Archive for the ‘Facial Feminization Surgery’ Category

The Story of a Trans Woman’s Face

March 29, 2018

The Story of Our Patient’s Facial Feminization Was Featured in The New Yorker Magazine

“Abby Stewart sometimes thought that she was born to be a teacher. At the small college in Colorado where she was an instructor in the biology department, she enjoyed preparing lectures for business or history majors who were simply fulfilling a requirement by taking her course in anatomy and physiology. She worked hard to prove to these students that they should still care about biology, and one way she captured their attention was by describing natural phenomena that, at first glance, might seem peculiar. She revealed that clown fish—like Nemo, in the Pixar movie—are hermaphrodites, starting out as male but sometimes becoming female as they mature…” Continue reading on The New Yorker’s website. 

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Asian Masseter Muscle Reduction

January 31, 2018

Reduction of the Masseter Muscle for Asian Patients (Surgical & Non-Surgical)

When undertaking any form of plastic or cosmetic surgery, it is critical to take into consideration each patient’s ethnicity. Different ethnic groups have different facial proportions and different cultural concepts of what constitutes ‘beauty’. A skilled plastic and craniofacial surgeon will take these into account and adapt surgical procedures accordingly. Often, patients of Asian ethnicity — such as Korean, Japanese, Chinese, and other Asian countries and regions — may seek out a jaw and chin narrowing procedure known as Asian V-Line surgery. Depending on their existing facial proportions, the patient may also need to reduce the size of their masseter muscle to reduce a prominent mandibular angle and jaw width to produce a narrower, slender and more feminine facial profile.

What is the Masseter Muscle? Why is it larger in those of Asian background?

The masseter muscle runs down the cheekbone to the lower jaw on each side of the face. It is known as one of the “muscles of mastication” because it helps us to chew food and move our jaw up and down while speaking. The masseter is typically larger in people of Asian ethnicity due to natural genetic differences creating a wider face proportion. Typically Asian women, or Asian transgender individuals seeking facial feminization, want a softer, smoother appearance to the jawline, and therefore seek to reduce the size of the masseter muscle at the same time.

Reduction of the masseter muscle for those of Asian ethnicity may be performed by either non-surgical or surgical method…

1. Non-Surgical Reduction of the Masseter Muscle using Botox® or Dysport®

The masseter muscle can be reduced significantly using non-surgical injectable treatments such as botulinum toxin — more commonly known as Botox® or Dysport®. The procedure is non-invasive because it involves a series injections placed directly into the masseter muscle. The treatment is performed over several sessions with small doses of botulinum toxin until the masseter muscle has reduced down by degrees to the desired appearance. The number of sessions will depend on the individual’s reaction to the treatment. Some people may only need 1-2 sessions, others may need 3-4 sessions to achieve the desired results. In most patients, the masseter muscle will stay reduced in size permanently – even without further injections.

2. Surgical Reduction of the Masseter Muscle:

For some Asian patients, non-surgical masseter muscle reduction will not have the desired effect, making a surgical reduction of the muscle their best option. The surgery is performed on the inside of the mouth between the gum and cheek via small incisions that leave no visible scarring. The jaw bone and masseter muscle are surgically reduced and reshaped to achieve a rounder, smoother, and more slender contour. When the correct amount of muscle and bone has been removed, the incision is closed with self-dissolving sutures.

Which form of masseter muscle reduction is right for you?

Ultimately, an in-person consultation with your plastic surgeon will help you decide if a surgical or non-surgical option is the best course of action for you.

Read more about masseter muscle reduction here.

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Considering Facial Feminization? Unsure about V-Line Surgery vs. Feminizing Jaw Surgery?

January 24, 2018

Understanding the Differences Between V-Line Surgery and Feminizing Jaw Surgery is Critical

The Gender-Specific Differences of Male and Female Jaws

Typically, the male jaw is wider and taller than the female jaw. Men tend to have wider, heavier-set jawlines with a flatter base and a sharper angle between the chin and jaw. This gives the male jawline a prominent “square” look. Women’s jawlines typically have rounded edges, are more tapered and pointed.

