Long Face Syndrome and Facial Feminization Surgery (FFS)

January 13, 2018

What is Vertical Maxillary Excess? How can it be Corrected within the Context of Facial Feminization?

When a transgender person is seeking to undertake facial feminization surgery there are several relevant FFS procedures that may be recommended depending on existing facial structure and aesthetic goals. Some FFS procedures fall under the category of plastic surgery (soft tissues), others under craniofacial surgery (the underlying facial skeleton), and others yet under orthognathic surgery (surgery of upper and lower jaws).

One of the lesser utilized FFS procedures is the surgical correction of long face syndrome or vertical maxillary excess. This condition is a facial deformity caused by a disproportionately grown upper or lower jaw making the face appear overly long. Depending on the individual, the vertical maxillary excess may result in a very “gummy” smile and a thin, over-elongated face.

Surgical Correction of Vertical Maxillary Excess within the Context of FFS

Vertical maxillary excess is easily correctable with orthognathic (jaw) surgery and is ideal for transgender individuals who are transitioning into females and have an excessively long face relative to their gender-adjusted soft tissue envelope (the skin, subcutaneous tissue, and deep fascia). The surgery is often used in the setting of a staged procedure. For instance, depending on the individual’s existing features, we usually prefer to complete the maxillary impaction prior to doing a rhinoplasty, unless there is to be a long course of orthodontic treatment involved. This procedure should also be done before an upper lip lift is performed because the lip lift is a finishing touch based on balanced proportions of the facial skeleton. Otherwise, the rest of the surgical procedures follow the same long format surgical session within the cluster of procedures that make up FFS.

Reducing the height of the face significantly adds to the outcome of facial feminization because shortening the face creates a more feminine appearance. Typically men’s faces are longer or taller, more angular, with higher foreheads and hairlines than women. And women’s faces are typically rounder, shorter in height, and less angular particularly around the chin and jaw area — amongst other differences.

Other related procedures that may be recommended regarding the lower half of the face to enhance feminization may include upper lip lift surgery, chin recontouring, “Asian” V-Line surgery, or chin reduction surgery.

How is the Surgery Performed?

The mechanics of surgically reducing the length of the face are essentially identical as those used in the Le Fort Osteotomy – an orthognathic (jaw surgery) procedure. Known as the “workhorse” of jaw surgery, this procedure is typically used in non-FFS patients for the treatment of upper jaw malocclusion and cleft palate.

In FFS patients, the Le Fort Osteotomy I maxillary intrusion involves the cutting of the jaw in the area between the nose and teeth to shorten the maxillary bone. Then reattaching the bone to bring the upper half of the face more harmoniously in balance with the bottom half in order to shorten the length of the face to a more feminine aspect.

Read more about the Le Fort Osteotomy I here.

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The Problem With Chin Implants

October 18, 2017

Chin implants may be a popular choice for chin surgery but removing them is also one of the most popular revision surgeries that we perform.

Chin implants are typically used in chin surgery (genioplasty) to improve a “weak” or nonexistent chin, or within the context of Asian V-Line surgery. The popularity of chin implants has grown over the last few years and has become one of the fastest growing procedures in plastic surgery. Unfortunately, chin revision surgery (revision genioplasty) is also one of the most popular revision surgeries we perform due to the often unsatisfactory results or resultant medical complications of using chin implants.

Chin implants are problematic and often cause complications.

Although chin implants are an option in some cases, and occasionally used, we believe that placing a foreign object (an implant) into your own body is counterintuitive and often problematic when there are much better ways to reshape and augment the chin.

Often chin implants are placed by inexperienced or unskilled surgeons and sold to the patient as an “inexpensive” or simple solution. This, of course, is so often untrue, due to the frequency of need for chin surgery revision procedures! Instead of one operation, the patient needs another one — often at an increased cost because a secondary procedure is always more complex than a primary one — not to mention the suffering, stress and mental anguish over the first, failed procedure.

