Facial Feminization Surgery Techniques

Here are a lot of surgical techniques available to feminise a masculine face but not all surgeons use the same techniques to achieve the same results. Here is a rough overview of the main procedures.

Hairline

There are two options for reshaping and bringing forward masculine hairlines.

1: Scalp advance

In a scalp advance an incision is made along the hairline. A section of forehead skin is then removed from in front of the incision and the scalp is lifted and pulled forward to fill the gap. There is a limit to how far the scalp can be moved in one go and two or more separate advances several months apart may be required to achieve the desired result. There is always a visible scar from a scalp advance but how visible will be partly down to luck and partly down to your own tendency to scar. Many patients feel their scar is almost invisible except to people who know what they are looking for. If the surgeon is also doing work on the brow ridge, it can all be done via the same incision.

2: Hair transplants

In a hair transplant a strip of skin is removed from the back and sides of the scalp and all the hair follicles are dissected out (each follicle contains between 1 and 4 hairs). They are then be transplanted to the areas where they are needed and can be used to fill the corners of the male “M”, to bring the hairline forward and to thicken areas where the hair has become thin. There is a limit to how densely the hair can be packed in at one time so more than one procedure may be needed to achieve the desired density.

Forehead

To access the bones of the forehead an incision can be made across the top of the scalp from ear to ear. This means that any scar will be well hidden by your hair. If you are also having a scalp advance then the forehead will be accessed via the hairline incision instead. The skin of the forehead is then pulled down to reveal the bones. The orbital rims are solid bone and can simply be shaved down. The bone over the frontal sinuses is more difficult and there are 3 main options for dealing with it. These options depend on how far the bossing protrudes, how thick the bone is and the preferred techniques of your surgeon. The amount of bossing doesn’t actually tell you how thick the sinus bones are and some people with very little bossing can have thick bone with a small sinus cavity behind it while others with very prominent bossing might have very thin bone with a large sinus cavity behind it. Some surgeons access the bones endoscopically using smaller incisions but with this technique it is only possible to shave down the bones and not to reconstruct the forehead.

Option 1: Shave

If the bones over the frontal sinuses are thick enough then the bossing can simply be shaved down to give a flatter and more female contour.

Option 2: Shave and fill

Shaving alone may not be enough to achieve the desired result especially if the bones over the sinuses are too thin to be shaved down very much. A bone-filler can be used to fill in the indented areas around the bossing like the slightly hollow area that males often have in the centre of the forehead. Some surgeons feel that the shave and fill approach is sufficient to feminise most masculine foreheads; others disagree and prefer the reconstruction approach.

Option 3: Forehead reconstruction

Forehead reconstruction is the most complex technique. The orbital rims are shaved down as before but the bone over the frontal sinuses is first removed then re-shaped before being set back in place with wires or titanium screws. This technique is very powerful and can take a severely male forehead to well within normal female ranges.

An alternative forehead reconstruction technique has been developed by a top Thai surgeon that involves shaving the bones over the sinuses thin enough so that they become flexible and then literally compressing them into the right position.

Note: You may hear foreheads and forehead feminisation procedures classified as “Type I”, “Type II” or “Type III”. These classifications are best avoided as they are not used by all surgeons and the ones that do use them define them slightly differently from each other.

Eyebrows

Eyebrows can be lifted with a “brow lift” procedure. This is done by tightening the muscles attached to the outer third of the eyebrow or lifting the skin of the entire forehead. It can be performed via the incision made for a scalp advance or brow-bossing reduction; otherwise two small incisions are made in the scalp. If a brow lift is overdone it can leave the patient with a “surprised expression.

Nose

Noses can be feminised through standard rhinoplasty techniques. If you are having forehead work you will quite possibly also need a rhinoplasty and vice versa. This is because the nose and forehead need to flow nicely into each other – basically, if you can set back your brow bossing to the ideal position without it actually sitting behind the bridge of the nose and causing a step between the 2, you might be able to have your forehead done without needing a rhinoplasty. Likewise you might be able to have a rhinoplasty without forehead work as long as the changes to the bridge of your nose are not going to cause a step between your nose and forehead. See the links page for more information on rhinoplasty.

Cheeks

Cheek bones can be enhanced either with solid implants, a bone-filler paste or by using fat from another part of the body. Solid implants are available in several shapes and can be placed over or under the cheekbone or lower down near the sides of the nose according to the needs of the patient. Bone-filler is moulded to the desired shape in situ and sets solid. Both these techniques are for enhancing the cheekbones and the Incisions for them are usually made in the gums. If the cheeks need to be fuller and more rounded you can have fat from another part of the body injected into the area. Some of this is reabsorbed and you may need a top-up a few months later. After one or two top-ups, the fat is usually permanent. See the links page for further information on cheek augmentation.

