Finding Perfection In Your Reflection: The Transgender Patient Guide to Facial Feminization Surgery

Nicholas Bastidas MD

Table of Contents

Chapter 1: Facial Differences Between Man and Woman

Chapter Contributions: Jose Palacios BS

Introduction

In the context of gender affirming surgery of the face, specific features are evaluated to consider their contribution to masculinity and femininity. In this chapter, we will take a deep dive into the different anatomical features of the face and consider what makes it appear masculine or feminine. The modification of these features is the basis of facial gender affirmation surgery. Therefore, understanding what makes a face appear masculine or feminine is important for deciding what features can be modified to achieve a desired result. This may also serve as a guide to understand what is causing misgendering or dissatisfaction with one’s own appearance.

The following section describes what is considered typical in cis-men and cis-women. We are not describing these features as beauty ideals, rather as guides for determining what features give a face a more masculine or feminine appearance. Individuals can have facial features that are associated with masculinity, but still have an overall feminine appearance. The same applies for individuals with features that are associated with femininity that retain an overall masculine appearance. It is also important to note that while these feminine and masculine features apply generally, they were analyzed primarily in cis-men and cis-women of caucasian descent. A section later in this chapter is dedicated to pointing out how some of these features differ in people of african and east asian descent.

We will examine the face by splitting it into horizontal thirds and describing how the features found in each section contribute to a feminine or masculine appearance. The top third of the face begins at the hairline and ends at the eyebrows. The middle third of the face begins at the eyebrows and ends immediately below the nose. The bottom third of the face begins immediately below the nose and ends at the tip of the chin. We will also discuss the neck, which contributes greatly to masculinity or femininity and is immediately visible below the face.

Top Third of The Face:

At the very top of the face, we have the hairline. The two main aspects of the hairline to consider are the shape and the height. A hairline that is higher up on the face along with a larger forehead size is typically associated with masculinity. The hairline also tends to be well defined in an “M” shape which tends to become more pronounced with age. In contrast, a lower hairline with a smaller forehead is considered feminine (See Figure 1.1). This hairline tends to be less well defined, rounder in shape, and does not change dramatically with age.

The forehead is the region of the face between the hairline and the top of the eyebrows. As mentioned before, masculinity is associated with a larger forehead, although this varies by race and ethnicity. The size of the forehead is influenced by the height of both the hairline and the eyebrows. A larger forehead is a result of both a higher hairline and lower eyebrows. The opposite is true for a smaller forehead; the hairline is lower, and the eyebrows are higher. Independently, a lower, rounder hairline will produce a more feminine appearance at the very top of the face and higher eyebrows will give the eyes a more feminine appearance. Together, the lowering of the hairline and the raising of the eyebrows work together to give the top third of the face a feminine appearance from a front profile.

From the side profile two additional features are highlighted: the bossing of the brow ridge and the slope of the forehead. The most significant feature of the side profile is the presence or absence of eyebrow ridge bossing. Bossing refers to the protrusion of the brow ridge on which the eyebrows sit. This is one of the defining features of a masculine face. The degree of bossing varies from person to person, but a greater degree of bossing will contribute greatly to the masculine appearance of a face from a side profile. In contrast, a feminine face will show essentially no bossing at all (See Figure 1.2). Bossing also contributes to the slope of the forehead. A masculine forehead begins at the hairline and slopes outward until it reaches its maximal point at the most prominent portion of the brow ridge. In contrast, a feminine forehead will curve out slightly until about halfway down the forehead at which point it travels straight down until dipping just before the nose begins.

In summary, the top third of the face, which begins at the hairline and ends immediately below the eyebrows, can be feminized by changing a few key features. From a front profile, a lower, rounder hairline contributes greatly to the feminine appearance of the face. Along with a lower hairline, higher eyebrows contribute to a reduced forehead size and give the eyes a more feminine appearance. From a side profile, a flat eyebrow ridge greatly increases femininity of the face and gives the forehead a more concave appearance. The procedures that modify these features are discussed in a later chapter.

Middle Third of The Face:

The middle third of the face is demarcated by the lower edge of the eyebrows and the bottom of the nose, also known as the nasolabial junction. In this region, we have the eyes, the nose, the cheek bones, and the ears. In general, feminine eyes are open wider. This difference is subtle and is attributed to a wider orbit in the skeleton. Feminine eyes also have a slight tilt down toward the nose while masculine eyes are typically parallel with the ground (see Figure 1.3). Feminine eyes also tend to be rounder when compared to more elliptical masculine eyes.

The nose is a particularly intricate part of the face with many aspects to consider when trying to describe a feminine or masculine appearance. There are several features that determine its overall shape:

  1. Nose width
  2. Nose slope/dorsum
  3. Nose projection
  4. Tip rotation
  5. Nasolabial angle
  6. Nasofrontal angle

While most features of the nose are best appreciated from the side profile, its width is seen best from the frontal profile. The widths of the dorsum and alar base can both be considered.

The nose is located centrally in the face and travels from the eyebrows  to the beginning of the upper lip. Lines can be drawn from the eyebrows along the dorsum to the tip of the nose. These lines can help to determine the nasal width and symmetry. The distance between these two lines makes up the width of the dorsum, which changes along the length of the nose. The alar base is located at the bottom of the nose and is the widest portion of the nose. In general, feminine noses are narrower at the dorsum and alar base. However, the nose can take on an abnormal appearance if not in proportion with other facial features. The alar base, for example, is typically the same width as the distance between the eyes (see Figure 1.5). The dorsal width is more forgiving. Generally, it will narrow as it moves down along the dorsal aesthetic lines from the eyebrows until reaching its narrowest point at the nasofrontal angle. Then, it widens as it moves down to the tip of the nose.

The nasofrontal angle marks the transition from forehead to nose. This can be seen on a front or side view of the face. The angle itself is appreciated from the side profile. A sharper angle is considered to be more masculine than a wider angle. A feminine nasofrontal angle is considered to be wider, resulting in a smoother appearance. This angle is often between 115 – 120 degrees in masculine faces and 120 – 130 degrees in feminine faces. This angle transitions into the dorsum of the nose which runs from the nasofrontal angle to the tip of the nose.

The slope of the dorsum can be appreciated from the side profile. A masculine dorsum travels straight from the nasofrontal angle to the tip of the nose. In contrast, a feminine dorsum will have a slight concavity. The slope of the dorsum plays a role in determining the nose tip rotation, which is essentially the angle at which the tip projects from the face. A nose tip that points directly perpendicular off the plane of the face is considered more masculine. In contrast, a nose tip that points slightly up is considered feminine (see Figure 1.6). Tip rotation is measured by the nasolabial angle. The nasolabial angle is the angle formed where the nose ends, and the upper lip begins. A masculine appearance is produced by a nasolabial angle that is closer to 90 – 95 degrees whereas a nasolabial angle closer to 95 – 105 degrees produces a feminine appearance.

The final aspect of the nose that we can consider is how far the nose tip projects from the face, also known as nasal tip projection. From the side profile this determines how big or small the nose appears. In general, a nose will appear proportionate if nasal tip projection is 2/3 the length of the nose.

The nose, like other features of the face, must be considered in the context of the entire face. While some features are considered more masculine and others are considered more feminine, a nose that is too far in the masculine direction or the feminine direction can appear disproportionate.

The cheeks in the middle third of the face also play a role in determining masculinity or femininity of the face. Specifically, feminine cheekbones are higher, wider, and more prominent than masculine cheekbones. This makes the midface appear wider and contributes to the triangular shape of the lower two-thirds of the face, which is considered more feminine. The increased prominence creates a fuller appearance to the cheeks. Masculine cheekbones are flatter, narrower and lower, contributing to the more squarer appearance of the face (see Figure 1.7). The difference in cheek bones is subtle and can be made to appear more feminine with the use of make-up.

The ear can also be considered part of the middle 1/3 of the face. While a larger ear is typically considered more masculine, there is very little that differentiates a masculine and feminine ear.

Bottom Third of the Face:

The bottom third of the face is the region between the junction of the nose and the upper lip, known as the nasolabial junction, and the end of the chin from the front profile. The bottom third of the face includes features that differ significantly between masculine and feminine faces. These features include the lips, jaw, and chin. In general, feminine faces tend to taper sharply down to the chin whereas masculine faces tend to taper less and produce a more square  appearance. The upper lip, the distance between the nose and  lip border, tends to be larger in masculine faces. This is exacerbated by age where this distance tends to increase. Fuller lips with well-defined borders are also considered more feminine. In contrast, lips that are less full, with poorly defined borders are considered more masculine. The lips, however, can vary greatly based on ethnicity.

The jaw plays a major role in determining masculinity and femininity of the face. The jaw size and shape along with the muscle that sits over the jawbone (masseter muscle) create the square shape that is seen from the front profile. From the side profile, the angle of the jaw produces the sharp jaw angle that is characteristic of masculine faces. In a masculine face, the jaw angle is closer to 90 degrees, whereas in a feminine face this angle is closer to 110 – 120 degrees. The wider angle creates a softer appearing jaw while the smaller angle creates the classic prominent jaw angle. The overall size of both the bone and muscle of the jaw creates the overall prominent jaw seen in masculine faces. From a front profile, the lateral margins of a masculine face travel straight down and parallel until reaching the angle of the jaw on each side of the face. After the jaw angle, the jawlines travel in more of a straight line until reaching the chin. In contrast, jawlines in feminine faces are more curved, with almost no straight lines or angles until reaching the width of the chin.

The chin also heavily influences facial masculinity and femininity. From the front profile, a wider chin is seen on masculine faces while a narrower chin is seen on more feminine faces. The wider chin width gives the chin a flatter appearance that can be referred to as “boxy”. In contrast, the narrower width gives the chin a more “pointy” appearance. In masculine faces, the width of the chin is closer to the width of the mouth, while in feminine faces, the width of the chin is closer to the width of the nose. From the side profile, a chin with greater projection in front of  the face is considered more masculine. In feminine faces, the projection of the chin is typically less than the projection of the lips.

Another feature that  contributes to facial masculinity is chin clefting, commonly referred to as “butt chin”. While it is normal to see this feature in both cis-men and cis-women, chin clefting is often considered a more masculine feature. Chin clefting occurs when the underlying muscle has either abnormal positioning or size. The muscles directly beneath the skin of the chin are known as the mentalis muscles and they are found in a pair to the left and to the right of the chin midline. A cleft occurs when there is too much separation between these muscles or when the muscles are very thick making the groove between them more noticeable. This cleft can be reduced using fillers, fat grating, botox, or more invasive chin surgery. These options are discussed in a later chapter.

Together, the jaw and chin work in conjunction to produce the overall shape of the bottom third of the face and contribute greatly to its masculinity or femininity. A prominent jaw and wide chin result in a boxier appearance that is associated with a masculine face. A less pronounced jaw and narrow chin results in a sharper triangular taper in feminine faces. 

The Neck:

While the neck is not a part of the face, it is readily seen just below the face. The most important feature of the neck in the context of masculinity and femininity is the prominence of the thyroid cartilage, commonly referred to as the Adam’s apple. The thyroid cartilage is located directly above the windpipe and contains the vocal cords. As the name implies, it is made of cartilage and is a classic masculine feature. The lateral walls of the thyroid cartilage meet at this prominence and the angle that they form determines the degree of protrusion. A prominent thyroid cartilage is produced when the lateral walls of the thyroid cartilage meet to form a sharper angle. When the lateral walls form a wider angle, there is little to no projection from the neck.

The vocal cords are located within the thyroid cartilage and determine the pitch of one’s voice. A lower pitch voice is considered more masculine while a higher pitch voice is considered more feminine. This pitch is determined by the length of the vocal cords and their tension. Decreasing the size of the vocal cord opening will create a higher pitch voice.

Skin:

In general, masculine skin is described as thicker skin that produces more oil. The difference in skin thickness is largely due to the collagen density in the dermal layer of the skin. A masculine face will also tend to have much more facial hair throughout the bottom third of the face. Facial hair can be found around the lips, side of the face, chin and neck down to the level of the thyroid cartilage. Skin and hair are heavily influenced by hormone profiles. Higher levels of testosterone will result in thicker and more oily skin with thicker hair throughout the bottom third of the face. Higher estrogen levels will produce thinner, less oily skin with less facial hair growth.

A Holistic view of The Face:

While individual features can independently give the face a masculine or feminine appearance, the face should be considered holistically in the context of gender affirmation surgery. The face can be divided horizontally into thirds, as we have been discussing throughout this chapter, and vertically into fifths. Faces vary widely and can differ significantly from what is considered the norm. In order to guide a holistic discussion of the face, we will use these horizontal and vertical divisions to describe how the different components of the face harmonize with each other.

Beginning with the horizontal, the top, middle and bottom thirds of the face have distinct landmarks that create these divisions. The top third of the face is bounded by the hairline and the eyebrows. The middle third of the face is bounded by the eyebrows and the nasolabial junction. Finally, the bottom third of the face is bounded by the nasolabial junction and the chin. In order to draw the divisions on a face, we begin by drawing lines across the face at the hairline and at the nasolabial junction. We then draw a line halfway between the hairline and the nasolabial junction which transects the face at the eyebrows. This creates the top and middle thirds of the face. Finally, we draw a fourth at the bottom of the chin. This process divides the face into equal thirds.

In feminine faces, the highest point of the hair line is typically located at the midline as opposed to masculine faces which tend to have a more “M” shaped hairline. The eyebrow arch tends to be higher in feminine faces; as a result, the eyebrow arch will extend further into the top third of the face. In facial feminization surgery, the hairline is typically lowered, and the eyebrow arch is raised. This reduces the size of the forehead and produces a hairline to eyebrow distance that will be 1/3 of the overall face. If the forehead size is reduced too much or too little, the top third of the face will deviate greatly and may produce an undesirable appearance.

As mentioned before, the middle third of the face is bounded by the eyebrows and the nasolabial junction. The size is determined by the location of the nose and  hairline, meaning the top third of the face is intimately related to the size of the middle third. The height of the hairline will ultimately determine the size of both the top and  middle thirds of the face, both of which will be roughly equal in size.

Finally, the bottom third of the face is bounded by the nasolabial junction and the chin. This  is often larger than the top and middle thirds and can be further divided into thirds. If we cut the face where the top and bottom lips meet, the length above the line comprises one third and the length below that line comprises two thirds. Alterations of the upper lip and the chin should consider these established averages. The chin commonly extends past the lower boundary of the bottom third which illustrates the looseness of these aesthetic proportions. These proportions, however, serve as useful guidelines for taking a holistic view of the face.

The vertical fifths serve as guidelines for the location of facial features from left to right as well as facial symmetry. The eyes serve as the basis for delineating vertical fifths and the width of an individual eye indicates the width of each vertical fifth. The width of each eye is expected to be about the same as the distance between the two eyes. The distance between the two eyes is also expected to be the width of the base of the nose. The final two fifths are made up of the space between the eyes and ears. Each of these widths is roughly equal, although deviations are expected.

The divisions of the face into horizontal thirds and vertical fifths serve as a basis for analyzing the face and planning alterations. However, it is important to keep in mind that faces will vary widely and division into thirds and fifths are rough approximations.

Ethnic Considerations:

While most of the information on facial masculinity and femininity is centered around people of Caucasian descent, important differences exist between people of different ethnic backgrounds. People of east asian and african american descent have features that differ from those mentioned previously in this chapter. The nose tends to be a significant point of variation between different ethnicities and will serve as a central point of differentiation in this section.

People of African descent differ from the previously described characteristics in a few notable ways. First, we can consider the top third of the face. A round hairline that is not clearly defined is still considered more feminine in people of African descent, however, the hairline is typically found further back giving the forehead a larger appearance. The forehead itself retains the previously mentioned feminine features. In cis men of African descent, forehead bossing is often more prominent than in people cis men of Caucasian descent. Horizontal thirds and vertical fifth proportions mentioned earlier also vary in people of African descent. The middle third of the face tends to be smaller than the bottom and top third. The bottom and top thirds, however, remain equal to each other. The middle fifth of the face that is made up mostly by the nose also tends to be wider than the other fifths.

The nose has a few differences that are important to point out. In people of African descent, the nose typically has a wide base and dorsum. The tip of the nose tends to be rounder, flatter and less defined, often referred to as a bulbous nose. Overall, the nose takes on a flatter and shorter appearance. At the top of the nose, the nasofrontal angle, which marks the transition from forehead to nose, often measures greater than 130 degrees and tends to be directly between the eyes instead of higher up toward the eyebrows. The nose tends to have less projection with a poorly outlined dorsum, contributing to its flat appearance. The projection of the tip tends to be less than the previously mentioned 2/3 of the nose length. The angle formed by the bottom of the nose and the upper lip is typically less than 90 degrees which makes the nose tip point downward. The septum between the two nostrils, known as the columella, is often retracted and not seen on a front or side profile.

Overall, the midface, the region of the face between the eyes and the border of the top lip, has been described as having decreased projection. The chin has also been described as less prominent and both the top and bottom lips are typically fuller.

People of East Asian descent also differ in some facial features that we will try to specify here. While people of different regions in East Asia have anatomical variation, we will try to provide examples of general differences from people of Caucasian descent that we mentioned before. Beginning in the upper middle third of the face, people of East Asian descent tend to have increased distance between the eyes. This causes the middle fifth of the face to be wider than the other fifths. The jaw is also typically larger and more prominent, which results in increased distance between the left and right jaw angles. The lower third of the face also tends to be smaller than the middle and top thirds of the face, with the middle third of the face being larger than the top third. The forehead also tends to be less prominent than the rest of the face.

The nose tends to be wide along its length and the upper bony part of the nose tends to be shorter. The length of the nose and the tip are typically not well defined. From the side view, the region between the eyes tends to be less prominent or sometimes recessed. The angle that is formed at the junction of the forehead and the nose, the nasofrontal angle, tends to be greater than 130 degrees, making the nose appear flatter. The length of the nose also tends to be shorter with less projection from the face. This gives the nose an overall smaller appearance but the base of the nose is proportionally wider. The angle formed between the bottom of the nose and the upper lip tends to be larger, causing the tip of the nose to point slightly upward. Finally, the region of the face below the nose and above the top lip, the upper lip, also tends to be less prominent on the side profile. This is due to the decreased prominence of the underlying bone called the maxilla, leading to an overall flatter appearing face.

Ethnic differences should be considered when evaluating the masculinity or femininity of a face. This is also important in determining what changes to the face may increase or decrease masculinity or femininity. It is important that we do not define features found in a specific ethnic group as being either strictly masculine or strictly feminine as these features are not always consistent. Overall, a face should be examined in the context of a person’s ethnic background and we should be careful to not impose norms of one specific ethnic group broadly. In general, small and smoother features are considered feminine across different ethnic groups while larger and more angular features are considered more masculine.

Aging and Rejuvenation:

Several facial feminization procedures are identical to procedures used by cis gendered women for facial rejuvenation. As people age, wrinkles become more prominent, lips lose their fullness, and skin loses elasticity causing skin to droop and sag. The face becomes rougher while features such as the eyes, the jawline, the cheeks and the lips lose their definition. These changes cause faces to become more masculine. Therefore, reducing, preventing, or reversing the signs of aging will help to increase the femininity of a face.

