FACIAL FEMINIZATION SURGERY
Every person deserves to live as their true selves. If you were born with a sex that is not congruent with your gender, then I want to level the playing field by helping you finally look like who you really are.
After facial feminization surgery (FFS), you will still look like you, but an unmistakably feminine you. The most important and difficult part of FFS is coming up with a customized surgical plan that uniquely fits your desires and anatomy. No two faces are the same, so no two surgical plans should ever be the same. I use the latest technologies in virtual surgical planning based off of your CT scan, and I involve you in every stage of the planning process. My ultimate goal is to help you become your true self.
GUIDE TO FACIAL FEMINIZATION SURGERY
WHAT IS FACIAL FEMINIZATION SURGERY?
FFS is a combination of complex procedures that transforms every part of your face from masculine to feminine. The goal of FFS is to 1) treat gender dysphoria, 2) eliminate misgendering, and 3) help you love the way you look. FFS addressed your forehead prominence (frontal bossing), hairline, eye socket shape, nose, cheeks, temples, lips, chin, jawline, and neck (Adam’s apple). These procedures are usually done in one or two stages, depending on the number of areas we are addressing, totaling between 8-14 hours of surgery time.
WHAT’S THE DIFFERENCE BETWEEN DOING FACIAL FEMINIZATION SURGERY IN ONE OR TWO STAGES?
The shorter your surgery, the easier and faster the recovery. If we are addressing every part of your face, I prefer to do this in two stages: One stage to address your forehead and jaw and the other stage to address your nose, neck, cheeks and lips. These two stages are separated by three months to allow majority of your swelling to subside after the first stage. By splitting these surgeries into two stages, you can go home on the same day after each surgery rather than having to stay in a hospital for several nights with one long surgery. Additionally, you want your surgeon to be fresh and focused for your entire surgery, and that is just not realistic if I’m operating on you for 14 hours straight. If we are only addressing a few areas of your face, and not every region, we could potentially do everything in one stage.
HOW PAINFUL IS THE SURGERY?
Every patient experiences post-surgical pain differently, and the best way to stay on top of the pain is to take non-narcotic medications (Tylenol and NSAIDs) every 6 to 8 hours starting the night of surgery and add narcotic pain medications (oxycodone) as needed. You should expect pain and soreness in the areas we operated on, but you should also expect temporary numbness in some of these areas as well. The hairline incision will be numb for several months since I’m cutting through the sensory nerves that give sensation to the top of your scalp. These nerves should regenerate, but take up to a year. The nose will also feel stuffy after surgery from the internal splints that are inside each nostril. Thus, you will feel like you have a bad head cold until I remove the splints at your one-week post-op.
WHAT WILL MY RECOVERY BE LIKE?
You should plan to take two weeks off of work or school after FFS. Avoid any strenuous activities that may elevate your blood pressure (running, heavy lifting) for 2 weeks.
To decrease swelling after surgery, you should use intermittent ice packs to your face and sleep in a propped up position (ideally almost sitting upright) for one week. This sleep position may be uncomfortable, but is temporary.
Your swelling will peak at day 2-3 and start improving on day 4. It takes 3 months for 80% of your swelling to subside, and up to a year for all of it to resolve. You should expect to see your final result at the one year mark.
If we are working on your jawline, you should eat a soft diet (mashed potatoes, soft pastas, fish) right after surgery, then resume a regular diet two weeks later. If your jaw is not being operated on, then you can eat normal foods right away.
You should get up and walk frequently starting the night after surgery to reduce the risk of blood clots.
After forehead or nose surgery, you should avoid blowing your nose for 6 weeks.
Non-dissolvable stitches (blue or black) are removed 6 to 8 days after surgery to avoid leaving any marks, and dissolvable stitches (yellow or white) like the ones in your mouth or within your scalp will fall out on their own in 2 to 4 weeks.
If you have a bandage on your head, you should remove this at home 2 days after your surgery. The splint on your nose will be removed by me in clinic at your one-week post-op appointment. You can shower your hair after your head bandage comes off in 2 days, but try to avoid getting your nasal splint wet. No swimming or submerging your face under water for at least 4 weeks.
IS FACIAL FEMINIZATION SURGERY WORTH IT?
This is a very personal question, and if you’ve ever been misgendered, then you’ve probably asked this. What I don’t want my patients to feel is that they went through the pain, recovery, and emotional journey of surgery and ended up with minimal to no change. In order to prevent this, I do several things in surgery to maximize your transformation and eliminate masculine features:
Forehead/Browbone: I aim to remove the entire forehead prominence (bossing) so you have a flat brow ridge and rounded forehead.
