Facial Feminization Surgery (FFS) is a set of surgical procedures designed to soften and modify facial features perceived as masculine, exaggerated or non-harmonious with the rest of the body, which are decisive in the visualfacial identification of gender.

It is a relatively new surgical specialty with two goals: 1) FACIAL GENDER CONFIRMATION SURGERY (FGCS) AND  2) FACIAL HARMONIZATION SURGERY (FHS). The concept of FFS is, in fact, much broader than originally conceived and it is being now sought by people of any gender.

The techniques included in FFS are similar to those used for cis or trans individuals, in whom it is referred to as Facial Gender Confirmation Surgery. On the other hand, sometimes female gender patient with unusually prominent foreheads or wide jaws/chins may request these surgeries to “harmonize” their facial features and therefore the term, Facial Harmonization Surgery, is used.

 

WHY FACIAL GENDER CONFIRMATION SURGERY?

Early in our upbringing, we are trained to automatically recognize a face as “male or female”, long before learning about gender differences. The perception of gender through facial features occurs in a single glance, almost involuntarilywithin milliseconds of seeing one.

During childhood, all human faces are more or less feminine looking. This is why social transitioning is possible before puberty. Changing the way a child dresses or changing the haircut will transform a boy into a girl or vice versa, at least visually.

With the advent of puberty, the situation changes drastically. The prevalent sex hormones – oestrogen in females and testosterone in males get produced in larger amounts triggering irreversible changes in the adolescent body. In the face, certain gender markers develop. Males undergo masculinization of face while femalesundergo further feminisation. These are besides the other changes the hormones trigger in the rest of the body.

While other parts of the body can be hidden, camouflaged or exaggerated to appear more feminine, it is often difficult to have facial femininity without the help of gender-affirming facial surgery. It is for this reason that an individual in the process of gender transition may seek this surgery with the objective of an easier integration within the society in general.

FFS is generating significant interest in the transgender community in our country as well, since they  are often subject to discrimination, violence or worse. Modifying facial gender within the transition protocol is as important for some as hormone therapy and genital sex change.

What comprises FFS?

Once puberty changesthe face, surgery remains the only option to feminise it.

Some facial gender attributes can be corrected non-surgically such as

  • facial hair reduction using Laser
  • jaw line alteration with fillers
  • eyebrow shaping with botulinum toxin.

Most of these non-surgical changes are however usually subtle and/or temporary. FFS modalities are more permanent and definitive.Cross hormone therapy (anti testosterone) does help to soften male facial features, but it is not enough in itself, as it cannot remodel the bones.

For ease of understandingFFS procedures,the face is divided into three parts:

  1. Upper third: Forehead, hairstyle and hairline
  2. Middle third:Eyebrows, shape of eyes, cheeks and nose
  3. Lower third: Lips, Chin, lower jaw, facial hair reduction and Adam‘s apple correction

To provide a brief overview of what is exactly done in FFS, the following is mentioned in simplistic terms:

 

Upper third:

Forehead: The prominences of the forehead are literally shaved off to make it smooth and round, thereby feminising it.

Hair line: Feminisation can be done surgically or with hair transplant. Different designs are shown to the patient and their preferences taken into account.

 

Middle third:

Eyebrows: A lateral brow lift arches the eyebrows well.

Shape of the eyes: This can be changed to a certain extent with lateral canthoplasty/pexy, ie., elevation of the outer corner of the eye giving it a cat-eye appearance considered to be more feminine.

Cheeks: Use of a malar implant or facial fat grafting can smoothen the facial contours, thereby feminising it. Fat also has the benefit of improving skin quality and texture when used as nanofat, as it has stem cells.

Nose: A feminising rhinoplasty makes a significant difference to the face.

 

Lower third:

Chin: A genioplasty is usually planned to narrow the chin and reduce its height.

Mandible: Reshaping the lower jaw is the most important facial change. Reducing the body height, smoothening the contours/angles, reducing the flare at the anglehelp in feminisation. It helps reduce the facial width as well. Meticulous planning is required in case of the mandibular alteration.

Adam’s apple correction: Shaving off the tracheal cartilage projection is a relatively simple procedure and can be undertaken at any time.

Redistribution of facial fat can be achieved with facial fat grafting. Laser hair reduction can be undertaken for facial hair growth.

For a more holistic effect, skin enhancement with peels, lasers, fairness agents, acne treatment, etc are also required regularly.

Voice alteration can also be done via a thyroplasty/laryngoplasty where the vocal cords are tightened to make the pitch of the voice higher and more feminine. This is usually done by an expert laryngologist in the team.

As one can see, FFS involves experts from numerous fields such as plastic surgery, craniofacial/maxillofacial surgery, otorhinolaryngology, dermatology, endocrinology, etc. Only good team work can deliver sustainable results over time.

 

TREATMENT PLANNING

The key to achieve highly satisfactory results in FFS is meticulous planning and appropriate choice of techniques, best suited to the needs of the individual patient. There is no “one mould fits all” approach. Each feminization is unique.

Normally, one facial area is identified as “primary”, which is the main focus of the personalized feminization surgery. It is essential to have realistic expectations. After thorough facial analysis, “secondary” areas may then be suggested in order to optimize the final result in separate stages. Any additional procedures, within the frame of realistic expectations, are considered after a careful global assessment by the surgical team.

Treatment planning is based on a combination of physical assessments, 3D CT scans, anthropometric measurements, clinical photographs, and most importantly: the self-evaluation and perception of the patient. The idea is to help develop a clarity of thought as to which facial areas need to be modified. One need not address all the areas suggested above.

In gender reassignment patients, the opinion of a psychologist / psychiatrist to assess the patient’s psychological stability is often mandatory and crucial.

 

Future:

With more acceptance and demand of these complex procedures and the ever-increasing technological prowess, incorporation of tools like piezotome, CT guided 3D printing, CT based software to predict the re-draping of the soft tissues over the bony changes,  the demand for FFS and FHSare only going to increase and the results will improve with time. It would give a holistic overall meaning to GRS, which began with only make-up/cross dressing to actually changing one’s sex as well as appearance right down “to the bone”.

Long live IAAPS!

Dr. Mahesh Nair

Consultant Plastic Surgeon, Bangalore

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