Facial feminization surgery (FFS) is a set of cosmetic 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.
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, but subtle changes in the lips can have a strong effect.
For many transgender women, FFS is medically necessary to treat gender dysphoria, that helping trans women integrate socially as women
While most FFS patients are transgender women, some cisgender women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressers and drag queens.
Surgical procedures - Upper third of face
Some studies have shown that the shape of the forehead is one of the key differences between males and females. Hairline correction, forehead recontouring, eye socket recontouring, and brow lift are procedures are often performed at the same time, with rhinoplasty in mind.
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.
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). Males also tend to have indented temples and a flatter forehead than females.
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.
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. The data on which approach is better is limited and does not provide guidance. 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.
Men tend to have lower eyebrows relative to the position of their brow ridges when compared to women. Men's eyebrows tend to be below their brow ridges while women's eyebrows tend to be above their brow ridges. Accordingly, FFS to raise the eyebrows results in a face with a "womanlier" appearance.
In some literature the eye shape has been shown to be the key differentiating feature between males and females. 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). Some FFS alter the orbit shape; data on outcomes is limited.
Males tend to have larger, longer, and wider noses than 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 remodeling what remains.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. Standard rhinoplasty procedures are generally used. There is limited data on outcomes.
Cheek dimples are usually considered as an attractive feature of facial beauty. Unfortunately, not all beautiful girls have dimples. We used a new and simple technique for natural dynamic dimple creation, passing a transcutaneous bolster stitch after scraping off the dermis of all mucomuscular attachments, and without bolster stitch if does not want. This procedure done under local anaesthesia as a daycare. This procedure is safe, reliable and easily reproducible. As no tissue is excised, chances of bleeding and haematoma formation are negligible. With this procedure, the patient satisfaction rate is very high, and patients seen long time after surgery continue to be pleased with their surgically created dimples. Dimples on cheeks enhance facial beauty and expression. They occur in both sexes.
Positioning of the dimple
The position of the dimple is marked by the patient in front of the mirror. The point of intersection of the perpendicular line dropped from the external canthus and horizontal line drawn from the highest point of the cupid's bow laterally. Similarly, the patient is asked to create a negative suction and suck the cheeks inside. The site of the maximum depression is the marked site of the dimple.
The patient is discharged immediately with antibiotics and analgesics. Meticulous oral hygiene with mouthwash and oral rinse is of utmost importance. The bolster stitch is removed on postoperative day 7. Initially, there is a static dimple which deepens on animation, but gradually with time there is only a hint of dimple when static and accentuates on animation.
Drawback of this procedure is that the bolster suture is visible on the cheek for the first 7 days after the surgery, other rare complications are hematoma, bleeding, edema & extremely uncommon, there is a potential for injury to the buccal branch of the facial nerve.
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. The cheeks are reshaped by cutting away bone and repositioning the facial bones. 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.
Subtle changes to the shape and structure of lips can have a strong influence on feminization. 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.
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.
Females often have fuller lips than 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. Use of fat harvested from the person can result in lumps and doesn't last long. The longest lasting and least risky results appear to arise from use of acellular dermis products.
The chins of males tend to be longer and wider than those of females, with a squarer base, and to project outward more than female chins. Male jawlines tend to extend outward from the chin at a wider angle than those of females, and to have a sharp corner at the back.
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.
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.