Five Questions to Ask Yourself Before Booking a Consultation

The choice to undergo surgery needs to be considered very carefully. Your initial consultation with Dr. Deschamps-Braly will involve an in-depth examination and screening to determine if you are a good candidate for surgery. To save yourself time (and expense) we have compiled a list of 5 critical questions to ask yourself before booking your consultation. If you do not feel confident about addressing any of these five topics surgery may not be a good procedure for you at this time.

1. Are You Physically Healthy?

Before you decide to move forward with plastic or craniofacial surgery, Dr. Deschamps-Braly will need to determine if you are in good overall physical health. Maintaining a healthy lifestyle is important for surgery preparation and recovery. Depending on your health history and/or medical conditions, you may need to get additional clearance or testing in order to move forward with surgery from your PCP, therapist, orthodontist, etc. All potential patients must have the strength and constitution needed to make a full and rapid recovery.

2. What Are Your Expectations for Surgery?

Plastic surgery is not a miracle cure. Although surgery can dramatically alter one’s physical appearance it is not a panacea for any existing inner psychological conditions. Plastic surgery will not ‘fix’ any insecurities you might be suffering from. And while it might seem like a good way to address these issues, it is very important to know that surgery will not solve them. Ultimately, you will still be you.

Therefore, it is important to be honest and authentic with yourself about your expectations and the very specific reasons why you want surgery. During your consultation, Dr. Deschamps-Braly will discuss your expected results, risks, and potential benefits of surgery. It is important that the doctor and patient share the same aesthetic views. This is why your initial consultation is key to determining if you are the right candidate for surgery.

3. Do You Have Emotional Support?

Having a strong support system is very helpful around the time of surgery. Your surgery planning and recovery is an extensive process and will go smoother if you have friends and family to help you through it. You may also want to prepare yourself for the inevitable emotional “ups and downs” that will definitely arise throughout the post-op recovery process.

4. Can You Afford to Have Surgery at This Time?

We never want our patients to go into overwhelming debt to be able to afford their surgery. Surgery is stressful enough without the burden of debt weighing you down!

Our practice does not contract with any insurance providers so all of our patients are personally and fully responsible for payment of all fees and costs related to our services and medical care. If you are planning to rely upon an insurance provider we will require an advance deposit and we may offer to submit a “prior authorization” request to the provider. However, a “prior authorization” is not a guarantee of payment. Therefore you should have sufficient funds available to cover all fees and costs related to your surgery should your request be denied.
Read more about finance and insurance for surgery.

5. Research is wise, but ‘Surgeon Shopping’ obsessing can be detrimental.

Electing to undergo plastic or aesthetic craniofacial surgery is one of the more important decisions you will make in your lifetime. Educating yourself on the various options for procedures and surgeons is advised to ensure your confidence when making your decision. It is always a good idea to seek out more than one opinion. However, when the situation is such that you are not getting the answer you want from more than one surgeon, then you may want to reassess your goals.

We sometimes find a level of distrust with some patients who seek out multiple consultations. They simply don’t trust their doctors. This is a bad situation for both the patient and the surgeon. Getting many opinions from multiple surgeons can easily overload a person and the resulting confusion and anxiety may lead you to make a poor decision regarding surgery. We recommend that you consult with one or two reputable professionals and then consider their recommendations carefully before making any final decisions.
Read more about what to expect at your initial surgical consultation.

16 Mistakes To Avoid When Choosing Your FFS Surgeon

Choosing the right plastic surgeon to perform your facial feminization surgery can be a confusing and overwhelming process, for trans and cisgender women alike. Like any major decision in your life, it pays to do thorough research before making your final choice, because choosing the wrong surgeon could entail significant consequences. An inexperienced or unskilled surgeon may suggest procedures which are ill-suited for your facial features. Conversely, they may omit procedures that would be ideal for you simply because they are not comfortable performing what may be necessary. And of course, no one wants to seek out another surgeon to repair the work of the previous one, but unfortunately, that is a very common occurrence for FFS.

Many people start out by searching for patient reviews online. However, these can be inconsistent and may also be completely inaccurate due to exaggerated reviews or comments. It has been brought to our attention by patients visiting our practice, for example, that some surgeons have offered cash incentives for promoting their practice online. It is wise to take a “buyer beware” approach so you can be fully aware of any pitfalls or red flags to look out for. To help make the process easier for you, we’ve put together a list of factors to avoid when choosing your FFS surgeon.

1. By Googling “best facial feminization surgeon” or a similar search term

If you start your search for an ideal FFS surgeon by googling “best facial feminization surgeon” or “best FFS surgeon in the world” don’t expect to get trustworthy results. This is because these kinds of Google rankings are very easy to manipulate. It’s better to start your research based on meeting surgeons in person and understanding the volume and quality of their work.

2. Making your decision solely based on “Before and After” pictures on the Internet

Many FFS surgeons display “Before and After” pictures of patients on their websites and on social media. However, it’s important to remember that image manipulation via Photoshop is a common marketing tactic. So keep in mind that although “before and afters” may seem impressive, you need to be wary of what you are seeing. Photos presented as representative of a surgeons work should be taken with the same camera, with the same lighting, against the same backdrop, and preferably with minimal makeup in both the before and after photos, with the hair pulled away from the face. Patients who share Instagram-worthy “after” photos with makeup from unusual angles and flattering lighting are only promoting their own vanity and provide little insight into the skill of the surgeon who performed the work.

3. Does the surgeon have an overabundance of positive reviews on social media?

Just to reiterate, it’s important to take all online reviews with a healthy dose of skepticism. If you see a surgeon being overly praised, tread carefully. Listen to your gut instinct. If a review feels overly positive, or not authentic, it probably isn’t. Social media and online “influencer campaigns” are becoming more and more common.

4. Alternatively, does your surgeon spend a lot of time on social media?

If your surgeon appears to be spending more time on social media rather than operating on patients that may be a red flag. Ideally, if your surgeon has a good reputation and is in high demand they should be too busy operating on patients, rather than commenting on Facebook.

5. Does your surgeon spend a lot of time flying around to conferences all over the world?

You may think it’s a good sign that your surgeon spends a lot of their time flying around the world to provide local patient consultations. How convenient. However, your surgeon likely isn’t very busy if they need to travel in order to solicit your business. The best surgeons are generally too busy operating to do that sort of thing.

6. How many FFS patient procedures does your surgeon perform in a year?

Your surgeon’s workload is a good indicator of the actual demand for their facial feminization practice. Ask them how many FFS surgeries they perform within a year. Top facial feminization surgeons will typically undertake 2-3 facial full feminization procedures a week, this equates to at least 100 or more a year. When it comes to facial feminization there is no substitute for experience. Beware, however, because you likely cannot be sure that your surgeon is telling the truth about how busy they are. We have personally seen surgeons misrepresent their experience at academic medical conferences to their peers, so there is nothing really stopping them from misrepresenting their experience to you.

7. Is your FFS surgeon just a plastic surgeon? Or are they also a qualified craniofacial/maxillofacial surgeon?

Most plastic surgeons are capable of performing the sum of the soft tissue procedures included in facial feminization. But for a successful and long-lasting facial gender confirmation surgery, ‘bone work’ on the facial skeleton needs to be performed by a highly skilled surgeon with craniofacial/maxillofacial training. Only surgeons cross-trained in both plastic surgery AND craniofacial surgery should perform the cluster of procedures that are typical for FFS. For example, forehead contouring involves the reshaping the bones of the skull to a more feminine shape so your surgeon must know how to work with the underlying skeletal structure of the face as well as the soft tissues. Your surgeon must also have a thorough understanding of how to manage complications when they occur.

