Facial feminization
surgery
Facial Feminization Surgery (FFS) refers to surgical
procedures, which will alter a masculine face to a feminine shape through the
use of plastic surgery, reconstructive surgery, and maxillofacial surgery.
Procedures range from the use of soft tissue procedures, facial fillers,
implants, to more invasive procedures involving the buring (grinding) of facial
bones, and the cutting (osteotomy) of facial bones.
Due to the fact
people differ in facial characteristics; a combination of serval procedures may
need to be used to alter the face to the desired result to feminize the face.
Most people refer to Facial Feminization Surgery as FFS when describing it.
There are a number of surgical procedures that can be used to feminize
the face when it comes to FFS. Depending on your facial structure and degree of
masculine features, one or many of the following procedures can be used to
feminize the transsexual face:
Forehead contouring: Complated by a high speed
bur
Forehead
reconstruction: Complated by cutting out a section or sections of the
frontal skull
Forehead
compression/controlled facture: Research in progress
Jaw tapering: Completed by a
high speed bur or a bone saw
Chin contouring/Mentoplasty: Completed by a high speed bur and or
chin inplant
Sliding
genioplasty: Completed by cutting and removing the chin
Cheekbone augmentation
Through the use of implants
Cheekbone reduction Complated by a high speed bur
Lip contouring/Lip
lift
trachea
shave
blepharoplasty (Eyelid surgery to correct sagging or
drooping of the eyelids)
Rhinoplasty
Facial Implants
Facial Fillers
Facelift
FFS
surgeon listings
Further links about surgery can also be
found at the bottom of this page.
This surgery is not limited to female
to male transsexuals; since there are also options that can be applied to help
female to male transsexuals using this type of surgery to obtain masculine
features. I will be adding Facial Masculinization Surgery information at a
future date.
Jaw tapering/Jaw
contouring
Facial Feminization Surgery FFS has a great
many options of procedures, which can feminize the face of transsexuals. Jaw
tapering can have a great impact towards feminizing of the male bone structure
in the transsexual face if done correctly during your FFS. All facial
feminization surgery procedures carry a certain amount of risk.
It is
important that transsexual women educate themselves about the procedures
involved in the FFS process and research the available facial feminization
surgery surgeons throughout the world.
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View the affects of jaw tapering on the jaw in the above photo of the
skulls (CLICK TO ENLARGE).
The Mandible (jaw): In males the jaw tends to be
wider/fuller in the back angles for more of a square appearance (lateral and
posterior flaring of the bony angles) compared with a female jaw. Females have a
greater taper from the back of the jaw to the chin. Females tend to have more of
a rounded shape in the back of the jaw.
Some females tend to have strong
jaw angels and so having this procedure is subjective to the personal preference
of the patients having this procedure done.
Jaw tapering, Angle of mandible
reduction, and or Ramus reduction: This procedure involves removing a
section of bone from the jaw to give it more of a rounded affect from the ear
down to the new forward curve. This is done through a incision in the gumline of
the mouth (there are a few other areas the surgeon may gain access to the area
also) and the bone will be taken down with a bone contouring bur/saw. Depending
on the size of your master muscle, a Masseter Muscle Reduction might also be
done for further tapering, this procedure involves reduction with forceps and
scissors. In most cases the masseter muscle is reduced at the same time. If you
place your finger on the back your jaw and perform a biting action, you will
feel the master muscle at work. You can also bite down and clench your teeth and
feel the masseter muscle. The following link will provide more info and some
more photos of jaw tappering.
For more info about mandible reduction take a look at the
""bottom"" of this artical by Dr. Charles S. Lee
The
jaw tapering if done correctly can make the cheeks look fuller and give a
smoother taper from the ears to the chin.
Jaw Tapering and Masseter
Muscle Reduction are considered bloody procedures. So there will be weakness and
fatigue after these procedures. So expect to take at least a week off resting.
The amount of weakness and fatigue will vary based on the number of procedures
you are having done, health and age.
Is there pain after these two
procedures? From personal experience after these two procedures yes, the areas
do hurt for sometime. Pain is a factor after surgery, which you will have to
face head on and take some painkillers for a while before it gets better.
Surgeons use drain tubes coming from within the gum line incision at the back of
the jaw. These tubes can be very irritating during the time you have them in.
You won't be able to fully open your mouth all the way so you will have to eat
soft foods for a while because of the limited range of movement you will have
after this procedure and also becasue you will have a limited amount of bite
strength.
There tends to be a high degree of swelling after this
procedure that can take a few months to go down and there can be bruising in the
eyes, cheeks, and neck. From my experience with this surgery I drooled some for
the first ten days after and it was kind of irritating and was most prevalent
when I tried to eat much of anything during the first ten days.