Conclusion:

Faces vary widely both between people of different ethnicities and among people of the same ethnicity. Regardless of individual variations, there are general features that are associated with femininity and masculinity. This chapter is intended to serve as a guide for examining the masculinity and femininity of a face. By classifying features as either masculine or feminine, it becomes easier to determine what features someone may want to keep or alter to achieve a specific goal. This chapter may also serve as a basis for analyzing why misgendering may be occurring based on what features a face may possess. There are many ways to make a face appear more feminine or masculine with options including grooming, makeup, medical hormone therapy and surgery. These will be further explored in later chapters, with the concepts described in this section serving as a basis for planning modifications.

Chapter 2: Choosing Your Doctor

Chapter Contributions: Alexander Fang BA; Jennifer Gottfried BS

Introduction

The decision to pursue gender affirming surgical care is a highly personal choice in a transgender patient’s healthcare journey. Gender affirmation is an individualized journey that will look different for every patient, and surgery is not always a necessary part of the transition process. For patients who desire gender affirming surgery or are contemplating their options, finding and choosing a surgeon can be daunting. Most transgender patients rely on word of mouth recommendations and online searches to find LGBTQ+ friendly healthcare.1 In this chapter, we will discuss the process of finding and choosing a surgeon, covering topics such as questions to ask the surgeon, what to look for in a surgeon, and resources for finding transgender care centers in the U.S. with a special focus on the tristate area (New York, New Jersey and Connecticut). The goal is to provide patients with a starting point in the process of finding a surgeon and other transgender health services. By the end of the chapter, we hope that readers will feel more confident in beginning their search for gender affirming treatment and the options available for healthcare.

Finding LGBTQ+ Friendly Healthcare Providers

The most common methods of finding healthcare providers that are not only allies, but also knowledgeable in LGBTQ+ specific healthcare, include word of mouth and online resources.1 Many patients are able to locate transgender care centers via recommendations from others in the community. This applies to trusted primary care providers as well. If the patient has a doctor who they see regularly and feel comfortable with, the patient can ask that provider for recommendations for specialist services. There are also many online resources that can help a patient find an LGBTQ+ friendly provider. Below is a list of online resources to help find LGBTQ+ friendly providers and services nationwide:

  • Gay and Lesbian Medical Association (GLMA) provider directory
  • CenterLink LGBT Community Center Member Directory
  • World Professional Association for Transgender Health (WPATH) provider directory
  • Care Dash
  • National LGBT Chamber of Commerce (NGLCC) affiliate chambers
  • Out2Enroll health insurance coverage options
  • One Medical LGBTQ+ providers
  • The Trevor Project mental health support
  • Center for Disease Control and Prevention (CDC) health clinics by state
  • org provider search engine
  • com

Below is a list of Facebook and Reddit groups where you can share stories, find photos and resources and have an open discussion with regarding FFS (some Facebook groups are private and permission may need to be requested to join):

Considerations When Choosing a Surgeon

There are many considerations when choosing a surgeon to perform gender-affirming operations. This section will discuss three major topics you should take into account when beginning your search for a surgeon.

The first consideration is that of the location of the surgeon, including their office and where they perform the surgery. This may seem like an obvious first step, but ensuring that the surgeon’s office is accessible to the patient is very important for an optimal surgical experience. Many patients travel throughout the US, many even travel internationally looking for what they consider to be the “best” surgeon available. However, since the surgeries desired often require several stages of operations and occasionally need revision surgeries, you should look for a surgeon that you can easily communicate with in order to clearly set expectations, predict results and discuss problems.

In addition, you will most likely need someone to take you home after you leave the hospital. When choosing a surgeon, you should ensure that you will be able to get to and from the office. This may mean choosing an office close enough to call a taxi or rideshare, or communicating with friends and family about rides. If you are concerned about transportation, particularly following the procedure, be sure to ask the surgeon what options their office provides in regard to postoperative transportation.  Many patients visiting from out of town set up long term stays or rentals.  It would be smart to plan on seeing your surgeon at least twice postoperatively before traveling back. Most surgeons try to see their post-operative patients within 3-7 days after discharge and again 1-2 weeks later. 

Second, you will want to ensure that you are going to an LGBTQ+ friendly office. There are a few steps you can take after finding a provider you think is LGBTQ+ friendly to confirm that the providers have sufficient supportive knowledge and have taken steps to create a safe environment for their patients. First, you should read reviews written about the office and provider to see if other LGBTQ+ patients have had a positive experience with this provider. Next, you should read through the website affiliated with the office to see if there is non-inclusive, gendered language. The website may also reveal LGBTQ+ service awards that can reaffirm the provider’s claims about being a safe provider. Third, many offices will have you fill out paperwork before the first appointment, either online or to bring in person. Check to see if the intake forms are transgender-friendly and make it easy for you to communicate your preferred pronouns, gender identity, and preferred name. If you are still concerned after taking these steps, it is never a bad idea to call the front desk. Below are some questions that might help confirm the office’s inclusivity:

  • What are the nondiscrimination policies in place at this office?
  • How often does the doctor treat LGBTQ+ patients?
  • Are there employees who identify themselves with the LGBTQ+ community?
  • When was the last time staff participated in LGBTQ+ healthcare-specific training?

The final major consideration when choosing a surgeon is that of insurance coverage. A considerable barrier to finding LGBTQ+ supportive healthcare is the constraints placed upon patients by insurance. With that in mind, ensure that a provider will take your insurance before committing to appointments or procedures. This should be a significant consideration when choosing a provider. Have the office contact your insurance company to confirm coverage or call your insurance company directly to ask for a list of surgeons who participate with your plan.

What to Look for in a Surgeon

This section discusses general qualities a patient should look for in their search for a surgeon. Topics include trusted referrals, board certification, specialization, insurance coverage, and bedside manner. We will explain important overarching themes regarding what to look for in a surgeon, and the next section will provide specific questions that will help patients assess these qualities.

If you are under the care of a primary care physician who you trust and feel comfortable with, begin by asking for a referral for a gender-affirming surgeon. Referrals serve as a form of endorsement from your provider that a surgeon has a good track record with other patients seeking the same procedure. You should also ask the provider why they are recommending this surgeon. The physician should be recommending a surgeon based on skill and positive patient outcomes, not because they are in the same medical group, or simply because they accept your insurance. While insurance coverage is important in finding a surgeon, it should not be the primary or only reason for referral.

Board Certification is an essential quality for a surgeon before choosing them to perform a procedure. Ensure that the surgeon is board certified in plastic surgery. While this may seem like a simple step, it is important to ensure that the surgeon is board certified in the specialty the patient is looking for. Most gender-affirming surgeries fall under the umbrella of plastic and reconstructive surgery. In facial feminization surgery, a fellowship in craniofacial surgery is ideal as these surgeons have performed specific subspecialized training in altering the facial skeleton and soft tissues of the face and neck. 

In addition to board certification, look for a surgeon that has performed the procedure you are seeking for many years. They should have numerous photos of their outcomes to show you, and should be able to tell you their rates of serious complications.There are many surgeons who perform only one or a handful of very specific procedures, sometimes called “super” specialization. Find a surgeon who specializes in the procedure you are seeking. Performing the procedure multiple times is often associated with better outcomes. 

Ideally, the surgeon you choose should accept your insurance. Ensure that they have clear materials explaining the full costs of the procedure, any additional fees, and what you will have to pay out of pocket. Many offices offer financial services to help you establish a payment plan with additional resources for payment assistance.

Next, you should evaluate the bedside manner of the surgeon. In other words, how do they treat you during the consultation? The surgeon should be comfortable with answering all of your questions, and should be able to answer them in a way that is easy to understand. During the consultation you should not feel rushed. Instead, they should take the time to fully explain the procedure to you from start to finish.  Try to understand how easy it will be to communicate with the surgeon and the office. Is there a patient navigator you can call directly?

Finally, remember that comfort with the surgeon is an important consideration. If following a consultation you do not feel confident in the surgeon, you should schedule another consultation with a different practice. It can be easy to get caught up in the excitement of surgical consultations, and you may be tempted to overlook red flags. However, in order to ensure the best possible results, it is important to remember that it is never a bad idea to get a second opinion. The surgeon should be able to provide you with a list of other providers who can offer a second opinion, and should not begrudge you asking them to do so. Surgeons who are offering gender-affirming surgeries should be comfortable engaging with transgender patients, and should put you at ease when you raise potential concerns. Any unprofessional behavior toward you or their coworkers is a red flag you should take seriously. They should have gender-affirming practices implemented in their office that create a positive, respectful environment for you.

Questions All Patients Should Ask When Looking for a Surgeon

This section will address the topics a patient should cover during a consultation appointment after they have located a provider they are considering to be their surgeon. These questions and topics will help you thoroughly vet the surgeon’s experience not only with LGBTQ+ patients, but also with the specific procedure you are seeking. This section will discuss training, experience, procedure preference, photographic examples, and cost. It is our hope that this section will serve as a guide for you during consultations and will ensure you have a thorough understanding of the surgeon so that you can make the best decision for yourself about who to trust with your surgery.

The first topic concerns the surgeon’s training and education. Ensuring the surgeon has the proper education and board certifications is just as important as assessing their training. Many surgeons offering gender affirmation surgeries have received special training in these procedures, and they should be willing and able to explain to you what this training included and how it improved their care for transgender patients. Examples of questions to ask:

  • What are the surgeon’s medical credentials?
  • What are they board-certified in?
  • Do they have specific training in gender-affirming surgeries?

The patient may also want to ask about the surgeon’s experience and specialization in regards to the procedure. Experience is one of the most important factors in finding a surgeon who will provide you with the highest level of care. These questions should enable you to understand the surgeon’s depth of experience in the procedure you are seeking. A good surgeon should be able to confidently tell the patient how many of these types of procedures they have performed, and provide details on their specializations. Surgeons who are highly specialized in one procedure will often have the best outcomes for that procedure, as opposed to surgeons who have a more general scope of surgical practice. Examples of questions to ask:

  • How many procedures have they done?
  • How many gender-affirming procedures do they perform per week?
  • What types of gender-affirming procedures do they specialize in?
  • How long have they been working with transgender patients?
  • Do they primarily work with transgender patients?

There are many different techniques for gender affirming surgeries, and most surgeons have a preference for a specific one. These questions should help you decide if your goals are in line with the techniques the surgeon applies. If the procedure requires an implant or other surgical device insertion, the surgeon should disclose if they have a financial interest in choosing the materials they use. Examples of questions to ask:

  • What technique do they use for the surgery?
  • Why do they prefer this technique over others?
  • What are the risks and benefits of this technique? How do they compare to other techniques?
  • Do they receive any payments from surgical device manufacturers?

Aesthetics matter when considering gender affirming surgery. Asking the surgeon for photos of past procedures will help you decide if the procedures they completed in the past match the goals you have for yourself. An experienced surgeon should have many before and after photographs to show you, and a lack of photographic examples should be considered a red flag. Examples of questions to ask:

  • Do they have photographs of completed procedures they can show you?
  • How many examples do they have?

While previously mentioned in an earlier section, it is worth reiterating that you should ask many questions about the procedure and cost. Not all surgeons and care centers accept the same insurance carriers, and not all insurance companies cover gender affirmation surgeries. Ensure that the surgeon’s office can assist with financial health surrounding the procedures. Examples of questions to ask:

  • What types of insurance do they accept?
  • Does their office have a successful track record of getting pre-authorization for insurance coverage on this procedure?
  • What is the total cost of the procedure?
  • Does the cost include post-op appointments and any equipment?
  • What options do they offer patients without insurance (or whose insurance does not cover the procedure)?
  • Do they accept medical financing?

During the consultation, you should not only ask questions to see if the surgeon is the right fit, but also ask about the procedure itself to ensure that you have a full understanding of the pre-operative, operative, and post-operative components. Below is a list of frequently asked questions about procedures that will help you gain insight into the process. The surgeon should have educational material to provide you about the procedure.

At this point it is likely that you have researched the procedure thoroughly, but asking these questions will ensure you have a complete understanding of the procedure. Fully informed patients can make better decisions for themselves, and make the surgical experience run more smoothly for everyone. Below are questions about the operation that you should ask:

  • What do I need to do to prepare for the surgery?
  • What kind of anesthesia will be used?
  • How long will the procedure take?
  • What are the risks associated with this procedure?
  • What complications might develop?

Questions regarding the period after the procedure can be as important as questions about the procedure itself. You should ensure that you have a good understanding of the care you will need following the procedure, as well as what the surgeon’s office will provide you in terms of post-op care. Examples of questions to ask:

  • How long will I have to remain in the hospital following the procedure?
  • How will I feel after surgery?
  • How much pain should I expect to be in following surgery and how is this managed?
  • How long will it take to recover from surgery?
  • How much time off will I need from work to recover?
  • When can I resume normal activities following surgery?
  • Will I be able to care for myself when I get home, or do I need someone to help me afterwards?
  • When/how often do I need to follow up with the doctor after surgery?

Local Transgender Care Centers

Finding comprehensive transgender care can be a daunting task. This section hopes to provide a starting point and guidance for finding gender affirming healthcare in the tristate area. The first section of this chapter provided a list of resources for locating care nationwide. The care centers below offer a wide variety of services ranging from primary care, mental health services, and HIV/STD screening and treatment to hormone therapy and gender-affirming surgeries.

Locally, many of the major hospital systems in each state have LGBTQ centers offering specialized care to patients in the community. Options for care are listed on their websites. Local Planned Parenthood programs often offer comprehensive transgender care, and can refer patients to additional local services. Some Planned Parenthood locations provide the full spectrum of care, including hormone therapy and surgical care. If they do not have surgical options, they can refer you to local surgeons and practices who have experience treating transgender and nonbinary patients. It is important to remember that not all care centers provide comprehensive care, so make sure to search for one that provides the services you are looking for.

Below is a list of transgender health centers in the tristate area with a breakdown by state. If there does not appear to be a care center nearby, contact the closest center and ask them for a referral to a provider in your area. They should be able to help you find a local provider if  one is available.

  • New York
    • NYC
      • APICHA Community Health center
        • Services: Transgender health clinic, hormone therapy, HIV and STD testing and treatment, support groups, mental health services
      • Beth Israel Medical Center – LGBT Health Services
        • Services: Comprehensive primary care, hormone therapy and urgent care
      • Peter Kruger Clinic (Health care for people living with HIV)
        • Services: Primary care, hormone therapy, HIV care, mental health services
      • Callen-Lorde Community Health Center
        • Services: Sexual health care, hormone therapy, HIV testing, primary care, emergency PEP for HIV exposure, case management
      • Community Healthcare Network
        • Services: Transgender health programs, HIV care, mental health, support groups, dentistry
      • Housing Works
        • Services: Medical and dental care, clean syringes, substance use, mental health, support groups
      • Metropolitan Hospital Center – Comprehensive LGBT Health Center
        • Services: Comprehensive primary care, pediatric/young adult care, mental health and support groups, HIV and STD screening and treatment
      • Mount Sinai – Center for Transgender Medicine and Surgery
        • Services: Comprehensive primary care, hormone therapy, surgical care
      • Mount Sinai – Peter Krueger Clinic (Health care for people living with HIV)
        • Services: Primary care, hormone therapy, HIV care, mental health services
      • Northwell Health – Center for Transgender Care
        • Services: Primary care, immunization, HIV prevention and treatment, STD screening and treatment, hormone therapy, mental health, surgical care (plastic surgery, breast surgery, and urological care)
      • NYU Langone – Transgender Health
        • Services: Surgical care, hormone therapy, rehabilitation care (physical therapy), mental health services, adolescent care
      • More resources for the NYC area:
        • NYC Health: Resources for transgender and gender nonconforming people
      • Upstate NY
        • Oneonta
          • Gender Wellness Center – Transgender Health Services
            • Services: Hormone therapy, mental health services, surgical services, primary care (adolescents and adults)
          • Albany
            • The Plastic Surgery Group – Jeffrey Rockmore, M.D.
              • Services: Facial rejuvenation, breast enhancement, body contouring, cosmetic and reconstructive surgery
            • The Endocrine Group – Robert Busch, M.D.
              • Services: Hormone therapy
            • Albany Medical Center Endocrinology Group – Erik Cohen, M.D., Matthew Leinung, M.D.
              • Services: Hormone therapy
            • Prime Care Internal Medicine – Frank Fera, M.D.
              • Services: Primary care
            • Upstate Urology – James Barada, M.D.
              • Services: Urology
            • Rochester
              • Trillium Health – Trans Center of Excellence
                • Services: Primary care, supportive services (financial assistance, temporary housing, transportation), hormone therapy, STD screening and treatment, pelvic health, mental health services, support groups
              • Rochester Center for Sexual Wellness
                • Services: Mental health services, support groups, name and gender marker change assistance, medication management, STI testing, referrals to surgeons for gender affirming surgeries
              • Rochester Regional Health – Diabetes & Endocrinology
                • Services: Hormone therapy and referrals to surgeons for gender affirming surgeries
              • University of Rochester Medical Center
                • Services: Comprehensive care (adolescent and adult)
              • Highland Hospital – Jeffrey Gusenoff, M.D.
                • Services: Weight loss plastic surgery and breast augmentation
              • Syracuse
                • LGBTQ+ Primary Care at SUNY Upstate
                  • Services: Primary care, hormone therapy, PREP and HIV care, mental health services, gyn/pelvic exams, support services
                • University Internists
                  • Services: Primary care
                • Upstate University Hospital – Karen Teelin, M.D.
                  • Services: Primary care (adolescent), hormone therapy
                • CNY Cosmetic & Reconstructive Surgery
                  • Services: FTM mastectomy, MTF breast augmentation, facial contouring, body contouring
                • Buffalo
                  • Evergreen Health
                    • Services: Primary care, medical case management, hormone therapy, STD screening and treatment, referrals for pelvic health, PrEP, mental health care and surgical care
                  • Pride Center of Western NY
                    • Services: Hormone therapy, pelvic care, STD screening and treatment, counseling, referrals to primary care
                  • Erie County Medical Center
                    • Services: HIV/AIDS care, plastic & reconstructive surgery, primary care, mental health services (including urgent care)
                  • Buffalo Women Services
                    • Services: Gynecologic care for LGBTQ patients, hormone therapy
  • Connecticut
    • UConn Health
      • Services: Hormone therapy, surgical care, pelvic physical therapy, voice therapy
    • Middlesex Health
      • Services: Primary care, hormone therapy, surgical care
    • Wheeler Clinic
      • Services: Primary care, hormone therapy, dental care, behavioral health, medication-assisted treatment, prevention & recovery services
    • Gender and Life-Affirming Medicine (GLAM) Center at Anchor Health Initiative
      • Services: Primary care, hormone therapy
    • Hartford Gay & Lesbian Health Collective
      • Services: STD testing & treatment (including HIV), dental care, breast & pelvic exams, LGBTQ+ friendly medical and behavioral health referrals
    • Anchor Health Initiative
      • Services: Primary care, HIV/AIDS care, hepatitis C management
  • New Jersey
    • Rutgers Center for Transgender Health
      • Services: Full spectrum of medical and surgical care for transgender and non-binary patients
    • Robert Wood Johnson University Hospital – PROUD Gender Center
      • Services: Primary care, surgical care, facial feminization and masculinization surgery, hormone therapy, gynecology/urology, voice training, referral to behavioral and mental health care
    • Bergen New Bridge Medical Center
      • Services: Primary care, hormone therapy, surgical care, behavioral health services, PrEP, HIV/STD screening & treatment, OB/GYN services, specialty referrals, immunizations, preventative care services, and social work
    • University Hospital – Newark
      • Services: Primary care, hormone therapy, surgical care, and referrals
    • Alliance Community Healthcare – Jersey City
      • Services: Hormone therapy, behavioral health, HIV care, artificial insemination, referrals for surgical care