“Asian” V-Line Jaw Surgery vs. Feminizing Jaw Surgery

Many of our patients who are considering undertaking facial confirmation surgery to feminize the face, often mistakenly think that they need “Asian” V-Line surgery for the jaw when what is actually needed is feminizing jaw surgery — otherwise known as FFS-specific jaw contouring or jaw tapering.

What is the difference between “Asian” V-Line Jaw Surgery and Jaw Tapering?

V-Line jaw surgery typically works to narrow the jawline and bring it forward. This procedure is typically ideal for women who have an overly-square jawline and want a more feminine, streamlined appearance to the jaw and the chin. This tactic, however, doesn’t work to feminize a male’s face because typically a male face is taller or longer, so a V-Line procedure would only make the face appear more elongated. In the case of a male transitioning into a female, what is really needed is jaw contouring surgery to shape the jaw into a more feminine aspect as well as a vertical reduction genioplasty (shortening the height of the chin). In comparison, a V-Line procedure commonly should not reduce the vertical height of the chin as that would run counter to the intended appearance.

If the face to be feminized is overly long, a condition that is known as vertical maxillary excess or “long face syndrome”, we may also recommend surgical correction via a jaw surgery procedure known as the Le Fort Osteotomy I. Read more about Long Face Syndrome and Facial Feminization here.

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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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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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Women With Masculine Looking Faces

September 18, 2017

Facial Feminization Surgery for Women

Often when we talk about facial feminization we are referring to the surgery within the context of transgender individuals. However, there is another set of circumstances wherein facial feminization surgical procedures may be incredibly useful: for cis-gendered women (female assigned female at birth) who are born with “masculine”-looking features and who are want to appear more feminine.

What features make a woman’s face appear “masculine”?

The most common complaint we hear from our female patients who are seeking facial feminization is either the forehead and brow and/or the jawline and chin is too prominent or too “bold”. These two features — more than any others — contribute to a masculine-looking appearance.

The good news is that a plastic surgeon, such as Dr. Deschamps-Braly, who also has extensive craniofacial and jaw surgery expertise can help to feminize these features while still ensuring that you still look like you. And herein lies the true skill of any form of gender-related facial surgery: along with excellent surgical skills, your surgeon must also possess a deep understanding of gender-related aesthetic differences in terms of male/female facial proportions, and an appreciation for what constitutes “beauty” in the feminine face to ensure an optimum outcome.

Recommended surgical procedures to create a more feminine appearance:

There are many ways you can make your face appear more feminine. After an in depth consultation, your surgeon may recommend one or more of the following procedures, depending on your circumstances and desired results:

  • Feminizing Forehead Reduction and Contouring: to create a more feminine, softer appearance of the forehead, and reduce the heavy appearance of the male brow.
  • Feminizing Brow lift (Browplasty) – raises the eyebrows into a higher, more feminine position on the face. Also helps to reduce common telltale signs of aging such as forehead wrinkles, crow’s feet, horizontal or vertical lines such as frown lines and furrows between the eyebrows.
  • Feminizing Rhinoplasty (nasal surgery) – some women may have a very prominent or ‘masculine’ looking nose. In such cases, feminizing rhinoplasty may help.
  • Feminizing Cheek Enhancement – gives the cheeks a rounder and smoother feminine appearance. Depending on your existing features and the desired effect, the procedure includes either cheek augmentation or cheek reduction.
  • Feminizing Chin Recontouring (Genioplasty) – alters the shape of the male chin by reducing, reshaping, or augmenting (making the chin larger). Most often the male chin is reduced in size and reshaped to be less angular, creating a smoother and more feminine aesthetic.
  • “Asian” V-Line surgery – suitable for all ethnicities: this surgery works to contour and slim the lower jaw, creating a more slender jaw line while at the same time reducing jaw width and a producing a sharper, better-defined chin profile.
  • Jaw Contouring – The male jaw is usually wider and more angular than the female jaw. Men tend also to have a sharp back “corner” to the jaw, which can be made to appear rounder and smoother through jaw contouring resulting in a more feminine look. The bone of the jaw can also be shaved along its lower edge and chewing muscles reduced to make the jaw more slender.