After
jaw or chin surgery the doctor will advise you not to sleep on either side of
your face for like three months and to sleep on an elevated position on your
back. This can be uncomfortable for people who are not used to sleeping on their
back.
Here are some actual photos of the mandible from different
views
Mandible, top view.
Mandible, frontal view.
Mandible, lateral view.
Mandible, posterior view.
Here are some
photos of two burs (referred to as pineapple burs) which are used for grinding
bone. The shorter bur is a standard bur used by most surgeons and the second bur
was especially designed per specs of Dr. Mark Zukowski to operate at 15,000 RPM
and for greater reach during endoscopic surgery. The photos were taken a few
days after I had chin and jaw reconstruction with Dr. Zukowski after he allowed
me some time with his Surgery Tech for questions about the burs and to take
photos. Photos
of the burrs
The risks and
complications from jaw tapering and massester muscle
reduction:Over reduction, Under reduction, Step down
problems, Hematoma, Blood loss, Infection, Permanent change in sensation, Nerve
damage, and Blood clots.
Long term affects
from facial feminization surgery on the mandible and
chinThis is a serious health development people will have to
deal from having aggressive surgery on the chin and jaw as they age.
This will vary in ages due to dental health and a healthy lifestyle.
Oral and dental diseases may also lower the age for this possibility during the
lifespan of people under going these procedures.
In older age (65 to 70
long term good health will increase the ages for this possible condition) the
chin and jaw bone becomes greatly reduced (the bones lower in height) in size
through the loss of the teeth and alveolar process (the bone area where the
roots of the teeth reside) being absorbed may cause the possibility of chin or
jaw facture from aggressive surgery in those areas due to the lowered height in
the chin and lower to mid section of the jaw.
This should be considered
before surgery since the chin and jaw reduce sizes to almost half their original
sizes in old age. Factures in old age are very difficult to correct and can lead
to a massive amount of other health related issues.
In the below article
there are a number of photos of what happens to the jaw and chin in different
periods of life. The section on this issue can be found in the bottom of the
article.
Long term affects on the mandible and
chin
Chin Contouring and
Chin Reconstruction
In females the chin tends to be
either a sharp point or a gentle rounding as in an oval face like an upside down
egg. Males tend to have more of a square looking chin and it tends to be wider
and vertically high compared to a females chin. This depends on the age of the
male to female transsexual since a number of male to female transsexuals in
their late teens and early twenties will fall into a female range of size and
shape when it comes to the shape of their chin. There are two procedures to
shape the chin to a female shape the first is grinding and the next is a sliding
genioplasty (cutting of bones and placing them in a new position).
Chin
Contouring/Mentoplasty: This procedure involves making an incision
either through the gumline or underneath the chin to gain access to the area and
then grinding down the bone to shape your chin into a female shape. Some times a
chin implant or a bone paste will also be used to further shape the chin. Chin
contouring involves grinding down the chin on each side with a bone-contouring
bur and from the information I have been given by surgeons is that 5MM of bone
can be removed using this method. Of course a surgeon would be limited to a
shorter distance of removal then 5MM, if the Mental foramen (Mental nerve
openings) is lower than that 5MM removal estimate because the surgeon must also
maintain a safe distance from the mental nerve openings, meaning that a certain
amount of bone below the mental nerve opening can’t be worked on so the surgeon
can maintain a safe distance from the mental nerve.
Chin contouring can
address removing height, width and some length from your chin. This procedure to
shape the chin has a much lower potential of complications than the sliding
genioplasty. When the chin is set too far forward without significant dept of
bone to contour, a sliding genioplasty will be in order to reduce the dept of
the chin.
A little note for those interested in the mental nerve. Mental
nerve openings can be described as a hole on each side of the chin and the nerve
comes out from those two openings. You can see the mental nerve openings in the
skull graphics I have posted on this page. The openings can also be observed in
x-rays of the jaw and chin depending on the density of the x-rays taken. There
are also several known abnormities of the mental nerve openings, which can
include lack of mental nerve openings, multiple mental nerve openings and
openings in very low positions. (Absence and Variations on Mental Nerve Openings)
The risks and
complications from chin contouring/grinding:Poor cosmetic
outcomes, necrosis, reaction or rejection of implants or bone filler, hematoma,
infection, permanent change in sensation, slight step down problems, blood
clots, and nerve damage (nerve damage is rare with this procedure, but
possible).