Chapter 2 Citations:

  1. Kassel G. Tips for finding a healthcare provider who’s an LGBTQ+ ally. Healthline. https://www.healthline.com/health/mental-health/find-lgbtq-ally-health-provider#Intro. Published May 17, 2019. Accessed October 10, 2021

Chapter 3: Preparing For Facial Feminization

Chapter Contributions: Robin Rivera FNP-BC

Preparation for Facial Feminization Surgery

Treating Gender Dysphoria is typically conducted via three separate methods: hormonal therapy, psychotherapy and surgery. Though early methods had traditionally focused on sex-reassignment as the main form of gender reassignment, recent studies have shown that a combination of hormone and surgical interventions may be necessary to ease gender dysphoria in many patients.1,2 However, there are still patients who may only require one intervention and therefore, the treatment of gender dysphoria must be made by a team of different specialists, spanning many different medical fields.3 The World Professional Association of Transgender Health (WPATH) outlines the guidelines for treatment of gender dysphoria as follows: mental health assessment, hormonal therapy referral and surgical intervention referral.4

Transgender women identify as women but may have a masculine appearance. The main goal of facial feminization surgery (FFS) is to make the patient’s masculine features more feminine (see Chapter 1). The outcomes of this type of surgery may be incredibly comforting to MTF patients and aid in both affirming self-identity as well as easing societal concerns.5

Mental Health Assessment

Before a patient may be referred to hormonal or surgical intervention, a mental health assessment must be conducted by a trained professional in psychiatry, psychology, social work, nursing, marriage and family counseling, or mental health counseling to confirm the diagnosis. The mental health professional should have, at minimum, a master’s degree or equivalent in clinical behavioral science with documented licensing, the ability to distinguish gender dysphoria from other coexisting mental health concerns, and the competence and supervised training in counseling and continuing education training on the treatment of gender dysphoria.4

Gender dysphoria diagnoses must meet the criteria established in the DSM-V. The role of the mental health professional is to continually assess the transgender patient, and counsel patients considering hormone therapy and/or surgical intervention to ensure they are prepared and have made a fully informed decision with realistic expectations of postsurgical outcomes.3

Hormone Therapy

Following the mental health assessment, the criteria for a hormone therapy referral are as follows:

  1. Patient has well-documented and continual gender dysphoria
  2. Patient has reached age of majority for their location
  3. Patient is able to make a fully informed decision and give consent for treatment
  4. Any other health concerns, if present, must be well-controlled

Since feminizing hormone therapy creates physical changes to the patient that are more in line with their gender identity, it is important to consider this prior to planning any FFS procedures. Many changes induced by feminization hormones take up to 2 years to manifest and such changes can eventually become permanent. For transgender women, hormone therapy alone can potentially cause breast growth, decreased erections, decreased testicular size and increased body fat content (see Table 3.1).6

Figure 3.1. Feminizing effects in MTF transsexual persons as a result of hormone therapy

EffectOnsetMaximum
Redistribution of body fat3-6 months2-3 years
Decreased strength/muscle mass3-6 months1-2 years
Decreased oiliness and skin softening3-6 months 
Decreased libido1-3 months1-2 years
Decreased erections1-3 months3-6 months
Male sexual dysfunctionVariesVaries
Breast growth3-6 months2-3 years
Decreased testicular size3-6 months2-3 years
Decreased sperm productionVaries>3 years
Decreased body hair growth6-12 months>3 years
Scalp hair/baldnessNo regrowth, loss of hair stops 1-3 months1-2 years

Though there are no hard set criteria that are specified for duration of hormone therapy prior to non-genital surgical intervention, it is typically recommended that patients undergo hormone therapy as well as hair removal for a minimum of 12 months prior to surgery in order to allow the hormones to achieve their expected and intended feminization results. In addition, the WPATH does not require that patients live in their identified gender role for 12 months prior to non-genital surgical interventions, but it is recommended in order for the patient to be accustomed to the day-to-day lifestyle changes that come with gender affirmation surgery.

Referral to Surgery

Surgery is typically the last intervention in the treatment of gender dysphoria. Though some patients may successfully feel comfortable in their gender identity without the use of surgical interventions, others find that surgery is necessary for alleviating their gender dysphoria symptoms. Studies have demonstrated that gender affirmation surgical intervention in MTF patients can improve sexual function and overall sense of comfort for patients.8,9

Prior to receiving any surgical treatment for gender dysphoria, a patient must have 1-2 referrals from licensed mental health professionals, depending on the intervention. These referral letters should document the patient’s treatment history, progress of the condition and treatment and the patient’s eligibility for the given procedure. Though the WPATH has outlined letter criteria for breast and genital surgeries, they do not have specific criteria for FFS procedures.4

Insurance

A large consideration when seeking surgical intervention is the cost of the procedure. As FFS procedures can vary based on individual patient needs, the financing of the surgeries also varies.There are many different approaches and techniques in facial feminization, with some taking longer and utilizing different materials than others; all of these variables factor into the differing costs. After the patient consults with a surgeon and discusses their desired outcomes and needs, the surgeon is able to make a recommendation and give an estimate of cost.10

In general, many FFS procedures are not covered by insurance. In a recent study on national variation of insurance coverage for FFS, it was found that, when looking at the top three commercial health plans per state, only 27 of 150 held beneficial policies for FFS. These beneficial policies typically covered chondrolaryngoplasty and 78% of these policies offered preauthorization. These more favorable insurance policies were typically in states with more legal support for transgender individuals. In more restrictive states, the policies were less favorable.11 There are insurance policies favorable to providing FFS surgery; it is important to identify these plans (both commercial and medicaid) in your state. Some national corporations offer insurance that covers FFS to all of their employees. 

 If FFS is not covered, patients should expect considerable out-of-pocket costs. The number of procedures decided upon between the patient and their plastic surgeon play a significant role in potentially increased charges, with increased procedure times further increasing anesthesiology and outpatient center costs. Other costs, such as special implants, can also increase the final amount that the patient will need to pay. Lastly, the patient may have to take into account any personal costs, such as those accrued from travel and accommodations for the procedure.10

Summary

FFS procedures are an important step in many patients’ gender affirmation. However, once a patient is diagnosed with gender dysmorphia, it is still quite a process to get referred to surgery.3 Before surgery can be recommended, patients must first receive a confirmed diagnosis and undergo mental health evaluations with proper documentation and letters. They should complete hormone therapy and live in their chosen gender identity for a recommended period of 12 months. Once these steps have occurred, they can begin conversations with their surgeon about recommended surgical routes for the desired outcomes. Once a surgery has been conducted, the patient should continue to follow up with both the surgeon and their mental health professional.  Certain insurances will cover most FFS procedures, but this may vary state to state. Check with your provider in advance and potentially seek to change insurance plans to a more favorable one prior to undergoing FFS.

Chapter 3 References

  1. Green Richard M.D., J.D. & Davis T. Fleming B.A. (1990) Transsexual Surgery Follow-Up: Status in the 1990s, Annual Review of Sex Research, 1:1, 163-174, DOI: 10.1080/10532528.1990.10559859
  2. Benjamin H. The transsexual phenomenon*. Transactions of the New York Academy of Sciences. 1967;29(4 Series II):428-430. doi:10.1111/j.2164-0947.1967.tb02273.x 
  3. Pittman TA, Economides JM. Preparing for facial feminization surgery. Facial Plastic Surgery Clinics of North America. 2019;27(2):191-197. doi:10.1016/j.fsc.2018.12.002 
  4. Coleman E, Botzer M, Bockting W. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. Minneapolis, MN: World Professional Association for Transgender Health; 2012. 
  5. Spiegel JH. Facial feminization for the transgender patient. Journal of Craniofacial Surgery. 2019;30(5):1399-1402. doi:10.1097/scs.0000000000005645 
  6. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons:an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2009;94(9):3132-3154. doi:10.1210/jc.2009-0345 
  7. Hage JJ, Karim RB. Ought Gidnos get nought? treatment options for nontranssexual gender dysphoria. Plastic & Reconstructive Surgery. 2000;105(3):1222. doi:10.1097/00006534-200003000-00063 
  8. De Cuypere G, TSjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Archives of Sexual Behavior. 2005;34(6):679-690. doi:10.1007/s10508-005-7926-5 
  9. Gijs L & Brewaeys A. Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges. Annual Review of Sex Research. 2007;18:1, 178-224, DOI: 10.1080/10532528.2007.10559851
  10. Ousterhout DKM. Facial Feminization Surgery: A Guide for the Transgendered Woman. Omaha, NE: Addicus Books; 2010. 
  11. Gadkaree SK, DeVore EK, Richburg K, et al. National variation of insurance coverage for gender-affirming facial feminization surgery. Facial Plastic Surgery & Aesthetic Medicine. 2021;23(4):270-277. doi:10.1089/fpsam.2020.0226

Chapter 4: Surgical Procedures Offered For Facial Feminization

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 is best performed by a specialist familiar with working on these complex areas. As highlighted above, there are many differences in the facial structures between a masculine and a feminine face. All of these elements must be taken into account during surgery to obtain the best results.    

Adam’s Apple Reduction (Tracheal Shave)

During puberty, the cartilage of the larynx grows prominent, particularly in cis-males. The growth appears to be directly correlated to the person’s testosterone levels and a full prominence is considered to be a classical masculine feature. This could be an area of significant dysphoria for transgender patients, especially from the side (profile) views. 

Above the trachea (windpipe) is the thyroid cartilage, the prominence which creates the “Adam’s apple”. This can be accessed and reduced via a stealth incision hidden under the chin. Scars directly over the thyroid cartilage are noticeable and should be avoided by your surgeon. The surgeon will begin by tunneling down to the area; the associated muscles are dissected and pushed to the side, exposing the laryngeal prominence. After exposure, the cartilage is shaved using either a surgical blade or a burr if the cartilage is calcified. Excessive resection of the cartilage can destabilize the underlying vocal cords which attach from the inside of the throat on the back surface of the cartilage, therefore resection must be done safely and cautiously. Some voice surgeons combine this surgery with vocal cord surgery so they can reduce the prominence while directly looking at the cords with a specialized camera. Swelling of the area can persist up to 4-6 weeks after this procedure. You may experience some soreness with swallowing during this postoperative period. Professional and semi-professional singers should be cautious with this operation and would definitely benefit from the added procedure of laryngoscopy (camera visualization) at the time of reduction to maximize visualization of the vocal cords, ensuring optimal safety.

Brow Lift (Browplasty)

Brow lifting is an essential part of forehead feminization and should not be overlooked when choosing feminization procedures.  Feminine eyebrows tend to sit higher on the face (above the orbital bone) with a slight arch on the sides. If combined with forehead reduction, the brows can be dissected and freed from the underlying bone of the orbital rim and temporal area. Removing excess skin in the widow’s peak portion of the scalp tends to allow surgeons to purposefully elevate the brows in addition to advancing the hairline. Stitches can be placed in brow soft tissue to achieve preferential lateral brow elevation, while resuspending areas directly to the scalp muscles. If a lateral brow lift is desired without forehead reduction, stealth incisions can be made in the temporal area (widow’s peak area) and eyelids to directly lift the brow without the entire coronal (ear to ear) incision. 

Cheek Enhancement (Augmentation & Reduction)

Depending on the current appearance of your cheeks, they can either be enhanced to create a more full shape, or reduced to create a more narrow width. Augmentation is commonly accomplished via implants, soft tissue grafts (fat or dermal-fascia) or silicone injections. When implants are chosen, an incision inside the mouth can be used to place the implants on the facial bones (zygoma). Screws are often placed to fixate the implant into the bones so they don’t rotate or migrate over time.  

Grafts can be used to augment the soft tissue portion of the cheek via tiny stealth incisions. Fat is harvested from around the belly or thigh, processed and then re-injected into the desired areas. The Coleman technique is often used, where surgeons meticulously inject very small volumes (0.1ml) per pass of the cannula over the cheek with an average of 3-5ml of fat injected per side. For reference, one syringe of cheek filler (hyaluronic acid) in the office is 1 ml of volume. 

A downside to fat grafting is that not all of the fat will be incorporated into the tissue. Our data suggests only 50-70% of fat grafted will remain after 1-2 months. Many patients will require a second or even third round of fat grafting to achieve maximum volumization of their cheeks. Procedures are often spaced 2-4 months apart and surgeons account for this by often overcorrecting with their injections so that the desired volume is achieved. That being said, building optimal volume will still require additional injections since surgeons  have to build upon the fat that has been incorporated.

Implants can be customized, 3D printed, or molded and placed on top of the cheek bones through an incision in the mouth. We suggest fixating it to the bone using screws, as the implant can migrate and create fullness in the less-desired area of the cheek. A higher risk of infection and migration make implants a less common choice than fat grafting.

Chin Recontouring (Genioplasty)

Depending on the specific shape of your chin, recontouring can include reducing, reshaping, or augmenting the shape and size of the chin. An incision is made within the mouth to facilitate dissection and exposure of the chin. The mentalis muscles (elevators of the lower lip) are divided and sometimes thinned to allow better contour of the chin. There are a pair of nerves called the mental nerves that give sensation to the lower lip; these nerves must be protected during  exposure and dissection of the chin. Surgeons cut the mandible at least 5 mm below the opening where the nerve emerges from within the skull in order to protect these sensory nerves from damage.

The overall height and width of the chin is longer and wider in males and the genioplasty planning should account for the individual differences found in your anatomy. A chin implant alone only treats a recessed chin by adding volume. Osseous genioplasty allows the surgeon to physically shape the bone and remodel it into your desired form. Often a width reduction of 6-10 mm is performed by removing the central chin segment and bringing the bone edges together. Sliding the segments upward along the bone can reduce the overall height of the chin as well as improve chin projection. A chin that projects well gives our patients a side benefit of adding more definition to the shape of the neck. 

Many surgeons now use 3D imaging technology to coordinate planning via a CAD/CAM design which facilitates 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. Permanent titanium screws and plates are used to maintain and establish the newly constructed chin architecture.  These screws are not visually apparent 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 followed by placement of dissolvable stitches 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 appearance. The skin and fat can be reduced and or repositioned to help improve the overall look of the eye. Incisions can be created in the sulcus (the line that is only visible when your eye is closed) ensuring any scars will remain well hidden when your eye is open. The excess skin is removed, reducing skin hooding and creating a clean, sharp eye line. 

Some patients desire a change in the shape of the eyelid. The angle of the corner of the eye can be resuspended in a canthoplasty procedure, resulting in the desired “cat eye”. The canthus (side area where the upper and lower eyelids meet) can be elevated in a higher position creating an oblique almond shaped appearance. The scars for this are hidden in the crows feet resulting in immediate improvement with minimal exposure of any scar. 

Facelift/Neck Lift

Sagging skin of the neck and face can be a source of dysphoria for many of our patients and is also an unfortunate result of aging. A youthful, feminine face has fullness on the side cheeks without deep smile lines. 

A facelift involves elevating the soft tissues and resuspending them in a more youthful “upward” feminine position. In addition, excess skin can be removed, and the folds and jowl can be softened. The incisions are hidden in the shadows of the face around the ear. A neck lift is often combined with the facelift in order to perfect the contour of both the upper and lower parts of the face. For a neck lift, an incision under the chin can be used to allow the surgeon to contour the neck; excess fat can be removed under the neck muscles (platysma) through this incision. Sutures can also be used to tighten the neck muscles, further adding neck definition. 

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 scars hidden at the bottom or behind the ears. This can also easily be done in the office under local anesthesia. You may need to have your ears pierced again after this procedure.

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 patients, particularly when viewed from the side profile. Masculine foreheads are more convex and have prominent orbital rims with bulging frontal sinuses. The surgeon must effectively address all of these characteristics to create a soft, feminine profile.

Frontal sinus

The frontal sinus is the area directly above and directly between your eyes. As we grow older, this part of the skull fills with air and mucosa. Masculine frontal sinuses are 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 the anterior table is the air and mucosa filled sinus which drains 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 is to create an almost vertical line from the base of the bridge of the nose towards the scalp. This can be accomplished by either burring down (type 2 setback) the  prominent bone of the anterior table, or by setting the bone back further into the sinus cavity (type 3 setback). 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 of the anterior table and you should ask if they routinely do this. A type 3 setback involves the temporary removal of the entire anterior table bone; once separated, the surgeon begins remodeling it from the inner side with the high speed burr. Then the surgeon reduces the frontal sinus septum, the bone that separated the conjoined right and left sinus sides internally, and then fixes it back onto the forehead in a setback position. We recommend that your surgeon uses a resorbable plate that will dissolve over the course of 1-2 years rather than a permanent titanium plate which may be visible over time underneath the thin skin of the forehead. 

Orbital Rims

The top 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 feminine anatomy. After exposing the area through the incision described above, we can soften these features using a high speed burr, thus allowing us to sculpt your desired look. The orbital rim is vertically elevated on the side by removing the bone that hangs over in this area; the convexity is similarly flattened over the top part of the bone. These changes are immediately appreciated postoperatively and are especially visible from the side profile. 

Frontal bone

Some patients have a full, convex middle forehead that would benefit from frontal bone remodeling. Using a high speed burr, the prominent portions of the frontal bone can be flattened to reduce the middle forehead bulging and soften the appearance of this part of the forehead. 

Hairline advancement

The approach to forehead remodeling requires a long incision for adequate 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 result is a shorter forehead with more hair bearing skin visible from the front and side views.  

The temples are often areas 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 earlier you start, the better protection against hair loss. The widow’s peak area can be improved by advancing the hair bearing skin forward, creating a more youthful and feminine hairline. 

The scalp tissue is very vascular and commonly bleeds. To control bleeding, we often inject adrenaline prior to making incisions. This allows the blood vessels to constrict 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 skin on your scalp is also typically tight. Try to pinch the skin of your scalp together to realize this level of tightness. The scalp skin doesn’t move much and restricts how far we can lower the forehead. The deeper scalp tissue however, once released, can allow for more forward movement, particularly in the areas over the widow’s 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 for 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. We 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 within the first postoperative week. 

Typically a half to one inch of hairline advancement can be safely accomplished using this technique. The scars are minimized with proper timing of suture/staple removal and non surgical scar treatments such as silicone lotions, steroid injections and lasers where applicable. Massaging the scar may also help reduce scar thickness, so it is important to ask your surgeon when to begin this form of self therapy. If you have a history of keloids, please inform your surgeon as this would need to be addressed with steroid injections at the time of surgery and early on during your 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. We use 3D planning and surgical guides to remove the prominent angles with precision without injuring the sensory nerve that runs near this area, the inferior alveolar nerve. Swelling in this area can persist for 2-3 months; a supportive garment such as a jaw bra may help with contour conforming. 

