Facial Feminization Surgery: Everything You Need to Know

Facial feminization surgery (FFS) encompasses a series of surgical interventions designed to make your face appear more feminine. This operation is most commonly performed in transgender women or non-binary people as a type of gender-affirming surgery.

While facial feminization surgery has many potential benefits, the decision to proceed with it requires careful thought and preparation, especially given the surgery's psychological and social implications.

What Is Facial Feminization Surgery?

Facial feminization surgery is performed by a plastic surgeon who has training in craniomaxillofacial and soft tissue surgery.

The surgery is usually done under general anesthesia. In certain cases, it may be performed under local anesthesia with intravenous sedation (the area being operated on is numbed and you are put into a light sleep).

Facial feminization surgery is most commonly performed as a treatment for gender dysphoria, which is when an individual experiences significant distress related to a strong desire to be of another gender.

The surgery may also be performed in cisgender women who desire a more feminine face or facial feature (e.g., a lower hairline).

With facial feminization surgery, there are several different surgical procedures a person may undergo. These may be staged over time or performed during the same surgery, depending on surgeon discretion and patient goals/preferences.

Procedures that fall within the scope of facial feminization surgery include:

• Forehead reduction and contouring: The brow bone is cut and reconstructed, and the bones around the eye sockets are reshaped. The frontal bone between the eye sockets is taken out, made smaller as needed, and reattached.
• Hairline lowering: The hairline is lifted and moved forward to shorten the forehead and create a rounder shape.
• Direct brow lift: The deep tissues that attach your eyebrows to their underlying bone are released, allowing the surgeon to lift the brows into a more feminine position. 
• Corrugator muscle resection: The corrugator muscle (which allows you to furrow your eyebrows) is partially removed.
• Blepharoplasty: Excess skin and fat from your upper and lower eyelids are removed.
• Earlobe reduction: Earlobes are reduced and reshaped, and your ear cartilage may be manipulated to change the overall contour of the ear.
• Rhinoplasty: The bridge of your nose is made smaller and the tip is refined. Your nose may also be reshaped.
• Upper-lip shortening: The space between the base of your nose and upper lip is shortened.
• Jaw reduction: The squareness/flaring at the back of your jaw is reduced. The bone beneath the bottom teeth may be shaved down and the height of the chin may be lowered.
• Chin reduction: Your chin is shortened and reshaped to have a more oval-shaped appearance.
• Adam's apple reduction (tracheal shave): Excess thyroid cartilage (your Adam's apple) is removed.
• Fat grafting: Fat from your abdomen is removed and injected into your cheeks, lips, and/or temples.
• Facelift: Excess skin from the lower face and neck is removed. This is followed by tightening of the remaining skin.

Keep in mind that not everyone interested in facial feminization surgery necessarily desires all of the above procedures. Furthermore, not all healthcare providers may offer them.

For example, a transgender woman or non-binary individual who feels uncomfortable or distressed with the gendered structure of their face may desire several procedures, including a forehead reduction, rhinoplasty, tracheal shave, chin and jaw reduction, and fat grafting.

On the other hand, a cisgender woman with a receding hairline may only desire a hairline advancement procedure.

Surgical Techniques

Depending on the specific procedure being performed, there may be more than one approach that a surgeon can use.

For example, a forehead reduction may be performed using an open or endoscopic approach. With the traditional "open" approach, a surgeon makes a large incision to perform the operation. With the endoscopic approach, smaller incisions and special, pliable instruments are used to perform the procedure.

Incision sites may also vary with certain procedures. For instance, with the forehead reduction, a surgeon may utilize a hairline approach (the incision is made over the front of the hairline) or a coronal approach (the incision is made across the top of the head).

Criteria and Contraindications

Even though transgender or non-binary patients undergoing breast augmentation ("top surgery") or vaginoplasty ("bottom surgery") need to meet certain criteria set forth by the World Professional Association for Transgender Health (WPATH) before being approved for surgery, there are no specific criteria for patients undergoing a facial feminization procedure.

That said, if you are seeking facial feminization surgery as a component of your gender transition, your surgeon may recommend that you receive clearance from a qualified mental health professional.

In addition, while there are guidelines that exist for the specific timing of facial feminization surgery, your surgeon may recommend that you delay any procedures until you have been on estrogen therapy for at least a year (if applicable). While estrogen won't affect your bone structure, it will redistribute facial fat, and this may alter your surgical plan.

Contraindications to facial feminization (which are surgeon dependent) may include:

• Insufficient social support to move through the surgical process
• Poorly controlled medical conditions
• No confirmed diagnosis of gender dysphoria (if applicable)
• Inability to provide informed consent of surgery
• Unrealistic expectations

Potential Risks

The risks associated with facial feminization surgery depend on the specific procedure being performed.

