Transgender Facial Feminization Surgery: What You Need to Know

Pros 

• FFS can improve self-esteem by allowing patients to align how they feel on the inside with the face they present to the world. One transgender woman who underwent FFS says she finally feels like her face reflects her gender identity. “The face looking back at me is very close to the face I’ve always felt I should have. And that’s had a profound impact.”
• Research has found that transgender women who undergo FFS have a higher quality of life and better overall mental health, compared to trans women who don’t undergo either FFS or other gender confirmation surgeries.
• Facial feminization surgery results are permanent.
• Doing several procedures in one surgery can save time and be more cost-effective.  
• Piggybacking procedures means going under general anesthesia only one time, instead of many.
• Some insurance policies will help you pay for gender-affirming surgery.
• FFS before and after photos show dramatic transformations.

Cons 

• You need to halt hormone replacement therapy for two weeks before and two weeks after surgery.
• FFS typically takes 4 to 5 hours, but it can take up to 10 hours, depending on what’s involved. Longer operations can increase your level of risk and be very expensive.
• Risks of facial surgery include infections and nerve damage, as well as possible complications from general anesthesia.
• Recovery can take months, and you may not see your final results for a year, once all the swelling has resolved.
• Some reviewers on RealSelf who rated FFS “Not Worth It” tend to say that their results were incomplete and that their before-surgery look was better.

FFS treatment plans include a customized combination of these procedures. 

Forehead reduction (aka hairline lowering or scalp advancement) makes the hairline look fuller while making the forehead more proportional to the rest of the face. 

• Through an incision along the hairline, the surgeon releases the skin of the scalp, shifting it forward one to three centimeters below the existing hairline.
• They then remove excess skin before 
• Forehead reduction surgery is often performed in combination with hair transplant surgery.

Brow bone reduction (aka forehead contouring or frontal brow bossing) is a complementary procedure.

• An incision along the hairline (or just behind it) allows the surgeon to access the underlying bone structure. 
• They then carefully shave down (or cut and set back) the bony ridge above the eyebrows, which tends to be more pronounced in cisgender men. 
• Implants or bone grafts may be used, to round out the forehead and soften sharp angles. 

A brow lift repositions a droopy brow, smooths the forehead, and eliminates heaviness above the eyes. 

• The most common technique is a lateral or temporal brow lift, which targets the tails of the eyebrows (they tend to fall more with age than the central aspect of the brow). 
• A temporal lift usually requires two small incisions, hidden in the hairline behind the temples. 
• If the entire brow needs a boost, your surgeon may perform a more invasive coronal brow lift through an incision that spans the scalp, from ear to ear. Just keep in mind that elevating the central brow can create a startled expression if it’s not done judiciously.

Blepharoplasty (commonly called eyelid surgery) removes excess skin and/or fat to make the eyelids look younger and more awake. 

• With upper eyelid surgery, the incision is hidden in the crease of the top lid. 
• In the case of lower eyelid surgery, an incision is typically made inside the eyelid, leaving no visible scar.

Rhinoplasty can balance the nose with the rest of the face and make it look more delicate.

• The procedure reshapes the bone and cartilage of the nose, typically to reduce its size and projection, smooth the bridge, and refine the tip.
• Surgeons can use an open approach, making an incision across the columella (the strip of skin between the nostrils) to lift the skin to expose the underlying anatomy. If you’d like to avoid the small scar, a closed approach is usually possible.  
• Immediate healing time post-rhinoplasty is usually about two weeks, but swelling can take a year to fully resolve. 

Lip lift surgery shortens the space between the base of the nose and the upper lip, to expose more of the vermilion (the dark-colored part of the lips), roll the border up slightly, give more contour to the Cupid’s bow, and show more of the upper teeth.

• A bullhorn lip lift, the most commonly performed technique, removes a small amount of skin (in the shape of bullhorns) below and to the sides of the nostrils. It leaves a small scar that’s hidden under the base of the nose. 
• An Italian lip lift removes two small areas of skin under the nostrils. It leaves a smaller scar, but it also has more of a risk of distorting the nostril base.

Lip augmentation can make the lips look fuller and give them a more traditionally feminine shape. 

• Lip fillers have the advantage of adding both volume and definition, though their results are temporary.  
• Fat grafting can’t create more definition, but it can add volume, with far more long-lasting results. This procedure involves liposuction to harvest excess fat from another body area (usually the abdomen or hips). It’s then purified and finely processed prior to reinjection. Results can last years or even decades.

Cheek augmentation with implants, fillers, or fat grafting can create the fuller cheeks common to many cisgender women. 

• Cheek implants and facial fat transfer are surgical procedures, requiring at least a week of downtime but offering long-lasting results. 
• Cheek implants are placed through an incision inside the mouth, sparing obvious scars.
• Fat grafting involves liposuction to remove fat from areas of excess, which can leave small marks on the donor site. 
• Dermal fillers deliver a volume boost and more contoured cheekbones for one to two years, with no real downtime.

Chin surgery (genioplasty) and/or jaw reduction can slim the chin and jawline. 

• A surgeon uses a laser or surgical saw to cut the bone, repositioning it to sculpt the desired jawline. 
• Sliding genioplasty can draw forward a receding, misaligned, or weak chin, or set back an overly prominent chin, creating better balance in the lower face. 
• A chin implant is a less invasive alternative for those desiring more projection.
• Jaw reduction gives the lower face a more tapered look. 
• Botox and other neuromodulators can also be used to slim a square jaw over time, without surgery and the requisite downtime.

Adam’s apple reduction (aka tracheal shave) reduces the cartilage surrounding the larynx, to make the Adam’s apple less pronounced and give the neck a smoother, more feminine contour. 

• An incision is made under the chin (where it meets the neck) or in a natural fold.
• A surgeon shaves the cartilage with a burr tool, refining it to a flat surface. 
• The vocal cords are monitored throughout the procedure via an endoscopic camera, to help avoid damage. 

RealSelf Tip: Estrogen-based hormone therapy can help give the face a more feminine appearance by increasing and shifting the distribution of facial fat. It won’t change your bone structure, but it’s still a good idea to wait until you’ve been on hormone therapy for at least a year before pursuing facial feminization surgery (and other types of gender-affirming surgery). You'll then be asked to stop taking hormone replacement therapy two weeks before surgery, to reduce the risk of post-op blood clots. 

Related: 7 Things to Know About Gender Confirmation Surgery

• Average Cost:
• $39,480

• Range:
• $15,001 - $60,000

FFS costs vary widely, depending on your surgeon’s location, their credentials, the procedures you select, and the type of anesthesia you have. It’s not uncommon for an extensive FFS operation to cost upwards of $70,000, or even $120,000, especially if your surgeon has a reputation for excellence that can command top dollar. 

Some insurance providers cover transgender facial feminization surgery. Check with your insurance company to see if your coverage includes it.

If you aren’t covered, consider reaching out to transgender advocacy groups or legal services for financing advice.

Your surgeon will require a referral if FFS is part of a gender dysphoria treatment plan. Ask your mental health professional to write a recommendation letter, following the World Professional Association of Transgender Health (WPATH) guidelines. 

The transgender facial feminization surgery photos in our gallery have been shared by the surgeon who performed the procedure, with the patient's consent.