Facial feminization surgery

Facial feminization surgery includes a range of procedures that change the shape of the face to look more feminine. The surgery can change the look of the cheekbones, brow, lips, jaw and chin. It may include hair transplants or moving the hairline to make a smaller forehead. Skin-tightening surgery, such as a face-lift, might be involved too.

Facial feminization surgery may be done to help treat distress that can happen when a person's gender identity differs from the sex assigned at birth or from sex-related physical features. This condition is called gender dysphoria. Facial feminization surgery can help better align facial features with a person's gender identity.

Many facial features, including the jaw, brow and chin, reflect sex differences. While other body parts can be covered or hidden, facial features are easy to see. For some people who have a gender identity that differs from the sex assigned to them at birth, changing facial features is an important step in affirming their gender.

Some risks linked to facial feminization surgery are the same as the risks of other types of major surgery, including:

• Bleeding.
• Infection.
• Injury to parts of the body close to the surgery site.
• A bad reaction to the medicine that puts you to sleep, also called anesthetic.

Other risks of facial feminization surgery include:

• Scars on the face.
• Facial nerve injury.
• The area where a cut was made during surgery, called an incision, coming apart. This is called wound dehiscence.
• A buildup of fluid under the skin. This is called a seroma.
• A solid swelling of clotted blood within tissues. The medical term for this is a hematoma.

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in facial feminization procedures. Every person has a unique facial structure. Talk with your surgeon about your expectations and goals for the surgery. From that information, the surgeon can suggest procedures that will be most likely to meet those goals.

The surgeon also may give you information on details such as the type of anesthesia that will be used during surgery. Talk with your surgeon about the follow-up care you may need after surgery.

Follow your healthcare team's directions on getting ready for surgery This often includes guidelines on eating and drinking. You may need to make changes in the medicine you take. You also may need to stop using nicotine, including vaping, smoking and chewing tobacco.

You might need a CT scan before surgery to help with surgery planning. The scan can give your surgeon detailed information about your face structure. A member of your healthcare team likely will take photos of your face before surgery too.

Consent

Facial feminization surgery might cause changes that can't be changed back. Because of that, you must give your informed consent for the surgery. Before you give consent, have a detailed conversation about the following with your healthcare professional:

• Risks and benefits.
• Cost.
• Treatments you could have instead of surgery.
• Possible health problems that could come from the surgery.
• The possibility that you may need more surgery to correct problems or to get the results you want.
• Changes from the surgery that can't be undone.
• The social and legal effects surgery could have on your life.

Evaluation for surgery

Before surgery, a healthcare professional checks for medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. You also may have a behavioral health evaluation with a healthcare professional who has expertise in transgender health. These evaluations help ensure that you'll have support for your daily needs, wound care and emotional health after surgery.

Other considerations

Health insurance coverage for facial feminization surgery varies widely. Before you have surgery, check with your insurance provider to see what's covered.

Before surgery, you might want to talk with other people who have had facial feminization surgery. If you don't know someone, ask your healthcare professional about support groups in your area or online resources you can trust. People who have had these surgeries may be able to help you set your expectations and goals for the surgery.

During the procedure

Facial feminization surgery might include:

• Forehead contouring. In men whose gender identity aligns with their sex assigned at birth — also called cisgender men — the bony ridge above the eye sockets tends to be bigger than that of cisgender women. In cisgender women, the forehead tends to be higher, smoother and more rounded. To make the forehead look more feminine, part of the forehead bone can be taken out, reshaped and put back into place.
• Eye and eyelid changes. Cutting away extra eyelid tissue may make the eyes look more feminine. This surgery is called blepharoplasty.
• Cheek augmentation. Cisgender women tend to have round cheeks in the middle of their faces. For a more feminine look, implants may be placed in the cheeks. Or the surgeon might take fat from another part of the body, such as the belly or thighs, and put it in the cheeks. Sometimes this surgery also involves moving the cheekbones to a different position.
• Nose reshaping. This surgery is called rhinoplasty. It may include making the nose smaller and changing its shape and angles.
• Lip changes. Cisgender women tend to have a smaller space between the base of the nose and the upper lip. Cisgender men tend to have longer upper lips. A lip lift can shorten the distance between the lip and the nose. It also can make a shorter, more curled lip. Lips can be made bigger with implants or fillers. That also may be done by taking fat from another part of the body and placing it in the lips.
• Jaw angle changes. The jaw can be made smaller and narrower by removing outer layers of bone from the lower jaw.
• Chin width reduction. To shorten and narrow the chin for a more feminine look, the surgeon makes a horizontal cut along the chin bone. A small wedge of bone is removed. Then the chin bone is put back in place.

Other head and neck surgeries to create a more feminine look include:

• Tracheal shave. This procedure also is called thyroid cartilage reduction or chondrolaryngoplasty. It makes the thyroid cartilage, also called the Adam's apple, smaller. A small cut is made under the chin. It's usually in the shadow of the neck or in a skin fold to hide the scar. During surgery, the surgeon takes some of the cartilage out and reshapes what's left.
• Hair transplantation. In this procedure, hair follicles from the back and side of the head are removed and transplanted to balding areas of the head and the temples.
• Lowering the hairline. During hairline-lowering surgery, a cut is made at the edge of the hairline. Then the scalp is moved and fixed to bone lower on the forehead. Extra forehead skin is removed.

You also might consider skin-tightening surgery, such as a face-lift or other similar treatments.

After the procedure

After surgery, you likely will have pain, redness and swelling in your face. These symptoms usually are most noticeable in the eyes, nose, jaw and chin.

Follow the directions your care team gives you about what you can and can't do after surgery. People who have facial feminization surgery usually need to rest and recover for about one month. After that, most people can return to their usual routines. But talk to your healthcare professional if you have questions about activities after surgery.

It might be hard to chew and swallow right after the surgery due to stitches and swelling. Your surgeon may suggest that you see a dietitian to make sure you get the nutrients you need. A healthy diet is an important part of recovery.

During your recovery, it may be helpful to talk with a mental health professional who specializes in gender-affirming care. That professional can support you and work with you as you adjust to physical, emotional and social changes after surgery.

You might not see the full and final results of facial feminization surgery for about a year. During recovery, schedule follow-up appointments with your care team. At those appointments, your healthcare professional can check your healing and talk with you about concerns or questions you have.

If you are not happy with the results of the surgery, you may need another surgery to make more changes to your face. You also might need more surgery if your facial features look out of balance after you've fully healed.