Sliding
Genioplasty/Chin Reconstruction
Sliding Genioplasty/Chin
Reconstruction: This procedure involves making an incision in the gum
line in your mouth or underneath the chin and cutting the chin with a bone saw
then removing the chin for shaping of the segment or segments and placing it
back in place with plates and screws. This procedure requires more time under
general anesthesia than Chin Contouring. Depending on the shape of your chin,
there are a number of options your surgeon will consider with a sliding
genioplasty. This procedure also requires that a certain distance from the
mental nerve openings be maintained with further care being taken to maintain a
safe distance from the roots of the teeth. The osteotomy (the cut made to remove
the chin) should be at least 0.5 cm below the mental foramina (mental nerve
opening) and at least 0.5 cm below the roots of the teeth. Reference information
at: Yale University and Yale Medical Center Article regarding
genioplasty
History of the Procedure:
1942 Hofer -
Extraoral horizontal sliding osteotomy of a receding chin
1957 Obwegeser and
Trauner, Through intraoral approach to osseous genioplasty
Contraindications: If you have long teeth with a short mandibular height
it is a relative contraindication for an osseous genioplasty or an aggressive
bony reduction. Reference information at: Artical by Edward
W. Chang, MD, DDS, about sliding genioplasty
These genioplasty
procedures require the soft tissues to be elevated from the bone and nerve areas
be identified and after the chin has fixation, with the plates and screws, the
soft tissues of the chin need to be resuspended to prevent chin ptosis.
Biodegradable plates and screws are also in use.
Addressing Length Of The Chin With A
Sliding Genioplasty: If the surgeon feels that your chin is too far
forward or too far back, the surgeon will cut the chin with a bone saw and
remove it for shaping by grinding down the edges then it will either be moved
forward or backward to get the desired position. Some grinding of the center of
the jaw will be required so the chin will fit flush with the jaw. Either the
surgeon will place marker points as to where the holes have to be drilled for
the screw placement or the surgeon will make maker points for self-tapping
screws (self-tapping screws don't require holes being drilled. Holes will be
drilled in the placement areas for the plates and the chin will be secured with
eight screws and three plates.The chin will be secured in place with a four to
six hole plate (surgeons sometimes use slang and call this a butterfly Plate) in
the center of the chin and further secured by two two holed plates in the lower
mid section of the jaw. The plates may have to be bent so they will fit flush
with the bone segments. In most cases bone filler will be used to smooth down
areas and to fill in gaps.
Addressing Width Of The Chin With A Genioplasty: If you have a
wide chin then the chin will be cut with the bone saw and your chin will be
removed and a section of bone will be removed from the center of the chin which
will cause the chin to be in two pieces then the chin will be further shaped by
grinding it to a new shape. Some bone will also be ground down from the center
section of the jaw to create a new step down for the newly shaped chin segments
so they will fit flush. Either the surgeon will place marker points as to where
the holes have to be drilled for the screw placement or the surgeon will make
maker points for self-tapping screws (self-tapping screws don't require holes
being drilled. The two sections of the chin will be secured in place with a four
to six hole plate (also called a butterfly Plate) positioned in the center of
the two pieces of the chin and bent to fit flush with each side of the two
segments (right and left) and two screws will be place on each side of the plate
through each chin segment. A plate will be added to each mid section of each of
the chin segments and be secured in place with one screw above and one screw
below the cut made to remove the chin. In most cases the plates will be bent a
little to fit flush with the bone and the place and screw fixation will be
completed. A bone filler will be needed in most case to smooth down areas and to
fill in gaps.
Addressing Height Of The Chin With A Genioplasty: If the vertical
height of the chin is too high then a wedge of bone will be taken out from the
chin to reduce the vertical height and some of the above options can also be
taken for further shaping or position. After the chin is removed it will be
ground down to give it a new shape so it will match the shape of it’s new
location and the center of the jaw will also require some grinding for a new
step down. Either the surgeon will place marker points as to where the holes
have to be drilled for the screw placement or the surgeon will make maker points
for self-tapping screws (self-tapping screws don't require holes being drilled.
Holes will be drilled in the placement areas for the plates and the chin will be
secured with eight screws and three plates. The chin will be secured in place
with a four to six hole plate (also called a butterfly Plate) in the center of
the chin and further secured by two two holed plates in the mid section of the
chin. The plates may have to be bent so they fit flush with the bone segments. A
bone filler will also be required in most cases to smooth areas and fill any
gaps.
More info about genioplasty and photos of the procedure being
done
There is the possibility of combining all the
above genioplasty procedure options during the genioplasty if required. But
combining the genioplasty procedure options will also increase the risks of
complications and the time in the OR.