Along with the technical skills of facial plastic and craniofacial surgery, your chosen FFS surgeon must also have the keen eye of an artist and a deep appreciation of facial aesthetic harmony to ensure a truly feminine and beautiful result. This may be an obvious factor but is sometimes forgotten when choosing an FFS surgeon.

8. Making your decision based on geographic location.

Top facial feminization surgeons are spread out across the world. So depending on your budget and needs you may want to travel to find the best surgeon for you. If you choose a surgeon based solely on geographical proximity you may be seriously limiting the quality of your choices. For most people, FFS is a major, one-time life event with significant expenses and major sacrifices made in terms of money spent and time needed for recovery. The quality of the work is something that should not be compromised. It makes no sense to arrange your FFS as if you were buying a new car. But unfortunately, many people do just that and end up seeking out another surgeon in a different city to revise the previous surgeon’s work.

9. Your friend’s FFS surgeon worked for her, so you’ll choose the same one.

You might go to a hairdresser that a friend recommends but the same is not true for facial feminization surgeons. Your friend may have had a positive experience but because everyone is different your facial feminization needs will not be the same as your friend’s. For example, if you need a specialized procedure such as a feminizing rhinoplasty (nasal surgery or “nose job”), you want to be sure that your surgeon has a good track record of performing rhinoplasties for men and women in general and also specifically for feminization. In fact, this procedure is one of the most-often requested FFS revision procedures because the ‘new nose’ needs to sit in harmony with your newly feminized features and unless your surgeon has had ample experience in performing rhinoplasties, the result may be less than optimal. It is easy to assume that an “FFS surgeon” will have comprehensive experience in all aspects of FFS but that is often not the case.

10. Have you checked your surgeon’s qualifications, credentials, training, or associations?

Often we assume too much about doctors who call themselves ‘surgeons’. Make sure you check all relevant education, training, qualifications, and certifications to confirm that your surgeon is legally qualified to undertake the plastic and craniofacial surgical procedures that are included in facial feminization surgery. They should have these qualifications clearly and proudly listed on their website and should not hesitate when you ask to see them or have them explained to you.

11. Is your FFS surgeon “Board Certified”?

If your facial feminization surgeon is here in the US, you want to ensure that they are US Board Certified. This means that they have Board-certified status by The American Board of Plastic Surgery.

Alternatively, if your FFS surgeon is located overseas, do a bit of research and find out what the top plastic and craniofacial qualifications and associations are in that specific country, and make sure that your chosen surgeon has these attained credentials.

12. Do they treat you as a real human being or just a set of FFS procedures?

You’re about to make one of the most important decisions of your life, if not THE most important decision, so it can at times feel quite emotional and overwhelming. You want to make sure that your surgeon has a good “bedside manner”, is personable, and treats you like a human being and not just a set of surgical procedures. The same is also true for their clinic staff, ranging from the Physician’s Assistant to the front desk. You want to feel welcome and cared for every step of the way. You’ve already undertaken a significant effort to get to the point of making this momentous decision and their entire staff should support you in the continuation of your gender confirmation journey.

13. Does the surgeon perform FFS in a state-of-the-art hospital or private clinic?

Make sure you know the answer to this critical question. It’s all too easy to just assume that the surgery will take place in a hospital, but that may not always be the case. Ask your surgeon if your surgery is going to be performed in a state-of-the-art hospital or a private clinic. Although small clinics can make you feel as though you’re getting a more personalized level of service, they often may lack the specialized medical facilities that may be necessary in the event of an emergency. To ensure your FFS is done safely by a highly experienced dedicated FFS surgeon be sure to confirm the surgery will be performed in a hospital operating room.

14. Is the surgeon willing to operate on you without a consultation first?

Make sure that you meet your surgeon in person before going ahead with your FFS surgery. Not just on Skype, email or the phone. Especially if you’re traveling to another state or country, it may seem like an extra expense to visit their office for an in-person consultation beforehand but any surgeon with integrity would always want to meet you first for an in-person consult. The best FFS surgeons will want to do a complete interview and physical examination beforehand in order to recommend which specific FFS procedures will work for you.

A responsible surgeon will also want to determine the personalized scope of your FFS and what, if any, variances will be needed. Is this the best procedure for you at this time? Are there any non-surgical alternatives (for example reduction of the Masseter muscle)? Will you need more than the one surgical session? Or any specialized equipment or implants? Do you need corrective jaw surgery first for a misaligned bite?

Reluctance to have an in-person consultation beforehand should be a big red flag.

15. Does your surgeon actually specialize in FFS? Or is it something they do “on the side”?

As you may already know, facial feminization surgery is a highly specialized skill set and not something that just any plastic or craniofacial surgeon can perform. It takes years of studying, specialized training, and then obtaining a large experience in facial feminization surgery (FFS) – hundreds of surgeries- to do this type of surgery with success. If your surgeon does FFS “on the side” to their other general plastic or craniofacial surgery, we’d advise you to keep searching for a facial feminization specialist. You should also ask your prospective surgeon detailed questions about their practice. What procedures do they do? How much of their weekly work is specifically FFS? Another common issue is that surgical residents in training may suggest that they were trained in FFS surgery when in reality they simply assisted the primary surgeon. Watching a procedure and doing them on your own are very different things.

16. Does the surgeon undertake thorough pre-op planning and x-ray imaging?

The key to a successful FFS outcome is pre-op planning. Your FFS surgeon should order a full set of x-rays and measure every feature of your face down to the millimeter. Additionally, your surgeon should have access to the latest in imaging technologies such as Virtual Surgical Planning (VSP), a pre-operative planning method that is sometimes used when certain anatomical details are involved. It involves the visualization of a surgical procedure using 3D imaging software. The central benefit being that VSP assists in predefining each step of the procedure including goal planning and bone segment navigation to ensure a symmetrical and aesthetically beautiful result. Do not hesitate to ask your prospective surgeon about their pre-op planning procedures. Poor or inadequate planning procedures are a good indicator of an inexperienced surgeon.

Five Lip Procedures Recommended for FFS

The lips are one of the most prominent areas of the face and a primary point of direct focus during interpersonal communication and intimate human connection. As such, the mouth and the surrounding area provide major opportunities for individuals looking to rejuvenate and feminize their appearance.

Some of the most common procedures for feminizing the lips are purely for rejuvenation purposes, this makes them ideal if your lips are showing signs of aging such as fine ‘lipstick’ lines or wrinkles, loss of volume (thinness), and/or sun damage.

Surgical lip rejuvenation procedures include the lip lift (upper lip reduction), the corners of mouth lift, and perioral dermabrasion. If you’re seeking a less-invasive lip rejuvenation treatment, you may want to explore popular non-surgical procedures like around the mouth such as dermal fillers and Botox® or Dysport® injections.

A well-qualified, Board Certified surgeon with experience and training in facial feminization surgery can advise you on which of these procedures would be most suitable for you depending on your unique facial features, age, and skin condition.

1. Upper Lip Lift (Upper Lip Reduction)

The upper lip is “lifted” via a simple surgical procedure whereby the surgeon creates an incision directly beneath the nose and a small strip of facial tissue skin is removed. The lip is then elevated upwards to expose about 3-5 millimeters (1/8”) of the teeth into a more youthful and female position. This makes the previously hidden and pinkest part of the lip more visible, exposing a portion of the upper teeth as is common with female faces. The resulting look is very youthful and feminine and since the procedure is done without the use of fillers or plumping agents the results appear to be very natural with very little minimal visible scarring because the incision is hidden under the nose.
Read more about Upper Lip Lift here.