Top lip length

To shorten the distance between the nose and top lip an incision is made just under the nose. A section of skin is then removed and the gap is closed to raise the lip. Depending on the angle of the cut, this can also be used to roll the lip out a little giving it a fuller and more feminine shape. A similar technique involves making an incision along the top edge of the lip, removing a section of skin as above and then closing the gap though any scarring left along the edge of the lip can be very noticeable. There is a limit to how far a lip can be raised if it is to look natural and work properly. The whole section of skin from lip to nose can be angled back slightly if necessary.

Lip shape

There are many different types of implant that can be used to make the lips fuller. These can be natural or synthetic and may be solid or injectable. Not all of them are permanent and not all of them are removable.

Chin

The chin can be changed by shaving the bone to the desired shape or through a procedure called “sliding genioplasty”. In a sliding genioplasty the chin-bone is cut through from front to back to separate a “horseshoe” of bone. This horseshoe can be moved forwards or backwards to correct a receding or protruding chin and sometimes another section of bone is removed altogether so that when the horseshoe is reattached, the chin is shorter. The angle of the original cut also affects the final height of the chin. Implants or bone-filler paste can also be used to correct a receding chin. The incision for chin work is made in the lower gums. Liposuction can also be used under a masculine chin to help remove weight from the lower face.

Jaw

The jawbone can be reduced by bone shaving or cutting and quite a lot of bone can be cut away to round off and narrow the square corners at the back. To make the jaw even narrower the large masseter muscles that attach to the corners can be surgically reduced. Incisions for jaw work are usually made inside the mouth but are occasionally made externally under the jaw. Patients over the age of about 40 often experience some loose skin around the jaw after bone has been removed from the jaw or chin. This can be tightened up a few months after the original procedure with a lower face-lift.

Adam’s apple

The Adam’s apple can be reduced (a procedure often referred to as a tracheal or “trach” shave) but there is a limit to how much can be removed without risking permanent damage to the extremely delicate voice box. Also, the cartilage that forms the Adam’s apple tends to harden with age which may limit the amount that can be removed in an older patient. The incision for a trach shave is either made directly over the Adam’s apple or just under the chin. Trach shaves seem to carry a higher risk of complications than most other FFS procedures and should always be considered very carefully.

Gender Reassignment Surgery

Gender reassignment surgery is no longer the novelty it once was. Thousands of transsexuals, both male-to-female and female-to-male, worldwide have now undergone this procedure. But it is still true that only a small fraction of those people who consider themselves to be transgendered actually go this far. The cost is a major barrier for many people. Others find ways to accommodate their transgender feelings while continuing to live in their birth sex or in some in-between state.

Gender reassignment surgery is expensive, costing thousands or tens of thousands of dollars, depending on which procedures are undertaken. Some governments will cover the entire cost under their medicare programs. Others will cover it partially or not at all.

Surgery is irreversible. Once the original sex organs are removed and new organs constructed, there is no going back. Surgery also renders the patient sterile. Although several surgeons have speculated that it may some day be possible for post-operative transsexuals to be parents, this is not possible today.

Like any surgery, gender reassignment surgery has its dangers. But if one is in good health and follows the surgeon’s guidelines to prepare for the operation, one can expect good results. It is equally important to follow a proper routine after surgery, or much of the surgeon’s work can be undone.

Surgical techniques are constantly evolving. In the ’60s, it took a team of at least two surgeons as long as 12 hours to perform the operations. Results were superficially satisfactory, but patients were not always able to have normal sexual intercourse or experience orgasm.

Today, some surgeons perform male-to-female reassignment surgery in under three hours, with almost no blood loss. And most post-op patients report normal sexual functioning, including orgasms within three months to a year after surgery.

Life is more complicated for female-to male transsexuals. There are several techniques for constructing a new penis and each has its drawbacks. But post-op patients are generally happier now than prior to surgery and some are reporting near-normal sexual functioning.

Male to femaleAlthough each surgeon has his preferred technique, the overall procedure is similar across the board. The testes are removed, an opening is created in the correct spot for the new vagina, the inside of the penis is removed, the skin of the penis is inverted like a glove and used to line the vagina, sensitive parts of the penis are used to create a clitoris, the urethra is shortened and relocated to the appropriate place, the skin of the scrotum is used to create labia.

