Of the many gender confirmation surgeries, facial feminization procedures are arguably some of the most impactful—and the most challenging to perform. “What I’ve learned from my patients is that facial feminization can be even more important than bottom surgery. They know who they are—it’s the outside world that is misgendering them,” says Dr. Jeffrey Spiegel, a board-certified plastic surgeon in Newton, Massachusetts. Other people aren’t seeing your genitals on a regular basis, but they are seeing your face every day; changing your facial features so that they affirm your gender in a way that’s visible to all makes this a surgery of supreme importance, he adds. (It bears mentioning that gender-affirming facial surgery more often involves feminizing the face for transgender or even cis women. Testosterone does a very good job of making the face more masculine for female-to-male transgender patietns, but estrogen doesn’t have the opposite effect, notes Dr. Speigel.)
The visibility of the face also means there’s a very small margin of error. “If something goes wrong with a surgery on the body, that’s not ideal, but at least it can be covered up in public. That’s obviously not the case for the face,” notes Dr. Jordan Deschamps-Braly, a board-certified plastic surgeon in San Francisco. Point being, choosing the right doctor is paramount for any type of plastic surgery, but the stakes are even higher when it comes to facial feminization. Ahead, expert advice on how to find the right provider for you during the consultation process.
Inquire about their training
“Any plastic surgeon can claim to be a facial feminization surgery expert, making it imperative in this type of transgender surgery to find an experienced surgeon,” cautions Beverly Hills, California, board-certified facial plastic surgeon Dr. Toby Mayer. It’s considered to be one of the most difficult types of plastic surgery, yet there’s still a growing number of doctors who say they know how to do it without ever having been trained in it, adds Dr. Spiegel. Along with the fact that the entire face needs to be taken into consideration, transgender women have different skin and tissue from those of cis women, requiring a different surgical technique. Think of it this way: “A person who can fly a small propeller plane probably isn’t going to be able to fly a 747, even if they are a great pilot,” he analogizes. Be specific and ask the doctor you’re considering exactly where and with whom he or she trained, he suggests.
Aside from being board-certified, doctors who have undergone craniofacial surgery fellowships are usually well positioned to be trained in facial feminization surgery, notes Dr. Deschamps-Braly. “A good question to ask is, ‘How are you qualified to perform this surgery, besides your basic credentials?’” he says.
Ask how many transgender surgeries they’ve performed
Quality matters, of course, but so does quantity. The expertise and skill required can only be achieved over time. “Until someone has had 300 to 400 cases, you really run the risk of getting a subpar surgery,” warns Dr. Deschamps-Braly. For context, a surgeon who is very busy and performing FFS almost exclusively would likely do somewhere between 100 to 130 surgeries per year, he says, meaning it can be a solid three to four years before they’re truly experienced. Dr. Mayer feels it takes even longer, advising that any facial feminization surgeon should have a minimum of five years of experience.
Pay close attention to before-and-afters
Seek out a doctor who has a large volume of before and after photos they can share. (It’s also a good idea to make sure these include patients who are the same ethnicity as you, as feminizing facial features can vary drastically based on ethnicity, notes Dr. Deschamps-Braly.) It can be challenging for lay people to look at these photos, however, because many people confuse beauty with feminine gender, he adds. For that reason, ask the doctor to walk you through each photo and explain exactly what they did and why they did it as well as how it impacts the end goal of others seeing that patient as a woman, he suggests. Similarly, consider asking for patient testimonials or ask to speak with some of the doctor’s previous patients, notes Dr. Spiegel.
There are, however, a few specific things to keep an eye out for in B&As. “Make sure there are photos where the patient has her hair pulled back. Many doctors won’t show the hairline because the way they perform hairline lowering surgery leaves a scar, which ends up limiting how the patient can wear her hair,” notes Dr. Mayer. You also want to make sure the noses don’t have scoops or pinched tips and, ultimately, that the results look both fememine and natural, he adds.
Discuss your entire face
“Facial feminization surgery is all about fitting individual procedures together, to form an overall balanced, natural, feminine result,” says Dr. Mayer. It’s why the fact that someone is good at rhinoplasty doesn’t mean that they can perform a successful FFS, he adds, again underscoring the importance of finding specially trained surgeons. And there’s no shortage of individual factors that impact the final result. This includes things such as hairline pattern and position; eyebrow position; shape of the orbital bone, forehead, chin, jaw and neck; the length of the lip; the presence of an Adam’s apple; and many more, points out Dr. Spiegel. “Some patients come in and have only one very specific goal or thing they want to change. And that’s fine, we can do that, but keep in mind that it may not alter your perceived gender,” he says. “It’s worth being open to your doctor’s recommendations and discussing your face from top to bottom and how each feature affects how people see you.”
Ask the doctor for specifics
As you discuss your various features, push your doctor for exact numbers. The best facial feminization surgeons understand female normative facial value versus male normative facial value and will be able to quantify the changes they’re suggesting, says Dr. Deschamps-Braly. If they can’t tell you exactly how much smaller they’re going to make your chin or how much they’re going to alter the length of your upper lip and why, that’s a big red flag, he cautions.