2. Lip Augmentation (Lip Filling and Plumping)

Lip augmentation is a procedure that involves the surgeon augmenting (or filling) the lips via injection. There are two options for lip augmentation:

• Surgical fat transfer (fat grafting or fat injection)
• Non-surgical dermal filler via injection

Fat transfer involves the surgical relocation of fat from your own body, most likely from the abdomen or thighs. The fat is then injected in multiple injection points into the lips. Fat transfer is highly recommended for lip rejuvenation because it is a safe and more natural way to plump and increase the volume of the lips. Since the fat that is transferred is from the patient, the body is less likely to absorb or remove it and the results are usually permanent for most people.

The injectable dermal filler option has the advantage of being a non-surgical and less invasive procedure. There are many commercially available fillers such as Restylane®, a proven commercially available product. However, it is important to note that artificial fillers are resorbed by the body over time and necessitate repeat injections.
Read more about lip augmentation here.

3. The Corners-of-Mouth Lip Lift

The lips at the corners of the mouth are usually less visible and less pink in color than the rest of the lips, and with natural aging, may become downturned creating a ‘sad face’ look. The corners-of-mouth lift works to give the lips a fuller and brighter pink continuous sweep across the entire mouth. The corners-of-mouth lift improves the ratio of the natural “sweep” of the lips and increases the visibility of the pink portion of the lips. This procedure focuses exclusively on lifting the very corners of your mouth and does not affect lip movement, which is necessary for the expression of your full range of emotions.
Read more about corners of mouth lift here.

4. Perioral Dermabrasion To Rejuvenate The Entire Mouth Area

Dermabrasion is a safe and effective treatment for reducing the appearance of acne scarring, fine lines, and wrinkles. It also alleviates sun-related skin damage and uneven pigmentation (sun spots). Dermabrasion is relatively painless, and although it removes several layers of skin, it and can be performed as a day procedure in the operating room with very little downtime.

The process involves literally ‘buffing’ the skin with a high-speed, rotating dermabrasion instrument. The depth and degree of the treatment are customized depending on the desired results and the amount of resurfacing required. While dermabrasion is usually performed on the face it can also be done on other areas of particularly dry or damaged skin such as the back of the hands or decolletage.
Read more about facial dermabrasion here.

5. BOTOX® And Dysport® Injections For Reducing Wrinkles And Smile Lines

BOTOX® and Dysport® injections are frequently recommended for rejuvenating and softening the lips and surrounding area. Both products have been proven to be safe, effective, and long-lasting. When these popular injectable treatments are applied by a skilled and qualified provider–and performed with skill and artistry–the results can be quite dramatic and still yet very natural-looking.

Worry lines and deep wrinkles smooth and soften almost immediately, giving the face a rejuvenated and refreshed appearance that lasts for 4 to 6 months or more. Subsequent treatments may produce an accumulative effect in with results lasting much longer, up to 8 to 10 months in some cases.
Read more about BOTOX® and Dysport® injections here.

Before Taking the Leap, You May Also Want to Explore Facial Feminization Without Surgery

If you’re considering facial feminization surgery you may also want to take a look at non-surgical, non-invasive facial treatments AKA “liquid facial feminization”. Of course, feminization without surgery will not produce the same dramatic results that surgical feminization will produce, but there are several facial treatments that will assist in feminizing the face to a degree–depending on your age, facial bone structure, and skin condition.

The following treatments are a great way to dip your toe into feminization gradually feminize–and depending on your age–rejuvenate your facial features…

Masseter (jaw) muscle reduction via Botox® or Dysport®

One of the most requested facial feminization procedures is jaw contouring (jaw reshaping or tapering). However, depending on your facial structure, you may also want to ask your surgeon about masseter muscle reduction via Botox® or Dysport® injections.

The masseter muscle runs down the cheekbone down to the lower jaw on both sides of the face. The masseter may be enlarged in some people if there is frequent grinding of teeth (bruxism) resulting in increased muscle bulk, facial asymmetries, and an overly-square and masculine jawline. Injections of Botox® or Dysport® injections directly into the muscle work by essentially relaxing and ‘atrophying’ the muscle and thereby reducing its size. Depending on the individual, the masseter may stay reduced permanently – even without further injections.

Botox® or Dysport® for frown lines and wrinkles

Botox® and Dysport® injections are one of the most popular treatments for reducing lines and wrinkles. They work to feminize the face by smoothening the skin and reducing signs of aging such as crow’s feet and frown lines. This treatment is also ideal if you have deep ‘furrow’ lines between your brows causing an overly ‘serious’ expression or heavy appearance to the brow.

It is critical that your chosen Botox® and Dysport® treatment provider has had experience with injecting transgender women. This is because the careful and precise placement of injections is the key to producing a positive result. Essentially, the skill of injecting Botox® accurately is not only that of a medical professional and also of an artist who is sensitive to the overall aesthetic of your face.
Read more about Botox® and Dysport® injections here.

Dermal facial fillers (facial volume) via Restylane®

Depending on your facial features and underlying structure there may be certain areas of the face that appear sunken or hollow, such as the under-eye area, cheeks, around the mouth, and lips. Dermal fillers such as Restylane® are an ideal way to fill out these hollow areas, correct any volume loss due to aging and feminize facial contours. Dermal fillers are ideal for:

• Lip filling and plumping
• Alleviating crow’s feet and forehead wrinkles
• Adding volume to cheeks, chin contours, forehead, and nose
• Filling facial hollows especially sunken areas under the eyes
• Reducing the appearance of “sad mouth” (oral commissure creases)

One of the biggest advantages of Restylane® is that you can dissolve the filler if the placement needs fine-tuning or adjusting. It is this incremental approach which makes it ideal for those new to facial feminization and rejuvenation.
Read more about Restylane® dermal fillers here.

Perioral (around the mouth) feminization & rejuvenation

The ‘perioral’ area of your face is the area immediately surrounding the mouth, including several features: lips, upper lip area (under the nose), nasolabial folds (“smile lines” or “laugh lines”), and the corners of the mouth. There are several non-surgical treatments that will help to feminize and rejuvenate this lower part of the face:

• Dermal fillers such as Restylane® add volume and fullness to the lips as an injectable, non-surgical treatment consisting of hyaluronic acid — a safe, natural, and long-lasting substance that boosts lip volume, improves structure–and most critically for feminization–improves the overall lip shape.
• When injected with the correct skill and artistry to areas around the mouth, Botox® and Dysport® injections can result in a very feminine and natural-looking result.
  Read more about perioral rejuvenation here.

Microneedling for smoothing imperfections and skin texture

Microneedling (skin needling) involves is the use of a series of tiny and very short needles to penetrate the skin. The procedure sounds painful but the needle is tiny creating a very mild sensation and only very superficial punctures of the skin’s epidermis. Microneedling is ideal for smoothing skin texture and for reducing the appearance of skin imperfections such as acne scarring, uneven pigmentation, and enlarged pores.
Read more about microneedling here.

Kybella® “Double Chin” reduction

Kybella® is an ideal treatment for those seeking a non-surgical and relatively painless solution to reduce a “double chin”. A short series of injections of a naturally-occurring molecule called deoxycholic acid targets submental fullness – the very specific type of fat molecule that creates a double chin.
Read more about Kybella® here.

Platelet Rich Plasma (PRP) AKA the “Vampire Facelift”

PRP is not technically a ‘facelift’ but it’s a relatively non-invasive procedure that works by harnessing your own biological nutrient-rich cells to stimulate the regeneration of the underlying structural integrity of your skin to stimulate the release of the skin’s own cells encouraging the skin to create new blood vessels, new collagen, and new skin cells.
Read more about PRP here.

