Facial feminization, or FFS, are a series of procedures designed to help soften your appearance by altering both the facial skeleton and soft tissue. Skeletal foundation surgery is imperative for long term, naturally appearing results and are best performed by a craniofacial specialist.
Adam’s Apple Reduction (Tracheal Shave)
A thinner, more flat throat is achieved by reducing the size of the signature male adam’s apple. The cricoid cartilage can be shaved through an incision that is hidden well underneath the chin. The cartilage is shaved using either a surgical blade or a burr if the cartilage is calcified. Over resection of the cartilage can destabilize the underlying vocal cords and must be done safely.
Before FFS with tracheal shave
After FFS with tracheal shave
Brow Lift (Browplasty)
Feminine eyebrows tend to sit higher on the face with a slight arch on the sides. At the time of forehead contouring the brows can be elevated using suture techniques. the Lateral part of the brow can be preferentially lifted
Cheek Enhancement (Augmentation & Reduction)
Chin Recontouring (Genioplasty)
Depending on the specific shape of your chin, chin recontouring can include reducing, reshaping, or augmenting the shape and size. An incision is made within the mouth to facilitate dissection and exposure of the chin. The mentalis muscles (elevators of the lower lip) and divided and sometimes thinned to allow better contour. There are a pair of nerves called the mental nerves that give sensation to lower lip and must be protected.
Dr. Bastidas MD uses 3D planning CAD/CAM design to create a surgical guide to facilitate safe cutting of the chin bone without nerve damage. In addition, the width of the chin can be easily reduced, vertical height shortened, and chin advanced if necessary to complete the refinement of your facial profile. This is known as osseous genioplasty. Permanent titanium screws and a plate are used to maintain and establish the newly constructed chin architecture. These screws are not obvious to you, nor will they set off metal detectors. The soft tissue of the chin pad can then be thinned to complete the chin contouring and dissolvable stitches placed to close the incision.
A chin strap is placed postoperatively to maintain support for the chin during healing. The soft tissue may remain swollen for at least 2-3 months as the chin is the most gravity dependent part of the face. You will be instructed to wear the chin brace for at least 3 weeks during the healing process.
Eyelid Surgery
Excess skin of the eyelids can create a heaviness to the look of the eyes, resulting in a tired demeanor. The skin and fat can be reduced and or repositioned to help improve the overall look and openness of the eye.
The angle of the corner of the eye can be resuspended in a canthoplasty procedure, resulting in the desired “cat eye” many of trans patients enjoy.
Facelift
A facelift involves elevating the soft tissues and resuspending them in a more youthful feminine position. In addition, excess skin can be removed, and the folds and jowl can be softened. The incision are hidden in the shadows of the face around the ear. A necklift is often combined to help perfect the contour of both the upper and lower parts of the face.
Feminizing Earlobe Reduction
Ear lobes are vertically shorter in females and can be easily modified at the time of your facial feminization surgery. An incision is designed at the base of the ear lobes and a round appearing shorter lobe can be sculpted with the suture line (scar) hidden at the bottom or behind the ears.
Forehead Reduction and Contouring Surgery
There are many anatomical differences between the masculine and feminine forehead. The forehead is often the area creating most dysphoria in our trans patients, particularly when viewed in side profile. Masculine foreheads are more convex, and have prominent orbital rims and bulging frontal sinus. The surgeon must effectively address all of these parts to create a soft, feminine profile.
Frontal sinus
The frontal sinus is the area directly above and between your two eyes. As we grow from child to adult, this part of the skull fills with air and mucosa. In males, it is often larger and more protrusive. The frontal sinus has a thin layer of bone (called the anterior table) that is about 3-4mm thick. Underneath this is the air and mucous filled sinus) which drain into your nose. There is an additional thin layer of bone (posterior table) which protects the brain and does not need to be remodeled.
The goal for your surgeon is to create almost a vertical line from the base of the bridge of the nose towards the scalp. This can be accomplished by either burring down (type 2) the prominent bone of the anterior table, or by setting the bone back further into the sinus cavity (type3). Since the thickness of the anterior table is only 3-4mm, the surgeon is limited by how much they can reduce the bone without doing a type 3 setback. Many surgeons are uncomfortable with doing a proper removal and setback and you should ask them if they routinely do this. A type 3 setback involves the entire anterior table bone flap, remodeling it from the inside with the high speed burr, reducing the frontal sinus septum (bone that separated the 2 sides internally) and then fixating it back in a setback position. Dr. Bastidas MD uses a resorbable plate to set the bone back that will dissolve over the course of 1-2 years.
Orbital Rims
The top part of the eye socket is very prominent in a masculine face and much less convex in a feminine face. The eye socket is also wider and taller laterally in the feminine architecture. After exposing the area through the incision described above, we can soften these features using a high speed burr thus allowing us to sculpt the desired look. These changes are immediately appreciated postop and especially visible from the side profile.
Hairline Advancement
The approach to the forehead for remodeling requires a long incision for access. This incision can be placed either an inch behind your hairline or directly in front of it depending on your goal. If you would like to lower your hairline then the incision must be placed directly in front of it. This will allow your surgeon to effectively remove excess forehead skin while simultaneously advancing the hair bearing skin forward.
