Facial feminization surgery

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Facial feminization surgery (FFS) is a set of reconstructive [1] surgical procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue procedures such as brow lift, rhinoplasty, cheek implantation, and lip augmentation. [2]

Contents

Faces contain secondary sex characteristics that make male and female faces readily distinguishable, including the shape of the forehead, nose, lips, cheeks, chin, and jawline; the features in the upper third of the face seem to be the most important, and subtle changes in the lips can have a strong effect.

Candidates

For some transgender women and non binary people, FFS is medically necessary to treat gender dysphoria. [3] [4] It can be just as important or even more important than genital forms of sex reassignment surgery (SRS) in reducing gender dysphoria and helping trans women integrate socially as women; data on these sorts of outcomes are limited by small study size and confounding variables like other feminization procedures. [5] [6] While most FFS patients are transgender women, some cisgender women who feel that their faces are too masculine will also undergo FFS. [7]

FFS candidates should wait until the bones of their skull have stopped growing before undergoing FFS. The way to determine if the bones of the skull have stopped growing is to take successiveradiographs of the mandible and wrist bones to make sure that bone growth has stopped. [8]

Surgical procedures

The surgical procedures most frequently performed during FFS include the following. [5] [9]

Upper third of face

Some studies have shown that the shape of the forehead is one of the key differences between cisgender males and cisgender females. [5] [10] Hairline correction, forehead recontouring, eye socket recontouring, and brow lift are procedures often performed at the same time, with rhinoplasty in mind. [5]

Hairline correction

In males, the hairline is often higher than in females and usually has receded corners above the temples that give it an "M" shape. The hairline can be moved forward and given a more rounded shape, either with a procedure called a "scalp advance" wherein the scalp is lifted and repositioned, or with hair transplantation. [5]

Forehead recontouring

Cisgender males tend to have a horizontal ridge of bone running across the forehead just above eyebrow level called the brow ridge (or "brow bossing"), which includes the "supraorbital rims" (the lower edge, on which the eyebrows sit). Cisgender males also tend to have indented temples and a flatter forehead than females. [5]

The brow ridge is usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the glabella) sits over a hollow area called the frontal sinus. The frontal sinus is hollow, and thus it can be more difficult to remove bossing there. If the bone over the frontal sinus is thick enough the bossing can be removed by simply grinding down the bone. However, in some people, the wall of bone is so thin that it is not possible to grind the bossing away completely without breaking through the wall into the frontal sinus. [5]

FFS surgeons have taken two main approaches to resolving this problem. The most conservative approach is to grind down the wall of bone as far as possible without breaking through, and then build up the area around any remaining bossing with hydroxyapatite bone cement which can smooth out any visible step between remaining bossing and the rest of the forehead. In these cases, some additional reduction in the bossing can sometimes be achieved by thinning the soft tissues that sit over it. Alternatively, FFS surgeons can perform a procedure called a forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled in the new feminine position with small titanium wires or titanium orthopedic plate and screws. [5] The data on which approach is better is limited and does not provide guidance. [5] The risks of cranioplasty include the skull not healing properly, movement of the bone fragments, and the formation of cysts; these can usually be corrected by another procedure. [5]

Brow lift

Cisgender men tend to have lower eyebrows relative to the position of their brow ridges when compared to cisgender women. Cis men's eyebrows tend to be below their brow ridges while cis women's eyebrows tend to be above their brow ridges. Accordingly, FFS to raise the eyebrows results in a face with a more womanly appearance. [8]

Orbit recontouring

In some studies, the eye shape has been shown to be the key differentiating feature between cis males and females. [5] [10] Cis female eye sockets tend to be smaller, located higher on the face, to have more sharply angled outer edges, and to be closer together at their inner edges (the intercanthal distance). [5] Some FFS alter the orbit shape; data on outcomes is limited. [5]