Who performs non-surgical facial feminization?

All non-surgical facial feminization procedures are performed by Jennifer Fick, FNP-C, CANS, a Board Certified Aesthetic Nurse Specialist, read more about Jennifer Fick here. If necessary, Dr. Deschamps-Braly is on hand to consult in more complex cases.

What is the Difference Between a Facelift and Pan Facial Rejuvenation (PFR)?

Most of us know what a facelift is, but you may not be familiar with the term pan facial rejuvenation AKA “full face facelift” or predictive aging.

The short version is that pan facial rejuvenation (PFR) considers the “whole face” – rather than just altering specific sections, resulting in a more harmonious, and natural-looking outcome. It may also include any additional procedures such as eyelid surgery (blepharoplasty), brow lift, temple lift, or an upper lip lift–just to name a few.

If you are considering a facelift or PFR, there are several key differences that may help you to decide which procedure will work best for you…

1. Tailored approach: your PFR procedure is customized to your face.

Possibly the most important difference between a facelift and a PFR is that while a facelift is a single surgical procedure, pan facial rejuvenation is actually a cluster of procedures. The exact procedures that will be performed will depend on your desired results, skin condition, and facial features. This is because every face is unique and therefore ages in a unique way, so depending on your situation the actual procedures will also be unique to you. The ‘whole face’ customized approach of PFR means that the final result will appear more natural and harmonious.

The specific procedures that will end up being relevant to you will be decided upon during consultation with your surgeon. You may also choose to have non-surgical procedures included such as dermal fillers or Botox® or Dysport® injections.
Read more about the procedures that may be included in pan facial rejuvenation.

2. Age of candidate.

The ideal candidates for pan facial rejuvenation are typically over the age of 50 years, whereas facelift candidates may be younger, in their mid-to-late 40’s–depending on skin condition. But also, the ideal candidate is someone who is ready for a dramatic–yet naturally beautiful–transformation. Someone who wants “everything done at once”, rather than separate procedures over a longer period of time.
Read more to find out if you’re the right candidate for pan facial rejuvenation.

3. One surgical session–rather than several.

One of the key benefits of pan facial rejuvenation is that your surgery is completed in one single surgical session of 6-10 hours, rather than several surgeries spread out over a longer period of time. This means that the actual length of the surgery is definitely longer than a standard facelift but it also means that you won’t need to come back for a very long time–if ever.

Some people have concerns about “long format surgery” however, we take precautions to ensure that it is as safe and comfortable as possible.
Read more about the safety of long format operations here.

4. Longer recovery time.

Depending on your age and health, the recovery time for PFR may be slightly longer than a facelift. This may seem like a mild annoyance at first, but not if you look at your pan facial surgery in the big picture. Instead of the downtime associated with several surgeries over several years, you’ll only be out of action for a comparatively short period of time.

Two weeks post-op most of your swelling will have dissipated, but you may still have mild bruising and swelling around the eyes, behind the ears, or on the sides of the face and neck.

Towards the end of the third week, you’ll notice an improvement in the quality of your facial skin and incisions, but you may still experience mild itching and/or numbness. Any bruising should be completely eliminated by this time, and any swelling barely noticeable. At one month post-op you will probably be able to resume all your normal activities but please refrain from heavy exercise until the sixth-week post op.
Read more about post-op recovery time for pan facial rejuvenation here.

Fat Transfer for Facial Feminization (FFS)

Fat transfer (AKA fat grafting, fat injection, or lipofilling) is a popular surgical technique that is often used in facial feminization surgery. The procedure involves harvesting your body’s own fat cells, typically from your abdomen or inner thigh, and transferring them into facial areas such as under the eyes, into the lips, chin, or the cheeks, that may need added volume.

The popularity of fat transfer as a facial filler is largely due to it being your body’s own fat–rather than a synthetic material.

Typically, most dermal fillers are produced in pharmaceutical labs and, while they do have a well-established place in adding volume to facial structures, they have significant disadvantages over fat. Artificial fillers can be resorbed by the body necessitating repeat injections that can be expensive over time. They may not feel as natural to the touch as a fat injection, and if placed improperly, are sometimes visible through the skin.

The benefits of fat transfer over artificial dermal fillers for facial feminization:

• Longer-lasting, more permanent results
• Looks and feels very natural
• Invisible underneath the skin
• Your own fat moves more naturally with facial expressions

An additional benefit of using fat as a filler is that your body’s fatty tissue contains an abundance of powerful cells — naturally occurring cells that self-renew and have the ability to rejuvenate the skin. Your own cells will be transplanted along with your fat cells, improving facial volume and improving skin quality.

Fat transfer is ideal for filling in the following areas of the face…

1. Under-Eye Area

Depending on your age and skin condition it’s not uncommon for most people (of any gender) to have some hollowing of the under-eye area causing the eyes to look “sad” or overly tired. Fat transfer is perfect for filling out these hollow areas resulting in a more youthful and rejuvenated appearance.

2. Cheeks

In the context of facial feminization, the shape and profile of the cheeks are critical. Enhancing the cheeks via fat transfer gives the cheeks a rounder and smoother feminine appearance–without the use of artificial cheek transplants. We recommend lipofilling because the procedure gives your surgeon more control to sculpt and shape the cheeks to ensure facial harmony, while also addressing ageing-related volume loss in the cheeks.
Read more about cheek enhancement via fat transfer here.

3. Lips

There are several lip feminization techniques that are used in the context of facial gender confirmation with one of the most popular ones being lip augmentation (filling) via fat transfer. Essentially, your own body’s fat is used to fill and reshape the lips so they appear fuller and more feminine. Fat transfer is also the most natural and longest lasting method of reshaping your lips, being a permanent solution for most people.
Read more about lip feminization here.

4. Nasolabial Folds

Nasolabial folds are commonly known as “laugh lines” or “smile lines”. They are the grooves that extend out from the edges of your nostrils to the corners of your mouth. As we age these lines get deeper and more pronounced. Fat transfer is an ideal option to fill out these folds to create a younger, more feminine look.

For other concerns, such as skin texture and fine lines around the mouth, you may also want to explore non-surgical perioral (around the mouth) rejuvenation.
Read more about fat transfer here.

Facial Feminization Surgery – A Complete Guide to FFS

Everything You Need to Know about FFS

Facial feminization surgery (FFS) includes a series of plastic and craniofacial surgical procedures designed to feminize the face. FFS is ideal for trans women and non-transgender women who want a more feminine facial appearance. These surgeries can reduce the size and shape of the forehead, alter and refine the nose, make the lips fuller and the cheeks rounder, decrease the chin’s size and shape and shave the Adam’s apple, among other effects.

For transgender women, FFS procedures can significantly decrease the often harmful effects of gender dysphoria. Not ‘passing’ as your true gender can have devastating and damaging life-long effects. Matching an individual’s ‘outside’ with their internal sense of self can provide immense relief from the suffering and distress of living in a world that views you as something other than who you are.

Facial feminization can also have noticeable effects on how you are perceived, and how you interact with others in society. After all, first impressions are often based on appearance, including facial harmony and beauty. FFS can make it possible for you to be more consistently identified as a woman, and as a result, you can become more relaxed in relating to others as your true gender.

After facial feminization, many of our patients make comments such as: “I no longer fear looking at my face in the mirror when I get out of bed each morning.” Instead, the vision of one’s face glimpsed in a mirror is a source of self-confidence and joy.

Facial feminization can contribute to life-changing improvements, including an increased sense of self-worth and self-esteem, according to recent research. These surgeries can also have a beneficial impact on an individual’s personal and professional life.

