A Comprehensive Guide to Facial Feminization Surgery (FFS) (2024)

Medically reviewed by Jennifer Richman on June 6, 2024.

Facial feminization surgery (FFS) refers to a menu of procedures that patients can choose from to reshape and refine facial features to create a more conventionally feminine appearance. For transgender women, non-binary folks and gender non-conforming patients, FFS can be a crucial step in their gender affirmation journey. FFS can alleviate gender dysphoria by creating a greater sense of gender congruence between a patient and their facial features. In a free virtual or in-person consultation, patients can create a unique surgical plan to alter features in any of the following areas: the upper (hairline, brow bone & eyebrows), middle (nose & cheeks) and/or lower (lips, chin, jaw & trachea or Adam’s Apple) thirds of the face.

Facial features addressed: which procedure is right for me?

Facial feminization surgery is not a one-size-fits-all approach to gender-affirmation. Rather, patients get to choose which procedures will be included as a part of their operation. To help you figure out which procedures would be right for you, we recommend that you consider the following:

  • What features of your face bring you dysphoria? What changes to your face could bring you gender euphoria?
  • Some patients find it helpful to bring photos of facial features they would like–for example, in photos of family members–to a consultation to discuss which options could help them realize their goals.
  • Costs can be a limiting factor in deciding which procedures you will undergo. You can read more about pricing and insurance later on in this article.

The following parts of the face can be modified in FFS:

  1. Hairline: The hairline advancement technique can help reverse the effects of a receding hairline, giving the forehead a smaller and rounder appearance. This procedure can potentially eliminate the need for or be used in conjunction with hair transplants.
  2. Forehead: Procedures such as forehead contouring or brow bone reduction can create a flatter, more gently sloping forehead and soften the brow ridge.
  3. Eyebrows and eyelids: An eyebrow lift will raise the position of the eyebrows on the face; typically, having some or all of the eyebrows rest above the brow bone is associated with a more feminine appearance. A blepharoplasty can also be performed to remove excess skin in the eyelids, giving them a larger appearance.
  4. Cheeks and Cheekbones: Cheek augmentation through fat grafting or silicone malar (cheekbone) implants can enhance and define the cheekbones. Voluminous cheeks are conventionally associated with a more feminine facial structure.
  5. Nose: Rhinoplasty (nose reshaping) can change the appearance of the nose. Most commonly, FFS patients request that the bridge of the nose be made thinner and the tip to be inverted, giving the nose a slight upward turn. Patients can also request to adjust the nostrils if they would like.
  6. Chin and Jawline: The chin and jaw can be reduced or contoured through mandible contouring and genioplasty procedures. These techniques can slim down and soften the jawline, creating a more oval, heart, diamond or rectangular shaped face. Chin reshaping or reduction can also help achieve a more feminine facial profile.
  7. Lips: A Lip augmentation or a lip lift can create fuller, more defined lips. Most often, estrogen-dominant first puberties leave individuals with less space between their nose and top lip; a lip lift reduces the skin in this area to increase the size of the top lift. Augmenting the lips through fat grafting can also create a more conventionally feminine appearance.
  8. Adam’s Apple: A tracheal shave is a technique that involves reducing the size of the Adam’s Apple so it has a less prominent appearance. This procedure is performed in a way to not alter the vocal cords.

The specific combination of procedures will be tailored to each your unique facial structure and gender-affirmation goals. You can create a unique surgical plan with Dr. Ley or Dr. Facque by requesting a free consultation with them today.

Drawbacks: will FFS leave visible scars?

Scarring is another factor that patients take into account when deciding which FFS procedures to get. Though some procedures may leave visible scars, proper scar care can significantly reduce their appearance, making them practically invisible. That said, if you have a history of keloid scarring or have a darker skin tone and are prone to hypopigmentation, you may want to take that into consideration. The following procedures leave visible scars:

  • The hairline advancement, brow lift and brow bone contouring are three procedures that can leave a visible scar on the forehead, at the base of the hairline. Patients who undergo a brow lift and/or brow bone contouring without a hairline advancement can have the incision from this surgery hidden in the scalp. Doing so will hide the scar in the hair.
  • The rhinoplasty and lip lift procedures have the possibility of leaving a scar at the base of the nose. Rhinoplasties that do not involve alterations to the nostrils will leave a small incision between the nostrils that almost always disappears completely. Only lift lip and rhinoplasty patients that alter their nostrils will have a small scar line at the base of the nose.
  • Tracheal shave patients will have a small scar left on their necks from where the surgeon went inside to reduce the Adam’s Apple. Patients can ask the surgeon to make the incision under the jaw instead of on the neck, to hide the scar from sight.

Candidacy: am I eligible for FFS?

At the Gender Confirmation Center (GCC), we use the informed-consent model to determine surgical eligibility for legal adults. The informed-consent model for gender-affirming care proposes that adults who have the proper education about the risks and benefits of their desired procedure can determine for themselves if they are ready and willing to access surgery. This model is designed to prevent providers from unnecessarily gatekeeping access to medically necessary, gender-affirming care.

