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Facial Feminization Procedures Explained

Facial Feminization Surgery (FFS) is a group of facial surgery procedures that transform male-looking facial features to bring them closer in shape, size and proportion to typical female facial features. FFS is associated with multiple surgical specialties: oral and maxillofacial surgery, craniofacial surgery, and plastic and reconstructive surgery. When FFS was being developed in the mid-1980s, it was considered secondary to Vaginoplasty, but these days FFS surgeons insist that while not all patients will require FFS, these procedures are medically necessary and life-changing in some patients.

"You don't walk down the street looking in everyone's pants to decide what sex they are," one surgeon explained. "You look at their face."

When looking at a face, there are many aspects that suggest either a masculine or feminine presentation:

Female Facial Features	Male Facial Features
Low straight hairline	High, curved hairline with "widows peaks"
Short flat forehead	High obtuse, often angled forehead
High, arched tapered brows	Low, straight, heavy brows
Absence of frontal bone bossing	Frontal bone prominence; Prominent supraorbital rims ("Brow Bossing")
Large eyes, not deep set	Smaller, deeper, set eyes
A more delicate nose	Strong, long, prominent nose
Obtuse nasolabial angle (larger angle formed between nose and upper lip, nose tends upward pointing)	Acute nasolabial angle(smaller angle formed between nose and upper lip, nose is parallel or downward protruding)
Short upper lip with well defined philtrum complex	Long upper lip
Full everted vermilion	Narrow lip vermilion
Shorter, less prominent chin	Prominent chin, wider and blunter
Narrower jaw mandibles	Pronounced, angular jaw mandibles
Non-projecting thyroid cartilages (no "Adam's Apple")	Prominent thyroid cartilage

FFS can involve one or more procedures, such as forehead sculpting and contouring, mandible contouring, tracheal shaving, jaw and chin shaving, chin implants, rhinoplasty and cheek augmentation. FFS is customizable: you can pick and choose which procedures to have based on your personal transition goals and your Surgeon's recommendations.

Dr. Josef Hadeed has dedicated much of his practice to meeting the needs of his facial feminization patients. Dr. Hadeed has a specialized way of achieving the most feminine, natural-looking results while maintaining your personally identifiable facial characteristics. According to Dr. Hadeed, FFS not only helps feminize your facial characteristics, but it also refines your appearance by treating wrinkles, fine lines, sagging skin, and other facial imperfections for a more natural, feminine, and refreshed look.

Common FFS Procedures

Facial Feminization Surgery Explained

Upper Third

Hairline Correction

In males, the hairline tends to be higher on the face and imparts the forehead with a box shape; in females, the hairline tends to be lower on the face and imparts the forehead with a semicircular shape.

This procedure is relatively straightforward. An incision is made along the hairline. A section of skin is removed from the forehead, and the scalp is literally pulled down to its new position and stapled to the rest of the forehead. At the same time, the brows can be elevated to a higher position. Often done in conjunction with Forehead Recontouring and/or Rhinoplasty. Hair Grafting is another solution.

Brow Lift

Brow Lift refers to a surgical procedure that repositions the eyebrows higher, resulting in a more feminine appearance. This is considered one of the most effective procedures to feminize the upper face.

Many FFS Surgeons will also perform Forehead Recontouring and Hairline Correction along with a Brow Lift as this typically produces better results and all three procedures use use the same incision.

Forehead Recontouring

The male forehead, in addition to being overall larger, has thick bony ridges over the eyes known as "brow bossing" (more prominent orbital rims) and may slope foreward; the female forehead is flatter and convex in all planes.

Using either a separate incision, or the incision made for a scalp advance, the skin from the forehead can be turned downward to reveal the bones underneath. For some patients, it may be adequate to shave down the orbital rims to a flat, smooth contour. Other patients may require forehead reconstruction for optimal results. In this case, the bones overlying the frontal sinuses are removed, reshaped, and replaced using surgical-grade screws. Often done in conjunction with Rhinoplasty and/or Hairline Correction.

Middle Third

Cheek Implants

Females more often have full, round cheeks. Cheek implants or bone filler can be used to give the cheeks the desirable full, round appearance.

Rhinoplasty

The male nose tends to longer and wider, consistent with its overall larger size. The nose is more likely to be angled downwards. A female nose tends to be narrower, shorter, directed upwards, and slightly concave.

The shape of the nose is altered by changing the underlying bone and cartilage. Lateral and medial tissue can be removed from inside the nose to make it narrower. A bump can be smoothed out if desired. Also, the tip of the nose can be raised and reduced. Often done in conjunction with forehead recontouring.

Lip Lift and Lip Augmentation

To feminize the lips, an incision is made under the nose and part of the skin is removed; the remaining skin is resutured to the base of the nose, pulling the top lip up and shortening the distance between the top lip and nose. Lips can also be made to look more full using lip fillers, lip implants or fat/tissue grafting.

"My lip augmentation was done with silicone implants (unlike injections that you have to redo every 6 months these are permanent) inserted in channels he made inside my lips from inside my mouth. My lips are now wonderful and with the upper lip lift they look fantastic." - Patient of Dr. Toby Meltzer, 2020

Lower Third

Chin Recontouring

FFS Chin Recontouring The male chin tends to be wide, flat and square. The distance between the end of the chin and the lower lip is increased. Females have smaller chins that project forward slightly.

An incision is made through the chin to make a wedge of bone. This wedge can be advanced or retracted, or removed, to change the shape of the chin. Also, a chin implant may be used to give the desired forward projection of the chin.

Jaw Recontouring

The male jaw tends to be wider and larger, as does the overlying masseter muscle. The angle of the mandible forms a right angle, whereas in females the angle curves much more gently, approaching a straight line.

The angle of the jaw is cut or filed down to achieve a feminine contour and the jaw may be narrowed as well.

Neck

Tracheal Shave

Males have more prominent thyroid cartilage. In a Tracheal Shave, the thyroid cartilage ("Adam's apple") is shaved down to a more feminine size. The procedure is typically done on an outpatient basis with local anesthetic. Risks include removing too much cartilage and affecting the vocal chords, which may permanently affect the voice.

There are a few important distinctions between the ways that a Tracheal Shave can be performed. The most common method, referred to as the trans-cervical approach, involves a small horizontal incision over or just above the Adam's Apple cartilage. While this typically heals very well, it can result in visible scarring and adhesion. With the submental approach, the incision is made right under the chin, which effectively conceals any scarring.

A newer approach is the transoral transvestibular approach, also referred to as TOEVA and Scarless Neck Feminization. With this method, the Adam's Apple cartilage is accessed with an endoscope through incisions in the mouth, leaving no visible scarring on the neck. Surgeons in the United States who offer the TOEVA Tracheal Shave include Dr. Kyle Keojampa and Dr. Rahul Seth, both in California. Dr. Kamol in Thailand also offers this method.

Additional FFS Procedures

Blepharoplasty: "Eyelid Lift"
Otoplasty: Reshaping of the ear
Rhytidectomy: "Face Lift"
Temporal fossa augmentation: Filling in the temples; improves facial contour.
Non-surgical Facial Feminization: injectables such as neurotoxin and fllers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids.

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