Some surgeons do this in a single operation. Others prefer to do it in two steps. And sometimes, if there isn’t enough penile skin, a graft is taken from elsewhere to create the vagina.

Some patients also opt for other operations to give themselves a more feminine appearance. These include: breast implants, Adam’s apple shaving, larynx adjustment to raise the voice, removal of the lower ribs to create a narrower waste, facial reconstruction, and hair implants.

Female to maleFemale-to-male patients often undergo more surgery. Typically, the first stage is removal of the breasts to create a normal male chest. This is sometimes done in several operations. The first removes the bulk of the mammary glands and most of the excess skin. The second fine-tunes the result, removing further excess skin and perhaps reducing scars left from the first stage.

The next major surgery is a hysterectomy. This removes the womb, uterus and ovaries.

The final surgery is the creation of a penis along with the relocation of the urethra to the centre of the penis. There are two distinct ways of creating a penis. One utilizes a skin graft, usually from an arm. The other involves building up the clitoris, which is usually enlarged after a patient has been taking male hormones for some time.

Preparation for surgerySurgeons always supply information sheets to patients outlining their specific requirements. In general, one must stop taking hormones about a month prior to surgery. The hormones can raise the risk of surgery. Many patients worry that going off hormones will result in their bodies reverting back to something more like their birth sex, but in fact this can’t happen in such a short time. Many patients do report mood changes, or hot and cold spells, but these are only temporary and disappear when hormones are resumed about a week after surgery.

One must also stop drinking alcohol and not use ASA or any illicit drug. These can all interfere with healing and blood flow.

All surgeons will require that you undergo a complete physical, including a blood test, a month or so prior to surgery. The surgeon will supply you with a list of tests he requires. The presence of any major health condition, such as high blood pressure, obesity, a heart condition or a communicable disease like AIDS could make a patient ineligible for surgery.

Post-surgeryIt is critical that patients follow their surgeon’s advice on post-care procedures. Healing takes a long time and unless one sticks to the routines, results can easily be less than satisfactory.

The first three to five days after surgery are usually spent in hospital. The patient is on pain killers and attached to a catheter. One can be up and walking in three days, but no strenuous activity is permitted.

After about five days, patients are more mobile and can reduce pain killers a little. For male-to-female patients, catheters come out at about a week and dilation begins. For female-to-male patients, the catheter may remain in place for several weeks, depending on which surgical technique was used.

Patients return home about ten days after surgery, but this can vary from surgeon to surgeon. Pain fades within a month and one can return to work after about two months, although some discomfort may remain for several more months.

Full healing can take six months to a year. Some patients find they have swelling or numbness that is more of an irritant than an impediment to functioning. Certainly, a year after surgery, one should feel normal and function normally.

SurgeonsThere are only a handful of surgeons worldwide offering gender reassignment surgery. I don’t recommend any one surgeon or surgical procedure. It is important to investigate any surgeon you are considering. Ideally, you should talk to former patients to get their take on the surgery. If a doctor isn’t willing to put you in touch with former patients, be wary.

Also be wary of trying to find the perfect vagina or perfect penis. Everyone is different and any given surgeon will achieve different results with each patient. Age, genes and your health will partly determine the results you get. But you should expect that you function normally after surgery and that at least superficially you look as if you were born with the new plumbing.

Check list of surgeons. The U.K., The United States and Austral-Asia and please feel free to contact them, either via their Web sites or by mail or phone. Surgeons will often send information kits if you request it. If you contact the Canadian surgeons by phone, don’t worry if one of the secretaries answers in French, they all speak English as well.

Winnipeg Transgender Group – 2006

My Facial Feminisation Surgery

Smoakie Bulle Just after midnight on New Year’s Eve 2000, six months or so ago, my friends and myself were invited into a house across the road from where I live to join a party. It was one of those only- on-New-Year’s-Eve-with-a-skinful-occasions, and when I went in I was treated as the bloke across the road in a frock. It was he and him without cease – they just saw me as male, unbelievably, and I began this year deep in yet more of those unending tears back at my flat. Will this never end, I said, is there no way out of this? After all I have done, after living well as a woman for all this time, rarely read, or so I thought, after Sex Reassignment Surgery, after thousands of little white oestrogen pills, with a skin like a baby, a girl at last and happy and well in my world? After all I’ve been through, and it means nothing?

