What is Facial Feminization Surgery?

From a technical point of view, FFS can be defined as the set of surgical procedures associated with different surgical specialties (Oral and Maxillofacial Surgery, Craniofacial Surgery, Plastic and Reconstructive Surgery) designed to soften and modify primary and secondary facial features perceived as masculine, exaggerated or non-harmonic, and which, therefore, are decisive in the visual identification of facial gender.[5]

The effect of testosterone and its derivatives, particularly during puberty, conditions the appearance of facial features related to gender identity, which can be divided into primary and secondary aspects. Primary aspects – those features determined by the development of the craniofacial skeleton – differentiate the masculine and feminine craniofacial structure in significant ways. Generally speaking, the male facial skeleton has greater bone volume and some well-defined features that distinguish it from its female counterpart. In general, the three basic pillars of craniofacial gender are the frontonasoorbital complex (forehead and eye orbit area), the nose, and the jaw and chin complex. However, other structural elements, including the cheeks or the trachea, are also important when addressing a patient’s feminization needs.

In addition to structural facial features, a series of secondary traits or secondary facial features are equally important in the identification of facial gender. These include, most notably, the hair and hairline pattern, facial hair and skin texture, and the distribution and volume of facial fat.

The development of the structures described above under hormonal influence is not reversible, and thus these features, which determine a significant part of an individual’s facial gender, can only be approached and modified using surgery, always respecting the intrinsic architecture and anatomy of the craniofacial skeleton.

Although both the primary and secondary facial features are decisive in the visual identification of facial gender, it is important to bear in mind that FFS is not cosmetic surgery and should not be mistaken as such. However, they do overlap to some degree and that can cause a great deal of confusion for patients. So, what is feminization? Facial feminization is based on bone surgery and the readjustment of the overlying soft tissues. Especially in older patients, the soft tissue may be too slack to readapt fully to changes in the jaw and chin area. In these cases, surgical adjustment (lifting) of the soft tissues may be required. This type of adjustment should not be undertaken at the same time as the jaw and chin surgery, but should be done several months later when the swelling from the jaw and chin surgery has subsided.

Facial Feminization Surgery (FFS) in society

Many negative stereotypes and prejudices exist about the transgender community, which is met with an attitude that ignores the true underlying question of gender identity. Trans people want to be recognized for themselves, to live in the gender identity they choose and not the sex assigned to them at birth. They may experience significant psycho-emotional stress, which can be aggravated by societal misunderstanding, rejection and discrimination. Fortunately, political and legislative steps are beginning to be taken, although substantial progress needs to be made before full social acceptance is reached. On 22 April 2015, the Parliamentary Assembly of the Council of Europe approved by an absolute majority a general resolution on the human rights of trans people.[6] In it, the Assembly calls on its member States to respect, protect and enforce the rights of trans people, including the right to non-discrimination and the right to quick, transparent and accessible legal gender recognition. Furthermore, the Resolution asks the States to make Trans healthcare models accessible to this group, including reassignment treatment as part of the public health system.

The complete integration and recognition of all people on the gender spectrum with full rights is one of the latest battles in the fight for human rights. An analogy can be found in the social rejection experienced by AIDS patients in the early 1980s, the fight to control this illness and perceptions about it today. Transgender healthcare must begin to adhere to protocols that cover any and all possible fields of action (psychological, paediatric, endocrinological and the distinct surgical disciplines). Medical attention for gender identity issues does not need to be a marginal field, but rather may be placed within the existing networks of healthcare disciplines. There is still a long way to go before this goal is reached. The next step is to further work to raise public awareness, educate society, and depathologize the status of transgender patients, as well as train professionals in the field.

The protocol for trans health already has some well-established steps, such as the importance of taking a psychological approach and the need for appropriate hormone therapy. Up to current times, undisputed concepts such as the importance of genital reconstruction in this protocol (which belongs to the individual’s private sphere), have started to give way to more important underlying questions like the role of facial gender confirmation in patients who are going to play a gender role in society different to the one they were born with. These patients all around the world are increasingly beginning to request surgical modification of their facial gender although, unfortunately, they often cannot find centres which appropriately meet their needs.

It is impossible to estimate the number of transgender people in the world. The main difficulty lies in finding a reliable case study, due to the fact that most publications that have tried to establish these numbers have based their estimates on the number of diagnosed patients who have sought some kind of gender confirmation treatment; not included is the large number of patients who have not been diagnosed or sought treatment.[7] This article hopes to serve as a reference point, for those who seek to learn more about the scientific basis for facial gender and to act as an engine for the dissemination of information. The importance of education and research into this field has a dual aim: to improve the quality of life for trans people and to achieve their full social integration.

How to choose the best FFS surgeon?

Historically, the facial feminization surgeon has worked solitary. Apart from being alone for long hours of surgery, the specialist also faces any complications, whether they are preop, postop or even during the operation, practically unassisted. Nowadays, the FFS patient may opt for a safer alternative in a multidisciplinary team, permitting a higher level of expertise and innovation of each of the feminizing procedures: a team capable of controlling the entire process of FFS whilst aiming for the highest quality in services and results.

Apart from prioritizing your safety along with consistent, natural outcomes of FFS Surgery, it is also important to consider the support network which the chosen clinic offers during the evaluation, planning and especially the aftercare.  Demand credentials, if the clinic has an insurance policy, statistics of complications, other patient referrals, and first and foremost a comprehensive, detailed evaluation process after which you should feel the appropriate treatment plan for you has been proposed.  Choose the clinic which provides patients with a global system to ensure the highest quality patient care, an important factor in the days and months after surgery.

[1] Spiegel J. Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty. Laryngoscope 2011;121:250–261
[2] Ettner R et al (eds). Principles of Transgender Medicine and Surgery. New York: Haworth Press 2007
[3] Davey A et al. Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls. J Sex Med 2014;11(12):2976-85
[4] Walch SE et al. The attitudes toward transgendered individuals scale: psychometric properties. Arch Sex Behav 2012;41(5):1283-91
[5] Capitán L et al. Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results. Plast Reconstr Surg 2014;134:609-19
[6] Resolution 2048 (2015), provisional version, 22 April. Discrimination against transgender people in Europe. Parliamentary Assembly of the Council of Europe 2015
[7]Standards of Care for the Health of Transsexual, Transgender and Gender Noncomforming People (7th version). World Professional Association for Transgender Health (WPATH) 2012