Ultimately, the decision with regards to which surgical procedures will suit your circumstances is one that will be made in consultation with you and your surgeon.

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Asian Facial Feminization Surgery

September 11, 2017

Feminizing the Asian Face

We often often tell our patients that performing facial feminization surgery on a person of Asian ethnicity is very different than other types of FFS.

If you are of Asian background, either Korean, Japanese or Chinese, and you’re seeking facial feminization surgery (FFS) it’s critical to understand that what constitutes a typically female Asian face may be vastly different — aesthetically and structurally — than a typical European, African American, or Polynesian face. For this reason it’s very important to ensure that your plastic and craniofacial surgeon understands these sometimes very subtle, and sometimes very dramatic differences, and that they have had extensive experience in feminizing Asian faces.

The forehead is the key to feminizing an Asian face.

First and foremost, the shape and size of the forehead and the brow should be the main focus of facial feminization for those of Asian background. Forehead feminization typically includes reduction and contouring to create a smoother, rounder, more feminine forehead. Also, a feminizing brow lift and/or brow shaping procedure works to reduce the distinctly ‘heavy’ Asian male brow bossing and “opens up” the eyes to create a more feminine and rejuvenated appearance.

There are several key differences that we take into consideration when we feminize an Asian forehead. For example, a Chinese female forehead will typically project significantly less than a caucasian female, however, a Japanese forehead may even be different than a Chinese one, wherein sometimes the forehead is even positioned ‘behind’ the eyeball, with no overhang above the eye.

The hairline position on the forehead will also be a little different depending on which Asian background you come from. When undertaking feminizing hairline lowering on Chinese and Koreans we make allowance for the fact that they have slightly higher hairlines to begin with, so we may not lower the hairline as significantly as we might for a person of European background.

Feminizing the Asian nose and jawline.

When it comes to feminizing the lower face the most common procedure we recommend for those of Asian background is “Asian V-line” jaw reduction surgery. This is because Korean, Japanese, and Chinese males (and females) will typically have much heavier and wider-set jaws. Asian V-line surgery is very popular all throughout Asia for both men and women.

Feminization of the nose is also quite different for those of Asian ethnicity. In our experience, most Asian FFS patients will seek to in fact augment their nose to make it larger. This may seem counterintuitive in terms of feminization because typically we make the male nose smaller to feminize it. However, in some cases a feminizing rhinoplasty will include augmentation to ensure it the nose maintains a natural aesthetic balance with other newly feminized facial features.

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


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Congratulations. You’re beautiful, but are you “feminine”?

April 7, 2016


Beauty is often mistaken for femininity with regards to facial features – especially within the context of gender-related plastic surgery such as facial feminization (FFS).

Therefore, it is critical to note that there is a world of difference between aesthetic beauty and a truly feminine face.

A common type of operation we perform is surgery to correct a previous surgeon’s work for an unsatisfied or unhappy patient. Often, attempts to make the face more beautiful may not have achieved the primary goal of making the face more feminine.

In nearly all cases, revision surgeries are necessary because what constitutes masculinity or femininity in the patient’s facial features has not been successfully captured or represented. The patient may appear more beautiful, but not “feminine” or “masculine” – as is their desired gender representation. (more…)

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Debunking Three Common Myths About Female Hairlines

February 9, 2016

Demystifying 3 Common Myths About Feminine Hairlines

By Dr. Sara Wasserbauer, Surgical Hair Restoration Specialist

If you are trying to achieve a more feminine facial appearance, you may know that hair, and specifically the shape and height of your hairline, is a major component of this transformation.