The risks and
complications from a Sliding Genioplasty/Chin
Reconstruction:Over reduction, under reduction, nerve
damage, necrosis, poor cosmetic outcomes, reaction or rejection of implants or
bone filler, hematoma, infection, permanent change in sensation as with pain or
tenderness, step down problems, gum recession, tooth root exposer, tooth loss,
chin ptosis, blood clots, non union between the bone segments or screw and or
plate misplacement.
Concerns about
titanium plates and screws:There are several studies and
articles, which suggest corrosion of titanium causes titanium particles to be
found in scar tissue, and in locoregional lymph nodes. Some studies also have
talked about titanium found in the lungs. I will be adding section on this in
the future and more related links.
Here is a artical relating to titanium particles being found in the
body.
Long term affects
from facial feminization surgery on the mandible and
chinThis is a serious health development people will have to
deal from having aggressive surgery on the chin and jaw as they age.
This will vary in ages due to dental health and a healthy lifestyle.
Oral and dental diseases may also lower the age for this possibility during the
lifespan of people under going these procedures.
In older age (65 to 70
long term good health will increase the ages for this possible condition) the
chin and jaw bone becomes greatly reduced (the bones lower in height) in size
through the loss of the teeth and alveolar process (the bone area where the
roots of the teeth reside) being absorbed may cause the possibility of chin or
jaw facture from aggressive surgery in those areas due to the lowered height in
the chin and lower to mid section of the jaw.
This should be considered
before surgery since the chin and jaw reduce sizes to almost half their original
sizes in old age. Factures in old age are very difficult to correct and can lead
to a massive amount of other health related issues.
In the below article
there are a number of photos of what happens to the jaw and chin in different
periods of life. The section on this issue can be found in the bottom of the
article. In the below article there are a number of photos of what happens to
the jaw and chin in different periods of life. The section on this issue can be
found in the bottom of the article.
Long term affects on the mandible and
chin
Lip contouring/Lip
lift
The length from the upper lip to the nose is shorter
in females then in males. There are a number of options that can be taken for
the upper lip reduction.
The upper lip can be raised using sutures (lip
suspension) to hold it in place.
Details about lip suspension
The better option is to have the
upper lip reduced by way of a 'v' incision below the nose, where a little skin
is removed to reduce the distance between the underside of nose to the upper
lip. The effect of this is lifting the upper lip upward and outward, giving it a
nice contour with a little more fullness.
Some try to accomplish the
female lip contour through the use of fillers and this can some work well for
them, but it is a good idea to try to keep a balanced look and try not to ask
for the max amount of filler to be injected. This link provides further
information about lip augmentation lip lifts. Covers lip
augmentation and lip lifts
If you are having a scalp
advancement done at the same time as a lip contouring, the surgeon can use part
of the skin, which is removed from the scalp advancement to augment the lips by
slicing it and shaping it then pulling it through your lips from a small
incision inside your mouth on each site of the lips. The thought behind this is
that using your own tissue will limit rejection since it is your own tissue.
There is however still a change of rejection.
These procedures are
mostly done under local anesthesia unless more major procedures are being done
also in which case you could have it done under general anesthesia.
The risks and
complications from lip lift
Infection, little scaring, very low risk procedure.
The risks and
complications from lip augmentation
Infection, little scaring, over correction, rejection from filler or
implant used and would have to be removed leading to scaring.
Cheekbone
augmentation (Malarplasty)
The cheekbone augmentation
section will be getting a more detailed update soon.
Females tend to
have much fuller cheeks compared to most males. Fullness of the cheekbones
presents a more youthful appearance. As we age most people loose fat from there
cheeks over time giving us less prominent cheeks.
Cheekbone augmentation
entails an intra-oral incision or a inner lower eyelid incision to augment the
bone with implant material, silicone implants, polyethylene (MEDPOR) implants,
and polytetrafluoroethylene (Gore-Tex) implants (More information available in the facial implant
section). The implants can be held in place either by the compression
created by the tissue above and or sutures, which are removed at a later date,
or they can be further secured with a single screw through each implant.
There are some fillers surgeons may use for cheek augmentation depending
on the amount of cheek augmentation needed. The fillers that need to be avoided
for cheekbone augmentation are silicone injections and hydroxyapatite paste.
Note: The problems presented by silicone injections is the particle size
of silicone oil martial used and that this causes migration throughout the body.
Traces of injectable silicone have been reported to be found in organs and lymph
nodes. There are reports and studies leading to long-term health issues relating
to silicone injections.
Note: Hydroxyapatite paste (HA paste) has a
problem with loss of augmentation due to being resorbed into the body.