That said, general risks of this surgery include:

• Prolonged bruising and swelling
• Bleeding and/or hematoma formation
• Infection and problems with wound healing
• Nerve damage and subsequent numbness after surgery
• Failure of the bones to heal
• Infected titanium plates/screws that may require removal
• Scarring
• Hair loss along the incision line

Purpose of Facial Feminization Surgery

The purpose of facial feminization surgery is to change masculine facial features into feminine ones. These changes address the gendered differences in facial structure that occur due to testosterone exposure during various phases of development.

By undergoing facial feminization surgery, a person may experience one or more of the following benefits:

• A reduction in gender dysphoria (if applicable)
• Greater social acceptance
• An improvement in self-esteem and quality of life

If you are considering facial feminization surgery, your first step will be to schedule a consultation with a plastic surgeon who specializes in this type of surgery.

During your consultation, your plastic surgeon will review your goals and expectations, the recommended procedures, and all potential risks involved. Out-of-pocket costs will also be discussed at this visit.

If you are considering any bone-related procedure (e.g., forehead or jaw), you will need to get X-rays or a computed tomography (CT) scan of your facial bones. Your surgeon will also take photographs of your face during this visit.

If you decide to proceed with surgery, various tests will be recommended for medical and anesthesia clearance.

Such tests often include:

• Blood tests like a complete blood count (CBC) and a coagulation panel (to check for bleeding disorders)
• Chest X-ray
• Electrocardiogram (ECG)

Depending on surgeon preference and/or if you are trying to obtain insurance coverage, you may also need to see a mental health professional for a letter of referral. This is typically only needed if you are undergoing surgery as a gender-affirming operation.

The mental health professional will review your gender identity and dysphoria and help you determine how the surgery fits into your overall treatment plan.

How to Prepare

Once you are scheduled for facial feminization surgery, your surgeon will give you instructions on how to prepare.

Location

Facial feminization surgery is performed in a hospital or surgical center. After surgery, you may go home or to a hotel (if you are out of town), or your surgeon may have you stay overnight in the hospital.

Whether you are staying overnight in the hospital or not, be sure to arrange for a loved one or friend to drive you home once discharged.

You should also arrange to have someone stay with you for the first few days (perhaps up to a week) after surgery to help you with your recovery and other logistics, like household chores, picking up medications from the pharmacy etc.

What to Wear

Since you will be changing into a hospital gown upon arrival, wear loose-fitting clothes on the day of your surgery. Do not wear makeup, hairspray, nail polish, or deodorant.

Food and Drink

Do not eat or drink anything after midnight on the eve of your surgery.

Medications

Two weeks prior to surgery, you might be advised to stop taking certain blood-thinning medications, like non-steroidal anti-inflammatory drugs (NSAIDs).

Since estrogen increases your risk of blood clots, your surgeon will ask you to stop estrogen therapy (if applicable) for a designated period of time before surgery.

What to Bring

Make sure you bring your driver's license, insurance card, and a list of your medications.

If you are staying overnight in the hospital, be sure to pack the following items in your bag or suitcase:

• Any medical devices you use (e.g., asthma inhaler, eyeglasses, etc.)
• Wide-collar, zip-up, or button-up shirt to wear when leaving the hospital
• Small personal or comfort items (e.g., cell phone and charger)

Pre-Op Lifestyle Changes

Avoid smoking or tobacco use four to twelve weeks before surgery.

Your surgeon will likely ask that you avoid any facial treatments (for example, electrolysis or chemical peels) two weeks before your surgery date.

What to Expect on the Day of Surgery

Depending on the specific procedure or procedures being performed, the operation time for facial feminization ranges from 90 minutes to several hours or longer.

Before Surgery

Upon arrival at the hospital or surgical center, you will be led into a small pre-operative/holding room. Here, you will change into a hospital gown.

A surgical nurse will review your medication list, record your vitals (heart rate, blood pressure, etc.), and place an intravenous (IV) line into a vein in your arm. This IV will be used for administering fluids and medications during and after surgery.

Your surgeon and anesthesiologist will come to greet you and review the operation with you. You may need to sign one or more consent forms at this time.

From there, you will walk on your own into the operating room or be wheeled on a gurney.

During Surgery

The precise steps of your surgery will depend on the type of procedure(s) you are having.

That said, here is a general breakdown of what you can expect during surgery:

• Anesthesia administration: If you are undergoing general anesthesia, an anesthesiologist will give you inhaled or intravenous medications to put you into a deep sleep. Once you are asleep, the anesthesiologist will insert an endotracheal (breathing) tube into your trachea (windpipe). The breathing tube is connected to a ventilator that controls your breathing during surgery.
• Incision: After your skin is cleaned with a solution, your surgeon will make one or more incisions. The incision location depends on the specific procedure being performed. For example, with a tracheal shave, the incision is usually made in the skin covering the throat, just under the chin.
• Reconstruction: Once access is obtained to the desired region of the face, your surgeon will perform various surgical techniques (e.g., shaving, reshaping, removal of tissue or bone) to obtain a more feminine aesthetic. In some cases, devices like plates, screws, or implants may be utilized.
• Closure: Incision sites will be stitched up, and depending on the procedure, your head may be wrapped with gauze and a bandage.
• Prep for recovery: Anesthesia will be stopped and the breathing tube will be taken out (if undergoing general anesthesia).

