Facial Gender Affirming Surgery

What is facial gender affirmation surgery?

Facial feminization and facial masculinization surgery (FFS and FMS, respectively), are types of gender affirmation procedures. Most commonly, FFS refers to surgery sought out by a transwoman to achieve a facial appearance that is more classically feminine, and FMS surgery is typically performed for transmen who seek more typically masculine facial features. These procedures may also be performed for gender nonbinary people who desire a more masculine or feminine facial appearance, as well as ciswomen or men who desire to enhance the femininity or masculinity of their facial appearance. However, nearly all of these techniques are already well established and used in routine oculofacial cosmetic and facial plastic surgery.

Are there facial gender affirmation procedures that can be performed in office?

Gender affirmation procedures range from simple in-office procedures with minimal downtime to more comprehensive surgical approaches depending on each patient’s specific goals. Less invasive procedures include facial contouring with dermal filler (for example, with Juvederm® or Restylane® products) and neurotoxin (such as Botox® and Dysport® ) and laser or radiofrequency skin resurfacing. Options that give more dramatic results include hairline modification, eyebrow recontouring or lifting, chin and cheek augmentation, and orbital rim and forehead recontouring surgery. Typically, our surgeries are performed in a day surgery center (sometimes even in the office) and you can return to your own home the same day.

Who is a candidate for facial gender affirmation procedures?

Physically and emotionally healthy people are the best candidates for facial gender affirmation surgery. Anyone who is over 18, in good overall health, and willing to have reasonable expectations is a good candidate for facial gender affirmation surgery. Certain medical conditions, such as high blood pressure, heart disease, and diabetes may increase the complexity of these procedures and require extra attention. Reasonable expectations are a key part of preparing yourself for success for any gender affirming procedure. Facial gender affirmation procedures may go a long way in aligning your facial appearance with your gender, but it is also important to recognize that these types of procedures are part of the bigger picture of transitioning, which may also include speech therapy and changes to mannerisms, gait, and walk, etc. The procedures we offer are often a very important part of your transition and can significantly impact satisfaction with your appearance and quality of life, but they are just one piece of the puzzle.

What is Facial Feminization?

Although it is sometimes hard to pin down exactly which facial features are quintessentially feminine, modern society has plenty of examples of commonly held ideas about features that are interpreted as more feminine or masculine. Beards and facial hair are at the masculine end of the spectrum, while arched, delicate eyebrows and lack of a brow ridge are at the feminine end. Other ideas of feminine faces include wider eyes with room for make-up; narrower, shorter noses; less obvious “Adam’s apple”; rounder, fuller cheeks; fuller lips with a shorter distance between the top lip and the nose; smaller ears, lighter, narrower jaws and a less square chin. Facial feminization involves making changes to one or more of these features. Since the eyes are the first thing that most people notice, we will often begin with changes that will make the eyes and eyebrows more beautiful and feminine. At each step in the process, we work with our patients to see the bigger picture and create a more feminine overall appearance, even if some individual features are left unchanged.

What is Facial Masculinization?

Just as for feminine features, it is also sometimes to difficult to determine which facial feature are at the masculine end of the spectrum.  Among those that are commonly interpreted as masculine are heavier, straighter eyebrows that are closer to the eyes, with an underlying brow ridge or “brow bossing”.  Thinner, longer lips are seen as more masculine, as are wider, larger noses, and flatter, less plump cheeks.  Powerful men in fiction are often described as having a strong jaw and a well-defined chin, and these are also typically seen as masculine features.  Procedures that will increase the prominence of some or all of these masculine features are considered as part of a process of facial masculinization.  At each stage along the way, we work with patients to reassess how to best accomplish their objectives.

What are the most common Gender Affirming procedures?

The most common procedures in this group include

  • Fillers and botulinum toxin to gently reshape the brows, cheeks and lips
  • Waxing and/or laser hair removal
  • Laser and light-based treatments to soften and improve the complexion
  • Rhinoplasty surgery (nose job)
  • Eyebrow lifting or contour changing surgery
  • Reduction of the brow ridge
  • Blepharoplasty (eyelid surgery)
  • Fat grafting from the hips or belly to the face
  • Lip lift to shorten the distance between the upper lip and the nose and accentuate the lip shape
  • Chin/jawline augmentation or reduction
  • Otoplasty to reduce the prominence and/or size of the ears
  • Hairline surgery to raise or lower the hairline
  • Tracheal shaving to reduce a prominent Adam’s apple.

Can I have multiple areas treated in one surgery?

Yes, in general, multiple areas of the face can be addressed during one trip to the operating room or session in the office. However, for best results, your doctor may sometimes recommend performing procedures at different times (what we would refer to as a “staged approach”). If this is the case, we will discuss and explain the options thoroughly with you at the time of your evaluation.

How do I prepare for Gender Affirmation surgery?

You may be asked to get lab testing and pre-operative medical evaluations to ensure your safety during surgery. Depending on the type of procedures to be performed, a CT scan may also be needed. You may also need to adjust your current medication regimen. If you smoke, stopping before and after surgery will have a huge impact on your healing and ultimate success of your results. The most important preparation is usually mental, and ensuring that you and your surgeon are on the same page with your expectations for surgery and how these procedures will fit into your overall treatment goals is critical. It may be appropriate for our doctors to coordinate care with your other physicians, mental health care providers, and caregivers to find the optimal ways to help you.

How long is the recovery?