Your hairline frames and defines your face, making it a particularly important component of feminization or Facial Feminization Surgery.

For example, a masculine-shaped hairline will make a small nose or long eyelashes appear more masculine; whereas a softer, more feminine hairline can feminize a face, even if you have a strong jaw line and thick brows.

There is a wealth of information—and misinformation—on the Internet about the female hairline, including shapes and heights. With this in mind, we want to demystify some common misconceptions and debunk popular myths to ensure that you have all of the information you need when considering your options. (more…)

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Caitlyn Jenner’s Surgery

June 12, 2015

By Daily Beauty Reporter:

As we recently learned from Buzz Bissinger’s account in Vanity Fair, Bruce Jenner checked into a Beverly Hills clinic for transformative surgery on March 15th. Ten hours later, Caitlyn Jenner officially emerged. But what exactly is facial feminization surgery—and how difficult was her recovery?

Facial feminization is an aggressive remodelling of every aspect of the facial skeleton. A mere facelift won’t do it—saws are involved, along with burrs to whittle down bones. A typical operation can last up to 12 hours. But for these patients, it’s worth the risks, the pain, and the high five-figure price. “As a transgender individual, perhaps nothing is more vital to you than having a body that matches how you feel,” wrote Douglas K. Ousterhout in his 2009 book, Facial Feminization Surgery: A Guide for the Transgendered Woman (Addicus Books).

Semi-retired now, Ousterhaut is the San Francisco plastic- and cranio-facial surgeon who pioneered the specialty in 1982, after his first transgender patient asked for help. “Dr. O has done more than 2,000 of these surgeries,” says his associate and hand-picked successor, Jordan Deschamps-Braly, who did not do Jenner’s surgery. It’s been widely reported that two L.A surgeons, Harrison Lee, a maxillo-facial surgeon, and Gary Alter, a urologist and plastic surgeon, together performed Jenner’s facial transformation, breast augmentation, and other unspecified body procedures.

In the 1980s, facial feminization was unchartered territory. To plan his first operation, Ousterhaut, who had devoted 25 years to pediatric birth defects, first studied the 1,500 human crania in the Atkinson Skull Collection at the University of Pacific School of Dentistry, comparing male and female bone structure. His work eventually became the basis of a whole new surgical specialty. We don’t know exactly what procedures Jenner underwent, but the following is Ousterhaut and Deschamps-Braly’s menu of the most important feminization procedures—and a tiny snapshot of what’s involved. (Warning, what follows is not for the squeamish.)

Advancing the Scalp. A high forehead is an instant clue of maleness. Creating a lower hairline and recontouring the brow are procedures that must be done together, says Deschamps-Braly. In a 19-year-old male, the distance from hairline to the center of the eyebrow is 2.6 inches; it’s just two inches in a woman. Lowering the hairline with scalp advancement requires an ear to ear incision across the top of the head. The scalp is then pulled forward and reattached lower down. If the hair in the front section of scalp is thinning, a strip of it is trimmed away. Hair-follicle implants can be done later. Before the scalp is sutured into place at the lover level, the brow is raised lifting the eyebrows to a more feminine position.

Forehead feminization. The skulls of men and women are vastly different. “The foreheads of genetic males slope back—while a female brow is more vertical. Genetic males have a heavy bony ridge protruding above the eye sockets making the sockets deeper than a woman’s,” explains Deschamps-Braly. “We use a saw and remove the ridge carefully, often exposing the sinus cavity which we refill with some of the extra bone.” Males also have bony hoods over their eye sockets. To feminize the eyes, these need to be removed with a 40,000 rpm mechanical burr. A small percentage of facial feminization patients need their brows augmented above the brow ridge with the same synthetic resin used in making dentures. All this bone work can be done through the same long incision created for the brow advancement. “Without feminization, your forehead will always be a giveaway to your birth gender,” wrote Ousterhaut.