Some of our patients have fullness in the soft tissue over the lower jaw. The main muscle in this area is the masseter which is responsible for chewing. Botulinum injections (botox) repeated over the course of 12-24 months may reduce the overall volume of these muscles. Up to 50 units per side may be necessary for botox administration. If the temporalis muscles are also injected, twice that amount may be necessary. Overgrowth of these muscles can be due to teeth grinding or clenching and you should see your dentist for a night time splint to further reduce this musculature.

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 or soft tissue. Fat can be removed from your belly area and injected into your lips to act as permanent filler. Fat transfers may partially resorb requiring additional sessions of fat grafting to achieve your exact goal. A fascial soft tissue graft may also be used to add further volume and lip support. A strip of tissue called the deep temporal fascia can be taken from the scalp and inserted into your lips to similarly provide volume. 

Lip Lifts have gained popularity as a way to show more red upper lip (vermillion) along with more central teeth. A shorter distance from the base of the nose to the start of the upper lip is considered a classically feminine trait. A bullhorn incision is created in the creases of the nose, and upper lip skin is removed which raises the underlying lip. A shorter upper lip is considered a hallmark of youthfulness since as we age, this distance naturally lengthens. Upper lip lifts can also be performed in the office under local anesthesia as a secondary or tertiary facial feminization procedure. If you already are showing too much of your teeth, a V-Y advancement may be a better alternative. The lip is lifted out from the inside rather than from above so as to only show more lip and not more teeth.

Neck Fat Removal

A droopy, poorly defined neck can be an area of major dysphoria for our patients.  Depending on one’s specific issue, 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. Most of the fat, however, may lie under the neck muscles (the platysma) and a direct approach for fat removal is often combined with liposuction in these cases.

Rhinoplasty (Nasal Surgery)

The nose is the center of the face and is often an area of dysphoria for patients. A masculine nose is often larger, broader, less rotated and has 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 beak like bone during surgery. The nasal bridge can also be lowered to create a more delicate appearing nose. Through either a closed approach, where all incisions are inside your nose, or open approach where a small incision is made under your nose, a rasp can be inserted to file down the excess and prominent bone. If a larger reduction is needed, your nose may have to be broken from the sides (low osteotomy) to improve the pyramidal shape after shaving.

Nasal Tip

The tip of the nose is composed entirely of cartilage and soft tissue. The cartilages can be shaved to create less bulk and also redirected and reshaped using suture techniques.  Excess soft tissue may be debulked to further show definition. Cartilage grafts are often required to help add structural support as well as additional projection to  create a smaller, more defined tip. Cartilage can be obtained from your septum, the harder tissue that separates the left and right nostril cavity. However, if not enough cartilage is  obtained, cartilage can be used from cadavers without any significant immunoreactivity.

Nasal Bone Osteotomies

The nasal bones can be brought closer together by 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. You will need to wear a splint or cast during at least a 4-7 day healing period. You may have temporary bruises around your eyes after this part of the procedure which typically lasts 7-10 days. 

Nostril Show/Alar base reduction

The nostril shape can be reduced and the alar base reshaped to create a more delicate appearing nose and smaller nostrils from a bottom view. This requires an incision around the edge of the nostrils which makes for well hidden scars in the creases of the nostrils.

Revision Surgery

We often see patients that are dissatisfied with their facial feminization results from other surgeons. This may range from complete undercorrection to mild asymmetries. With so many complicated procedures being performed at the same time, it is not unreasonable to expect certain tweaks and necessary adjustments. We encourage surgeons to set realistic goals with their patients and not to overpromise.

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 you can have all the information necessary to determine the best plan of action. Typically you want to wait 6-12 months after your operation to allow swelling to resolve and the full extent of healing to occur. 

Chapter 5: Surgical Recovery Tips

Chapter Contributions: Inkyu Kang BS

Introduction

While undergoing a surgical procedure with substantial recovery time may seem daunting, there are many ways healing can be expedited during your recovery process. In this chapter, we will discuss methods to improve your recovery experience and ultimately give you the tools and knowledge to feel more comfortable during this time. Aspects that will be covered include pain management, infection control, postoperative diet, physical activity after the operation as well as available assistance services. This text is meant to serve as a supportive guide and is in no means a substitute for medical advice. It is of utmost importance in your recovery to strictly follow the guidelines that your doctor provides you after the procedure.

Before discussing the postoperative period, we must begin with the pre-operative timeframe. In order to experience the smoothest recovery, you must be properly informed about the procedure and have realistic goals that are aligned with your surgeon. Based on a variety of factors including age, anatomy, and the procedure performed, each person’s recovery is unique.  Therefore, your doctor will ensure that you are in the required level of physical health prior to performing any operation. They will assess factors in your lifestyle that can contribute to recovery time including smoking or drinking habits as well as perform a physical exam, take bloodwork and review any current medications and allergies you may have.

After these important discussions with your surgeon, planning is essential to ensure sufficient time and support to recover. In order to have a postoperative experience without undue stress, you must finalize plans with work, school and/or caregivers. You should begin planning four to six weeks before the operation to ensure that everything is in order. Once plans are set and the operation is getting closer, you will be given instructions on how to prepare for your procedure. This usually includes absolutely no eating or drinking after midnight the night before your surgery. Some surgeons will have you clean your skin the night before with antibacterial wipes.  A proper dental exam prior to FFS may be helpful if you are undergoing any mandible surgery.  Tooth decay and gingival disease should be addressed before the procedure in order to minimize complications.  Overall, successful communication with your healthcare team and personal planning will help you achieve the best postoperative result. 

Directly After The Operation

Directly after your procedure, you will wake up in the recovery room of the operative facility. The nursing team will be taking care of you as the anesthesia wears off. During this period, you may feel very sleepy and forget details such as speaking with your surgeon after the procedure. You will most likely have to stay overnight in the hospital and so , the nursing team will eventually move you to a hospital room once they feel that you are ready. Recovery rooms usually only allow one visitor when you are fully conscious (30-45 minutes after arrival).  Many surgeons work with their hospitals to get you a private room for your recovery at no additional expense.  Be sure to ask your surgeon about this before the operation.

During this short stay in the hospital and in the 24 hours after your surgery, your healthcare team will want to make sure that you are drinking plenty of fluids and resting to ensure proper recovery. However, they will encourage you to move certain parts of your body and eventually walk with assistance. While it may seem strange to move so early after a surgical procedure, lack of movement in this timeframe may lead to a blood clot. The team will encourage you to move your lower extremities including flexing and extending your feet and bending your knees while sitting upright in bed. Eventually, they will have you  walk with assistance as this will increase blood flow in your legs and prevent blood clots. During the operation, a urinary catheter may be inserted into your bladder through your urethra.  Some burning or discomfort may be felt during the first 24-48hrs after.  If the burning persists or is new onset after this allotted time, consider workup for a urinary tract infection (UTI). Throughout this time, communication with your surgeon as well as the nursing team is essential. Speaking with them about your pain level and discomfort will help ensure you are as comfortable as possible. 

Pain Management

It’s normal to have pain and/or discomfort after your procedure.  Your healthcare team will work with you to provide the best pain control. Pain can be defined as the perceived sensory and emotional reaction to actual or perceived tissue injury. There are two types of pain: nociceptive and inflammatory. Nociceptive pain occurs when nerves around your body are stimulated by damage to tissue. Inflammatory pain involves your body’s immune system interacting with and sensitizing nerves; inflammatory pain is also stimulated by tissue damage. Surgery causes tissue injury that leads to both types of pain and thus, different medications can be used to help in your postoperative recovery period.

The first group of medications include Tylenol, also known as acetaminophen, non-steroidal anti-inflammatories (NSAIDs) and selective COX-2 inhibitors. Tylenol is a medication that works by inhibiting the production of two enzymes that can eventually cause pain and fever in the body. Studies have shown that a single dose of Tylenol postoperatively achieves a 50% reduction in pain. There are different ways that Tylenol can be taken including by mouth, through an IV and rectally. In the first 2-3 days after your procedure, it may be recommended to take Tylenol every 6 hours or as needed to help with your pain. However, there are a few reasons to be careful when taking this medication. If you have liver disease, caution must be taken with Tylenol as it is metabolized by the liver. Additionally, if you are taking cold medications at home, check the label to see if Tylenol is in the product as this may be harmful to combine. Finally, if you have a known allergy to Tylenol, refrain from taking the medication. Overall, a discussion with your physician is necessary to ensure what you are taking for pain is safe and effective for your body.

NSAIDs (Advil, Motrin, Aleve) are a class of medications that also block certain enzymes in the body to help with pain control. NSAIDS work well to reduce inflammation and are often combined with other medications to help reduce the amount of narcotic pain medicines you might need.  However, they have several  side effects that may be dangerous if taken in high doses or for extended periods of time. NSAIDs can cause stomach ulcers and gastrointestinal (GI) bleeding as well as affect the kidneys, especially if they are not fully functioning to begin with. Some surgeons do not like to use NSAIDS because of a higher risk of bleeding, so please speak with your doctor prior to using these medications. 

Selective COX-inhibitors (Celebrex, Vioxx) function similarly to the NSAIDs but only inhibit a specific enzyme in the body that plays an active role in inflammation. These medications carry many similar risks to NSAIDs but don’t have as great of an impact on the gastrointestinal system.

Furthermore, corticosteroids, commonly referred to as steroids, can also be used in the postoperative period. To simplify a very complex mechanism, they decrease your body’s immune  and inflammatory response. They have been shown to reduce postoperative pain and swelling after certain procedures, but need to be carefully monitored as they also have significant side effects. Certain forms of steroids may be injected around the time of the operation. This use has been shown to decrease postoperative pain scores and narcotic usage. An oral form of steroids, known as a Medrol Dosepack, may be prescribed after particular procedures, usually those involving the mouth. Six pills are taken orally on the first day with the dose gradually tapered over each subsequent day.  However, prolonged use of steroids have also been shown to cause delayed wound healing, increased surgical site infections and high blood sugar levels. Therefore, a detailed discussion with your physician is necessary to ensure that this medication is a right choice for you. 

The alpine plant Arnica montana is a homeopathic medication that has been recommended by homeopathic practitioners for treating injuries due to its ability to control bruising, reduce swelling and promote recovery. Certain studies have shown that Arnica montana has antimicrobial and anti-inflammatory properties, although a scientific review of homeopathic Arnica montana papers has shown this evidence of effectiveness to be insufficient.   Despite this, it has been shown that Arnica montana may reduce bruising from rhinoplasty, although further research is needed to determine the clinical benefits. This medication can be purchased over the counter, similar to Tylenol, and may be used in the postoperative period for two weeks. Some physicians recommend taking this medication the day before surgery but please have a careful discussion with your surgeon about the risks and benefits of homeopathic medications before committing to one.

Opioids is a type of medication that has received wide media attention in recent times as it is a very common analgesic used in the healthcare system. Opioids bind to receptors in the brain to modify pain signals and decrease its perception. Well-known opioids include oxycodone and hydrocodone. These medications are typically prescribed for three to seven days after the operation if pain is very severe and not controlled with medications like Tylenol. However, pain is variable among patients, as many may not need any opioid medication at all. While opioids are effective for pain relief, side effects include euphoria, sedation, anorexia and respiratory depression (slowing or stopping of breathing). Additionally, the addictive potentials of these medications are well established with estimates of postoperative chronic opiate use in patients who never took the medication prior to surgery ranging from 5-13%. Opioid medications commonly induce constipation and so, your provider may  prescribe a stool softener, such as Colace, to avoid straining excessively after the surgery. Some opioid prescriptions, such as  Percocet, are combined with Tylenol. Therefore, it is important to not take Tylenol while taking an opiate that also contains this medication. Nevertheless, a proper and safe use of opiate medication is possible after a thorough discussion with your physician. Opioids are usually  dispensed in an oral form to be taken every 3-4 hours as needed after the operation, with instructions to discontinue their use as soon as possible.

Infection Control, Wound Care

It is of utmost importance to do everything possible to prevent infection after your operation. When skin, the natural barrier against outside bacteria, is broken during a surgical procedure, there is an opportunity for germs to invade into the underlying soft tissue. These infections usually occur within 30 days after the surgery and are characterized as a superficial or deep incisional surgical site infection.

As the name implies, superficial infection occurs just in the area of skin where the surgical incision was made. The skin may appear red and tender with some swelling. There is usually no pus associated with superficial infections. A deep incisional infection occurs beneath the incision area in muscle and tissue, and will have a soft, full area with overlying warmth and redness to the skin. Pus may be expressed from the wound edges. Therefore, deep infections should be drained immediately.  While infections can occur in anyone, there are certain risk factors which may predispose individuals to develop infections including age, malnutrition, obesity, diabetes, steroid therapy, chronic inflammation and prior radiation. 

There are certain cardinal signs to look for in the development of an infection. If signs are present, this needs to be communicated with your healthcare team immediately. In all types of surgical site infections, the development of redness, delayed healing, fever greater than 100F or 37.7C, pain, tenderness, warmth and/or swelling may be seen. If you see pus coming from the site of the incision, your surgeon may choose to take a sample of this and see if any bacteria grows in a laboratory socan provide you with the best antibiotic to combat the infection. Deep incisional infections involve a collection of pus that has accumulated in that space, called an abscess, which is composed of tissue that is disintegrating surrounded by inflammation. In all cases of surgical site infection, as stated before, it is imperative that this be communicated with your healthcare team.

However, there are many measures that you can take to help prevent infections from occurring, such as taking medications and applying wound care techniques.  During the postoperative period, you will usually be prescribed an antibiotic in multiple forms to prevent infection at the surgical sites. The first is an oral antibiotic and may either be a penicillin derivative such as Augmentin, a cephalosporin such as Keflex, or an antibiotic known as Clindamycin. These may be prescribed from four to seven days after your operation, to be  taken at various time intervals as prescribed by your doctor. For each specific procedure, however, there are various ways that wounds will need to be dressed and ointments applied in order to maintain an infection-free area.

Depending on what procedures you had performed, there are different recommendations for the best postoperative recovery. In certain procedures, a drain will be placed, often removed prior to discharge. If you have had a scalp advancement, brow lift, or forehead reduction performed, you will wake up with a large dressing on your head. This will be removed on the first or second postoperative day.  Subsequent caring for this wound will be of utmost importance, starting with a gentle wash of the incision area once or twice a day using mild soap and water. Application of an antibiotic ointment to the incision should be performed daily. Bacitracin is usually recommended for ten days postoperatively as it decreases the risk of allergic reactions and/or local irritation. You may then be instructed to switch to Aquaphor and/or Vaseline ointment for the next two to three weeks. If you have had a procedure on your eyes performed, you may also be sent home with antibiotic eye drops with detailed instructions that will help to prevent infection in this area. Additionally, if you have had a procedure performed in your mouth (such as mandibular angle reduction or genioplasty) where intraoral incisions were made, you may be sent home with chlorhexidine antibiotic mouthwash, also known as Peridex, that you can use after meals for the first two weeks after surgery. Subsequently, you may be instructed to switch to using an equal mixture of hydrogen peroxide and saltwater in the second week. For a procedure on the nose such as a rhinoplasty, you will likely be sent home with antibiotic ointment that can be applied to the incision site around the bottom of the nose and around the nostrils three times per day. Additionally, it may be recommended to use nasal saline spray every few hours to help reduce some of the stuffiness.

 Your physician and healthcare team will instruct you on management of the bandages that you are sent home with and the procedure for changing them. Normally, in scalp advancement, brow lift, and forehead reduction, ACE bandages or a jaw supportive garment will be kept on the area for the first week (except when showering). In the second week, light, loose fit dressings are recommended overnight. Showering is usually recommended 24-48 hours after surgery to help keep the incisions clean. You may be recommended to wash your hair daily and wash, brush and dry your hair towards the incisions, not away from them. Furthermore, it is generally recommended not to place anything hot, such as a hairdryer, on the scalp for one month, as the area may have altered sensation after the surgery, which puts you at risk for burns with such appliances. Some bleeding in the incisional area after surgery is normal. For light bleeding, you can change the gauze and/or apply light pressure to the area. For severe and/or ongoing bleeding, please speak with your physician right away and/or head to the nearest emergency department to receive professional assistance. If you have had a rhinoplasty performed, you will usually have tape across the top of your nose immediately after the procedure and a rigid splint on top of the tape to protect your nose. If you have had work done on your septum, including straightening a crooked septum, you may have plastic splints, known as Doyle splints, in place after the operation. All of these dressings and splints must remain dry and will usually be removed one week after the operation. For jaw tapering and chin surgery, you will most likely have a bulky facial dressing as well as compressive tape on your chin to be removed one to two days after the operation. After removal of this dressing, you may be fit for a compressive garment to be worn over the next two weeks.

For scalp advancement, brow lift, and forehead reduction, there will be sutures in the area of the surgical incision which can usually be removed at around the 7-12 day mark, depending on your healing progress. This is the recommended time frame in order to prevent the formation of scars along the incision site. Some surgeons use dissolving stitches, so removal is not needed.

All incisions should remain clean and dry in the postoperative period, so swimming is prohibited for three-four weeks. You  may also have small butterfly closures known as Steri-Strips on the area. These strips are used to close wounds and can help the edges of the skin grow back together. For rhinoplasty, sutures will usually be removed one week after the operation where the dressings and splint will also be changed. In mandibular angle reduction and genioplasty, incisions will likely be inside the mouth using dissolvable sutures. In thyroid cartilage reduction, also known as a tracheal shave, there will be a small horizontal incision under the chin that is usually closed with dissolvable sutures and with Steri-Strips. It may be recommended to minimize sun exposure for as long as nine months after the procedure. Additionally, if you are in the sun, it is best to wear a protective hat and use sunblock. This will help with formation of a non-visible scar. These are general recommendations; your physician will instruct you on specific applicable wound care techniques during the postoperative period. 

Bruising and Swelling

It is very normal for the area to be bruised and swollen after a facial operation as the face is very vascular. A bruise is caused when blood leaks from small blood vessels, known as capillaries. Swelling occurs due to increased movement of fluid and white blood cells into the surgical area after a procedure. Bruising usually occurs simultaneously with swelling. There are steps that you can take to aid in the resolution of both processes. 

After the procedure, you may feel tightness, tension and/or heat in the surgical area. These are all normal sensations and are usually due to swelling; there are several actions you can take to help decrease swelling in the surgical area. You can apply cold compresses in the first two-three days for 20 minutes every hour to help reduce inflammation. Additionally, it is recommended to raise your head on a pillow when sleeping for the first two weeks. It is usually not recommended to sleep flat, face down or on your side during this interval. Swelling and bruising around the eyes and face are expected and will usually begin to subside within the two weeks after the operation. However, some bruising and swelling may persist for months. Sometimes your eyes can be swollen shut, but this should improve in a few days. For procedures involving the nose, swelling may cause you to breathe primarily through your mouth. If congestion occurs, you may be recommended to use nasal saline spray every few hours. As stated before, postoperative swelling can persist for quite some time, even extending for several months to longer than a year. Therefore, it is imperative that you follow the instructions your healthcare team provides in order to achieve the best results. You may experience numbness in certain parts of your face after the surgery which can last for several weeks. Sensation will improve as the nerves heal. The ability to sense where your head is in space, a sensation called proprioception, may be altered after surgery so please take special caution when getting into and out of cars during this period.