Chin implants often cause complications, with the most common being:

  • The implant shifting from its original location,
  • The implant eroding into the roots of the anterior teeth,
  • And, most commonly a squaring of the chin which in females, in particular, can have an undesired masculinizing effect that is altogether unsatisfactory.

It is our belief, that a far better option in our experience, is to reshape the underlying skeleton or foundation of the chin by altering or repositioning the bone. In fact, there are several non-implant options for genioplasty surgery: the chin may be moved forward, down, centered, widened, or narrowed — depending on the desired outcome. In these cases, outcomes are improved because there are more “degrees of freedom” for the surgeon to reshape the chin into an aesthetically pleasing shape that is in harmony with other facial features.

The risks, complications and side effects of chin implants.

Apart from the obvious risk of choosing an unskilled or inexperienced surgeon to insert a chin implant – that the aesthetic result will not be a satisfactory one – there are several other serious medical complications and side effects to be aware of:

  • Damage to the marginal mandibular nerve — leading to permanent loss of movement in the lower lip
  • Damage to the mental nerve (a sensory nerve which provides sensation to the front of the chin and lower lip as well as the buccal gingivae of the mandibular anterior teeth and the premolars)
  • Implant is placed in the superficial tissues — not under the periosteum (the dense layer of vascular connective tissue enveloping the bones) leading to implant movement under the skin
  • The wrong sized chin implant is used resulting in a chin looks out of sync or inharmonious with other facial features
  • Injury or damage to the teeth, gums, or surrounding nerves
  • Permanent loss of sensation, and/or scarring.
  • Slow healing, infection, or internal bleeding leading to removal of implant
  • Inadvertent masculinization of the female chin
  • Unsightly deepening of the labiomental crease (the deep groove underneath the lower lip)

It is critical that when you choose a surgeon for your chin surgery, that you choose a U.S. Board Certified surgeon. The risks of choosing an uncertified, unskilled or inexperienced surgeon are too great and must be avoided at all costs.

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African American Facial Feminization Surgery

September 26, 2017

Feminizing the African American Face

If you are of African American heritage and seeking to have facial feminization surgery (FFS) it’s critical to understand that what constitutes a typically female African American face may be vastly different — aesthetically and structurally — than a typical European, Asian, or even Hawaiian (Polynesian) face.

So before you select a plastic and craniofacial surgeon for your facial feminization surgery, it’s imperative to ensure that they have an in-depth understanding of the differences between the facial structures of people of different ethnic backgrounds, and most importantly proven experience with performing FFS on African Americans.

The forehead is the critical to feminizing the African American face.

The shape and size of the forehead and the brow should be the main focus of facial feminization for those of African American heritage. Typically the forehead will project a little further outwards than that of a person of Asian descent, but not as far as that of a person of European descent.

Forehead feminization typically includes forehead reduction and contouring to create a smoother, rounder, and more feminine forehead. Also, a feminizing brow lift and/or brow shaping procedure is recommended to reduce the distinctly ‘heavy’ African American male brow bossing and to “open up” the eyes to create a more feminine and rejuvenated appearance.

The hairline position on the forehead will also be different because African American women tend to have naturally higher hairlines than European women. Therefore, when we perform feminizing hairline lowering we make allowance for the fact that African American women have slightly higher hairlines to begin with, so we may not lower the hairline as significantly as we might in others. Ultimately, it all depends on your newly feminized facial features to ensure aesthetic balance and a natural looking result.

Feminizing the lower half of the African American face.

Typically, feminization of the nose via feminizing rhinoplasty is recommended for those of African American heritage. Often gender transition patients are seeking a narrower, more streamlined female nose. However, we also want to make sure that your nose will maintain a size and shape that is in harmony with your natural African American facial features, so that you still look like you.

Feminizing jaw surgery is also recommended because often the male African American jawline is quite broad and angular – often wider and squarer than what we see in other ethnicities. The jaw will often need to be narrowed and softened via feminizing jaw contouring or reshaping.

Read more about the cluster of surgical and non-surgical procedures that comprise facial feminization.

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