What follows is a succinct overview of each surgical procedure that falls within the scope of facial feminization. We also discuss the history of gender confirmation surgery, and frequently asked questions about FFS.

CONTENTS:

Procedures:

1. Forehead Reduction and Contouring
2. Scalp Advancement (Hairline Lowering)
3. Brow Lift (Browplasty)
4. Rhinoplasty (Nasal Surgery)
5. Cheek Enhancement (Augmentation & Reduction)
6. Earlobe Reduction
7. Lip Lift and Lip Filling
8. Chin Recontouring (Genioplasty)
9. Jaw Contouring (Reshaping or Tapering)
10. Adam’s Apple Reduction (Tracheal Shave)
11. Facelifts and Facial Feminization
12. Ethno-Specific Facial Feminization
    ++++• Feminization of The Asian Face
    ++++• Feminization of the African American Face

History:

• History of Facial Feminization & Gender Confirmation Surgery

Frequently Asked Questions:

• Why Choose A Plastic Surgeon With Craniomaxillofacial Training For Your FFS?
• Have You Had FFS Surgery Before But Are Less Than Happy With The Results?
• Can I Have A Facelift At The Same Time As My Facial Gender Confirmation Surgery?
• Can I Do My FFS In Different Phases? Or Should It Happen All At Once?
• How Long Will The Surgery Take? How Safe Is Long-Format FFS Surgery?
• How Long Will It Take To Recover From Facial Gender Confirmation Surgery?

1. Forehead Reduction (Contouring & Reshaping)

The forehead dominates approximately one-third of the human face. So, it is a crucial area for facial feminization. The forehead and the brow are significant indicators of gender, since their characteristics vary greatly between males and females. Reducing the size and shape of the forehead might be the single most notable procedure for feminization of the face.

Forehead reduction and contouring, especially when performed in conjunction with a hairline lowering procedure, results in a more naturally feminine appearance. Existing facial bone asymmetries can also be remedied at the same time, resulting in increased facial symmetry and aesthetic harmony.

The procedure involves reshaping the forehead and the bones around the eye sockets. This reduces the large bony ridge of a masculine-looking forehead and the eyes become more pronounced, noticeable and feminine. The changes in these traits can have a profound effect on your overall gender appearance.

Although the procedure varies by patient, an incision is made in every case at, or above the hairline, depending upon the final hairline positioning. The brow bone is osteotomized or cut and reconstructed, and the orbital bones around the eye sockets are reshaped. The frontal bone between the eye sockets is removed, reduced as needed, and reattached. At the same time, it is not unusual to perform other surgeries, such as hairline restoration, in order to take advantage of the incisions made during a forehead procedure.

2. Scalp Advancement (Hairline Lowering)

The height of a forehead and how the face is framed by the hair makes a real difference in whether you are identified as male or female. Female faces typically are recognized as having “smaller” characteristics, and this is largely because the female hairline is situated lower on the forehead.

Scalp advancement surgery brings the scalp and its hair follicles lower down on the forehead. The procedure consists of making a trichophytic incision along the forehead where the hairline is desired, and then pulling the entire scalp forward. This movement brings the hairline into what is perceived as a typical hairline height and shape for a woman. By using a trichophytic incision, the hair follicles can be buried underneath the skin closure at the end of the surgery, so that hair will grow through the scar and in front of the hairline.

Hairline lowering is usually completed together with a larger group of complementary feminization procedures as part of a long-format surgery. It is also a common procedure for cisgendered women with receding hairlines.

3. Brow Lift (Browplasty)

Not all brows need to be lifted. In fact, some just need to be shaped into a more feminine and aesthetic form. Depending on the existing facial features, the brows may naturally elevate to a higher position as they age. For an aesthetically pleasing brow, the shape and position of the “tail” of the brow is actually more important than its overall height. With aging, the facial volume in our temple area decreases. This loss can be significantly improved by restoring volume with a natural filler such as the patient’s own body fat via a fat transfer procedure.

Brow lift surgery is performed under general anesthesia usually via an “open” approach during a long-format facial feminization surgery session. Although endoscopic brow techniques are common, better results can be achieved with an open approach, because it allows for better control of the final result. Regardless of the surgical technique, an incision is made in the hairline or in front of the hairline, which leaves little to no visible scarring. Typically, during a brow lift the corrugator muscle (a small muscle near the eye) is severed, which eliminates the future need for Botox®. It also permanently alleviates vertical wrinkling between the eyebrows.

A brow lift may also be performed at the same time as a hairline restoration, rhinoplasty, or forehead reduction/contouring.

4. Rhinoplasty (Nasal Surgery)

Rhinoplasty reduces the size of the nose, and alters its shape and profile to make it appear more feminine. This result is achieved by narrowing and/or altering the nose internally, and/or reshaping and moving the nasal cartilage.

The biggest challenge with feminizing the male nose is to ensure that it retains aesthetic harmony with all other existing or newly feminized facial features. It is critical that the “new nose” is aesthetically in balance with the rest of the facial structure.

The art of rhinoplasty surgery is an extremely delicate process — regardless of gender — and it is also one of the most difficult plastic surgery procedures to undertake successfully.

Rhinoplasty is almost always performed at the same time as forehead feminization and hairline lowering to ensure that the end result is aesthetically balanced.

5. Cheek Enhancement (Augmentation)

The cheeks are a significant aspect of the feminine face. If you feel that your cheeks are too masculine, cheek enhancement via augmentation works to give the cheeks a rounder and smoother feminine appearance. Some patients may prefer higher, more prominent cheekbones, while reducing excessive fullness or “chubby” cheeks.

Cheek augmentation is typically performed with non-surgical fat transfer or fat grafting. This procedure involves fatty tissue being removed from another part of the patient’s body (usually the inner thigh) and injected into the cheeks. Injection of the fat causes the cells within it to mobilize, and thus, use of fat grafts can improve circulation and rejuvenate tissue. We’ve seen marked improvements in the quality and texture of patient skin after fat grafting that is apparent by six months after surgery.

6. Earlobe Reduction

Earlobe surgery feminization is often performed in conjunction with a series of other facial gender confirmation procedures. Earlobes may be reduced, reshaped, and cartilage may be sculpted to modify the overall contours of the ear. Feminizing an earlobe can be achieved by reducing and reshaping a larger and longer ear. The earlobe, or the peripheral lobule, is trimmed and reshaped as desired for a more feminine look. The single most important step in feminizing an ear is crafting a smooth and natural interior lobe border.

The cartilage of the ears continues to grow throughout our lifetime. Gravity over time also causes earlobes to sag, stretch, and enlarge, creating pendulous earlobes, a condition commonly called “megalobe” — which may not look feminine, or aesthetically pleasing.

7. Lip Lift and Reshaping

Feminization of the lips may include several procedures depending on patient features, age, or desired outcome. Lip feminization is often performed as a part of a larger facial feminization surgical process. The most typical lip FFS procedures include:

• Upper lip lift (upper lip reduction) lifts the upper lip to a more feminine and “open” position to improve the visibility of upper teeth. A lip lift makes the lips – and the entire face – look more feminine by shortening the upper lip, improving the visibility of the upper teeth, and creating a more youthful appearance.
• Lip Augmentation (Lip Filling) fills the lips so they appear fuller, “plumper” and more feminine. Lip augmentation may be done either through the use of injectable fillers or fat transfer injections.
• Corners-of-Mouth Lift: Often less of the red part of the lips shows near the corners of the mouth in men. A corners-of-mouth lift is done to improve the natural “sweep” of the lips and increase the visibility of the red portion. This procedure does not affect lip movement, which is necessary for the expression of a full range of emotions.