Rhinoplasty

Cis males tend to have larger, longer, and wider noses than cis females; also, the tip of the female nose will more often visibly point slightly upwards than that of a male. Hence, the procedure involves removing bone and cartilage and remodelling what remains. [5] [10] In most cases this is performed in an open procedure, but endonasal procedures have been used; in all cases when reducing the nose there is a risk of interfering with nasal valve function. [5] Standard rhinoplasty procedures are generally used. [11] There is limited data on outcomes. [5]

Cheek implants

Cis females often have more forward projection in their cheekbones as well as fuller cheeks overall, with a triangle formed by the cheekbones and the point of the chin. Planning of cheek contouring is done while planning reshaping of the chin. [5] The cheeks are reshaped by cutting away bone and repositioning the facial bones. [5] Augmenting the cheeks with implants or with fat harvested from other parts of the body is common. Risks of implants include infection, and the implant moving and becoming asymmetrical; fat can eventually be absorbed. [5]

Lips

Subtle changes to the shape and structure of lips can have a strong influence on feminization. [5] The distance between the base of the nose and the top of the upper lip tends to be longer in males than in females and the upper lip is longer; when a female mouth is open and relaxed, the upper incisors are often exposed by a few millimeters. [5]

An incision is usually made just under the base of the nose and a section of skin is removed. When the gap is closed it has the effect of lifting the top lip, placing it in a more feminine position and often exposing a little of the upper incisors. The surgeon can also use a lip lift to roll the top lip out a little, making it appear fuller. [5]

Cis females often have fuller lips than cis males, so lip filling is often used in feminization. Injectable fillers are low-risk but tend to be absorbed after six months or so, and many implants have higher complication rates like infection or rejection. [5] Use of fat harvested from the person can result in lumps and does not last long. [5] The longest lasting and least risky results appear to arise from use of acellular dermis products. [5]

Chin and jaw contouring

The chins of cis males tend to be longer and wider than those of cis females, with a more square base, and to project outward more than female chins. [10] Cis male jawlines tend to extend outward from the chin at a wider angle than those of cis females, and to have a sharp corner at the back. [5]

The chin can be reduced in length either by bone shaving or with a procedure called a "sliding genioplasty", where a section of bone is removed. The jaw can be reshaped through jaw reduction surgery; sometimes this is done through the mouth. The chewing muscles can also be reduced to make the jaw appear narrower. [5]

The biggest risk in these procedures is damage to the mental nerve that runs through the chin and jaw; other risks include damage to tooth roots, infection, nonunion, and damage to the mentalis muscle that controls the lower lip and is at the edges of the chin. [5]

Adam's apple reduction

Males tend to have a much more prominent Adam's apple than females following puberty. [5] [10] The Adam's apple can be reduced with a procedure called a chondrolaryngoplasty; the goal of the procedure is to reduce the size without leaving a scar. [5] There are risks of damage to the vocal cords and destabilization of the epiglottis. [5]

Associated procedures

Beautification and rejuvenation procedures are often performed at the same time as facial feminisation. For example, it is common for eye bags and sagging eyelids to be corrected with a procedure called "blepharoplasty" and many feminization patients undergo a face and neck lift. [5]

History

FFS techniques are derived from maxillofacial, otolaryngology, and plastic aesthetic and reconstructive surgery. [5] [8]

FFS began in 1982 when Darrell Pratt, a plastic surgeon who performed sex reassignment surgeries, approached Douglas Ousterhout with a request from a transgender woman patient of Pratt's; the patient wanted plastic surgery to make her face appear more feminine, since people still reacted to her as though she were a man. [12] Ousterhout's prior practice had involved reconstructing faces and skulls of people who had had birth defects, accidents, or other trauma. [12] Ousterhout was interested in helping but knew that he did not know what a "female face" was, so he investigated by first reading the physical anthropology from the early 20th century to identify what features were "female", then deriving measurements defining those features from a series of cephalograms taken in the 1970s, and then working with a set of several hundred skulls to see if he could reliably differentiate which were females and which were males using those measurements. [6] [12] Ousterhout then began working out what surgical techniques and materials he already used could be applied in order to transform a male face into a female face. He pioneered most of the procedures involved in FFS and was involved in their subsequent improvements as well. [6]

