearance. This usually involves moving the hairline forward and making it rounder.
  • Adam's apple: The thyroid cartilage is reduced. Sometimes this surgery is done on its own and this is referred to as a "tracheal shave."

Not all people interested in facial feminization surgery are interested in all of these procedures. Not all doctors offer them. Before getting facial feminization surgery, it is important to talk to other patients who have used the surgeons you are considering and see pictures of the work that they do. The right surgeon for one patient may be the wrong surgeon for another.

In addition, while there are biological differences in the effects of testosterone versus the effects of estrogen, not everyone has the same understanding of femininity and what that looks like.

Benefits of Surgery

There has been relatively little research on the outcomes of facial feminization surgery. However, one often-cited paper did compare the effects of facial feminization surgery, genital reassignment surgery, or both on quality of life. That paper found that while transgender women who had not undergone any surgical intervention had a lower mental health-related quality of life than cisgender women, that wasn't true for those who had surgery.

It also found that either type of surgeries, or both types of surgery, were all equally effective in improving mental health-related quality of life. Unfortunately, this has been used by some insurance companies to justify only covering one type of surgical affirmation for transgender women. This fails to acknowledge that genital surgery and facial surgery have the potential to affect quality of life quite differently across various domains.

Race and Facial Surgery

If you are a person of color who is interested in facial feminization surgery, it is particularly important to feel comfortable with your surgeon's approach to facial feminization. Surgeons who work to conform the face to "standard" measurements may be, knowingly or not, only working from measurements of Caucasian faces.

Although there have been facial anthropometry studies of diverse racial/ethnic groups, some surgeons may work from a single set of numbers that don't reflect different facial growth patterns across ethnic groups.

Puberty Blockers

Some young transgender women who transition early may never undergo puberty in their natal sex (the sex they were born). If they are started on puberty blockers near the first signs of puberty, it may not only prevent some of the major changes induced by testosterone—facial hair growth, shoulders broadening, genitals enlarging—but it may also prevent some of the facial changes that lead to a more masculine appearance.

To date, the extent that puberty blockers affect perception of facial gender has not yet been studied. However, it is plausible that young transgender women who never undergo puberty in their natal sex may have less interest in, and/or need for facial feminization surgery. Prior to puberty, gendered facial differences are relatively minor.

Recovery

The specifics of recovery from facial feminization surgery will depend on the procedures used. It will also depend on whether all the procedures are done at once or the surgery is performed in stages. The first may lead to more intense recovery.

The second could lead to a recovery that is more protracted over time. Common symptoms during the recovery phase include swelling, numbness, and pain. It can take months to fully recover sensation to different areas of the face.

A Word From Verywell

Every person's gender journey is different. Some transgender women have no interest in any gender reassignment surgery. They don't feel a need for surgery, or sometimes any medical intervention, to live comfortably in the world. Some transgender women need a vaginoplasty to feel most like themselves. They may want to feel more comfortable in the bathroom or in the bedroom.

Still, others feel like facial feminization surgery is what will be most helpful in being perceived as a woman—by others and/or by themselves. Feeling affirmed in your gender and feeling safe in your gender is about what makes sense to you. It's not about conforming to anyone's expectations but your own.

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Article Sources

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