Right, I said to my partner, gritting my teeth yet again, this is it. I’ve had enough, I won’t live with this. I’m going to have my face fixed this year no matter what. You see, I knew what it was these people were seeing, what it was in me that made them see the old maleness; it was in the structures of the bones of my face, and this is what I decided had to be changed. In for a penny, in for a pound, that’s my way. I forgot how to spell kompromize a long time ago. Why stop before the end? Why not the best?

I stumbled on the Anne Lawrence website (annelawrence.com/twr) years ago, and with its links it has led me through many a maze, and it was here that I learned of Facial Feminization Surgery (FFS). Go and look for yourself, and what you will find is a revelation. Once you see it, it’s obvious, and male and female faces are never the same again. It all comes down to hormones again, that demon testosterone and the ravages it had on our bodies and minds.

In late adolescence, boys turn into young men. I’ve watched this happen to my son, who is now eighteen. The bones change, and what makes a man a man, and brings a woman like myself a life behind a mask, is the creation of, from the top down;

The brow ridge, and brow bossing. For me, the most significant of all. Like many results of the work of testosterone, my browridge formed almost a hood over my eyes. The line of the forehead in profile came down, then out just before the eyes, then right in. Oestrogen does not make this happen, and the brow in natal women remains the same as in children, where the line of the forehead comes straight down, leaving the eyes more open and unhooded. As we first look at the eyes when we meet someone, this subconscious marker of gender is highly significant.

The nose in the natal female is often smaller, narrower, less significant; the testosterone nose wider, more powerful a presence.

The prominence of the chin and the line of the jaw. This is more well-known. The female chin comes more to a point, it is rounded and is slighter in profile; it doesn’t stick out so much. The testosterone jaw is often wider, coming to strong angled points below the ears.

Of course, faces come in billions of forms, none of them the same, and masculinity and femininity shows in other ways on the face, but the main markers of maleness and femaleness are consistent. Freud said that the first point of recognition when we meet a person is that of gender; is this a male or a female? The rest of identity follows, is built on this. The subconscious indicators of gender come in the form of dress and body language, ways of moving, ways of dressing, the skin, the voice, the way we speak, the way the person feels to us; on and on. Many of these we can work at and change, but the bone structures of the face, the frame upon which the skin hangs, can only be changed by surgery, and this is what we look at first, this is what sets the tone for all that folows.

If you look on the Net, you will mostly see the work of Dr Ousterhout in San Francisco. The results of this surgery can be astonishing; craggy male faces turned into attractive women’s. For some, a life which would be unbearable becomes a joy.

No wonder so many transsexual women don’t mind what Dr Ousterhout charges; anything to get me out of this! When I contacted some of the women who had put their results up on the Internet, I was told of Ousterhout’s costs, and my heart sank. Around $28,000. Plus two trips to San Franscisco. It comes to around £20,000. A great surgeon, no doubt, but way too expensive for me.

So I looked for alternatives. This was not so easy. What I was looking for specifically was a cranio-maxillary-aesthetic surgeon with experience of transforming the transsexual face at a good price. I needed a surgeon who works with the bone structures of the face, with empathy and understanding of who and what I am, and these guys hardly come on every street corner.

Still, with determination I found one, not advertised at all, tucked off in a corner of Belgium. Dear Dr Noorman van der Dussen. I went to see him in February, loved him, and had extensive facial surgery at the Eeufeestkliniek in Antwerp on April 18th. Not bad, eh? Less than four months from New Year’s Eve and it was all done.

I had my brow ridge removed; Dr Noorman van der Dussen (all of this is his surname, let’s call him Dr NvvD) told me afterwards that he had removed about 1 centimetre of bone from over my eyes. A centimetre! Usually these things are done in millimetres. I had a lot to lose.

My nose, which was always slender, had its upturned, ski-jump end removed. My upper lip was enhanced. My chin was narrowed, taken back, the angle changed, and the jaw line altered to fit. Seven hours on the operating table; not a small thing to do.

I left the clinic the day after surgery and went to a hotel, amazingly, but it was fine. As Dr NvvD said, all you need is comfort to recover, better and cheaper in a hotel. I had two days of great discomfort, but almost no pain at all, thank God. How lovely I looked; bandages over the scalp, right round the jaw, my nose in a plastic cover taped to my face, one eye closed completely and the colour of a red fruit, the other open a crack, gorgeous colours everywhere, looking like a creature from a strange part of the universe in Star Wars.