Diet and Physical Activity

In the postoperative period, eating foods that allow for optimal healing will be beneficial to the recovery process. It is usually recommended to eat soft and nutritious foods for the first two-four weeks after the operation. Please try to avoid anything that is hard, crunchy or chewy; a good rule of thumb is to not eat foods any tougher than the consistency of scrambled eggs. Foods that may fit in this category include yogurt, scrambled eggs, rice, soup and smoothies. Also, gently wash your mouth with warm water or antibiotic mouthwash after each time you eat. Temporary weight loss may occur but it is important to maintain a nutritious diet and communicate with your healthcare team during this period.

Diet may also play a part in the bruising process.  Evidence supports that vitamins A, C, zinc, arginine, glutamine, glucosamine, bromelain, Aloe Vera and Centella asiatica may be beneficial to surgical patients. However, many patients will be advised to avoid them. Thus, a thorough discussion with your physician is necessary to see what is recommended for you. Furthermore, there is a lack of clinical trials to evaluate the safety, efficacy and drug interactions of these potential beneficial substances. From the current data, however, adequate protein supply as well as adequate supplementation of Vitamin A, Vitamin C, zinc, arginine, glutamine and glucosamine may be beneficial. Additionally, postoperative topical application of Aloe vera and Centella asiatica extracts may facilitate a scar with greater tensile strength.

In regards to physical activity after the operation, it is imperative to first speak with your physician to see what their recommendations are in the timeline they want you to follow. Generally, it is recommended to take a rest from strenuous movement but stay lightly active in the postoperative timeframe. In the first 24 hours after the operation, resting and staying in bed will help with recovery but just as it was stated before, it will be imperative to move the lower extremities to prevent the formation of a blood clot. During the first few days at home, it is beneficial to walk briefly and as often as tolerated. You can use the help of another person to support you when walking. These light walks can start to increase to 5-10 minutes at a time if you feel comfortable. Additionally, you may be asked to avoid bending over and performing acts that significantly increase your heart rate during the first two weeks after your surgery. Furthermore, it is usually recommended to avoid lifting anything heavier than 20 pounds for the first two weeks after the operation. Around the two-week postoperative mark, you may be recommended to resume light activity such as longer walks, driving and working at a desk. Exercise and strenuous activity such as running or weightlifting may be advised for resumption no earlier than four weeks after your operation. Some physicians may recommend returning to work 10-14 days after the operation with a reduced workload for an additional two weeks thereafter. 

Supportive Services

The postoperative period can be physically as well as emotional taxing for some patients. Thus, some patients may choose to utilize supportive services to help in the recovery process. There are many services including post-surgical nursing care that may be available in your local area. This support usually involves a professional caregiver who comes to your home and assists in the recovery process. They may help with a multitude of post-surgical activities including regular changing of dressings and wound management, monitoring vital signs and postoperative complications, assisting in management of pain along with the prescribed pain medications and supporting your activities of daily living (dressing, bathing and eating nutritious foods). Furthermore, having emotional support may be beneficial during your recovery period. 

Another recommendation for the postoperative recovery period is to have a friend and/or family member at your home to help in the recovery process. This person can check on your well-being as well as support you physically and emotionally. A friend or family member may help you by picking up meals, groceries and prescriptions, assisting with home cleaning and tidiness and maintaining your overall weekly schedule to achieve your postoperative goals. The physical and emotional support of a friend or loved one may prove most efficacious in your recovery.

Citations

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  2. Schoenbrunner AR, Janis JE. Pain Management in Plastic Surgery. Clin Plast Surg. 2020 Apr;47(2):191-201. doi: 10.1016/j.cps.2019.12.001. Epub 2020 Feb 1. PMID: 32115046.
  3. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008;19(2):173-184. doi:10.1155/2008/846453
  4. Kullar R, Frisenda J, Nassif PS. The More the Merrier? Should Antibiotics be Used for Rhinoplasty and Septorhinoplasty?-A Review. Plast Reconstr Surg Glob Open. 2018;6(10):e1972. Published 2018 Oct 16. doi:10.1097/GOX.0000000000001972
  5. González-Castro J, Lighthall JG. Antibiotic Use in Facial Plastic Surgery. Facial Plast Surg Clin North Am. 2016 Aug;24(3):347-56. doi: 10.1016/j.fsc.2016.03.011. Epub 2016 May 24. PMID: 27400848.
  6. Hamman MS, Goldman MP. Minimizing bruising following fillers and other cosmetic injectables. J Clin Aesthet Dermatol. 2013;6(8):16-18.
  7. MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev. 2003 Nov;8(4):359-77. PMID: 14653765.
  8. Ernst E, Pittler MH. Efficacy of Homeopathic Arnica: A Systematic Review of Placebo-Controlled Clinical Trials. Arch Surg.1998;133(11):1187–1190. doi:10.1001/archsurg.133.11.1187

Chapter 6: Makeup Tips to Accentuate Femininity Before & After FFS

Chapter Contributions: Maissa Trabilsy MA; Nicole Schiraldi BS

INTRODUCTION

Femininity is not personified by the female, nor is masculinity by the male. There exists a wide and varied spectrum between femininity and masculinity, and one physical characteristic, or the absence of, does not define a particular position within the spectrum. The balance between femininity and masculinity within one’s identity is complex and influenced by both the anatomy and physiology of different body parts, the voluntary and conscious efforts to manipulate one’s appearance and one’s placement within the spectrum. This chapter explores the role of makeup and wigs within the transgender community and how facial and hair modifications serve to increase femininity.

Monteiro and M. Poulakis of the University of Indianapolis conducted a study exploring how transgender patients’ perception and expression of beauty were influenced by cisnormative societal beauty standards. There are approximately 1.4 million adults that identify as transgender in the United States.1 These individuals experience widespread prejudice, stigmatization, and ostracization. These experiences make transgender individuals more likely to try and conform to cisnormative beauty standards. One participant, of 12, stated that they “try to meet the societal standards as much as they can. They won’t leave the house anymore without putting on a face.”1 They also stated that they often apply more makeup than cisgender women because “if society just senses… a pink outfit or long hair… their brains are just going to tell them subconsciously there’s a woman standing there.”1 Another participant expressed the constant pressure they face to adhere to conventional beauty standards regarding femininity. They stated that “we’re just trying to blend in. We’re trying to look more feminine… and less masculine.”1 Participants expressed their discontent for societal evaluations and perception of transgender beauty. Their discontent was accompanied by feeling the need to conform to these standards and essentially “play the game” of expressing femininity.1 This expression is done largely through cosmetic modification of the face and hair.

MAKEUP

Decoration of the face and body is among the most universal and enduring behaviors practiced by humans. Traces of paint pigments date back to over 75,000 years ago. Among some societies, painting the body and face is the most valued form of art.2 The practice of cosmetics and other forms of decoration has become so widespread as they are integral parts of self-expression and what defines us as individuals. Additionally, makeup has been a key player in the race to achieving societal beauty standards for centuries. This is exemplified by the rapid changes and continuous evolution seen in “mainstream” makeup. Popular makeup trends mirror ephemeral societal beauty standards. As the beauty standards and societal norms regarding physical appearance change, we see a change in the application and presentation of makeup. Similarly, makeup has become one of the strongest tools within the transgender community to enhance femininity and achieve their ideal outward expression of true gender identity. 

The use of cosmetic pigmentation and other forms of makeup can radically increase femininity in the face. A major reason for that is because the application of makeup increases facial contrast. It is known that female faces are lighter in pigment, greener in tone, and have more contrasted features than male faces, as stated in one study by Richard Russell.2 With lighter skin, the female face typically has “greater luminance contrast surrounding the female eyes and lips.” In this same study with 29 participants, increased facial contrast was considered more feminine in female faces and less masculine in male faces, using Likert scale ratings. Furthermore, a comparison of 12 faces with and without cosmetics yielded the results of more femininity perceived in each of the cosmetically modified faces.2 The use of makeup and  pigmentation to increase contrast among the facial features of transgender patients perceptually femininizes the face.

The use of makeup in itself is not gender specific, but can be fundamental in creating  femininity in the transgender patient. The concept of facial contouring through manipulation of  darker and lighter shades of makeup has become most popular in recent years.3 Facial contouring can effectively transform the appearance of a patient’s face and neck, noninvasively. The  “attractive female jaw” is regarded as smaller and less prominent than the more defined male jaw characterized by a strong square mandibular angle. The rounded mandibular angle is another defining feature of the ideal feminine jaw. Furthermore, a more pointed chin enhances the femininity of the face.3 Overall, the female face is often regarded as smaller and more rounded.4 More masculine faces are square in shape with more defined and sharp angles, while the feminine face is more oval-shaped with round, curving angles. As compared to females, male chins and jawlines can be up to 20% longer.4 Makeup and the manipulation of different shades to create illusions of shadows and highlights can be used to replace the strong and angulated masculine face with a soft and rounded feminine face.

Feminization of the face encompasses more than the overall shape. Going beyond the overall outline of the face created by the hairline and jawline/chin, features of the eyebrows, nose, cheeks, and lips bring significant femininity to the face, all of which can be created through the use of makeup. As compared to straighter masculine eyebrows, female eyebrows are more arched, especially in the lateral portions, and sit more superiorly to the orbital rim.4 Eyebrow modification, or “filling in”, is an easy and cost effective method of increasing femininity. Furthermore, contouring of the nose can radically feminize the face of transgender patients. Rhinoplasties are among the most popular surgeries within the transgender community, but a feminine nose can largely be achieved through makeup. Female noses are smaller and shorter than male noses, and they characteristically have narrower bridges and more upturned nasal tips.4 Feminine faces also include more prominent and anteriorly located cheekbones, as well as fuller lips with a more prominent “Cupid’s bow”, the M-shaped dip in the center of the upper lip.4 These anatomic  features are known to be defining features of the female face and crucial to the overall femininity of the face. The ability of the transgender community to create these facial features and essentially replicate this anatomic aesthetic through makeup has radically changed these patients’ pursuit toward achieving and embodying their true gender identity. Makeup allows the transgender patient to match what they feel on the inside to how they want to look on the outside. These changes in appearance can yield significant changes in how fulfilled and satisfied these patients feel about their own identity.

WIGS, WEAVES, AND EXTENSIONS

Wigs trace back to ancient civilizations and have remained a prominent feature in today’s society, but they have not always carried the same meaning. The function of hair modifications has changed across different decades and centuries. Historically, wigs served as symbols of high socioeconomic status; wigs were explicit emblems of wealth and class. They served as ways to cover imperfections and ease the burden of hygiene.5 Tracing back to Ancient Egypt, elaborate wigs signified higher rank within rigid social hierarchies. Wigs were a defining accessory of 16th century Western Europe, crowned by monarchs such as Queen Elizabeth I of England and King Louis XIV of France.5 The popularization of wigs by monarchs made the hair modifications a household item among the aristocrats and upper classes. Furthermore, it was not uncommon for wigs to fall out of style during times of unrest and significant change, such as after the fall of the roman empire and during the french revolution.5 This reinforces the idea that wigs were political, socioeconomic statements, which were specific to the time period, its aristocracy and class structures. Interestingly, wigs were not tied to femininity throughout history as they are now. Prior to the 19th century, wigs were equally as prominent, if not more prominent, among men compared to women.5 Wigs were statements of wealth and high-class status. They were not gender specific and were not significant or distinguishing within the constructs of gender identity.

In modern society, hair modification is symbolic of self-expression and beauty. Wigs or weaves and extensions, which integrate with a person’s natural hair, are ways to embrace and express one’s identity, making them integral parts of the transgender patient’s physical appearance.6 Hair is strongly associated with femininity in today’s society. The ability for transgender patients to embrace these modern beauty standards is instrumental to their satisfaction with their gender identity. Traditionally within the U.S., any type of hair modification was strongly associated with aging and chronic medical conditions. However, this stigmatization of wigs gradually shifted due to changes in beauty standards,norms and the acceptance of beauty across different races, ethnicities, and cultures.6 Wigs have once again become an important expression of self, no longer only of wealth or political status. Furthermore, the industry of hair modification has destroyed many of the barriers between races/ethnicities and societal beauty standards. Wigs, weaves, and hair extensions help bridge the gap between gender and race in the pursuit of self expression, while increasing femininity and achieving societal beauty standards. 

The ability to add onto or completely cover one’s natural hair has been revolutionary in the  transgender community’s pursuit of femininity. The role of hair in creating femininity goes far  beyond length. Although longer length is classically regarded as feminine, there are also  feminine features within the hairline. Feminine hairlines are lower in height on the forehead than  those seen on men. Furthermore, the male hairline is often characteristically seen as a distinct  “M” shape with a central peak, known as the “widow’s peak”.7 Therefore, a lower and more  rounded hairline is generally accepted as feminine. The feminine hairline can also be described  as less defined and sometimes slightly heart-shaped. Wigs and other hair modifications give transgender patients the ability to change not only the length and overall appearance of their  hair but also their hairline.7  It is the femininization of those finer details that can be most crucial to the transgender patient’s satisfaction with their gender identity and self-expression.

Thanem of Stockholm University noted the lack of embodiment of transgenders within studies of gender, work, and organization. Within the article, Thanem reflected on their own experiences, stating that “wearing stereotypically feminine props such as… a wig or my own hair in a more feminine style… affects how I feel and how I relate to others.” They also state how increased expression of femininity makes them feel “more confident, energized, invigorated and excited.”8 Transgender patients’ relationships with femininity and societal beauty standards remain a largely unstudied field. However, it is acknowledged how difficult and unfair the life of a transgender patient can be and how they often feel pressure to conform. The use of wigs and makeup facilitates the transgender expression of how they feel internally and how they desire to be perceived externally.

Scars

A common concern that arises regarding surgical facial feminization procedures is that of scars. Although scarring is the natural healing process of injured skin, such as injury from a surgical procedure, there are ways to make scars minimally visible, or in some cases, not visible at all. In this section, we will address why scarring occurs, what type of scarring one can expect from facial feminization procedures specifically, and ways to reduce or conceal the scars through medical and cosmetic means. By the end of this section, we hope readers understand how and why scarring will occur from facial feminization procedures, as well as different ways to minimize the appearance of scarring.

Scar formation

Many of the common facial feminization procedures require incisions, or cuts into the skin. These incisions injure the skin and will leave scars due to the body’s natural healing process. The wound healing process consists of three main stages: inflammation, proliferation, and remodeling.

The first stage, inflammation, consists of the body’s response to clean out the wound and prepare it for repair. The body does this by using special immune cells called neutrophils and macrophages that clear away dead cells and bacteria. Inflammation begins at the time of injury and generally lasts up to four days. During this time, the skin around the incision may be swollen, warm, and red as part of the inflammation process.

Once prepped, the next stage, proliferation, occurs. In this stage, the body produces granulation tissue, which can be thought of as temporary scaffolding in the wound site to allow for the development of new blood vessels and more permanent tissue. In this stage, collagen, a protein that contributes to the structure of the skin, is laid down to provide structural integrity to the new tissue. At the same time, new blood vessels are formed leading to the scar taking on a pink, puffy complexion. This will eventually fade to a lighter, flatter scar during the remodeling phase, which can take a few months to complete.

In the final stage, the wound strengthens through replacement of the initial collagen with a stronger, more organized version of collagen. This will cause the scar to become firmer and flatter. As mentioned earlier, the scar will also lose the pink color, as many of the newly formed vessels begin to naturally regress. The scars that surgical procedures yield are generally referred to as “hairline scars,” as the scars are very thin lines. This is because the incisions made are very precise and the suturing process brings together both sides of the wound to best promote healing.

Facial Feminization Surgery Scar Locations

In terms of facial feminization procedures, there are typically four locations for incisions: hairline/coronal, under the nose, inside the mouth, and under the chin. The decision for the location of the incision depends on the procedure being performed.

The hairline/coronal incision runs along, or is hidden behind, the hairline. Hairline advancements and forehead shape contouring would involve this incision location. When possible, surgeons will intend to make a coronal incision behind the hairline so that the scar is hidden in the hair. However, sometimes this is not possible, and hairline incisions, which run uncovered along the hairline, will be made.

The second location for an incision is under the nose and the curves under the nostrils. This incision would be used for lip augmentations, a lift lip, or a rhinoplasty. These incisions generally leave scars that aren’t very noticeable as they lie in the crease of the curves under the nostrils.

The third incision location is inside the mouth. It is important to note that injuries to the oral mucosa, the skin in the mouth, heals completely without scarring. This is due to the inherent characteristics of the oral mucosa. The location of this incision would run under the gum line under the bottom teeth. This incision is made to perform mandible/jaw reduction, chin width reduction (genioplasty), or cheek augmentations.

The last location is under the chin. This incision is made to perform tracheal shaves, which decrease the size of the Adam’s apple. This incision is visible but will generally not be seen from a face-forward view as it is made on the underside of the chin.

Minimizing scar appearance: medical methods

While the presence of scars after surgeries is almost guaranteed, the surgeon will try to minimize the risk of scarring as much as possible during surgery. This includes incision and suturing techniques. Additionally, there are ways to reduce scar size and color during the healing and repair process postoperatively.

The use of antibiotic ointment and silicone gel will help to prevent scars from getting infected and keep the scars hydrated. Avoiding infection is very important in the timely and healthy healing of the scar, so antibiotics prescribed by the surgeon should be used as directed. Silicone gel sheets have been shown to improve hydration of the skin which creates a conducive environment for proper healing.

It is also important to keep scars out of the sun. Sunlight can leave permanent pigment along the incision lines causing the scar to become darker than the surrounding skin. This is called hyperpigmentation and can be avoided by wearing hats and by using sunscreen.

Scar massages have also been shown to aid in the healing process. Massage the scar for 10 minutes, two to three times a day for a span of six months to a year after surgery. To properly massage a scar, use the tips of the fingers to apply small, firm, circular movements along the scar. This helps to soften the scar tissue and prevent any raised texture along the scar lines. Scars inside the mouth can be massaged with the tongue instead of with the fingertips. Cocoa butter or lotion can be used as lubricants to aid in the massaging. Slight pulling or burning may be felt depending on tenderness of the scar and intensity of the massage.

Dermabrasion is a type of surgical skin planing that uses a rapidly rotating device to remove the outer layer of skin. This procedure is commonly done with the goal of removing surgical scars, acne scars, age spots, and wrinkles. The procedure will remove the outer layers of skin to reveal the fresh layers underneath. A moist dressing will then be applied to the skin to keep it protected while it heals. Dermabrasion has been shown to soften the texture of surgical scars to help them better blend in with the surrounding skin.

Finally, laser therapy has also been shown to improve surgical scars. The laser creates microscopic holes in the scar which will be replaced by healthier skin. The goal is that over time, the old scar tissue gets replaced with more healthy, uniform skin. While lasers cannot completely remove scars, they can make them less noticeable and uncomfortable.