Hairline: I advance your hairline as close to 5cm as possible. If you’re starting with a hairline that is too high (>8cm), and I don’t think I can get it close to 5cm, then I would recommend hiding your scar behind your hairline and getting hair transplant at a later time. Also, I braid your hair during surgery so none of your hair will be shaved.
Nose: I aim for a straight dorsum, refined and non-bulbous tip, and a feminine nasal-labial angle of 95 to 100 degrees. If the base of your nose is wide, I will break and narrow the nasal bones. I will also address any breathing issues at the same time.
Jaw: I carefully analyze your facial proportions and alter your jawline and chin to meet the most aesthetic and feminine balance. Often, this means I narrowing the width of your jaw, soften the prominent angles, and narrowing the chin with either contouring or a V-line genioplasty.
Lip: If you have a long upper lip, I recommend a lip lift. I also augment the lips with your own fat and with your scalp tissue from your forehead (which I remove when I advance your hairline).
Neck: Excess prominence from your thyroid cartilage (Adam’s apple) is shaved down. Your vocal cords lie behind this cartilage, so your anatomy sometimes limit by how much I can shave.
Your involvement: I involve you in every step of the planning process. We will go over the Virtual Surgical Planning (VSP) at your pre-op appointment, and customize the surgery to your goals.
WHAT ARE THE POSSIBLE COMPLICATIONS?
No surgery is without risk for complications, and you should avoid any surgeon who neglects to discuss these risks with you. Complications in FFS are very low, but you should know these risks:
Swelling: Swelling is not so much a risk but rather a guarantee. You should expect to be very swollen in all the areas operated on after surgery. The majority of swelling subsides by three months, but it takes one year for all of the swelling to resolve.
Numbness: The top of your head will be numb after forehead surgery. This is because I cut through the sensory nerves that start from your brow region and travel to the top of your scalp. While this is unavoidable, these nerves tend to regenerate over time, and majority of patients will regain sensation at their scalp by one year. Your lower lip may also be temporarily numb after the jaw and chin surgery since the sensory nerves get stretched during this portion – this should be temporary.
Muscle weakness: The nerves that control lower lip retraction and eyebrow elevation may get stretched during surgery resulting in weakness. These facial movements should return by 3 months after surgery.
Alopecia: You may experience hair thinning or falling out around your hairline incision or at the top of your scalp behind your incision. This is because the hair follicles get “shocked” from undergoing surgery. This is more common if you have a personal or family history of hairline recession or thinning, and have been on Rogaine or other hair growth stimulators in the past. The majority of patients will eventually regain their hair after the initial “shock” period, but this may take several months.
Bleeding (hematoma): Your face and head are very rich with blood vessels, and I take time to carefully cauterize any that bleed. However, sometimes one may continue to ooze after the incisions are closed. This leads to a hematoma (collection of blood). Most of the time, bleeding will stop on its own or with compression. Small hematomas will resorb on their own, but larger ones may require a return to the operating room to stop the bleeding. I place a snug head wrap after FFS but I do not typically leave drains.
Infection: FFS is not a sterile surgery. It involves operating in your nose, sinuses, and mouth. You receive antibiotics during your surgery and for a week afterwards to minimize risk of infection. You should monitor for signs of infection: increased redness, swelling, warmth and pain that usually start 2 to 5 days after surgery. If infection is caught early, usually a course of oral antibiotics will be adequate to treat this.
Intracranial injury: This is a theoretical risk, and I have never seen it, but since the surgery involves cutting and burring of the skull, there is a potential risk of getting in too deep and having a brain injury. I use custom 3D printed guides based on your CT scan to identify exactly where your frontal sinus borders are and how deep I burr to avoid this potentially devastating complication.
Scarring: Every incision will lead to a scar. I try to place incisions in areas that are discreet. However, poor scarring can still happen, especially if you have a history of poor scarring.
Nose-specific risks: With rhinoplasty, there is a small risk of having a hole develop in your septum, called a septal perforation. While I aim to maximize your nasal breathing function during surgery, you will likely feel more congested immediately after surgery due to swelling.
Tracheal shave risks: A dreaded complication to tracheal shave is injury to the vocal cords, which attach on the internal surface of the thyroid cartilage. I take a conservative approach to tracheal shaving, and if I’m getting close to the vocal cords, I don’t go any further.
WHO SHOULD I GO TO FOR FACIAL FEMINIZATION SURGERY?