Recovery time varies depending on the procedures you desire. For in-office procedures like botulinum toxin and filler, there is minimal downtime and impact on your daily activities. For surgical procedures that involve a trip to the operating room, recovery time is most typically about 1-2 weeks, but may be longer for more extensive recontouring procedures. Generally, we ask that you lie low for about 7 days and limit heavy lifting or strenuous activities. Depending on exactly what changes you would like to make, your expected recovery time may be shorter or longer, and what to expect after surgery is something that will be discussed in detail at the time of your evaluation.

Can I have this surgery if I am on medication? (such as hormones, etc)

Yes, you can move forward with facial gender affirmation procedures while on many medications, including hormone therapy. In some cases, if you are on estrogen therapy and have other risk factors for developing blood clots, you and your surgeon may discuss together the risks and benefits of temporarily stopping your treatment around the time of surgery, although this is not always necessary. Some medications, especially blood thinners (like aspirin, ibuprofen, Coumadin, Plavix, Eliquis, and others) will be stopped for varying amounts of time before your procedure to reduce the risk of bleeding and complications. The same is true of herbal supplements with blood thinning effects, such as aloe, fish oil, ginkgo, ginger, and turmeric. Some types of blood pressure lowering or stimulant medications must also be stopped. This will all be thoroughly reviewed and you will receive specific personalized instructions regarding your medication regimen before surgery.

Here is a little more information about what we offer at the Fante Eye and Face Centre:

Facial filler:

Facial filler offers an excellent less invasive option for contouring of the jaw, chin, cheek, brows, and nose. Fillers are also commonly used to give additional volume and definition to the lips as well as soften deeper lines around the mouth. Fillers are placed in the office after the application of an anesthetic cream. You may expect results to last for up to 1 year, after which time patients typically return for an additional treatment.

Neurotoxin (Botox, Dysport, Xeomin, Jeuveau, and others):

In addition to providing a more youthful appearance with the relaxation of lines around the eyes and mouth, neurotoxin injections may also be used to contour the jawline for the appearance of a slimmer face.

Eyebrow and eyelid lifting and shaping:

In general, females have a higher and more arched brow. Eyebrow lifting and recontouring may be performed to achieve this more typically feminine look. Usually, the best way to achieve this is with an endoscope through incisions hidden behind the hairline. The eyelids themselves may also hang low in some patients, or extra skin may be present on the eyelid itself. Surgery such as blepharoplasty or ptosis repair may also give a more feminine and lively appearance and, if desired, more room to wear eye makeup.

Hairline surgery:

Re-shaping and either raising or lowering the hairline may be performed to give a more feminine or masculine appearance. Typically, an incision will be made just at or within the hairline across the forehead to allow us to perform this recontouring. This may be performed in the office or in a day surgery center. 1-2 weeks is a typical recovery period, although the scar along the hairline will continue to fade for up to 1 year after surgery.

Forehead contouring:

Forehead contouring is performed primarily to sculpt and reduce prominent brow bones, also known as “brow bossing” or brow ridge to feminize the face Typically, bone is removed to reduce the appearance of the bony ridge under the eyebrows. This also reduces the appearance of a sloping forehead. Sometimes an implant can be added for particular effects. Incisions are typically hidden at or behind the hairline for this type of surgery, which is performed at a surgery center under general anesthesia.

Fat grafting:

Fat grafting to the face is a powerful technique we use to soften and reshape the contours of the face. Fat is harvested from your own body (typically areas such as the belly, hips, or inner thigh), refined, and injected into the face. It is similar in concept to having filler placed, but with longer lasting and more dramatic results.

Cheek and chin recontouring:

More prominent cheekbones with rounded cheeks offer a soft, youthful, feminine appearance, and cheek implants may be placed to add volume, lift, and structure. In cases where filler is not sufficient, or for patients or need a more dramatic and durable change, facial implants are great options by themselves or in addition to other procedures, such as fat grafting. Chin implants can be used to add height, projection, or improve contour. Particularly in transmen seeking a more masculine jawline, chin implants can significantly impact the perception of a face as a masculine one.

Otoplasty and earlobe reconstruction:

If prominent ears are a problem or if you would like to close holes in previously pierced ears, we can help you. Earlobe reconstruction may be used to shorten elongated, loose earlobes for a more feminine and youthful appearance or to eliminate the hole from an earlobe piercing. Typically, this can be performed in-office and takes 1 hour or less. Otoplasty refers to surgery to change the shape, size, and position of the ears, typically performed if a patient desires ears that are less prominent and lie closer to the head.

Lip lift:

As an addition to or in the place of lip filler, a lip lift physically raises and upturns the upper lip giving the appearance of increased volume, softness, and a more feminine shape. Incisions are typically hidden at the base of the nose, where some tissue is removed to shorten the distance between the nose and upper lip. This surgery may be performed in the office and usually lasts an hour or less.

Skin treatments and body sculpting at ReDerm MD® medical spa:

Our aestheticians are experienced in a wide range of facial and body rejuvenation techniques. ReDerm MD® offers in-office skin resurfacing treatments as well as body sculpting with CoolSculpting. They are also able to help with any needed tips for skincare and feminizing makeup.

Will facial gender affirming surgery or procedures be eligible for insurance reimbursement?

Generally, these procedures are not covered by private or government health insurance plans since the focus is on appearance, rather than function. Under most plans, these procedures and surgery are considered cosmetic unless there is history of prior surgery or medical treatments for major trauma, cancer, or major reconstruction. Our office will work with you to create reasonable quotes and/or payment plans for out-of-pocket expenses for cosmetic procedures and surgery, and you will always receive an estimate of what your costs will be before any work is done.

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