Facial feminization surgery (FFS) is an umbrella term for surgical procedures that modify masculine facial features to achieve a feminine appearance using reconstructive surgery techniques.
FFS is performed almost exclusively on trans women and other transfeminine individuals. While feminizing hormone therapy (using estradiol and frequently antiandrogens) can change facial appearance via fat redistribution, it cannot change masculine bone structure, such as a prominent brow ridge, wider nose, or larger chin; because of this, FFS is a medically necessary treatment and in many cases is required to treat gender dysphoria.
The procedures performed during FFS vary based on an individual's priorities and facial features, but the surgery frequently includes work to address the forehead, nose, chin, and jawline. Coverage by health insurance varies significantly by location; some US states have passed laws requiring health insurance companies to cover FFS.
Medical necessity
FFS may be medically indicated to alleviate the suffering caused by persistent gender incongruence (gender dysphoria). Medical guidelines should be consulted to assist in determining the indication. If hormone therapy does not achieve sufficient feminization of the face and an unbiased observer continues to perceive it as male, the lack of perception as a woman can make the person's everyday life difficult or even impossible and perpetuate gender dysphoria. A distinction is made between aesthetic surgical procedures and FFS, which modifies sex-typical characteristics and constitutes medically necessary treatment.
Numerous studies conclude that FFS can significantly improve the well-being and quality of life of trans women by reducing gender dysphoria, with a low complication rate. Compared to the general female population and to trans women who had undergone gender-affirming genital surgery, FFS, or both, the mental health-related quality of life of trans women who had not undergone any surgical procedures was statistically lower.
A review shows that the evidence for an improvement in quality of life with a reduction in gender dysphoria through FFS has grown and has now reached a higher level of evidence. It is recommended that specific facial feminization surgeries, including Adam's apple reduction and facial hair removal, be included in international guidelines as medically necessary treatments.
History
FFS techniques originate from the fields of maxillofacial surgery, otolaryngology and plastic-reconstructive surgery. In his previous practice, Ousterhout had already reconstructed the faces and skulls of people who had been affected by birth defects, accidents or other traumas. Although he was interested in helping, he did not know what constituted a female face. So he first studied early 20th-century anthropology to find out which features were considered feminine. He then derived measurements that defined these features from cephalograms taken in the 1970s. Finally, he worked with a set of several hundred skulls to see if he could reliably distinguish which skulls were female and which were male based on these measurements. Ousterhout then determined which surgical techniques and materials he was already using to transform a male face into a female one. He pioneered most of the FFS procedures and was also involved in their subsequent improvements.
Surgical procedures
The following are typical surgical procedures performed during FFS. The choice of procedures should focus on typically male characteristics. Computer-assisted imaging techniques (such as CT and MRI) should be used to identify male features and simplify planning.
Upper third of the face
Feminization of the upper third of the face is considered a safe procedure that has a significant effect on gender perception. Compared to the lower jaw or midface region, the influence of feminization of the upper third of the face on gender perception is significantly higher. Hairline correction, forehead correction, eye socket correction and eyebrow lift are procedures that are often performed at the same time as rhinoplasty.
Receding hairline
In men, the hairline is often higher than in women and usually has receding corners above the temples, giving it an 'M' shape. The hairline can be moved forward and given a rounder shape, either by lowering the hairline, lifting and repositioning the scalp, or with a hair transplant. In addition to hairline advancement, temporal rotation flaps may be used to excise skin near the temples where hair no longer grows due to androgenic alopecia, further feminizing the hairline shape.
Forehead reconstruction
Men typically have a horizontal bone ridge that runs across the forehead just above the eyebrows, known as the brow ridge, which also includes the supraorbital ridges (the lower ridge on which the eyebrows sit). Men also tend to have indented temples and a flatter forehead than women.
The brow ridge is usually solid bone and can be easily sanded down. However, in some people, the bone wall is so thin that it is not possible to completely grind down the bump without breaking through the wall to the frontal sinus. The most conservative approach is to grind down the bony wall as much as possible without breaking it, and then build up the area around the remaining bulge with hydroxyapatite bone cement, which can even out any visible steps between the remaining bulge and the rest of the forehead. In these cases, additional reduction of the protrusion can sometimes be achieved by thinning the overlying soft tissue. Alternatively, FFS surgeons may perform a procedure called forehead reconstruction or cranioplasty, in which the glabella bone is taken apart, thinned and reshaped, and reassembled in the new feminine position using small titanium wires or an orthopaedic plate made of titanium and screws. Standard rhinoplasty procedures are generally used. However, there is limited data on the results. The planning of cheek contouring is carried out simultaneously with the planning of chin reshaping. The cheeks are reshaped by removing bone and repositioning the facial bones. It is common to enlarge the cheeks with implants or with fat harvested from other parts of the body. Risks associated with implants include infection and the possibility that the implant may shift and become asymmetrical; fat may eventually be absorbed.
Typically, an incision is made just below the bridge of the nose and a piece of skin is removed. When the gap is closed, the upper lip is lifted and moved into a more feminine position, often exposing part of the upper incisors. The surgeon may also roll the upper lip outwards slightly through a lip lift, making it appear fuller.
Lower third of the face
Chin and jawline
Men's chins tend to be longer and wider than women's, with a more square base, and protrude more outward than women's.
The greatest risk with these procedures is damage to the mental nerve, which runs through the chin and jaw; other risks include damage to tooth roots, infection, non-union and damage to the mentalis muscle, which controls the lower lip and is located at the edges of the chin. The Adam's apple can be reduced in size using a procedure called chondrolaryngoplasty; the aim of the procedure is to reduce the size without leaving a scar. There is a risk of damage to the vocal cords and destabilisation of the epiglottis. for example, it is difficult in Germany due to individual assessments by the Medical Service. In Switzerland, too, coverage can be obtained following a court ruling in 2018.
In the United States, the situation has improved significantly thanks to the Affordable Care Act (ACA), and the number of cases where health insurance companies cover the costs has risen significantly. In addition, many states have passed laws prohibiting health insurance companies from excluding gender-affirming surgery. California in particular is considered a pioneer in this area.