See also

Related Research Articles

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Plastic surgery is a surgical specialty involving the restoration, reconstruction, or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery covers a wide range of specialties, including craniofacial surgery, hand surgery, microsurgery, and the treatment of burns. This category of surgery focuses on restoring a body part or improving its function. In contrast, cosmetic surgery focuses solely on improving the physical appearance of the body. A comprehensive definition of plastic surgery has never been established, because it has no distinct anatomical object and thus overlaps with practically all other surgical specialties. An essential feature of plastic surgery is that it involves the treatment of conditions that require or may require tissue relocation skills.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

<span class="mw-page-title-main">Adam's apple</span> Feature of the neck

The Adam's apple is the protrusion in the neck formed by the angle of the thyroid cartilage surrounding the larynx, typically visible in men, less frequently in women. The prominence of the Adam's apple increases in some men as a secondary male sex characteristic during puberty.

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

Feminizing Gender-affirming surgery for transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.

Douglas K. Ousterhout is a retired craniofacial surgeon who practiced in San Francisco, CA, United States. His specialty was facial feminization surgery for trans women, and he was widely considered the foremost facial feminization surgeon in the United States. Ousterhout also pioneered facial masculinization surgery for people undergoing female-to-male gender reassignment. Ousterhout received MD and DDS degrees from the University of Michigan Ann Arbor. He is a voluntary clinical professor of surgery in the School of Medicine and an adjunct professor of dentistry in the Dental School at University of California, San Francisco.

<span class="mw-page-title-main">Rhytidectomy</span> Type of cosmetic surgery

A facelift, technically known as a rhytidectomy, is a type of cosmetic surgery procedure intended to give a more youthful facial appearance. There are multiple surgical techniques and exercise routines. Surgery usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. Exercise routines tone underlying facial muscles without surgery. Surgical facelifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures and are typically performed under general anesthesia or deep twilight sleep.

Chin augmentation using surgical implants alter the underlying structure of the face, intended to balance the facial features. The specific medical terms mentoplasty and genioplasty are used to refer to the reduction and addition of material to a patient's chin. This can take the form of chin height reduction or chin rounding by osteotomy, or chin augmentation using implants. Altering the facial balance is commonly performed by modifying the chin using an implant inserted through the mouth. The intent is to provide a suitable projection of the chin as well as the correct height of the chin which is in balance with the other facial features.

<span class="mw-page-title-main">Frontal sinus</span> Airspace below ridge of eyebrow in humam anatomy

The frontal sinuses are one of the four pairs of paranasal sinuses that are situated behind the brow ridges. Sinuses are mucosa-lined airspaces within the bones of the face and skull. Each opens into the anterior part of the corresponding middle nasal meatus of the nose through the frontonasal duct which traverses the anterior part of the labyrinth of the ethmoid. These structures then open into the semilunar hiatus in the middle meatus.

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A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep "worry" lines that run across the forehead.

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<span class="mw-page-title-main">Frontonasal dysplasia</span> Medical condition

Frontonasal dysplasia (FND) is a congenital malformation of the midface. For the diagnosis of FND, a patient should present at least two of the following characteristics: hypertelorism, a wide nasal root, vertical midline cleft of the nose and/or upper lip, cleft of the wings of the nose, malformed nasal tip, encephalocele or V-shaped hair pattern on the forehead. The cause of FND remains unknown. FND seems to be sporadic (random) and multiple environmental factors are suggested as possible causes for the syndrome. However, in some families multiple cases of FND were reported, which suggests a genetic cause of FND.

<span class="mw-page-title-main">Facial hair</span> Hair grown on the face, chin, cheeks, and upper lip region

Facial hair is hair grown on the face, usually on the chin, cheeks, and upper lip region. It is typically a secondary sex characteristic of human males. Men typically start developing facial hair in the later stages of puberty or adolescence, at around fourteen years of age, and most do not finish developing a full adult beard until around sixteen or later. However, large variations can occur; boys as young as ten have also been known to develop facial hair, and some men do not produce much facial hair at all.