Unfortunately, there is no standard definition of what FFS entails, and thus anyone doing any procedure on the face of a transfeminine patient seeking more feminine features can say they are an FFS surgeon. In order to achieve most patients’ goals for FFS, extensive bone, cartilage, and soft tissue work is needed. Thus, it is important to choose a surgeon that specializes in craniomaxillofacial surgery and also has extensive training and experience in facial aesthetic techniques.
Plastic Surgeons spend 6 years of residency training in plastic surgery of the entire body, including bony facial surgery and aesthetic facial surgery. Craniofacial Surgeons are fully trained Plastic Surgeons who spend an additional year in fellowship performing complex facial surgeries. I am a Craniofacial Plastic Surgeon, and completed my year-long Craniofacial Fellowship at UCLA under the guidance of my mentors Dr. Justine Lee and Dr. Wayne Ozaki. Unfortunately, only a few Craniofacial Fellowships offer training in FFS currently.
Facial Plastic Surgeons are Otolaryngologists (5 years of residency), who spend one additional fellowship year learning plastic surgery of the face.
Oral surgeons are dentists who spend 4 years of residency training focusing on dental surgeries and jaw surgery.
WHEN SHOULD I GET FFS?
You should seek an FFS consultation when you feel you are ready. I prefer that you have undergone medical transition for at least one year before committing to surgery. This is because you may be very happy with the results of estrogen alone, and thus can avoid surgery all together. Another reason is that your hairline may improve on estrogen. This would potentially change the location of the scalp incision.
The other requirement I have is a letter from a Behavioral/Mental Health professional supporting you for this surgery. FFS is no small procedure and may change your face in dramatic ways. Thus, it requires commitment, patience, and realistic expectations. Thus, having a long-term relationship with a Mental Health professional who specializes in gender health is extremely important.
For patients who are transitioning later in life: you may benefit from a combination of FFS procedures as well as facial rejuvenation procedures to address facial aging, such as facelift, necklift, and eyelid lifts. These procedures are typically not covered by insurance.
CAN I CONTINUE TO SMOKE CIGARETTES BEFORE FACIAL FEMINIZATION SURGERY?
No. For your health and safety, you should not undergo FFS if you are using any products containing nicotine.
If you’re a current tobacco user, I require cessation of all nicotine products (including gum) for at least 4 weeks before and 4 weeks after surgery. Nicotine constricts your blood vessels that are vital to wound healing, and increases risk for numerous other surgical complications.
DO I NEED TO STOP ESTROGEN BEFORE SURGERY?
No. When I first started my practice, I asked my patients to hold estrogen for 2 weeks prior to surgery, due to a theoretical increased risk of venous thromboembolism (blood clots in the legs or lungs) during surgery. However, there has not been any reported cases of this occurring during FFS. Thus, I don't think the burden of holding estrogen is worth the theoretical risk, so I no longer ask my patients to hold their estrogen.
WHAT DOES THE CONSULTATION AND FOLLOW-UP LOOK LIKE?
Initial consultation: When we are meeting for the first time, I like to spend an hour together so I can learn about your specific goals, take comprehensive measurements and photographs of your face, and formulate a preliminary surgery plan with you.
Facial CT Scan: Between the consultation and your pre-op visit, you will undergo a CT scan of your face. Based on your CT, I perform Virtual Surgical Planning (VSP) to pre-plan all of the cuts and contouring of your facial skeleton. VSP produces sterilized 3D-printed customized cutting guides that I use in your surgery – this not only produces precise pre-planned results, but also maximizes safety and efficiency in the operating room. I consider VSP and custom guides to be the state-of-the art in FFS surgical planning. The rhinoplasty and soft tissue work does not require VSP.
Pre-op visit: About two weeks before your scheduled surgery, I will meet with you to go over the surgery and recovery in detail, and obtain your consent for surgery. During this visit, if we are using VSP, I will review all of the plans with you.
Post-op visits: After surgery, I’d like to see you at 1 week, 3 months, 6 months, and 12 months, then every year thereafter. It takes a year for all of your swelling to resolve, and I like to keep a close eye on your healing process and answer any questions you may have along the way.
WHAT IS THE COST OF FFS?
Traditionally, facial feminization surgery was only done by a small handful of plastic surgeons for cash-pay because insurance companies considered FFS to be “cosmetic.” Fortunately, some medical insurances are finally starting to cover FFS as a medically necessary surgery. However, we are still experiencing rejections for authorization by most insurances. I will be your advocate. My team and I will work with you to appeal rejections and exhaust every option for insurance coverage. It may mean numerous phone calls and appeal letters from you. Ultimately, if your insurance does not cover FFS, you can still undergo FFS with self-pay, with cost determined by how many areas we are addressing.