8. Chin Recontouring (Genioplasty)

Chin re-contouring (genioplasty/mentoplasty) reduces the shape of a large or prominent chin — when a more feminine look is desired. This procedure is intended to impart a natural balance by reducing and reshaping the chin to be smaller, less angular, with a smoother and more feminine aesthetic. Also, any existing congenital asymmetries can be eliminated to increase symmetry and create an aesthetically pleasing appearance.

Chin implants are typically not used in this type of operation. In fact, it is impossible to feminize a chin with just an implant because any implant will invariably have the effect of actually enlarging the chin — the exact opposite outcome of the goals of feminization. Chin implants also can cause potential problems, such as infection due to rejection, shifting of the implant later, and/or possible damage to the roots of the teeth or nerves that give your lips sensation.

Another method that is commonly employed for chin contouring is a T-osteotomy, which involves cutting and removing a T-shaped piece of bone, and then fusing the remaining bones of the chin together. It is almost impossible to correct both a square jaw and produce a slender “V-Line” shape to the chin — simultaneously — without using this technique for chin recontouring.

9. Jaw Contouring (Reshaping or Tapering)

Jaw contouring (also known as jaw tapering or jaw reduction) is used to modify and feminize prominent male jawlines. The back “corner” of the male jaw can also be reshaped to be rounder and smoother. Bone can be shaved off along the lower edge of the jaw and chewing muscles reduced (see: Masseter Muscle Reduction) to make the jawline appear narrower.

Jaw contouring works to narrow the overall width and shape of the face, subtly refine jawline angles, and improve the overall proportions of facial features so that the face appears more feminine. Individuals with asymmetrical or lopsided-appearing faces also benefit from this procedure. The results will look natural and provide balance and harmony to facial proportions, as well as making the face appear more feminine.

10. Adam’s Apple Reduction (Tracheal Shave)

The size of the Adam’s apple can be reduced significantly with a surgical procedure known as a tracheal shave, thyroid cartilage reduction, or Adam’s apple reduction. It involves literally reducing or shaving the thyroid cartilage down to decrease the size of the Adam’s apple. This procedures makes the neck and throat appear more feminine, and helps fulfill the goals of facial gender confirmation.

Typically, the procedure involves an incision in the throat just under the chin. The vertical muscles of the throat are then separated to expose the Adam’s apple and the tracheal cartilage is shaved to reduce its size.

Incisions should not be made on the front surface of the throat where it is very visible. This may also result in a very undesirable outcome: the scar can stick to the cartilage underneath, and move up and down when the patient speaks or swallows.

11. Facelifts and Facial Feminization

A facelift (rhytidectomy) is a surgical procedure designed to reduce the effects of aging in the facial and neck areas. The procedure is used to tighten sagging skin, reduce lines and wrinkles, and eliminate jowls and excess fat.

To achieve the best outcomes, a facelift should not be attempted until six months after the completion of any facial feminization procedures. Also, any weight loss plans should be completed before any facelift procedures are undertaken.

The most commonly used facelift procedure after feminization surgery is usually the surgery known as the deep plane facelift or SMAS (Superficial Muscular Aponeurotic System). In this facelift, the surgeon works with the deep, underlying layer of facial muscle and fibrous tissue under your skin. Modern facelifts work on a much deeper, structural level than in years past, and literally lift the underlying facial structures for a more natural-looking, longer-lasting result.

In most people, the neck will show signs of aging even before the face, so a neck lift may be recommended in tandem with a facelift. Undertaking both of these procedures at the same time enhances the positive results and ensures facial aesthetic harmony. However, depending on your age, a full surgical neck lift may not actually be necessary, and you may also want to explore non-surgical options such as Botox® or Dysport® injections for a rejuvenated and youthful appearance.

12. Ethno-Specific Facial Feminization Surgery

Facial feminization procedures will often vary in patients of different ethnicities.
Individuals of Asian and African descent need key modifications of the procedures typically performed on individuals of a Caucasian background.

Feminization of The Asian Face

First and foremost, the shape and size of the forehead and the brow should be the main focus of feminization for those of Asian background. Forehead feminization typically includes reduction and contouring to create a smoother, rounder, more feminine forehead.

Also, a 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 need to be taken into consideration with facial feminization of an Asian forehead. For example, a Chinese female forehead will typically project significantly less than a Caucasian female. However, a Japanese forehead is evenly positioned “behind” the eyeball, with no overhang above the eye.

The hairline position on the forehead will also be a little different depending on the specific Asian background. When undertaking hairline lowering on Chinese and Koreans, it is important to allow for the slightly higher hairlines of these individuals before facial feminization. So the hairline will not be lowered as significantly in these patients as it might be for people of European background.

When it comes to feminizing the lower face, the most common procedure for those of Asian background is the “Asian V-line” jaw reduction surgery. This procedure is important, 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. Most Asian FFS patients will seek to augment their nose to make it larger. This may seem counterintuitive in terms of feminization, because typically the male nose is reduced in order to feminize it. However, in some cases, a rhinoplasty will include augmentation to ensure that the nose maintains a natural aesthetic balance with other newly feminized facial features.

Feminization of The African-American Face

The shape and size of the forehead and the brow should be the main focus of facial gender confirmation 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 for African Americans typically includes forehead reduction and contouring to create a smoother, rounder and more feminine shape. Also, a brow lift and/or brow shaping procedure is recommended to reduce the distinctly “heavy” African-American male brow bossing. This procedure “opens up” the eyes to create a more feminine appearance.

The hairline position on the forehead will also be different because African-American women tend to have naturally higher hairlines than European women. Thus when lowering the hairline it is important to make allowance for the fact that African- American women have slightly higher hairlines to begin with, so the hairline may not be lowered as significantly as with others. Ultimately, the best results are attained by ensuring that the newly feminized facial features are aesthetically in balance and have a natural look.

Typically, gender confirmation of the nose via rhinoplasty is recommended for most FFS patients. Often, African-American transgender patients seek a narrower, more streamlined female nose. However, it is important that the nose maintains a size and shape that is in harmony with its natural African-American facial features.

Jaw surgery is also advised because the male African-American jawline is usually quite broad and angular – often wider and squarer than what is seen in other ethnicities. The jaw will often need to be narrowed and softened via jaw contouring or reshaping.