After Surgery

After surgery, you will be taken to a recovery area where you will slowly wake up from anesthesia. At this time, you may feel pain and nausea. A nurse will administer medications, as needed, to ease your symptoms.

If you are being discharged that day, it will likely be a few hours after the procedure. If you are staying overnight, you will be moved to a hospital room once you are fully awake.

Recovery

The specifics of recovery from facial feminization surgery depend on the procedures used and whether all the procedures are done at once or the surgery is performed in stages.

That said, whether you are recovering from one or multiple procedures, you can generally expect swelling, pain, and tightness.

Since your face contains lots of blood vessels, it easily swells and bruises, and this can be quite dramatic after your surgery.

To minimize swelling (which peaks two to three days after the operation), your surgeon will probably advise you to ice your face.

When icing, be sure to stick to these tips:

• Apply the ice to your face for no longer than 20 minutes within an hour-long period
• Place a cloth between the ice pack (frozen peas or crushed ice in a zipper bag also works) on your skin.

Your surgeon may also ask that you keep your head elevated for at least two weeks after your surgery. This usually requires that you use lots of pillows or a soft foam wedge behind your head when sleeping.

Double-check with your surgeon, but taking an over-the-counter herbal product called Arnica may also be recommended to further ease any bruising and swelling on your face.

Facial pain and tightness after surgery will vary in severity based on the procedures you underwent.

To ease discomfort, take your pain medication exactly as prescribed. You will likely be given an opioid to start, followed by Tylenol (acetaminophen) alone.

Wound Care

Your surgeon will probably give you the OK to shower around 48 hours after your operation. When showering, wash your incision sites very gently with warm water and soap and pat the skin dry with a clean towel.

Don't submerge your incisions sites underwater (e.g., when taking a bath or swimming) for three to four weeks.

You may be prescribed an oral antibiotic or an antibiotic ointment to apply to your incision sites, once or multiple times a day for the first week after surgery.

Ask your surgeon about how to re-dress your incisions after washing them and applying ointment. Typically, you will need to cover the incisions with gauze and rewrap your head with bandages.

Diet and Activity

Most patients can resume a normal diet after surgery; although, your surgeon may have you stick to soft foods (e.g., yogurt or scrambled eggs) in the beginning.

Your diet instructions may also vary depending on whether you had any procedures performed in or around your lips, mouth, or jaw.

Other common post-operative instructions may include:

• Avoid bending over or lifting anything heavier than 20 lbs for two weeks after your surgery.
• Avoid exercise or other strenuous activities for at least four weeks after your surgery.
• Take two to three weeks off from work (this may vary based on the procedures you had and your occupation).
• Avoid driving until you are off all pain medication and your surgeon gives you the OK.

Follow-Up

You can expect to see your surgeon for your first follow-up visit around one to two weeks after surgery. At this appointment, your surgeon will check your incision sites, remove any non-dissolvable stitches, and monitor you for complications.

From there, you will probably see your surgeon at these time frames after surgery:

• 6 to 8 weeks
• 6 months
• 12 months

Long-Term Care

Depending on the number and types of procedures you underwent, the final results of your surgery make take up to six to nine months to appear, and scars can take up to a year to heal.

To optimize your wound healing and surgical results, it's important to follow post-operative instructions carefully.

Minimize sun exposure and always wear sunscreen. If you are concerned about scarring, contact your surgeon. They may recommend certain ointments or treatments to address them sooner than later.

Possible Future Surgeries/Therapies

Since facial feminization surgery is sometimes performed in stages, you may begin preparing for the next procedure soon after recovering from the first one.

This "in-between" timeline is highly variable, though, and is determined based on a number of factors including surgeon discretion, procedure healing times, and patient preference.

In terms of restarting estrogen therapy (if this applies to you), confirm with your healthcare provider, but patients can usually restart within two to three days after surgery.

Coping

Research suggests that patients who have undergone facial feminization surgery are generally pleased with their results.

That said, the physical and emotional challenges that go along with surgery are very real. If you have decided to pursue surgery, be sure to reach out to friends and loved ones who can provide support for you during this time. If you haven't already, you may also consider finding a facial feminization support group.

A Word From Verywell

Every person's gender journey is different. While some individuals may feel that facial feminization surgery is necessary to feel affirmed in their gender, others may not.

Whatever your reason for undergoing facial feminization surgery, be sure to get recommendations for an experienced board-certified plastic surgeon.

Remember, too, that not everyone has the same understanding of femininity, so be sure to review how your surgical plan aligns with your expectations with your surgeon carefully.