Minimizing scar appearance: cosmetic methods

Once the scar healing phase has completed, some patients may remain dissatisfied by the presence of a scar. In these cases, there are ways to conceal the scars using makeup. Depending on which stage of healing the scar is in, different techniques can be used to best conceal the scar. In all cases, keeping the scar moist is very important not only for the healing process but also to make the scar tissue more receptive to makeup. Heavy creams or vitamin E can be used to hydrate the scar tissue, depending on how rough and dry the scar is. Additionally, a silicone-based primer can be used to fill in irregularities in the scar tissue, so that the skin’s texture appears more even.

During the proliferative phase of healing, the scar can appear pink due to the increased number of blood vessels in the scar tissue. A green color-correcting concealer can be used to neutralize the red color of proliferative scars due to the optical cancellation effect of red-green color combinations. This will aid in more easily covering up the color of the scar with additional makeup. Fake tans can also help in minimizing the color difference and hiding the scar by giving the scar tissue and surrounding tissue the same tone.

“Camouflage makeup” are specific lines of makeup made to help conceal scars. These products will be more highly pigmented than usual makeup to make hiding scars easier. These products can be purchased online or in stores and are sold by most cosmetic brands. The use of setting sprays or finishing powders is important to help keep the makeup in place as the makeup may be thicker or heavier than normal applications.

As previously explained, scarring is the natural healing process of the body in response to tissue injury and can be expected from facial feminization procedures. Despite that, there are different ways along the process to best minimize the appearance of scars, including locations of incision sites, promoting proper healing, medical procedures, and the use of makeup.

Chapter 6 Citations:

  1. Marshall CD, Hu MS, Leavitt T, Barnes LA, Lorenz HP, Longaker MT. Cutaneous Scarring: Basic Science, Current Treatments, and Future Directions. Adv Wound Care (New Rochelle). 2018;7(2):29-45. doi:10.1089/wound.2016.0696
  2. Poulos E, Taylor C, Solish N. Effectiveness of dermasanding (manual dermabrasion) on the appearance of surgical scars: a prospective, randomized, blinded study. J Am Acad Dermatol 2003;48:897–900.
  3. Telang PS. Facial Feminization Surgery: A Review of 220 Consecutive Patients. Indian J Plast Surg. 2020;53(2):244-253. doi:10.1055/s-0040-1716440
  4. Thomas JR, Somenek M. Scar revision review. Arch Facial Plast Surg 2012;14: 162–174
  5. Monteiro, Delmira and Poulakis, Mixalis (2019) “Effects of Cisnormative Beauty Standards on Transgender Women’s Perceptions and Expressions of Beauty,” Midwest  Social Sciences Journal: Vol. 22 : Iss. 1 , Article 10
  6. Russell, Richard. (2010). Why Cosmetics Work. The science of socialvision. 1093/acprof:oso/9780195333176.003.0011.
  7. Yahalom R, Blinder D, Nadel S. Refuat Hapeh Vehashinayim [Facial femalization in transgenders] (1993). 2015;32(3):52-70.
  8. Altman K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac 2012;41(8):885-894. doi:10.1016/j.ijom.2012.04.024
  9. Hafouda Y, Yesudian PD. Unraveling the Locks of Wigs: A Historical Analysis. Int J   2019;11(4):177-178. doi:10.4103/ijt.ijt_68_19
  10. B Burroway BS., et al. “The Societal Impact of Wigs”. Acta Scientific Clinical Case Reports 1.1 (2020): 21-23.
  11. Bared A, Epstein JS. Hair Transplantation Techniques for the Transgender Patient. Facial Plast Surg Clin North Am. 2019;27(2):227-232. doi:10.1016/j.fsc.2018.12.005 (8) Thanem, T. (2011). Embodying transgender in studies of gender, work and   Handbook of gender, work and organization, 191-204.

Chapter 7: Non-Surgical Enhancements

Chapter Contributions: Nissim Hazkour BA

The face has been called “the organ of emotion,” and is our primary means for social interaction. When we meet someone for the first time, much of the “first impression” stems from conclusions drawn as we subconsciously analyze the face of our new acquaintance. In addition to our perceptions of each other, the face plays a crucial role in shaping our own self-identity. Therefore, it is unsurprisingthat the face is a major communicator of gender identity as well, and that facial gender confirmatory treatments (GCTs) provide well-established benefits to many transgender patients.

In the first part of this chapter, we review the aesthetic goals and basic anatomy relevant to nonsurgical facial feminization procedures. Special consideration will be given to the cheekbones and lips, focusing on the role these structures play in the overall appearance of the face. Importantly, as discussed in prior chapters, we are not describing these features as beauty ideals, but rather as characteristics that contribute to a more masculine or feminine facial appearance. The aim is to provide a comprehensive guide for the reader to better understand the facial characteristics responsible for the dissatisfaction some have with their appearances, in addition to how these features contribute to societal misgendering of the transgender community.

This chapter offers a broad survey of the nonsurgical facial feminization procedures available to patients today, including injection of fillers, botox (e.g., botulinum toxin), and other chemicals (e.g., deoxycholic acid), with a focus on the potential benefits of lip and cheek fillers. We hope to guide the reader through details of these procedures, and how these enhancements contribute to increased confidence in, and satisfaction with, one’s self-image. The multiple options of filler and the steps of lip and cheek filler placement will be discussed in detail, focusing on how these enhancements impact the overall appearance of the face and contribute to feminization. Finally, we conclude with information to assist those considering these procedures in partnering with their health care team as they prepare for treatment.

By the conclusion of this chapter, we hope readers better understand the role of facial feminization as one aspect of comprehensive gender confirmation treatment, the options available to patients today, and the benefits these procedures offer.

A Cedars-Sinai study led by Dr. Maurice Garcia found that 73% of transgender women and 78% of transgender men experienced gender dysphoria by age 7. Notably, the earliest memory they could remember was at 4.5 years of age, with the first memory of gender dysphoria occurring at 6.7 years for transgender women. For transgender men, the earliest memory was at 4.7 years, with the first gender dysphoric memory at 6.2 years. Clearly, there is a significant time gap between these initial dysphoric memories and the beginning of most transgender transitions. For transgender women, this time difference lasted 27.1 years compared to transgender men, which lasted 22.9 years. This lapse is attributed to the mental and physical consequences of the lack of support for their gender identities as they developed.

When discussing surgical options for gender dysphoria, many transgender patients have reported that they experience facial dysphoria. Despite efforts with clothing and makeup, their faces can still be a significant source of dysphoria. Furthermore, they are often misgendered and commonly experience increased unwanted attention in public. Hormone replacement therapy and genital gender-confirmation surgery are not sufficient to completely treat gender dysphoria. As Dr. Douglas Ousterhout, the pioneer of facial feminization surgery, believes, “few people you meet see your genitals, but everyone sees your face and instantly makes assumptions about your gender, based on a subconscious assessment of your features.” According to Ascha, compared to generally accepted masculine features, feminine facial features include a smoother, rounder forehead, eyebrows that sit higher above the brow-bone, eyes that are more open, narrower noses, higher cheekbones, flatter temples, a smaller, pointed chin, and fuller lips. On the contrary, masculine faces are usually more square.25 These differences are not changed by hormone therapy or genital surgery. However, they can be altered via facial feminization surgery or the use of nonsurgical enhancements.

There are a number of nonsurgical enhancements that transgender women can use to enhance their femininity. Some of these nonsurgical enhancements include eyelash modifications, cheek filler, lip filler, and laser hair removal. Nonsurgical procedures are very appealing because they provide temporary aesthetic results with low risk and quick recovery times. Since surgery is invasive and irreversible, those who are undecided about surgery can consider non surgical options, which provide the added benefit of estimating what they could look like with surgery. Gender-affirming surgery is also the last step in the psychological and physical evaluation and treatment process of gender-affirming therapy. A previous study found that, in the order of most to least common, trans-women who chose to have procedures done on their faces chose laser most, then hair removal, surgery, and injectables. This order of preference is likely because of the costs and accessibility of these procedures.

Eyelashes

Prominent eyes and eyelashes are considered feminine across multiple cultures and can increase self confidence and well-being in all women. The societal favor shown towards people with subjectively beautiful eyes encourages many people to take steps to enhance their own eyes, often focusing on their lashes.

A study done by Pazhoohi from the University of British Columbia asked participants to rank computer-made pictures of male or female faces in order of least to most attractive, where the only difference between photos was the length of their eyelashes. Pazhoohi discovered that medium length eyelashes were most commonly preferred; furthermore, women were preferred to have longer eyelashes than men. The ideal eyelash length for women appeared to be about one-quarter to one-third of the width of womens’ eyes. For men, eyelashes were deemed most attractive at about one-fifth of their eye widths. They also discovered that women with particularly short lashes and men with particularly long lashes were ranked particularly low. These findings demonstrate a cultural influence in addition to a possible evolutionary bias. Eyelashes evolved to protect eyes from environmental debris and toxins, so eyelash length can reflect different states of health. Therefore, evolutionarily, it makes sense for length to be both a source of aesthetic attraction for humans as well as a way to gauge relative health.

Human eyelids have seventy-five to eighty lashes on the lower eyelid and ninety to one hundred and sixty lashes on the upper eyelid. Like all hair follicles on the body, all eyelash follicles are present at birth and new ones do not grow after birth. Lash length varies between individuals but the maximum length an individual lash can reach is 12 mm and shortly after, the lash will fall off the eye by itself. If a lash is pulled off of the lid, it will take about eight weeks to grow back. Lashes have a hair shaft, which is the part seen outside of the skin. Lashes curve due to the different types of cells along the root of the hair. However, lashes tend to curve more in caucasians compared to other ethnicities.

Currently, the most popular ways that people enhance their eyelashes are makeup or over-the-counter (OTC) cosmetics. Mascaras are often advertised to increase eyelash volume, length, darkness, and/or curl. Another temporary option is false eyelashes. False eyelashes, synthetic or donated from people, can come in a strip or more individual pieces, both of which are usually glued to the eyelid along the natural upper lash line, to lengthen their appearance. For those who want longer lasting solutions, lash extensions and eyelash transplants are available. Lash extensions use singular extensions that are attached to individual eyelashes. These artificial lashes require a stronger glue and a solution to remove them, both of which can cause allergic reactions. Depending on the procedure done and the eyelashes used, extensions can last from several days to several weeks. Non-mascara OTC products that are marketed to enhance eyelashes are not studied for safety or efficacy by the FDA and their methods of affecting eyelash growth have not been verified.

Medical options include eyelash transplantations and prescription options. Eyelash transplants are controversial when used for purposes other than those medically recommended, such as eyelid reconstruction or congenital eyelash defects. They are done by moving hair follicles from the scalp to the eyelid. However, because scalp hair has different characteristics from lash hair, those who have eyelash transplantations have to regularly trim the implanted lashes. This surgical procedure also comes with many possible complications, like most operations. A nonsurgical prescription option is bimatoprost ophthalmic solution 0.03%, which is the only FDA-approved product that safely and effectively helps patients grow their own eyelashes. It was originally developed for glaucoma patients, but a clinical trial noticed that almost half of the patients’ eyelashes were growing when they used the solution once a day for a year. This unintended effect led to testing the solution for enhancing eyelash growth and subsequent approval for use. However, the duration of effect that bimatoprost has on lashes is unknown and its effects have not been studied for longer than 4 weeks after discontinuing daily treatment. The solution has not been studied in people with systemic diseases or severe eyelash loss. The most common side effects are eye redness, due to increased circulation in the eye’s blood vessels, eye itchiness, dryness, pain, burning, eyelid pigmentation, and visual disturbances. There have also been reports of permanent changes of those with blue/green eyes to brown eyes. Eye infections are possible because of the route of application to the lid, but can be limited if the patient follows the sterile application instructions correctly. Keeping lashes clean is easily done by washing the face daily and ensuring that all makeup is removed. Micellar water and baby shampoo are both recommended options for maintaining cleanliness. To protect the hairs and seal in moisture, it is recommended to apply a small amount of vaseline to the lashes.

Skincare

Transgender people’s skin also changes in response to treatments undertaken during their transitions. Trans-women take estrogens, mainly estradiol, usually with an antiandrogen, which changes the hormone balance in their bodies. Estrogens quickly reduce sebum production, which can lead to dryer skin. While estrogen use is not directly linked to any skin conditions, it can exacerbate itchiness and eczema-like symptoms in those with previously dry skin. Skin dryness is often managed by a dermatologist. Estrogen also decreases and thins body hair, which is usually a welcomed side effect by patients.  However, since facial hair does not fully disappear and is particularly bothersome, hair removal is a common step taken to remove the hair.

Hair Removal

Different cultures throughout history have had varying definitions of beauty and attractiveness, yet hair removal has consistently shown up in beauty displays dating back to the neolithic ages. Each culture has unspoken norms regarding where body hair is deemed socially acceptable, based on the perceived gender values of individual cultures. People whose body hair falls outside of this norm may be deemed unhygienic or unattractive. In modern western culture, this social norm has been thoroughly ingrained in societal thoughts and behaviors. Young women are expected to start shaving their underarms and legs, and are pressured by society to avoid having hair in any area besides their heads, eyelashes, and eyebrows.1 In a study asking those who identify as women, 99.71% responded that they had removed body hair at least once in their lives. When asked why they chose to remove body hair, the most common response was that “hairlessness made them feel more feminine and attractive.”2

In the transgender population, multiple studies suggest that hairlessness is closely linked with patient body dysphoria and general satisfaction. In patients undergoing treatment, pre-treatment dissatisfaction was highest when the patients were ranking their genital body characteristics, facial hair, and breasts.3 Many subsequent studies suggest the same idea; transgender patients’ gender dysphoria stems strongly from their genitals and body hair. This gender dysphoria stems from social perceptions of gender. When transgender patients are able to be socially recognized in accordance with their gender identities, there was a marked increase in their body satisfaction score.4 The desire for hairlessness is mainly fueled by social constructs of gender, which largely depend on the absence of typical masculine traits. During puberty, androgens such as testosterone drive hair growth in hormone sensitive locations, such as the underarms and pubic regions, leading to the masculine pattern of body hair. This typically does not accurately represent the gender identity of transgender women. This concept can help explain why the dissatisfaction rates with body hair are high in transgender women.5

One of the barriers of care facing transgender patients today is the management of unwanted facial and body hair. All transgender patients deserve specialized, individualized treatment plans in order to achieve an external aesthetic that decreases gender dysphoria and increases body satisfaction. For example, transgender women often elect to remove hair from the face, neck, and genital area. On the other hand, transgender men often elect to remove hair from their forearms or thighs in preparation for hair grafts for phalloplasty (a surgical procedure in which a penis is created).6 Transgender men also commonly transplant hair to areas that create a more masculine aesthetic, such as the jawline and chest.

Transgender patients have many options to remove unwanted hair. Temporary solutions include shaving, epilation (plucking, waxing, depilatory devices), and chemical depilatories. Many will often seek more permanent solutions, like laser hair removal (LHR) and electrolysis hair removal (EHR) preoperatively.7 Primarily, transgender patients often undergo hormone therapy, but find that hormones alone are insufficient for their desired aesthetics. Secondly, hair removal is necessary preoperatively for surgeries, such as vaginoplasty or phalloplasty. In these cases, patients often undergo electrolysis to prevent hair growth that could have resulted in obstruction or infection during the surgery.8 Waxing is a very popular choice for temporary hair removal. Waxing involves either hard or soft wax, which is heated up and coated on the body hair. Removing the wax pulls the hair out from the follicle.9 This is often a preferred intermediate choice of hair removal for patients who do not want to shave but are not pursuing more permanent hair removal choices, such as LHR or EHR.

The principle behind LHR involves utilizing a specific wavelength of light to cause localized damage by heating either the melanin in dark brown/black hair or the pheomelanin in blonde or red hair. As the light produced by the laser is selectively absorbed by the melanin and pheomelanin in the hair, the skin surrounding the hair follicle is not damaged in the process. Consequently, only patients with black, brown, red, or dirty blonde hair can successfully get LHR. Patients with light blonde or white hair do not respond well to LHR since their hair lacks the necessary melanin or pheomelanin.The principle behind EHR involves sliding a metal probe into each hair follicle and delivering electricity to the follicle through the probe. This causes extremely localized damage to the hair through either overheating (thermolysis method) or by inserting sodium hydroxide, which is caustic to the hair follicle (galvanic method); a mixture of both methods (combination method) can also be used.11 In the present day, providers often recommend EHR over LHR because it is the technique of convention. EHR was the only permanent hair removal technique prior to the development of LHR, and therefore, providers may have more experience with EHR and feel more comfortable recommending it to their patients. However, multiple studies comparing postoperative complications suggest that LHR is just as effective and safe as EHR.12,13 Additionally, compared with EHR, LHR has the added benefit of treating larger areas in less time.10

Fillers: Cheeks & Lips

Recent studies using state-of the-art facial recognition software have shown that transgender women were correctly identified as female up to 98% of the time after undergoing facial feminization procedures, compared with only 53% of the time prior to receiving facial feminization treatments. More importantly, as a result, these patients’ self-reported increased confidence in their appearance by more than 300% on average after facial feminization.

While the styling of hair is an obvious form of self-expression worldwide, and facial structures such as the eyes have famously been termed “the windows to the soul,” other structures such as the lips and cheekbones also play important roles in forming the identity expressed by our faces. Consider the COVID-19 pandemic, for example, during which mask-wearing has become commonplace. Have you met someone wearing a mask, only to find that later, when seeing their full face in person, in photos, or on video conference, they look nothing like you expected? While masks only cover a portion of the face, the structures they hide play a key role in determining how we perceive the person wearing them, and how our own self identities are shaped. This simple example illustrates that, in addition to other facial structures, the lips and cheekbones can be significant determinants of our individual identities. Importantly, lip and cheekbone enhancement can be achieved with the use of injectable fillers, avoiding the need for invasive surgery to achieve desired results.

Basic Anatomy & Aesthetic of The Cheeks And Lips

Several anthropometric differences exist between masculine and feminine facial structures, as explained before. In review, the feminine face is rounder, more heart-shaped, less full, shorter in length with more prominent cheeks, and has more robust lips; the masculine face is typically marked by sharper angles and a more rigid outline which is longer and fuller, with less prominent cheeks and thinner, wider lips.

It is important to note that these general trends are not universal, and while the spectrum outlined here applies to the aesthetic goals of many transgender patients, ultimately it is up to patients and their clinicians to work together to determine the enhancements that will accomplish the individual goals of each patient.

The cheek is composed of many structures and layers. The outermost layer of the cheek is the skin, which lies atop an underlying layer of fat. These pads of fat determine the contour and fullness of the cheeks. Fat exists both above and below the cheekbone (zygomatic bone), and pads of fat extend both medially (towards the nose) and laterally (towards the ears). Below these collections of fat lie the muscles of the cheek, which work together to generate the wide variety of facial expressions and emotions we display. In addition to these tissues, the cheeks  contain and border a variety of crucial body structures, such as the salivary glands and important facial vasculature. Your plastic surgeon will safely place fillers in several locations in the skin and/or underlying fat, and these locations depend on the ultimate enhancements you aim to achieve.

