Facial Feminisation Surgery

What is facial feminisation surgery?

Facial feminisation surgery (FFS) is a group of surgical procedures that reshape masculine facial features to create a more feminine appearance. It's carried out almost only for trans women and others who are transfeminine, usually as part of a wider transition.

What does facial feminisation surgery treat?

Feminising hormone therapy can change the face by redistributing fat, but it can't reshape the bones underneath, things like a heavy brow bone, a broad nose, or a large chin and jaw.

Where this gap between someone's appearance and their gender identity continues to cause gender dysphoria, facial feminisation surgery aims to address the bone and soft tissue that hormones alone can't change.

What are the benefits of facial feminisation surgery?

Research points to facial feminisation surgery leaving trans women better off day to day, with less gender dysphoria and few complications along the way.

Studies comparing trans women who'd had facial feminisation surgery, gender-affirming genital surgery, both, or neither, found that those who'd had no surgery at all scored worse on measures of mental health tied to overall quality of life.

Feminising the top part of the face, the forehead, brow and hairline, tends to shift how someone's gender is perceived by others considerably more than changes lower down, around the jaw or midface.

Are there different types of facial feminisation surgery?

Facial feminisation surgery isn't a single operation. It's a set of procedures, and a surgeon works with each person to decide which ones fit their face and priorities. These typically include:

• Hairline and forehead: Moving the hairline forward and rounding its shape, sometimes with a hair transplant, alongside smoothing or rebuilding the brow ridge (the bone above the eyes)
• Eyebrows: Lifting the eyebrows to sit above the brow ridge, which is typical of a feminine face
• Nose (rhinoplasty): Removing bone and cartilage and reshaping what remains, since male noses tend to be larger, longer and wider
• Cheeks: Reshaping the cheekbones and adding volume, using implants or the person's own fat, for a fuller, more defined cheek
• Lips: A lip lift, shortening the distance between the nose and upper lip
• Chin and jaw: Reducing the length and width of the chin, and narrowing the jaw, sometimes including the jaw muscle as well as the bone
• Adam's apple: Reducing the thyroid cartilage at the front of the neck (a procedure called chondrolaryngoplasty).

What happens before facial feminisation surgery?

A letter from a mental health professional confirming that the surgery is needed to ease gender dysphoria is generally required first, in line with current guidelines. Surgeons often use imaging, such as a CT or MRI scan, to map out the facial bones and plan the procedures in detail.

More broadly, gender-affirming surgery in the UK generally isn't considered until someone has spent a minimum of twelve months living and being treated as their affirmed gender. Outcomes also tend to be better where you:

• don't smoke
• lose weight if your BMI is 25 or over
• have had hormone therapy already, where relevant to the procedure
• keep any long-term health issues, like diabetes or raised blood pressure, well managed

What happens during facial feminisation surgery?

1. You're given a general anaesthetic, since several procedures are usually carried out together in a single operation
2. Your surgeon makes incisions in places designed to stay hidden, such as inside the hairline or inside the mouth
3. Bone is reduced, reshaped, or built up using techniques suited to each area, for example grinding down or rebuilding the brow ridge, or repositioning the chin
4. Soft tissue procedures, such as an eyebrow lift or a lip lift, are carried out alongside the bone work where needed
5. Incisions are closed once all the planned procedures for that operation are complete.

What are the risks and complications?

Risks vary depending on which procedures are carried out:

• Forehead and brow surgery: The skull failing to heal cleanly, fragments of bone moving out of place, or a cyst forming, though a follow-up operation can generally put these right
• Cheek surgery: Infection, or an implant shifting and becoming uneven; fat used to add volume may gradually be reabsorbed by the body over time
• Chin and jaw surgery: Harm to the nerve threading through that part of the face, plus a chance of harming tooth roots, infection, the bone failing to fuse, or affecting the muscle that moves your lower lip
• Nose surgery: A chance that a smaller nose affects the nasal valves, the structures that help you breathe through your nostrils
• Adam's apple reduction: A chance of harming the vocal cords, or unsettling the epiglottis (the flap of tissue that protects your airway when you swallow).