The risks and
complications from cheek augmentation
Infection, Nerve Damage,
Extrusion, Seroma, Hematoma, migration of implant, Induration
Cheekbone
reduction/Reduction Malarplasty
The cheeks can be reduced
if there is too much cheek fullness. There are two options for reducing the
cheeks. Fat can be removed from the cheeks, which can have some good results or
through an intra-oral incision in the gum line to gain access to the cheekbones
so they can be reduced through the use of a bur to grind them down and may
requir the use of a bone chisel. There is extreme swelling and bruising after
the bony cheek reduction. I have heard of a few cases where the cheek bones have
been removed through the use of a bone saw and reattached, but this can present
a massive amount of problems. Further information about cheekbone reduction can
be obtained at: Cheekbone
reduction artical by Charles S. Lee, MD
The cheek reduction
through removal of fat will have less risk then the bony procedure. The bony
procedure has the chance of over reduction or asymmetry problems that are much
more difficult to correct then a under reduction from removing fat.
The risks and
complications from reduction
Infection, Nerve Damage, Over Correction, Under Correction,
Hematoma.
Forehead
Feminization Still working on this section
Skull before and after forehead
feminization
Forehead contouring
and Forehead Reconstruction
There are a number of
differences between the male and female forehead. The most distinguishing
difference comes in the form of the brow bossing, and the orbital rims males
tend to have. This bony ridge can have a impact on gender recognition. Males
also tend to have more of a bony slope from the top of the forehead to the brow
bossing and females tend to have a more round shape to the forehead both
vertically and horizontally. Brow bossing and orbital rims are age dependent
since the male hormone testrone causes these male charistics to develop after
the onset of puberty. The bones in the face grow until the age of 21 to 22 years
of age.
Some ethnic backgrounds have less masculine defined foreheads,
so for transsexuals from certain ethnic backgrounds won’t require the more
invasive forehead procedures offered.
Scalp Advancement The male forehead tends to
have a height difference in the hairline compared to most females. The hairline
is age dependent since the hairline recedes for males, as they get older. There
is no golden rule of what the hairline should be, compare the hairlines of woman
that you see on a daily basis and you will notice that the hairline varies from
woman to woman. A scalp advancement can be used to lower the hairline to a lower
position and the scalp advancement can also raise the height of the eyebrows in
this single procedure.
The scalp advancement involves making an incision
that begins right at the hairline. The forehead soft tissues will be elevated
almost as in a forehead lift, along with elevating soft tissues in an area under
the hairline to allow the hairline to be pulled forward creating a lower
hairline. If the hairline has receded on each side of your forehead then a few
more incisions might have to be made along each side to remove more skin. The
most common pattern of these incisions would be almost the shape of a triangle
because the surgeon needs to remove the distance between the receded areas. If
the area of recession is large then you will also be advised before the
procedure that you will be required to have hair grafts to fill that area
further. A lower incision will be made removing an area of skin and the incision
will be closed using medical staples.
Another scalp advancement can also
be completed six months after the first advancement for further hairline
improvement because the skin regains its elasticity after time.
Eyebrow Lift There is
also a difference in the height of the eyebrows in males compared to females.
Males tend to have a lower eyebrow position then females. Further information
coming in the future.
Here is a
listing of some helpful plastic surgery links.
Some
facial feminization surgery studies by Alfred G. Becking,
DDS
Some
more facial feminization surgery studies by Alfred G. Becking,
DDS
Detailed
informaion about Chin Implants and photos of the surgery being
done
This
site Offers some interesting details about implant materials including info
about grafts
Some helpful information about genioplasty and maxillofacial
surgery by Richard O’Donnell, M.D., D.D.S., Denver, CO. The surgery examples are
impressive.
A doctor discusses the chin implants verse bony reduction and some
useful info about rhinoplasty PDF file.
This site offers a
great many views of the skull, and info relating to the facial
bones.
Male and Female Skull Differences and skull
models
Details about scar revision and about available scar revision
procedures
American Society of Plastic
& Reconstructive Surgeons
Aesthetic Surgery
Journal
British Association of Plastic Surgeons
Plastic and
Reconstructive Surgery
British
Journal of Plastic Surgery
European
Journal of Plastic Surgery
Brazilian Society of
Plastic Surgery
Aesthetic Plastic Surgery
Annals of Plastic
Surgery
Clinics in Plastic
Surgery
I would like to thank all the doctors who
took the time to talk with me about these and other procedures. Their names link
to their surgeon profiles in my FFS and SRS surgeon listings for the USA and the
world
Dr. Gary
Alter
Dr.
Mark Zukowski
Dr.
Lazaro Cardenas
Dr. Yvon Menard And Dr. Pierre Brassard
Dr. Steven Denenberg
Dr.
Michael
Brownstein