The lips are also made up of many smaller structures. The lips surround the mouth, but also connect to the nose and extend inferiorly towards the chin. The ridge that connects the lower portion of the nasal septum to the upper border of the lip is called the philtrum, and the two pillars that define the ridge are actually part of the upper lip. The common groove below the lower lip (the mentolabial sulcus) also contributes to the overall appearance of the lips and mouth. The lips are made up of several different types of skin, which overlay fat and connective tissue, as well as muscles and facial vasculature. The red/pink part of the lips (vermilion) are separated from the rest of the skin that begins near the oral cavity. The contour of this colorful skin on the upper lip is often referred to as “Cupid’s Bow,” since it resembles an archer’s bow. Changes to the length and angles of Cupid’s Bow are important results of lip filler, as they contribute to feminization of the face. Your plastic surgeon may also place filler in, above, or around the lips depending on your goals.

Many nonsurgical treatments come in the form of injectables. Different types of injections achieve feminizing enhancement by different mechanisms. For example, injection of botulinum toxin (Botox) smooths the contours of the face by reducing muscle activity in the treated area. Nearly five million people choose to undergo Botox treatments each year, making it among the most common cosmetic procedures, according to the American Society of Plastic Surgeons. For trans-women, botulinum toxin can smooth wrinkles and soften the contours around the lips and chin for a more feminine look.

In patients with redundant skin and/or excess fat in and/or around the face and cheeks, other injectable treatments are available, including deoxycholic acid, available commercially as Kybella. Injection of deoxycholic acid is used to improve the appearance and profile of the face by targeting fatty tissues underneath the skin and breaking them down. Similar to other injections, this treatment may be repeated multiple times to achieve the desired results. While lipectomy and other surgical procedures have traditionally been the most popular options to reduce excess fat in the face and neck, this injectable serves as one example of the many nonsurgical options to achieve facial feminization, which are increasingly popular on the market today.

Filler injections are among the most popular nonsurgical enhancements of the face. Filler injections work by restoring volume to the treatment area, instantly plumping the treated structures and providing a smooth, natural look when performed by an experienced plastic surgeon. These treatments allow feminizing enhancement of the face without affecting the ability to create the facial expressions that define one’s emotional identity. After a single treatment, results are seen immediately and last for around six to nine months. Importantly, filler injections give you control over the way you look over time, as your face naturally ages with the rest of your body.

In the United States, temporary prepackaged injectable skin fillers include derivatives of hyaluronic acid (HA), calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLLA). Each of these fillers are biocompatible, biodegradable, and unlikely to migrate from the point of injection, allowing your plastic surgeon to achieve your aesthetic goals in a safe and tailorable manner. As mentioned above, fillers may work by simply occupying space and increasing the fullness of the treated area (linear fillers), while other stimulating fillers also promote growth of connective tissue called collagen. PLLA is a notable example of the latter type of filler, though linear fillers also induce some stimulating effects.

Depending on the area of the face being treated, your plastic surgeon will recommend particular products based on the characteristics of the filler and the ways in which it changes the appearance of the treatment area. For example, in areas like the upper cheekbones, the filler needs to retain its contour and shape, while on the lower cheeks and in fine line areas, “softer,” less solid fillers can spread to create a diffuse enhancement that looks natural, even when deformed by movements such as a beaming smile or a big yawn. In the lips, softer, less-viscous fillers are used. HA fillers come in a wide range of products, ranging in stiffness for this purpose. While thinner, softer HA fillers may be chosen for the lips, firmer, thicker HA products are chosen for areas where less movement is desired, such as the forehead. Importantly, while most patients do receive multiple injections, temporary or permanent discontinuation of filler injections do not render patients worse off than if they had never been treated. As such, filler injections are highly efficacious and are a relatively low risk option for nonsurgical facial feminization.

Preparing For Facial Feminization With Cheek And Lip Fillers

Once you have agreed with your physician on your desired lip and cheek aesthetic, and have come to terms regarding the best possible filler that achieves that aesthetic, your plastic surgeon will begin treatment by sanitizing the area and preparing your skin for injection. Numbing injections and/or creams may be used to minimize the moderate discomfort during the procedure, depending on the placement and amount of filler being injected. Many patients do not feel any pain during injection but depending on your pain threshold and the personalized nature of your treatments, your care team will work to make the procedure as comfortable as possible.

The injections come in individual syringes, ranging in the amount of fluid they contain. Depending on your age, skin, and the desired results, your doctor will determine how much product should be administered. Each syringe may be used via several injections within one area to achieve an even, natural fullness.

During the procedure, light bleeding may occur, as well as mild swelling and light bruising in the treated area. It is important to understand that these side effects are normal and temporary. Within a few hours, most patients notice a substantial reduction in swelling and/or bruising, and for the majority of patients, these side effects subside within one to two days. However, some patients may rarely experience swelling and/or bruising for up to two weeks.

Management of any discomfort or swelling after the procedure can be accomplished with  over-the-counter pain medications, like acetaminophen and ibuprofen, as well as ice packs and topical agents to reduce mild swelling and bruising. Your doctor will discuss the importance of avoiding pressure caused by scratching/massaging the treated area in the days after your injection, as the fillers settle and the minor irritations heal. In addition to avoiding pressure to the area post injection, you should wait two to three days to resume facial treatments, such as hot wax, peels, or microneedling. These considerations are important for the ultimate cosmetic result and the healing process. After a few days, you can return to a normal routine without any restrictions.

The final consideration after the first injection of cheek and lip fillers is the need for and  frequency of additional injections. Generally, the effects of your filler injections will last  somewhere from four to six months, but can last up to nine months or a year. As mentioned previously, discontinuing filler injections, either temporarily or permanently, will not render the facial appearance worse than prior to beginning filler injections. Your doctor will discuss the need for additional injections with you, including relevant factors such as your budget and schedule, the ways your body metabolizes and degrades the fillers over time, as well as your preferences regarding the degree of enhancement you continue to desire.

SUMMARY

In conclusion, a myriad of nonsurgical facial feminization procedures are available on the market today, many of which can provide safe, immediate, and drastic benefits to transgender patients. A variety of injectable products are widely accessible and can be used to achieve a broad range of aesthetic enhancements. Among these, cheek and lip fillers are popular injectable products that can be incorporated into longitudinal gender-affirming care at timepoints across the spectrum of  transition. Transgender patients who undergo facial feminization treatment report high levels of satisfaction with the effects, and most importantly, report increased confidence as a result of treatment.

Chapter 7 References

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Chapter 8: After FFS Procedures

Chapter Contributions: Nissim Hazkour BA

The spectrum of femininity and masculinity extends beyond the face. In this chapter, we will discuss various areas of the body and the respective qualities that can slide these areas along the stated spectrum of femininity and masculinity. We will review the anatomy and relevant physiology of these areas of the body, and discuss how they can play a pivotal role in portraying femininity or masculinity to oneself and to society. We are not describing these characteristics as beauty ideals, rather as guides for determining what features give a body a more masculine or feminine appearance. Differences across cultures, ethnicities, and ages will be analyzed, keying in on what we have recently discovered about the feminization spectrum across different demographics. The goal is to serve as an inclusive guide for the reader to better understand the personal features that may cause dissatisfaction with one’s appearance, in addition to the features that may cause societal misgendering, which is frequently experienced by the transgender community. Furthermore, this chapter includes an informative guide regarding the most effective, evidence-based gender affirmation procedures for various body areas, including the hairline, body silhouette, chest, hips, and buttocks. We hope to guide the reader through the aesthetics and details of bodily features, and how modifications of these details through procedures, such as hair transplant, breast augmentation, gluteal augmentation, and body contouring, can contribute to an increased sense of satisfaction with one’s self image.

This chapter concludes with an important discussion regarding voice and its impact on the perception of masculinity and femininity. The anatomy and physiology behind the creation of one’s voice will be explained, along with an overview of the history of societal norms associated with voice and the aforementioned feminine spectrum. The variety of voices across cultures, ethnicities, and ages will be explored, along with the specific problems different demographics of patients may encounter with regards to their voices. Voice changing surgery, or glottoplasty, will be discussed with a detailed overview of the steps of the operation. We will focus on the modifications made and how such modifications alter a patient’s voice to the desired point on the feminine spectrum. By the end of the chapter, we hope readers will feel they have gained a better understanding of their bodies, their causes for dissatisfaction, and the options and resources available to remedy these dissatisfactions.

Hair

Hair plays an important role in portraying the femininity or masculinity of one’s face. The main aspects of hair to consider in terms of the gender spectrum are the hairline and the distribution of hair throughout one’s body. As stated in previous chapters, the shape and height of the hairline can make a face appear more feminine or masculine; a hairline that begins higher up on the face is typically associated with masculinity. The higher, masculine hairline also tends to be defined in an “M” shape, colloquially referred to as the “widow’s peak”. The masculine appearing widow’s peak tends to become more pronounced with age as hair loss thins the crown and temporal region of the hairline disproportionately (seen in Figures 8.1-8.3). This type of hair loss, also called androgenic alopecia, is directly related to the hormone testosterone and it’s byproduct 5-dihydrotestosterone (5-DHT) which we gain cumulative exposure to as we age. 

This is important to note, as this knowledge regarding hair loss guides our discussions about hair with the transgender patient. It is important to gather information regarding patients’ personal and family histories, as hair loss can have hereditary causes. Nevertheless, the specific features that cause dissatisfaction for a patient is the main focus of the consultation.

In contrast to the masculine high widow’s peak, a lower hairline with a smaller forehead is considered to be more feminine. The feminine hairline tends to be less well defined and rounder in shape; it also tends not to change much as we age and experience hair loss. If anything, the feminine hairline tends to develop a minimal, off centered widow’s peak. Additionally, higher arched eyebrows give the eyes a more feminine appearance and the forehead a smaller appearance. A masculine eyebrow is less arched and wider horizontally. Together, lowering the hairline and raising the eyebrows work to create a more feminine front profile.

When treating transgender patients, the most common hair restoration procedures performed are hairline lowering procedures; facial hair restoration procedures, including eyebrow and beard transplantation and, less frequently, body hair transplantation are also done.

For patients who desire more feminine appearances to align with their identities, we recommend hairline lowering via hair transplant. This process will begin with a consultation, where the medical provider would explain the information described above. A thorough medical and family history would be taken, including hair loss and use of hormone therapy. This is critical as patients taking hormone therapy have a significantly decreased risk of potential future androgenic hair loss. It is optimal if the patient can bring photos that they feel physically represent their desired appearance. Once the patient and physician can properly conceptualize the desired result, the physician performs a physical exam in which the density of the hair, the height and shape of the hairline, and the extent of existing hair loss is determined. After the exam, the physician attempts to outline the desired hairline with a non-permanent marker. This is usually done by lowering the hairline and blunting the temporal areas, converting the more masculine “M” shape” into a soft, rounded heart-shaped design of the frontal region. Often a small widow’s peak is created slightly off center to better illustrate the heart shape. Rounding of the hairline is then performed along the frontal-temporal region, connecting to the temporal points. For the eyebrows, the patient is asked to fill in their desired shape with liner, along with providing the desired look via photography. In a joint effort, the physician and the patient will draw a symmetrical desired eyebrow with a nonpermanent pen, and the measurements of the brow are noted (length, width, midline separation).

Once the outline is agreed upon, the physician will decide which type of extraction technique will be used for the hair transplant procedure, based on patient preference and hair follicle quality. The two most common transplant techniques are the follicular unit extraction technique (FUE) and the strip technique. The FUE is the most commonly used technique; it involves either a two- or three-step method of extracting hair follicles from a donor site, usually a dense area of the head or body, without creating noticeable scars. This method focuses on extracting individual hair units in order to minimize scarring and maximize wound healing. This technique is slower, longer and more methodical than its strip-based counterpart. In exchange, the patient achieves the same results without a visible linear scar, which occurs with the strip method. FUE usually requires trimming the hair on the donor site of the head and/or body to very short lengths, in order to give proper visualization for extraction. However, with modern advances, there are now facilities that offer a non-shave FUE option, for those who are hesitant to cut their donor hair. For those who do not want to cut their donor hair, do not have non-shave FUE facilities nearby, and/or fail the test that measures the hair strength necessary for FUE, the strip method is a highly successful alternative. For patients planning to grow and wear their hair long, the strip method offers a faster yet equally successful option for transplant. This approach extracts multiple follicles at once from the donor site without the need for trimming beforehand; this results in quicker and less laborious procedures for patients. As a result, the patient will have a noticeable linear scar at the donor site that can usually be well camouflaged when the hair is grown out. This information will be conveyed to the patient, and a test-run of the FUE will be performed on a tiny patch of hair to see if the follicles are of satisfactory quality for transplantation. Based on the test results and patient preference, the extraction technique is determined.

Once the technique is decided and the outline is agreed upon, the physician traces the outline with a procedural marker, administers local anesthetic and an oral anxiolytic for the patient’s comfort. The procedure is done with the patient conscious and may take several hours. The extracted hairs are implanted using special implant devices within the outline, naturally mimicking the existing hairline’s directions and angles. The physician expertly chooses the proper density and number of hair placements throughout the outline in order to achieve the most natural-looking results. Patients are told to expect swelling for two days after the procedure. They are instructed on how to wash the hair and care for the grafts. Light washings are performed at follow-up visits.

Similar procedures are performed for patients who desire more masculine-appearing hairlines, often focusing on recreating the desired, sharp, and elevated widow’s peak. Other hair transplant procedures used to create a more masculine appearance are beard and body hair transplants. Similar to hairline recreation, beard and body hair transplant begins with outlining a desirable masculine aesthetic, based on patient preferences and chosen photography. Using FUE, donor hair follicles are taken from dense areas, often utilizing the head as a donor site for beards and transplanted within the accepted outlines. 

In summation, as hair distribution is critically tied to masculinity and femininity, hair transplantation procedures have gained understandable popularity in recent years. The spectrum ranges from the lower, less defined feminine hairline to the higher, sharply peaked masculine hairline. Where hair distribution falls on this spectrum can significantly affect a patient’s levels of identification with their overall appearance. Therefore, hair transplantation can further enhance gender affirmatory treatments for transgender patients.

Body Silhouette

Masculine and Feminine Body Anatomy and Silhouettes

It is crucial to consider the underlying anatomy when considering body contouring. There are key differences between the masculine and feminine body silhouettes. The traditionally idealized masculine body silhouette tends to have the following characteristics: It tends to have a more angular shape, a low waist to chest ratio which creates a desired V-shaped body, more muscle in the chest and upper back with minimal abdominal fat, and a toned abdominal wall with defined trunk muscles that makes the tendinous intersections visible.

The feminine body is defined by curves due to additional fat on the hips, buttocks, and thighs. The proposed determinants of feminine beauty include the waist-to-hip ratio (WHR), the body mass index (BMI), and curvaceousness. The ideal feminine WHR ratio, which divides the circumferences of the waist by the hips, is often accepted as 0.75. A BMI is calculated as body weight divided by the height squared (kg/m2). The BMI serves as an indicator of body fat and a range of 20-25 kg/m2 is considered normal. However, it is important to note that BMI does not take into account where fat is distributed on the body. Lastly, a curvaceous figure typically involves large breasts and wide hips with a smaller waist.

Fat distribution often differs in location by gender. Masculine bodies typically have higher fat concentration in the chest and central abdominal region compared to the extremities. Whereas, feminine bodies tend to deposit more fat in the thighs, hips, and pelvis. Hormones play a role in fat distribution differences. For example, the hormone estrogen is involved in the formation and break down of fatty adipose tissue. Research studies have found that increased levels of estrogen in adolescent females coincided with more subcutaneous fat deposition in the buttocks and thighs. Moreover, one study examined the physical characteristics of transgender women after cross-sex hormone therapy. The data showed that body fat in the trunk, legs, and hips increased by 18%, 27.4%, and 27.2%, respectively after 6 months of hormone therapy. The hormone testosterone enhances fat breakdown and inhibits fat uptake into adipose tissue. Testosterone also causes higher muscle‐to‐fat ratios, creating what is accepted as a more masculine body appearance.

Contouring Procedures

There are various procedures for body contouring. Non-surgical body contouring procedures aim to break down fat through injections, lasers, and ultrasound waves. Injection lipolysis destroys fat cells with a chemical called deoxycholic acid. Lasers direct heat to fat in a specific area to the point of irreversible damage. Lastly, high frequency ultrasound waves break fat cells down in the skin. These dead fat cells are then cleared away by the body’s lymphatic system. Surgical options for body contouring include liposuction for fat deposit removal and other procedures, such as breast augmentation or reduction, abdominoplasty (tummy tuck), and arm or thigh lifts.

Liposuction

Liposuction is a procedure that removes adipose tissue in targeted areas of the body.  The procedure is effective in contouring body shape in the thighs, arms, abdomen, buttocks, and waistline.

Preoperative Process

The preoperative process for liposuction starts with a consultation with a surgeon to discuss the patient’s expectations and goals for the procedure. A physical examination allows the surgeon to examine the body for asymmetries and identify the locations of fat deposits. Also, examining the patient’s skin quality is an important step; if the skin is excessively loose, liposuction can cause contour irregularities, voids, and/or abnormal appearances. For patients with a BMI over 30, rewarding postoperative results can be more difficult to obtain due to increased amounts of fat. The presence of a hernia is also a contraindication for the procedure due to the risk of recurring or worsening herniation. It is standard practice to obtain professional photographs of the patient’s treatment area for assessment before and during surgery.

Tumescent liposuction is one of the most common types and involves fluid injection into the treatment area before fat removal. The fluid is a mixture of local anesthetic (lidocaine) and an intravenous (IV) salt solution which improves fat removal. The fluid also contains epinephrine, which contracts the blood vessels, minimizing the loss of blood, bruising, and swelling.

Once surgical incisions are made in the treatment area, a cannula system is employed. The cannula tip is perforated with small holes. Constant cannula movement in a “windshield wiper” type motion breaks up the fat. A vacuum device is attached to the cannula and suctions body fat through the cannula holes, which travels to a clear canister.

Fat Grafting

Fat grafting is a procedure that involves reinjecting fat tissue harvested by liposuction. The collected fat is separated from the body fluids using a centrifuge. The Coleman technique is often used, in which small amounts of fat (0.3 mL) is delivered in a grid-like fashion at multiple depths. Larger fat injections can lead to fat death, calcification, and oil cysts. Therefore, this technique maximizes the contact between the fat and body tissue.

Postoperative Care

After the procedure, a compression garment must be worn at all times for two weeks, and then only at night for the following two weeks. Following surgery, the compression dressing can be changed after three to four days. Full activities can be resumed after three to four weeks. The healing process is complete once the swelling and bruising subsides. It can take up to three to four months to visualize the final contour.

Liposuction permanently removes fat cells from the body. Fat cells do not regenerate in the area where liposuction is done, nor do they move to another area of the body. However, patients should strive to remain within their post-surgery weight range. If weight is gained, some areas may become bigger as your body finds places to store the acquired fat.

Procedural Risks

Adverse effects include redness at the entry site as well as bruising, swelling, mild tenderness, and drainage from the insertion sites. Patients should be informed that bruising and swelling can persist for weeks. Ice packs, acetaminophen, and ibuprofen can be very effective for managing these symptoms. Safety considerations are paramount because a large volume of blood is simultaneously removed with the fat during liposuction. Removing too much blood can cause body fluid to shift into the extracellular spaces (outside of cells), limiting transport of nutrients and fluids to cells. These fluid shifts can lead to decreased blood pressure or hypothermia. Therefore, patients should be monitored and given intravenous fluids as needed.

