Facial Feminization Surgery (FFS) is a set of surgical procedures designed to soften and modify facial features perceived as masculine, exaggerated or non-harmonic, and, which are decisive in the visual identification of facial gender.
It is a relatively new surgical specialty with two goals:
FACIAL GENDER CONFIRMATION SURGERY (FGCS) AND
FACIAL HARMONIZATION SURGERY (FHS)
The concept of FFS is, in fact, much broader than assumed. It is being now sought by people of any gender.
The techniques included in FFS are similar for cis or trans individuals.
For example, sometimes females with unusually prominent foreheads or wide jaws/chins need these surgeries to “harmonize” their facial features. For such indications the term, Facial Harmonization Surgery, is used. In case of transgenders, it is referred to as Facial Gender Confirmation Surgery
WHY FACIAL GENDER CONFIRMATION SURGERY?
Early in our upbringing, we are trained to automatically recognize a face as “male or female”, long before learning about gender differences. The perception of gender through facial features occurs in a single glance, involuntarily.
The very first moment, we see a face, our brain assigns it a gender, male or female. Numerous studies have been done to find out, how and why the human brain identifies the gender of a face within milliseconds of seeing one. Still, it remains a mystery. The exact science is not known.
But what we do know about facial gender is this:
During childhood, all human faces are more or less feminine. This is why social transitioning is possible before puberty. Changing the way a child dresses or changing the haircut will transform a boy into a girl or vice versa, at least visually.
As puberty kicks in, the situation changes drastically. The prevalent sex hormones – oestrogen in females and testosterone in males get produced in more amounts triggering irreversible changes in the adolescent body. In the face, certain gender markers develop. Males undergo masculinization of face while females undergo further feminisation. These are besides the other changes the hormones trigger in the body.
While other parts of the body can be hidden, camouflaged or exaggerated to appear more feminine, it is sometimes difficult to attain facial femininity without gender-affirming facial surgery. It is for this reason that an individual in the process of gender transition may seek this surgery with the objective of an easier integration within the society in general.
FFS is generating significant interest in the transgender community who are often subject to discrimination, violence or worse. Modifying facial gender within the transition protocol is equally important for some, as is hormone therapy and genital sex change.
What comprises FFS?
Once puberty changes the face, surgery remains the only option to feminise it.
Some facial gender attributes can be corrected non surgically such as facial hair reduction using Laser, jaw line alteration with fillers, eyebrow shaping with botulinum toxin, etc. But most of these changes are usually subtle and/or temporary. FFS modalities are more permanent and definitive.
Cross hormone therapy (anti testosterone) does help to soften male facial features, but it is not enough in itself, as it cannot remodel the bones.
For ease of understanding FFS procedures, the face is divided into three parts:
- Upper third: Forehead, hair style and hairline
- Middle third: Eyebrows, shape of eyes, cheeks and nose
- Lower third: Lips, Chin, lower jaw, facial hair reduction and Adam‘s apple correction
To provide an overview of what is exactly done in FFS, the following can be put forth in simplistic terms:
Upper third:
Forehead: The prominences of the forehead are literally shaved off to make it smooth and round, thereby feminising it.
Hair line feminisation can be done surgically or with hair transplant. Different designs are shown to the patient and their preferences taken into account.
Middle third:
Eyebrows: A lateral brow lift arches the eyebrows well.
Shape of the eyes: This can be changed to a certain extent with lateral canthoplasty/pexy, ie., elevation of the outer corner of the eye giving it a cat eye appearance considered to be more feminish.
Cheeks: Use of a malar implant or facial fat grafting can smoothen the facial contours, thereby feminising it. Fat also has the benefit of improving skin quality and texture as it has stem cells.
Nose: A feminising rhinoplasty makes a lot of difference to the face!
Lower third:
Chin: A genioplasty is usually planned to narrow the chin and reduce its height.
Mandible: Most important is the change which can be brought about in the mandible. Reducing the body height, smoothening the contours/angles, reducing the flare at the angle help in feminisation. It helps reduce the facial width as well. Meticulous planning is required in case of the mandibular alteration.
Adam’s apple correction: Shaving off the tracheal cartilage projection is a relatively simple procedure and can be undertaken in the any sitting.
Redistribution of facial fat can be achieved with facial fat grafting. Laser hair reduction can be undertaken for facial hair growth.
For a more holistic effect, skin enhancement with peels, lasers, fairness agents, acne treatment, etc are also required regularly.
Voice alteration can also be done via a thyroplasty/laryngoplasty where the vocal cords are tightened to make the pitch of the voice higher and more feminine. This is usually done by an expert laryngologist in the team.
As we can see, it involves experts from numerous fields such as plastic surgery, craniofacial/maxillofacial surgery, otorhinolaryngology, dermatology, endocrinology, etc, only a team work can deliver sustainable results over time.
TREATMENT PLANNING
The key to achieve highly satisfactory results in FFS is with meticulous planning and appropriate choice of techniques best suited to the needs of the patient. There is no “one mould fits all” approach. Each feminization is unique.
Normally, one facial area is identified as “primary”, which is the main focus of the personalized feminization surgery. It is essential to have realistic expectations. After thorough facial analysis, “secondary” areas may then be suggested in order to optimize the final result. Any additional procedures, within the frame of realistic expectations, are considered after a careful global assessment by the surgical team.
Treatment planning is based on a combination of physical assessments, 3D CT scans, anthropometric measurements, clinical photographs, and most importantly: the self-evaluation and perception of the patient. The idea is to help develop a clarity of thought as to which facial areas need to be modified. One need not address all the areas suggested above.
Future:
With more acceptance and demand of these complex procedures and the ever-increasing technological prowess, incorporation of tools like peizotome, CT guided 3D printing, CT based softwares to predict the redraping of the soft tissues over the bony changes, etc, FFS and FHS, are only going to increase and improve with time. It would give a holistic meaning to GRS, which began with only make-up/cross dressing to actually changing one’s sex as well as appearance “to the bone”.
-Dr. Mahesh Nair
