Facial feminization surgery, or FFS, is a surgery that involves the cosmetic modification of your facial characteristics.

The goal is to soften masculinized features into a shape more typically recognized as feminine. FFS is commonly pursued by transgender women or assigned male at birth (AMAB) non-binary trans people. It can appeal to cisgender women as well.

FFS is tailored to each person and can encompass up to every aspect of the face and neck. FFS mostly focuses on bone structure and nose shape. Soft tissue work, such as face-lifts and neck lifts, can be incorporated when necessary.

Historically, FFS hasn’t been covered by health insurance or government healthcare. However, some insurers are beginning to cover FFS from select surgeons.

Out-of-pocket costs for FFS commonly range from $20,000 to $50,000 and above, depending on the surgeon and the number of component procedures performed.

Insurers often classify FFS as an elective cosmetic procedure. However, FFS can have more impact on a person’s mental health and social well-being than genital surgeries such as vaginoplasty and phalloplasty. As society becomes more familiar with transgender issues, the medical establishment seems to be slowly recognizing FFS as fundamental to transgender care, rather than optional and elective.

To choose the right surgeon, pursue in-person or Skype interviews with as many surgeons as possible. Make sure to ask as many questions as possible to get a sense of each surgeon’s variations in their technique, as well as their bedside manner.

Many surgeons give presentations or consultations in major cities and make appearances at transgender conferences. It also helps to reach out to former patients of the surgeons that interest you. You can do so via online forums, support groups, or mutual friends.

Masculinized and unmasculinized faces exhibit a number of subtle differences, which in combination tip the scale toward a face being interpreted as male or female. Each area of the face is addressed in separate procedures:

Forehead procedures

Forehead procedures contour the forehead by shaving down hard angles and reducing the prominence of the brow bone. Sometimes the brow can simply be shaved down when the brow protrusion is smaller and when the brow bone itself is thick.

Heavily shaving down the brow bone may result in a hole in the sinus cavity. For this reason, people with a larger brow protrusion require a more involved procedure. In these cases, the front of the brow bone is entirely removed, temporarily exposing the sinus cavity behind it. The removed bone is then contoured separately and replaced, so it lies flat.

Hairline alterations

Forehead work is often paired with procedures to alter the hairline in order to counteract the effects of receding hairlines or male pattern baldness.

The forehead is accessed through an incision in the scalp. The most common approach is to cut along the hairline, which allows for the scalp and hairline to be physically moved forward, lowering the entire hairline. This was the only procedure available for many years. Hairline advancement became the default standard, despite sometimes having a masculinizing effect.

In recent years, a new method of coronal incision (along the top of the head) has been pioneered by the FacialTeam in Spain. The coronal incision hides the incision scar within the bulk of the person’s head hair. It faces upwards, away from the view of most other people.

If you’re interested in receiving hair transplants, talk to your doctor about a coronal incision. Unlike the hairline advancement procedure, a coronal incision allows for simultaneous hair transplants. This is because the incision is far from the hairline.

Receiving simultaneous hair transplants with a standard hairline advancement will cause the transplanted hair to be rejected by the healing tissue surrounding the incision.

Hair transplants allow surgeons to target the areas of the hairline that need reinforcement without unnecessarily advancing parts that may not aesthetically need it. The coronal incision method is slowly being incorporated into other surgeons’ practices.

Nose procedures

Rhinoplasty, popularly known as a nose job, contours the nose to fit within unmasculinized norms while maintaining natural proportion with the rest of the facial features.

Transgender rhinoplasty doesn’t differ from standard cosmetic rhinoplasty. However, a surgeon experienced with FFS can sometimes provide better results, especially when multiple facets of the face are being altered at once.

When less extreme changes are called for, rhinoplasty can be performed without external scarring. When performing more involved changes to the nose, an “open rhinoplasty” may be required. This results in a small scar between the nostrils, but it’s often barely noticeable.

Cheek augmentation

Cheek augmentation is a less common procedure. It’s only recommended by some surgeons in certain cases.

Cheek augmentation can involve cheek implants or fat grafting. For many people, when synthetic hormones begin to redistribute body fat, the cheeks get sufficiently fuller on their own. This makes a surgical procedure unnecessary.

Lip lift

Masculinized and unmasculinized faces have different proportions of skin above the lips (up to the base of the nose) and below the lips (down to the tip of the chin).

Unmasculinized faces tend to have a shorter distance between the upper lip and the base of the nose. The upper lip often curls more upward. A masculinized face can be given a lip lift. This shortens the distance above the lip and adjusts the lip orientation.

Genioplasty

Genioplasty modifies the chin. Surgeons typically approach the chin and jaw through incisions within the mouth, along the gum line.

Some chins call for a chin reduction. In this procedure, bone and protrusions are shaved down and smoothed.

Other times, a chin augmentation is recommended. In this case, surgeons slice the bottom part of the chin bone into a wedge. They then slide it forward away from the jaw and reattach it in the advanced position. Alternately, a chin implant can be used when appropriate.

Jaw surgery

Jaw surgery focuses on the back corners of the jaw, where the bone turns up toward the ears. A surgeon can smooth strong protrusions. However, there are limits to the reductions. The jaw bone contains a crucial nerve. Aggressive reductions risk exposing or severing the nerve.

Tracheal shave

A tracheal shave reduces the appearance of the Adam’s apple. Sometimes the incision is made right at the Adam’s apple. When possible, the surgeon will make the incision just below the chin so that scarring is less noticeable.

Soft tissue procedures

Soft tissue procedures can be performed in conjunction with the core FFS procedures listed above. This may include:

But in most cases, these procedures aren’t fundamental to how people perceive the gender of a face.

Surgeons require that people stop taking hormone replacement therapy two weeks before surgery and refrain for two weeks after surgery before starting again. Make sure to tell your surgeon about any other medications you regularly take. They’ll let you know if you need to stop taking them for the procedure. Never stop taking medications with approval from a doctor.

Your surgeon might have other requirements based off of the procedure that you’re getting. If you’re going under general anesthesia, this includes fasting.

Risks of FFS include:

  • Nerve damage in the jaw or chin. This can result in permanent loss of feeling or function in the face and tongue.
  • Infections caused by chin and cheek implants.

Nerves are also severed during the scalp incision, but most people regain most or all of the sensation in their scalp skin as they heal.

If you opt for lip or brow fillers, be very cautious about permanent fillers, such as silicone. Dissolvable fillers (such as hyaluronic acid) allow for you to change the appearance of your soft tissue as your facial features change with age.

Recovery time varies based on which procedures are performed. In general, you can expect to go home after surgery. You’ll likely need full-time rest for two weeks. You should refrain from returning to work or lifting heavy objects for six weeks.

If you receive forehead work, your surgeon will anchor the eyebrows in place. Therefore, you must refrain from plucking your eyebrows for a few weeks while the anchors set and the tissue heals.

Rhinoplasty work is particularly delicate. Special care should be taken to not impact the nose for several weeks after surgery.