Lili Elbe 1926. Image source: Wikipedia

History of Facial Feminization & Gender Confirmation Surgery

The Beginnings Of Facial Feminization & Gender Confirmation Surgery

Prior to the advent of gender confirmation and facial feminization surgery, individuals with gender dysphoria had no viable medical or surgical options. They could “dress to pass” as the gender they identified with, but were still often seen by the world at large as their assigned gender at birth. Transgender individuals often lived with a deep sense of dissatisfaction and felt uncomfortable in their own skin — physically, emotionally and psychologically.
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• 1906: The Very First Known Case Of Gender Confirmation Surgery. In 1906, Karl “Martha” Baer attempted suicide by stepping in front of a streetcar in Berlin after his affair with a married woman was discovered. Baer was presenting himself as male, despite papers identifying him as female.
• 1907: Dr. Magnus Hirschfeld was consulted, and in 1907 Baer underwent a surgical procedure to masculinize his intersex genitals — likely via metoidioplasty. Assigned female at birth, he became one of the first people to undergo gender confirmation surgery in December of 1906. He also consequently became the first female-to-male (FTM) transgender individual. In January 1907, he was the first transgender person to gain full legal recognition when he had a new birth certificate issued that identified him as male.
• 1922-1969: The Early, Experimental Years: The origins of gender confirmation surgery can be traced back to the early 20th century when gender-related surgery was experimental and rare. One of the first identifiable recipients of gender confirmation surgery was Rudolph “Dorchen” (Little Dora) Richter, who had an orchiectomy in 1922 by her own request. The surgery took place at the Institut für Sexualwissenschaft (Institute for Sexual Science), founded by Dr. Magnus Hirschfeld in Berlin. Then later in 1930, Richter underwent penectomy by Dr. Levy-Lenz and vaginal reconstruction by Dr. Erwin Gohrbrandt. Dr. Hirschfeld was called the “Einstein of Sex” by a Hearst newspaper in 1931, and he pioneered modern day transgender healthcare. He and the institute he founded were a source of empathy for a population scorned by society. The Institute became a mecca for the study of sexology, and housed a museum for the education of the public. People from around the world visited the Institute to gain greater understanding of homosexuality and transgender people.
• 1930: Lili Elbe, a Danish transgender woman, was the next known case; her story was told in the 2015 film The Danish Girl. The first surgery (removal of the testicles) was made under the supervision of sexologist Dr. Magnus Hirschfeld in Berlin. The rest of her surgeries were carried out by Dr. Kurt Warnekros, a doctor at the Dresden Municipal Women’s Clinic.
• The 1950s: During the 1950s, transgender women benefited from newly available female sex hormone therapy. One of the pioneers in this field was the German-born psychiatrist and sexologist, Dr. Harry Benjamin, a peer of Dr. Hirschfield during the early 20th century in Germany. After immigrating to the United States, Dr. Benjamin became known internationally for his efforts to advance the field of non-surgical care for transgender individuals. He published papers and lectured to professional audiences extensively about transgender medical care. His book, The Transsexual Phenomenon, was the first large work describing and explaining the affirmative treatment path he pioneered. Dr. Benjamin also established the world’s first clinical psychiatric practice focused on the medical and psychological needs of the transgender individual. For over five decades, Dr. Benjamin conducted treatment in collaboration with carefully selected colleagues of complementary disciplines for hundreds of patients with gender identity issues
• 1952: Christine Jørgensen, an American trans woman, had gender confirmation surgery in Denmark. When her transformation made the front page of the New York Daily News, she became an overnight sensation. She used the opportunity to become a strong advocate for the rights of all transgender people. She was one of Dr. Benjamin’s early patients in the 1950s.
• 1966: The first male-to-female surgeries in the United States took place in 1966 at Johns Hopkins University Medical Center. The first physician in the United States to perform gender confirmation surgery was the late Dr. Elmer Belt, who did so until the late 1960s.
• The mid-1970s: Another notable person who underwent MTF transition was Renée Richards. She had male-to-female gender confirmation surgery in the mid-1970s, and successfully fought to have transgender people recognized officially as their new gender.
• 1980s: First Facial Feminization Surgery In 1983. In 1982, Dr. Darrell Pratt, a plastic surgeon who performed body-focused gender confirmation surgeries, approached Dr. Douglas Ousterhout with a request from “Lucy,” one of his male-to-female transgender patients. Lucy wanted plastic surgery to make her face appear more feminine. Dr. Ousterhout, a maxillofacial and plastic surgeon who studied advanced craniofacial surgery with the world-renowned Dr. Paul Tessier in Paris, agreed to the collaboration with Dr. Pratt. He performed a forehead feminization procedure on Lucy that involved the “Ousterhout Type II” forehead procedure–a procedure still used today. By undertaking a detailed study of the differences between male and female skeletons, Dr. Ousterhout was then able to devise several operations to alter the forehead of transgender patients. He also applied other craniofacial techniques to alter and shape the jaw, which he published in 1987. He became known as one of the pioneers of modern transgender facial feminization.
• 1998: Dr. Ousterhout left the University to devote approximately 80% of his practice time to the care of transgender patients.
• 2006: Dr. Ousterhout was one of about twelve surgeons in the world performing FFS.
• 2009: Dr. Ousterhout published Facial Feminization Surgery: A guide for the prospective patient, which was based on having completed nearly seven thousand procedures on more than eleven hundred patients.
• 2015: Dr. Deschamps-Braly completed the world’s first facial masculinization surgery on a female-to-male transgender patient. During this groundbreaking surgery, he performed the world’s first Adam’s apple augmentation–a procedure he created and devised. In the procedure, Dr. Deschamps-Braly used a natural implant made from the patient’s own rib cartilage to increase the size of the Adam’s apple.

Today, Dr. Deschamps-Braly continues Dr. Ousterhout’s legacy. In fact, Dr. Deschamps-Braly is the only surgeon that Dr. Ousterhout has trained and mentored in the art and practice of gender facial confirmation surgery. He carries on the practice of a longstanding and innovative surgical practice in facial feminization and groundbreaking work in facial masculinization (FTM).

Christine Jorgensen 1954. Image source: Wikipedia

FFS Frequently Asked Questions:

Why Choose A Plastic Surgeon With Craniomaxillofacial Training For Your FFS?

Most plastic surgeons are capable of performing soft tissue procedures. Yet for a successful and long-lasting facial gender confirmation surgery, bone work on the facial skeleton needs to be performed by a highly skilled surgeon with craniofacial training. We believe that only surgeons cross-trained in both general plastic surgery AND craniofacial and orthognathic (jaw) surgery should perform FFS. Needless to say, your surgeon must also have the keen eye of an artist and a deep appreciation of facial aesthetics and harmony.

Have You Had FFS Surgery Before But Are Less Than Happy With The Results?

Unfortunately, one of the most common types of facial gender confirmation procedure we perform is correction of a previous surgeon’s work. While some surgeons may know technically what is required for facial feminization, they may not understand the subtle qualities of what truly makes a face “feminine” versus what makes a face simply beautiful. To capture authentic feminine gender expression, your surgeon needs to fully comprehend the science and structural proportions behind male vs. female faces. He or she must also have a deep awareness of the more subtle aesthetic qualities of what constitutes gender. Read more about the characteristics of femininity: Congratulations. You’re Beautiful, But Are You “Feminine”?

Can I Have A Facelift At The Same Time As My Facial Gender Confirmation Surgery?

Dr. Deschamps-Braly recommends waiting at least six (6) months after your surgical procedure before pursuing a facelift or any other facial rejuvenation procedure. This is because feminine facial features are generally more petite than male features, so the facial gender confirmation surgery may leave some individuals with excess laxity of the skin. Depending on your age and skin condition, this excess laxity may resolve on its own, or it may need a facelift in order to remove it.

Can I Do My FFS In Different Phases? Or Should It Happen All At Once?

While we recommend that facial gender confirmation be completed in a single stage, the procedure can be broken up into phases—typically an “upper face” and ‘”lower face” phase. Each phase would include a cluster of surgical procedures that are closely related to each other to ensure a harmonious balance to the face (i.e. forehead and nose or chin and jaw). The two phases can be performed as close as two days, or as long as several years apart. And of course, a single, comprehensive facial gender confirmation surgical procedure can also be performed, and is preferable in most cases to save on downtime and of course, expense.

How Long Will The Surgery Take? How Safe Is a Long-Format FFS Surgery?

A set of facial gender confirmation procedures most often takes anywhere from 6 to 10 hours depending on the exact set of plastic and craniofacial surgical procedures that are required. Undertaking multiple surgeries at one time is very common and usually quite safe if you are in reasonable health. Your surgeon will help you to decide if the specific procedures you require are safe to do in one session.

How Long Will It Take To Recover From Facial Gender Confirmation Surgery?