Shadow and Light in Contouring

Sculpting procedures require attention to the shadow created by the masculine and feminine form. By removing more fat in any body area, there is less surface for light to illuminate. Therefore, the shadow surrounding the area is augmented. Conversely, creating convexity by transferring fat adds more surface area for light to shine on. These negative spaces, where fat has been removed, appear darker, whereas positive spaces, where fat has been added, receive more light and are brought to the attention of viewers. Masculine body contouring takes advantage of these optical rules. Fat grafting, contours, augments, and highlights the muscular fullness that is often desirable in the chest, upper arms, and back. For a more feminine look, the buttocks and breasts frequently require augmentation. Removing fat in areas directly surrounding the breast increases the negative space between the breast tissue and rest of the chest. When there is less fat and more shadow, there is more contrast which enlarges the appearance of the breast. Thus, creating these shadows improves the illusion of fullness and curvaceousness.

Chest

Along with the face, the chest is perhaps the most outward expression of gender identity in social contexts. The aesthetic of a feminine or masculine chest is a vital component of gender affirmation, with many patients reporting significant dysphoria due to the chest anatomy associated with their gender assigned at birth. Studies have demonstrated that up to 94% of transmasculine youth consider chest surgery as vitally important in affirming their gender identities and a near 0% rate of postoperative regret. Given this, it is no wonder that procedures of the chest are often the first performed for transgender patients. The ideal chest is ultimately an individual preference, yet classically, a feminine aesthetic includes a greater volume of breast tissue with more rounded contours, whereas a masculine aesthetic involves a lower volume with more squared contours. Gender affirmation procedures of the chest generally attempt to follow these basic principles.

The female chest is composed of breasts overlying the pectoralis muscles, with breast tissue extending from the clavicles (collarbone) to the sternum. The breast is composed of two main tissue types, adipose and glandular tissue. The appearance and mobility of breasts are also anatomic characteristics. The inframammary fold is the area between the lowest part of the breast and the chest, and determines the size of the breasts. The retromammary space is the area between the breast and the underlying pectoral muscles, and is responsible for breast mobility. The visual appearance of the nipple varies widely by individuals but is typically larger in females than in males. Breast augmentation procedures for transfeminine patients seek to recreate these characteristics in order to produce a natural aesthetic.

Prior to beginning the process of top surgery, there are a few steps that are recommended to ensure an ideal outcome. A presurgical medical history, physical examination, and appointment for blood work is critical in detecting any possible underlying medical conditions, which may need to be managed prior to surgery. Hormone therapy is often endorsed as it encourages the body to produce a natural increase in breast tissue, which ultimately improves the aesthetic outcome of augmentation procedures. An honest and candid conversation between the patient and the physician regarding expectations for surgery and beyond is critical. It is in this conversation that patients may present their preferences for breast shape and size and that the physician may communicate the ability to deliver the desired result. Once the patient and the physician are in agreement, they may proceed next to surgery.

Given that the preoperative chest usually has less breast fat and glandular tissue, a larger implant may be required to achieve the desired breast size. The nipple is also often more laterally positioned for the transgender breast than the cisgender breast, which can result in increased distance between the areolae following breast augmentation, although this can be corrected with additional procedures. The placement of the implant can be in two planes of the body: either behind the glandular tissue but in front of the pectoral muscles, or behind the pectoral muscles. To avoid “rippling”, or visible show, of the border of the implant, the ideal approach is to place the implant behind the muscle. However, this can be challenging in patients with increased pectoral muscle mass, as this can result in a wider distance of the breast base. The ideal placement of the implant and the possible aesthetic compromises should be discussed with the patient in depth prior to the procedure. The placement of the implant itself can be done through the armpit (axillary), below the breast (inframammary), or under the nipple (subareolar), though this last approach can be more difficult in transgender patients due to preoperative anatomy. Postoperatively, the patient and the physician should establish regular follow up appointments to monitor for complications, such as wound opening (dehiscence), subcutaneous collections of blood and fluid, and migration of the implants.

Hips

Basic Anatomy and Aesthetic of the Feminine/Masculine Hip

What is commonly referred to as “the hip” is anatomically made up of the thigh bone, or femur, and the pelvis. The ilium, ischium, and pubis bones make up the pelvis, which is one of the greatest differentiators between masculine and feminine skeletal anatomy. Feminine hips tend to include shorter, wider pelvises and lower iliac crests. They also have wider, more ovular pelvic inlets to accommodate the birthing process, as compared to the narrower, more heart-shaped inlets typically found in masculine hips. The underlying bone structure is one factor in determining an individual’s overall hip shape.

Soft tissue, like fat, which sits on the exterior of the pelvic bones, is another differentiating factor. Compared to testosterone, increased estrogen exposure tends to encourage fat deposition around the thighs, hips, and buttocks. This lends feminine hips a rounder overall shape, a greater lateral width and projection in the posterior direction.The opposite occurs in hips exposed to higher testosterone levels, which consequently carry fat tissue primarily in the waist and abdomen. Masculine hips tend to have a flatter projection and a more square, muscular shape.

As people age, especially during puberty, exposure to these hormones increases, which causes anatomical hip differences to become more pronounced. One way to quantify this difference is by measuring the WHR, which compares the circumference at the thinnest part of the trunk, typically over the iliac crests, to the circumference at the widest part of the hips, around the greatest projected area of the buttocks. A low WHR, around 0.7, is associated with an hourglass figure, whereas a ratio around 0.9 is considered more masculine. These ideals have remained fairly consistent in western culture over time, despite differences in ideal figures throughout the years.

While hormone therapy can direct fat deposition to a desired area, it is nearly impossible to modify the underlying hip bone structure after puberty. If a transition is undertaken after puberty and/or hormone replacement therapy is insufficient to achieve the desired hip shape, surgical interventions, such as gluteal augmentation, may be considered. Increasing the posterior direction of the buttocks will consequently lengthen the hip measurement, shifting the WHR toward a more typically feminine ratio.

Gluteal augmentation

Buttock or gluteal augmentation is a surgical procedure undertaken to alter the contour, size, and/or shape of the buttocks. This is typically achieved by implantation of a solid silicone piece and/or fat grafting. According to the American Society of Plastic Surgeons, the latter is far more frequently performed, with 95% of all augmentation procedures performed by fat grafting in 2020.. As both procedures can accomplish reshaping of the hip and buttock areas to a more feminine shape, we will discuss their respective benefits and risks in the following sections.

Gluteal Implantation

Gluteal implantation surgery requires a pre-operative consultation. During this meeting, the surgeon will work with the patient to determine the best course of action considering the patient’s goals, anatomy, current health status, and prior medical history.

Of major significance is the patient’s existing anatomy, including the length of buttocks, amount and quality of fat around the hips, and overall quality of the skin. There are two main implant shapes: oval and round. As a general rule, those with longer buttocks may benefit from an oval implant over a round implant, which is more suitable for those with shorter buttocks. Analysis of these variables, sometimes referred to as biodimensional analysis, will guide the choice in size, shape, and placement of the implant. Sizers offer a temporary approximation of the final result and further ensure an appropriate decision. Surgeons also frequently provide before and after results from previous patients.

Candidates for gluteal augmentation must be in relatively good health, have a healthy weight (BMI <30 kg/m2), and not use insulin for the treatment of diabetes. It is also imperative that candidates possess enough soft tissue to support the implant. This prerequisite typically only presents difficulties for very lean patients.

Before surgery begins, markings denoting the implant placement are made with the patient in the upright position. During augmentation, the patient is placed on the surgical table in the prone (face down) position. Bolsters are situated under the hips and chest for comfort and to improve the ease of access to the buttock area. Generally, anesthesia is administered through IV or epidural to ensure the patient doesn’t experience discomfort. As some procedures may last more than three hours, a catheter may be placed as well.

Current surgical guidelines suggest that the surgeon begins with a single vertical incision above the intergluteal cleft. The surgeon then should insert the implant, either subfascially or intramuscularly. In subfascial insertion, the implant is placed on top of the gluteal muscles and beneath the overlying tissue. This method allows for larger implant insertion and greater outward projection, particularly in the lower area of the buttocks. However, it also carries a higher risk of visible superficial contour deformities, as the implant lies closer to the surface. Intramuscular implants are placed within the gluteus maximus muscle. Because there is less space in this area, implants inserted using this method must be smaller. It is also typically accompanied by a slightly longer recovery period. However, the strong muscle tissue tends to hold the implant in place better than the subfascial tissue that lies above the muscle, decreasing the chance of the implant displacing to a suboptimal position. Furthermore, there are seldom visible contour deformities with intramuscular implants. Deciding which method to use will ultimately depend on the patients’ goals, anatomy, and the surgeon’s procedural expertise. Following implantation, the incision is then closed with multiple layers of sutures.

Common complications regarding aesthetic implants include implant displacement and capsular contraction. Implant displacement often occurs due to contraction of the muscles, which “squeeze” the implant out of place. A similar mechanism of action can occur with scar tissue around the area of the implant, as is the case with capsular contraction. Incidence of these complications increases with larger implants and subfascial insertion. Choosing the right implant size and shape, based on individual body dimensions, reduces such risks.

Seroma and wound dehiscence are additional complications associated with implantation surgeries. Exact causes of seroma, or the accumulation of fluids in the area operated upon, are unclear, though the use of a drain to allow fluid removal during surgery helps minimize its occurrence. Dehiscence is the separation of a surgical incision after closure and is not exclusive to implantation surgeries. The risk of dehiscence is minimized by practicing proper wound care and maintaining general healthy practices, like limiting smoking, controlling blood glucose levels, and by choosing an appropriately sized implant.

After surgery, patients are required to wear compression garments for approximately three to four weeks, as is common with most plastic surgery augmentations. For those three weeks, sitting is strongly discouraged. Strenuous activity is not recommended for at least eight weeks. It is also important to note that the implants are a long-term solution, but not a permanent one, as implants should be replaced approximately every ten years.

Gluteal Fat Grafting

Gluteal fat grafting aims to achieve a more feminine shape by removing fat from the flank, thigh, and sometimes trunk and arm areas, and inserting it into the buttocks. This technique may be especially attractive, as fat removal from the waist area further enhances the femininity of the silhouette by simultaneously decreasing the waist circumference and increasing the hip circumference.

This procedure will require a similar preoperative consult to gluteal implantations. During the consultation, the physician will determine if a patient has adequate fat mass to achieve their desired look, and if so, where the fat mass should be taken from. This is an especially important consideration in the transgender population, as some patients may not have the necessary fat volume to create more feminine silhouettes. Due to this limitation, a larger proportion of transgender patients (33%) choose gluteal implantation compared to cisgender patients (5%). However, gluteal fat grafting is still the augmentation method of choice for two-thirds of all transgender patients.

For the operation, the surgeon will mark the gluteal area in the standing position before beginning surgery. Epidural or general anesthesia and prophylactic antibiotics are commonly given, and the patient is operated on in the prone position as previously described. Liposuction is performed first. During this part of the procedure, fat is removed from the donor area using a thin cannula. The fat is then purified by removing any dead cells, extra fluid, and debris in the centrifuge. The surgeon then re-injects the purified fat cells into the marked areas of the buttocks. In most cases of fat grafting, there is no need for drain insertion.

Follow-up care  includes wearing a compression garment and avoiding sitting and strenuous activity for up to two months. During this post-operative period, the patient should be prepared for significant fat reabsorption, during which up to half of the transferred fat can be absorbed back into the body, significantly decreasing the newly acquired volume. However, this will be addressed pre-operatively and the surgeon will account for such losses in the initial plan, usually by overfilling the area.

Fat embolism is among the most serious complications of fat grafting. It occurs when gluteal blood vessels are damaged, allowing fat to leak into the bloodstream, where it can travel to the heart or lungs. This led to the American Society of Plastic Surgeons recommending that all fat grafts be placed on top of the muscle rather than inside it, to avoid potentially damaging the muscle vasculature. Although the risk involved in surgical procedures is never zero, using this technique greatly minimizes the risk of fat entering the vasculature. Fat grafting is similarly expensive to buttock implants. However, the fat that remains can create permanent results for the patient, though some patients require touch-up procedures in the following years.

Despite gluteal augmentation procedures being relatively new, their popularity is growing exponentially. As with any plastic surgery procedure, it is imperative to consult a board-certified plastic surgeon. Choosing an experienced physician will help mitigate the possible complications associated with gluteal augmentation. Despite such risks, gluteal augmentation, through an implant or fat grafting, can be extremely effective at reducing dysphoria in the hip area, through a simultaneous decrease in the WHR and increase in the femininity of the overall silhouette. For many individuals transitioning, it is a rewarding, feminizing, and gender affirming procedure.

Voice

Our voice is our primary means of communication, through which we convey emotions, thoughts, opinions, and personal information that reveals our underlying identities. It is highly unique to each individual and often serves as a reliable identifier. Oftentimes, a single word is all you need to recognize a familiar voice.

Rooted in societal norms, voices have historically been perceived to have gender associations. For example, vocal femininity is often characterized by higher frequencies, greater variability in tone, and greater breathiness, with a softer and more rhythmic articulation in comparison to more masculine vocal behavior. In addition to gender, voices can reveal the relative age of a speaker as acoustic parameters greatly change with chronic usage. With increasing age, the vocal folds become stiffer and thicker, contributing to decreased voice quality, instability, decreased frequency, and reduction in articulatory precision. While we may not be aware of these differences that come with age, we learn to draw these associations through increased interaction with elderly populations, young children, and adults. We can even go so far as to say that voices can clue us in to the ethnicity or race of a speaker, albeit not always accurately. Some studies have reported differences in fundamental frequency, shimmer, harmonics-to-noise measures, and varying degree of prevoicing between different ethnic groups. While these differences have yet to be investigated further, one can certainly understand that simply being brought up in a household with a similar cultural background can lead to mimicry of the overall usage of vocal apparatus.

Voice alteration is an imperative component of the feminization process. A voice that is incongruent with one’s self-identity can serve as a limiting factor for complete gender affirmation. It can impact body dysphoria and contribute to a decline in mental health, resulting in avoidance behaviors and low quality of life. A 2020 study published in the Journal of Voices demonstrated that 58.3% of women with vocal inconsistencies had more symptoms of anxiety and depression. These findings indicate a need to address this issue by offering medical intervention in return for higher quality of life. While desired vocal results can be achieved with non-invasive voice therapy, some individuals do require vocal surgery, which involves anatomical alteration of the vocal cords. This procedure is termed “glottoplasty”, and will be elaborated on later in the chapter. For now, we will elucidate the basic mechanics and anatomy that underlies the spectrum of feminine and masculine voices.    

The production of sound originates in the neck, more specifically in the larynx, which houses the vocal folds. The lungs conduct airflow through one’s throat down to the larynx, where the vocal folds constrict and modulate airflow to produce specific sounds. Typically, voices that are perceived to be more feminine not only differ in frequency and resonance, but also in the underlying anatomy of the voice box. For example, vocal cords that are typically associated with feminine voices are on average 11-15 mm in length while those associated with masculine voices are 17-21 mm in length. The sounds produced by the vocal folds are adjusted via laryngeal muscles, which stiffen, deform, and reposition the vocal cords to produce varying pitch, loudness, and quality of voice. While the anatomy of the vocal folds largely determines the quality of the sound produced, the adjustments that are made by the individual also play a role in the overall outcome of sound.

Vocal differences also tend to arise when sex hormones are released to drive further maturation and development. Vocal folds that are exposed to more testosterone become longer and thicker in comparison to their feminine counterparts, which is why they tend to vibrate more slowly. Additionally, the vocal tract length, or the length between vocal folds and lips, tend to be longer in biological males, which contributes to the lower resonant frequencies they produce. Generally, voices deemed more feminine tend to have vowel and consonant noises run at higher mean fundamental frequencies, roughly 200 Hz compared to 120 Hz for less feminine voices. Feminine voices are also considered to be more breathy.

Our brains process external information based on pattern recognition and grouping. Our minds build prototypes of things we encounter frequently as a way of sorting and storing information; these prototypes are called schemas. Over hundreds of years, our schemas of femininity have included high frequency voices as one of most dominant components. Thus, when we hear higher frequencies of voices, we often associate them with femininity, while lower frequencies are associated with perceptions of masculinity.

As mentioned before, these anatomical differences can be overcome with non-surgical interventions in a form of voice therapy. Patients can work with speech-language pathologists to audibly reaffirm their gender identities. This approach requires work on speed, inflection, resonance, and overall communication. It should be noted that vocal therapy tends to be more effective in patients who are on testosterone as a form of hormone replacement therapy (HRT).

Testosterone tends to lower the pitch of voice production. On the other hand, estrogen does not serve the same counter effect, making the process of feminizing the voice more challenging. It is important to note that the masculinizing effect of testosterone therapy on vocal folds is influenced by a number of variables, such as age of hormone initiation, duration of therapy, and original voice pitch. Nonetheless, most of what makes a voice feminine has little to do with frequency and pitch; if the right alterations are made regarding resonance, articulation, breathiness, and intonation, a voice can be trained to portray femininity. However, such alterations involve a certain level of awareness and voluntary control, which is why uncontrolled situations such as laughter, sneezing, crying, and yawning can lead to transient regression.

Glottoplasty is one of the most successful vocal feminization procedures, first introduced by Wedler in 1990. Patients who do not see satisfactory improvement after management with vocal therapy can become candidates for this procedure. Glottoplasty is a procedure which features an endoscope, a flexible tube with a camera and a light attached to it, used to navigate the oral cavity. The procedure involves thinning out the vocal cord tissue, followed by suturing the frontal portion of vocal cords. During surgery, patients are typically put under general anesthesia, in order to ascertain that patients do not feel or consciously experience anything. The patients are then intubated with an orotracheal tube to maintain their airways. Vocal cords are initially thinned out using curved micro scissors at the frontal third portion of the vocal cords. The thinned portions of vocal cords are then sutured together (Figure 8.13). By suturing and reducing the length at which vocal folds can vibrate, surgeons effectively increase the frequency of sound production, providing a feminizing effect. Post-operatively, patients are instructed to remain in an absolute vocal rest for fourteen days and a less strict vocal rest for another fourteen days after. Daily exercises are also encouraged as part of the vocal rehabilitation program. In combination with vocal rest and daily exercise, patients are prescribed proton pump inhibitors (PPI), antitussives and antibiotics. PPIs decrease stomach acid production and prevent the backflow of acid toward the vocal cords, antitussives suppress coughing episodes, and antibiotics fight off bacterial overgrowth. The average time period needed to gain a fully feminized voice ranges from six to twelve months, but the results are long lasting and do not interfere with breathing once healed. As with any procedure, there are minimal risks of complications, which include unpredictable healing, instability, and worsening quality of voice. Adhering to the post-operative protocol is of the utmost importance to minimize these risks and achieve optimal results.

Conclusion

Our voice is more telling of who we are than we realize. It is a window into our sense of self, our values, our temperament, and our emotions. Accordingly, voice alteration is one of the most pivotal steps in the feminization process that is made feasible by the glottoplasty procedure. Vocal feminization surgeries enable communication patterns and behaviors that are in accordance with one’s self identity, making considerable strides in patient satisfaction and mental well-being.

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