Nasal reconstruction using a paramedian forehead flap within oral and maxillofacial surgery, is a surgical technique to reconstruct different kinds of nasal defects. In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects.

The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively.

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Hairline lowering is a surgical technique that allows an individual to have their frontal hairline advanced certain distances depending on variables such as pre-operative hairline height, scalp laxity, and patient preference. It can be used to address a congenitally high hairline or sometimes a hairline that has recessed from hair loss. It is performed mostly on women.

Facial masculinization surgery (FMS) is a set of plastic surgery procedures that can transform the patient's face to exhibit typical masculine morphology. Cisgender men may elect to undergo these procedures, and in the context of transgender people, FMS is a type of facial gender confirmation surgery (FGCS), which also includes facial feminization surgery (FFS) for transgender women.

Jordan Christopher Deschamps-Braly is an American maxillofacial and craniofacial surgeon specializing in facial gender-affirming surgery for transgender people. He co-developed a procedure for building a new Adam's apple for trans men and is known for his work as a plastic surgeon for trans women.

References

  1. ↑ "WPATH POLICY STATEMENTS".
  2. ↑ Plemons, Eric (2017-07-27). The Look of a Woman. Duke University Press. doi:10.1515/9780822372707. ISBN   978-0-8223-7270-7.
  3. ↑ "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide". World Professional Association for Transgender Health. Archived from the original on 2015-08-14. Retrieved 2016-06-20.
  4. ↑ "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7" (PDF). World Professional Association for Transgender Health. 2012. p. 58. Archived from the original (PDF) on 2015-08-14.
  5. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Morrison SD, Vyas KS, Motakef S, Gast KM, Chung MT, Rashidi V, Satterwhite T, Kuzon W, Cederna PS (2016). "Facial Feminization: Systematic Review of the Literature". Plast. Reconstr. Surg. 137 (6): 1759–70. doi:10.1097/PRS.0000000000002171. PMID   27219232. S2CID   23174099.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. 1 2 3 Altman K (2012). "Facial feminization surgery: current state of the art". Int J Oral Maxillofac Surg. 41 (8): 885–94. doi:10.1016/j.ijom.2012.04.024. PMID   22682235.
  7. ↑ Jordan Deschamps-Braly, M. D.; Tuesday, August 21. "Facial feminization for cisgender women with masculine-looking faces". American Society of Plastic Surgeons. Retrieved 2021-08-12.{{cite web}}: CS1 maint: numeric names: authors list (link)
  8. 1 2 3 Ousterhout, D.K. (2009). Facial Feminization Surgery: A Guide for the Transgendered Woman. Omaha, Nebraska: Addicus Books, Inc. pp. 11, 15 & 22. ISBN   978-1-886039-93-3
  9. ↑ Stan Monstrey, Gennaro Selvaggi and Peter Ceulemans. Surgery: Male-to-Female Patient. Chapter 6 in Principles of Transgender Medicine and Surgery (Human Sexuality series). Eds. Randi Ettner, et al. Routledge 2007 ISBN   9780789032683. Pages 105 and 111
  10. 1 2 3 4 5 Van de Ven, BFML (2008). "Facial feminisation: why and how?". European Journal of Sexology. 17 (4): 291–298. doi:10.1016/j.sexol.2008.08.008.
  11. ↑ Noureai, SA; Randhawa, P; Andrews, PJ; Saleh, HA (2007). "The role of nasal feminization rhinoplasty in male-to-female gender reassignment". Archives of Facial Plastic Surgery. 9 (5): 318–20. doi: 10.1001/archfaci.9.5.318 . PMID   17875823.
  12. 1 2 3 Plemons, Eric D. (2014). "Description of sex difference as prescription for sex change: On the origins of facial feminization surgery". Social Studies of Science. 44 (5): 657–679. doi:10.1177/0306312714531349. PMID   25362828. S2CID   24609120.
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