Typically you will stay the night in the hospital immediately after your surgery. Your surgeon will visit with you in the morning on the day after your surgery to check in with you. The first few days you will experience facial swelling and also feel mild discomfort. However, because we will have taken steps to reduce your pain and swelling before you were operated on, this will subside rapidly.
We try to avoid use of opioid drugs, and instead utilize anti-inflammatory medicines and other research-based methods to reduce pain, relieve swelling and speed healing. Our post-surgical patients now only complain of pain that reaches a level of “2” or “3” on a 10-point scale. Read more about our post-op pain relief strategies here.

Within about 7 days after your surgery, most of the swelling and bruising will resolve. After about 3 to 4 weeks you should have a full recovery and be able to resume your usual activities and wear makeup. However, your results will continue to improve over the next few months, with the final result being evident at six to twelve months.

Facial feminization is major surgery, so it has some risks, and should not be entered into lightly. Yet for most patients, it is well worth the effort and expense to look like the person and gender they feel they are. To ensure the best aesthetic results, it’s crucial to select a surgeon with the right skills and experience, and to pay attention to your preparation for surgery and your own recovery afterward.

Acquiring information about facial gender confirmation surgery from reliable sources can also have real benefits. Your reading and research will add to your knowledge, and increase your confidence in your decisions about facial feminization and masculinization. To that end, be sure to see our blog to find out more about facial gender confirmation procedures.

Redoing Facial Feminization – the Four Most Frequently Revised Surgeries

Redoing Facial Feminization: Why is it sometimes necessary?

Facial feminization surgery is a highly complicated cluster of procedures that involve a lot of “moving parts”. And, like any plastic or craniofacial surgery that is performed for aesthetic purposes, sometimes the results fall short of patient expectations. In fact, 15% of all facial feminization surgery that we perform is to improve upon another surgeon’s work.

The main reason for this high frequency of FFS revision surgeries is to do with the difference between artistry and technical expertise. For example, your chosen surgeon may have the technical skills to perform feminization, but they may lack an in-depth understanding of the subtle aesthetic qualities that make a face “feminine” versus what makes a face merely ‘attractive.’

The most common complaint that we hear from new patients seeking FFS revision is that their facial features have not been successfully ‘captured’ or represented as their preferred gender by their previous surgeon. On the first impression, the patient may appear beautiful, but not as feminine as they desired. In such cases, revision feminization surgery is highly recommended.

The 4 Most Frequently Revised FFS Surgeries are…

1. Jaw Tapering and Chin Recontouring

At our clinic, the most frequently requested FFS revision procedures include both jaw tapering and chin recontouring.

The chin and jaw compromise a significant portion of the lower face, and if not performed correctly, their shape will affect all other facial features. The reason these procedures are the most often revised is that the techniques are somewhat esoteric and not generally taught at academic centers during most surgeons’ training, therefore, most lack any experience with them. Most often these two procedures are performed during the same surgical session so it makes sense to also revise both at the same time if needed.

• Chin recontouring works to reduce the angular shape of the male chin to be smaller, less angular, with a smoother and more feminine aesthetic. Sometimes less-skilled or poorly trained surgeons will use a chin implant to feminize the face but it is impossible to feminize a face with a chin implant and we strongly recommend avoiding chin implants for facial feminization.
  Read more about chin recontouring.
• Jaw tapering (AKA jaw reduction) works to smoothen and soften the jaw to make the jawline appear narrower and more feminine. Sometimes the surgeon may lack the aesthetic eye to create a jawline that enhances the patient’s other facial features, resulting in a need for a do-over jaw surgery.
  Read more about jaw tapering.

2. Forehead Reduction and Contouring

Forehead reduction is one of the most critical procedures included in facial feminization because the forehead makes up almost 30-40% of the entire facial surface. The forehead also essentially ‘frames’ all other facial features; therefore it is one of the most significant surgical procedures included in facial feminization.

Many of our feminization revision patients report that they are unsatisfied with the shape of their newly reduced forehead. The most common complaint is either that the forehead has been “ground down” (instead of contoured or reshaped) without sufficient improvement in the result. Usually, in this scenario, the depth of the eyes will remain unchanged. Also, the shape of their new forehead does not ‘sit’ in aesthetic harmony with other facial features.

The solution is a do-over ensuring that the result of the procedure enhances and contributes to the overall ‘feminine’ appearance of the face.
Read more about forehead reduction here.

3. Tracheal Shave – Adam’s Apple Reduction

The Adam’s apple is one of the most apparent ‘masculine’ characteristics, and as such, it’s reduction is frequently included in the cluster of surgeries that make up facial feminization. The ‘apple’ is minimized via a tracheal shave, otherwise known as an Adam’s apple reduction.

Even though this procedure seems quite straightforward, it is critical that an Adam’s apple reduction is performed by a qualified and experienced plastic and craniofacial surgeon with extensive experience in gender confirmation surgery. If not executed correctly, the thyroid cartilage may grow back necessitating a do-over, or even worse the voice may be damaged which often is difficult to correct. At the Dr. Deschamps-Braly Clinic of Plastic and Craniofacial Surgery, we use advanced surgical techniques to significantly minimize the risk of voice injury or regrowth of the cartilage.

A word of caution: if you choose an unskilled or unqualified surgeon for your Adam’s apple reduction, you run the risk of a voice injury if your surgeon is not skilled at identifying the positioning of the vocal cords and protecting them during surgery.
Read more about Adam’s apple reduction here.

4. Rhinoplasty (nasal surgery AKA “nose job”)

Another frequently requested FFS revision surgery is rhinoplasty or a ‘nose job’, this is because the procedure–in and of itself–is quite complicated, regardless of gender. And also, the main reason being is that the previous surgeon lacked the keen artistic “eye” that is necessary to produce a beautiful and truly feminine result. The surgeon had the technical skills to perform a rhinoplasty, but not the aesthetic appreciation of what constitutes a truly feminine nose. Often unskilled or inexperienced surgeons will “make the same nose” that they believe will work on everyone–a recipe for an unsatisfactory result.
Read more about revision rhinoplasty here.

How can you avoid the need for a feminization “do over”?

Facial feminization surgery is a big undertaking, and most people want to ensure that their surgeon gets it right the first time. The best way to ensure that your facial feminization surgery will be less likely to need a revision is to make sure that you choose a surgeon who has…

• Board-certified status by The American Board of Plastic Surgery
• Extensive, proven experience in gender confirmation surgery
• Training and qualifications in both plastic and craniofacial surgery

Additionally, it is critical that your surgeon shows evidence of having a keen artistic eye along with a deep understanding of what constitutes ‘femininity’, not only as it is expressed in the soft tissues of the face but also the underlying skeletal structure. An intimate and in-depth understanding of the structural characteristics of the female vs. male craniofacial skeleton is essential for a successful result.

Facial Gender Confirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery

Published in Clinics In Plastic Surgery, July 2018

“Facial feminization surgery was pioneered in the 1980s to provide options for trans women who were having difficulty with their outward appearance. This process presented a novel application of craniofacial surgery at the time. This text outlines the basic differences between male and female facial morphology, as well as the procedures we use to feminize the face…”

Continue reading the article here.

ICYMI: Dr. Deschamps-Braly’s interview in the London Times Magazine

The Times, June 16 2018

“In the bright light of a San Francisco operating theatre, a surgeon in blue scrubs, orange clogs and green plastic gloves sits on a stool with his arms folded, his left leg bouncing to the Velvet Underground track on the stereo and his eyes trained on a sedated patient strapped to a trolley whose eyelids he has just stitched shut. Six days ago Olivia was at her desk in Minnesota with colleagues who knew her only as a man. Now Jordan Deschamps-Braly, a doctor with the instincts of a sculptor, is preparing to peel off half of her face…”

Continue reading on the Times website.