Filling temple depressions. Some men also have shallow depressions in the bone beside their eyes. If they’re noticeable, fat can be injected through small entry points in the temple hair.

Rhinoplasty. Jenner had previously had surgery on her nose, which is a common element in the facial feminization process. Male noses are larger and longer, with bulkier tips than a woman’s. They point straight ahead or down, while the ideal female nose is thinner, shorter and sometimes scoops up.The angle at the radix (where the nose meets the forehead) is sharper in males and slopes gently in females. These characteristics can be achieved with surgery.

Changing the shape of the chin. A man’s chin is 17 percent longer than a woman’s and wider as well. A woman’s chin tends to be tapered or oval. Feminization requires taking, on average, a three-eighths-inch horizontal slice out of the chin bone (think of it as removing one book near the bottom of a stack). The bottom piece has to be anchored with plates and screws. If the chin protrudes or is receding, the lowest section can be pushed back or advanced. If the chin needs narrowing, a vertical wedge of bone can be removed at the tip below the tooth roots.

Lower-jaw tapering. The male jaw looks square from the front, but it has a wide, V-shaped bend between the ear and the chin. In contrast, a female jaw has a soft curve from the ear to the chin. The angular male jaw can be rounded by cutting the sharpness from the bend with a right-angle saw and smoothing the edge with a mechanical burr. This is a job for someone very experienced, because running through the jaw are blood vessels and nerves that relay sensation from the lower lip, front teeth, and chin.

Diminishing the Adam’s apple. The Adam’s apple is thyroid cartilage that sits on top of the trachea—the breathing tube—and anchors the vocal cords. Both men and women have one, but a man’s is more prominent. It can be reduced through a small incision under the chin that heals almost invisibly. In 5 percent of cases, male-to-female transgender patients (like Jenner) have it reduced before feminization surgery; Jenner underwent a tracheal reduction in January of 2014.

Raising the cheeks. While rounded cheeks are considered attractive in both men and women, Deschamps-Braly cautions against using cheek implants during the feminization surgery. “I do a cheek lift instead of implants. The cheek looks better. Implants are rarely necessary.”

Shortening lip height. Men typically have a longer upper lip area, averaging 21 millimeters in height compared to 15 millimeters for women. And it gets longer with age. This can be shortened with a short incision right under the nostrils. Lips can then be filled with dermal fat or hyaluronic acid.

Vocal pitch. This is one male trait that isn’t easy to change. Operating on vocal cords to make the voice less husky is risky. It could become deeper and chronically hoarse. “There have been great successes,” says Deschamps-Braly, “but the area is a no-man’s land and complications can’t be corrected.” For this reason, many male-to-female transgender patients skip the surgery and instead hire voice coaches to help them.

Jenner’s surgeon, Harrison Lee, told E! News that his patient had recovered quickly from her March ordeal. “She healed remarkably fast,” Lee said. “Maybe because she’s an Olympic athlete… I mean, at 65, she is in remarkable health.” The full healing process can take up to a year.

Jenner did tell Bissinger that her one moment of serious doubt came shortly after the grueling procedure. She had a panic attack—the first of her life—and thought to herself “What did I just do? What did I just do to myself.” A counselor from the Los Angeles Gender Center came to Jenner’s house and explained that such reactions are common and often temporary, induced in part by pain and medication. Deschamps-Braly agrees that few patients regret their surgery in the long run, despite the difficulties involved. “The operation is something they have longed for. In no time at all, they forget what they looked like [before],” he says. “Looking believably female is important. There’s a sense of relief. You can’t hide your face. There is less discrimination. Facial feminization surgery gives them a foundation.”

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For more information, or to make an appointment with Dr. Deschamps-Braly, please contact our San Francisco office +1.415.624.3922.

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