The temples are often area where some hair loss has typically occurred. This may be dependent on the timing of when you started taking estrogen. Hormones are protective against male pattern baldness and the early you start the the better. The widows peak area can be improved by advancing the hair bearing skin creating a more youthful and feminine hairlines.
The scalp tissue is very vascular and its not uncommon to bleed from it. To control bleeding we often inject adrenaline prior to making incisions. This allows the blood vessels to clamp down and reduce blood loss. In addition, surgeons may apply temporary surgical clips to the area that will further reduce bleeding of the skin edges.
The scalp skin is typically tight. Feel your own scalp and try to pinch the skin together to see my point. The skin doesn’t move much and will restrict how much we can lower the forehead. The deeper scalp tissue however, once released, can allow more forward movement particular in the areas over the widows peak. To accomplish this your surgeon can release the skin from the back of the scalp by dissecting wide and far (almost lifting the entire scalp). The deep scalp has a loose tissue plane that is bloodless (subgaleal) and allows safe and easy dissection. The hair bearing scalp is then advanced to its maximum front position while simultaneously determining how much hairless forehead skin can be safely removed.
Excess tension on the closure can lead to thick scarring, known as hypertrophic scars. Similar to a facelift, the goal is to create thin, blended facial scars, so your surgeon must choose just the right amount of tension during closure. The skin is closed in layers to allow for the best scarring and most efficient healing. I typically use a buried, resorbable suture underneath the skin (in the galeal layer) and follow this with a resorbable suture that connects the top layer of the skin together. Some surgeons choose to use staples for this part which is fine as long as the staples are removed by postop day #7.
Typically 1/2 to 1 inch of hairline advancement can be safely accomplished. The scars are minimized with proper timing of suture/staple removal, non surgical scar treatments such as silicone lotions, steroid injections and laser where applicable. Massaging the scar may also help reduce the thickness of it (ask your surgeon when to begin). If you have as history of keloids, please inform your surgeon as this would be need to be addressed with early steroid injections at the time of surgery and during the recovery period.
Jaw Contouring (Reshaping or Tapering)
In facial feminization surgery our goal is to create a slim, V shaped lower jaw to complement the face. The angles of the mandible, as well as the masseter muscle can create a square, boxy type of appearance in the masculine face. Feminization requires reduction of the mandible angles reducing overall lower facial width. This is done through an incision inside the mouth. Dr. Bastidas MD uses 3D planning and surgical guides to remove the prominent angles with precision and exactness.
Lip Lift and Lip Filling
Plush, pouty lips are often considered feminine and alluring. The volume of both the upper and lower lips can be expanded using your own fat. Fat can be removed from your belly area and injected to your lips to act as permanent filler. Fat transfers may partially resorb requiring additional fat grafting to achieve your exact goal.
Lip Lifts have gained popularity recently as a way to show more red lip (vermillion) and also more of your central teeth. An incision is created in the creases of the nose and upper lip skin removed which will raise the underlying red lip. As we age, this distance natually lengthens and a shorter upper lip is considered a hallmark of youthfulness. Upper lip lifts can also be performed in the office under local anesthesia as a secondary or tertiary facial feminization procedure.
Neck Lift/Liposuction
A droopy, poorly defined neck can be an area of major dysphoria for our patients. Depending on the problem, either simple liposuction to sculpt the neck, or tightening of the neck musculature can be performed. An incision can be made underneath the chin to allow for access to the soft tissues of the neck. A tracheal shave can be done through this same incision. Patients must wear a supportive garment for at least 2 weeks after this procedure.
Revision Surgery
We often see patients that are dissatisfied with their facial feminization results from other surgeons. We can offer revision FFS surgery to help improve your outcomes and resolve any remaining asymmetries or under-correction. The first step involves doing a complete examination and possible repeat CT scan imaging to determine the core of the problem. It is helpful if you can get the operative records and notes from your previous surgeon so we can have all the information necessary to determine the best plan of action
Rhinoplasty (Nasal Surgery)
The nose is the center of the face and so often an area of dysphoria for all patients. A masculine nose is often larger, broader, less rotated and often with less tip definition then a feminine nose. Using rhinoplasty techniques, a feminine nasal tip is sculpted to create a more angular, refined appearance. This may involve:
Dorsal reduction
The nasal hump can be eliminated by shaving down the bone during surgery. The nasal bridge can also be lowered overall to create a more delicate appearing nose.
Nasal Tip
The tip of the nose is composed entirely or cartilage and soft tissue. The cartilages can be shaved to create less bulk, and also redirected and reshaped using suture techniques. Often cartilage grafts are required to help add structural support as well as additional projection to help create a smaller, more defined tip.
Nasal Bone Osteotomies
The nasal bones can be brought closer together my precisely fracturing them at their base and moving them closer together. This will create a more narrow appearing nose after it heals. The nasal bones heal within 4-6 weeks and permanent correction can be obtained.
Nostril Show/Alar base reduction
The nostril shape can be reduced and the alar base reshaped to create a more delicate appearing nose. This required an incision (and thus scar) around the edge of the nostrils which is well hidden in the crease.