But recovery was swift. Five days after surgery I was out in the Belgian countryside with the friend who came with me – bless you Jane, where would I be without you? – and a new transsexual friend I made in the hotel, enjoying pancakes and coffee. Avoid the tea; this is not England. I had on so much covering make-up I could hardly lift my head, and there was swelling in plenty which made me look a little odd, but I made it.

Then I was back home less than a week after surgery, feeling tired and full of anaesthetic, but not too bad. No signs of surgery at all. Incisions were made behind the hairline for the forehead, inside the mouth for the chin and jaw. It was like a miracle had happened.

It took a few weeks for the whole thing to settle in properly, but it did, and now I am fine. But the test of the pudding is in the eating, and the test of FFS is not only in the looking, but in how I feel, the most important thing of all. And what I have to tell you is that I am very happy. It’s made all the difference in the world. When my friends look at me, they still see Persia. It’s not as if I have another face; what’s happened is that my own face has been softened and opened. It has been feminized. The work is subtle and very well done, integral, looking so natural that many people have no idea anything has been done at all. You are looking well, Persia, they say, not knowing what they are seeing.

The greatest effect can be seen in profile. All the prominent angles of my face have been removed. The overhanging brow, the ski-jump nose, the angular chin, all replaced with softness. I love it. I now have none of the indicators of the male on my face. I have always felt that the transsexual transition was, for me, a restoration of my own true being, and now I have even restored my own face. It is no longer the face of a brother I never had.

And I feel completely relaxed now. I am seen as a woman now, almost completely, except for on one of those bad days when nothing goes well. I am what I am, a transsexual woman, and there will always be someone somewhere who knows. But so little, so rarely that I no longer care.

The feelings of this cannot be expressed better than in the words of anon (name witheld by request), who underwent FFS at the hands of Dr. DouglasOusterhout in San Francisco, but the same is true of Dr Noorman van der Dussen, and anon expresses my own feelings with a beauty I cannot hope to match.

” When I went out before my surgery, no amount of radiated joy and peace would have kept me from being perceived oddly by some. I’m not talking about passing here, I’m talking about how, as a human being, people saw me. I want people to see *me* clearly, not through the filter of doubt about who I might be. Even as happy and upbeat as I was prior to surgery with Doug, the lines and curves in my face that didn’t belong to me abraded my confidence, were as wrong as a lock of hair that stands away from your scalp that no amount of coaxing can keep down.

I am sure that if Doug’s work did not exist, I would have made the best of it, but I suspect that as much happiness as I would have mined out of life, the difference between who I am and who my face said I was would have eaten away at me. Who knows.

Results aside, it allows me to not simply move through the world and society — the best I could hope for beforehand — but to actively embrace it, to find a peace within myself, or the possibility for it, that others see and perceive. It is a wonderful resonant cycle as the relaxed comfort in my own skin radiates from me to others, who in turn sense my centeredness and reflect happiness back at me.

It’s how I feel too. Undergoing this surgery has let me cross the line into my own womanhood in a way I could not quite manage before, no matter how well I did, how good I looked, and even then I could go to the women only sessions at the swimming pool and feel almost at ease. Now I am completely relaxed, found myself chatting to other women in the showers while we waited for one to be free the other day without me noticing what I was doing – an amazing feat of transformation when I think back to my early days.

There is a form of trasngendered political correctness in the USA these days which states that we should be accepted as we are, no matter how we are, this being our truth, this being one form of human existence the world needs to accept as another normalcy. We should be proud of who we are, no matter how we look.

Very good, but my own truth is that I am just a simple girl from Liverpool who wants to live without problem in this world; more than that, to live here with joy. I was like Dorothy in the Wizard of Oz – but I wanted to come home even more than she did. And I’ve made it, I’m back in Kansas, back in Brighton actually, just living in the world but now with restored exquisite normalcy. I am a very happy and fulfilled person, and my life is opening like a flower. What I have done, despite having no money to speak of, you can do too. Go for it.

The cost of the surgery with Dr Noorman van der Dussen, by the way, came to around £6,500. Not cheap, but a bargain in British or U.S. surgical terms. About a third of the cost here, if you could find the surgeon, and I don’t think he or she exists. I had SRS in Belgium too, under the kind knife of Dr. Seghers, a complete coincidence, so I know about Belgian medicine. It’s very good indeed, recommended.

By Persia West June 2001

Gender Trust – 2003, This information sheet is distributed by the Gender Trust and is intended as a basis for information only. The Gender Trust does not accept responsibility for the accuracy of any information contained in this sheet.