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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.
jawtapperedsmall.jpg
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 chin
This 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 canít 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 itís 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 chin
This 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 wonít 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 OíDonnell, 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