Other considerations we take into account for surgery include:

  1. Overall health: Prior to your surgical consultation, you will be asked to disclose your medical history. This includes any medications you are currently taking, your drinking and smoking habits, if you have a disability, if you have any medical conditions and if they are being monitored and/or treated.
  2. BMI: For facial surgery, we have no strict BMI candidacy requirements. Rather, your surgeon will create a unique surgical plan to minimize your risk of complications based on your medical history. For example, certain patients might need to stay a night in the hospital to monitor their health more closely after surgery.
  3. Hormone replacement therapy (HRT): The GCC has no HRT requirements for facial surgery candidacy. That said, per WPATH’s Soc 8 recommendations, many providers recommend that patients who are undergoing estrogen HRT wait until 1-2 years of treatment are complete before pursuing facial surgery. This is because it can take 1-2 years for physical changes in the face (like fat redistribution) to peak.
  4. Have a strong support system: A strong support network of family, friends, support groups and mental health professionals can be invaluable during the recovery and healing process. Especially for more intense surgeries like FFS, we strongly recommend that patients have a strong support network going into surgery
  5. Have realistic expectations: It’s crucial to have realistic expectations about the potential outcomes and limitations of the surgery, as well as an understanding of the recovery process.
  6. Insurance coverage: If you would like insurance to cover your FFS, you will need to meet certain support letter requirements. These are discussed below.

Costs and insurance coverage

The cost of FFS can vary, depending on which procedures you choose to undergo. Patients who are able to secure insurance coverage for their procedure can drastically reduce their out-of-pocket costs.

Patients who are interested in paying for surgery with insurance will be assisted by our free insurance concierge service. Our insurance advocacy team has successfully helped over 90% of interested patients secure full or partial coverage for their gender-affirming procedure. In order to prove that FFS is medically necessary, you will need to present a support letter from a licensed, mental health professional. Likewise, if our surgeons are outside of your plan’s in-network providers, you will need a referral letter from your primary care provider. For more information, click here.

Cash-pay patients are those who will not be using insurance to cover the costs of surgery. These patients may pay all surgical costs out-of-pocket, use medical credit to finance their surgery and/or be the benefactor of a gender-affirming surgery grant. For more information about these resources, click here.

The total price for FFS can range from $4,500 to $100,000 for cash-pay patients. For a more detailed cost-breakdown of gender-affirming facial surgery, click here.

The good news is, insurance has been covering FFS more than ever before. Dr. Facque (he/him) describes in the video below how you can figure out if your plan will cover surgery:

Benefits of Facial Feminization Surgery

Undergoing facial feminization surgery can provide numerous physical and psychological benefits for patients. These include:

  1. Enhanced Feminine Features: FFS can help accentuate and create feminine facial characteristics, such as a softer jawline, nose, and higher eyebrows, resulting in a more feminine overall appearance.
  2. Improved Self-Confidence: By achieving a facial appearance that better aligns with your gender identity, patients often experience a significant boost in self-confidence and overall self-esteem.
  3. Reduced Gender Dysphoria: FFS can help alleviate the feelings of gender dysphoria associated with having certain facial features, promoting a greater sense of congruence and well-being.
  4. Improved Social Interactions: With a more feminine facial appearance, individuals may feel more comfortable and confident in social situations.
  5. Psychological and Emotional Well-being: Studies have shown that gender-affirming procedures, including facial feminization surgery, can significantly improve mental health outcomes by reducing anxiety, depression, and overall distress related to gender dysphoria.

Recovering from FFS

Recovery from facial surgery can vary greatly from patient to patient, depending on the specific procedures they undergo. Below are some general guidelines you can keep in mind for the FFS procedures listed above. For a more detailed guide on recovery, click here.

  • Leaving the hospital: While FFS can be an out-patient procedure for some patients, others might need to stay the night in a hospital after surgery. Regardless of when you are discharged, you will need to be picked up by someone who will take care of you.
  • Around-the-clock care: Generally speaking, for the first 72 hours after surgery, you should be accompanied by someone around-the-clock. You will need help administering medications and icing your face every hour to keep down inflammation.
  • Pain and inflammation: Pain and inflammation will be at its peak during the first week after surgery. Depending on the procedures you undergo, you will likely leave the hospital with gauze over your incisions and bandages wrapped around your face as compression helps contain inflammation. Patients will likely be taking prescription pain medications for the first few days after surgery, during which they should not operate a vehicle. We recommend keeping your head elevated at all times and keeping snug compression garments or bandages on the face as much as tolerable for the first week after surgery. Swelling around the eyes, mouth and neck can be uncomfortable to tolerate, but patients can expect swallowing, opening the eyes wide, and other tasks to get easier as swelling improves.
  • Diet: We recommend that patients follow a low-to-no-sodium diet to reduce swelling during the recovery period. If there are any incisions in the mouth–from a jaw or chin augmentation–you will need to maintain a soft food diet for at least two weeks. Eating hard or sharp foods can pre-maturely open the incisions and delay healing.
  • Emotional recovery: Facial surgery not only involves an intense recovery process, but also requires great patience as you wait for one of the most visible parts of your body to heal. The physical toll and long healing timeline sometimes give patients temporary feelings of post-operative depression and even regret. For this reason, we encourage patients to lean on their loved ones and mental health professionals for the emotional hardships that may come up during recovery.
  • Physical activity: It is important to go on daily walks to reduce the risk of blood clots. For the first week, just walk around your house. Take care to avoid stairs, cluttered areas, loose rugs, and any other obstacles that could result in slips, falls, or injuries while you’re taking narcotics or have increased swelling around the eyes.
  • Final results: Facial surgery can be one of the most difficult gender-affirming procedures to recover from. Even after the first month of healing, inflammation will continue to decrease over the course of the first year. Likewise, it will take at least a year for scars to fully mature and for ligaments in the face to settle after surgery. For this reason, we generally tell patients that they will need to wait 12 months after facial surgery to see their final results.

Recovery from facial surgery can be an emotionally difficult process as you wait for the most visible part of your body, your face, to heal. Besides having an active support network, Dr. Facque describes in the video below how good communication with your medical providers can be of enormous help. You should be able to ask medical staff, like a physician’s assistant (PA) or a registered nurse (RN), if you will need medical attention for what you are experiencing in recovery.

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