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Facial Feminization Surgery

A Guide for the Transgendered Woman

Addicus Books, Inc.

Facial Feminization Surgery: An Overview

Looking feminine is of course extremely important to you. First impressions are often made based just on your face. Others perceive you during an initial contact by how you look. Your face establishes not only who you are but frequently what you are as well. As a transgendered individual, perhaps nothing is more vital to you than having a body that matches how you feel. Facial feminization surgery (FFS) can do just that. It can help you finally appear on the outside as the person you are on the inside.

Why Facial Feminization?

There is only one reason to feminize your face. You want to appear female. Whether you are a fully transitioning transsexual, or just going out once a month dressed as a woman, you want to be seen and thought of as being feminine in every way. If you do not look the part, others will identify you and speak of you, sometimes behind your back, as a man. Conversely, the more feminine your face appears, the more convincing you will be as a woman.

But there are many aspects to changing your features that you need to consider in moving forward with such serious surgery. For starters, where does facial feminization fit with sexual or gender reassignment surgery (SRS or GenderRS)? If you choose both, which should come first? And once you have decided to feminize your face, which features should your surgeon target and in what order? By the time you finish this book, you should be able to make informed choices as to each of these questions and many more. But first, let's take a quick look at the facial differences between the genders that make this surgery necessary.

Differences in Male and Female Facial Structures

Anthropologists and artists alike have long appreciated the basic differences between the skulls of men and women. Fueled by the male hormone testosterone in puberty, the masculine features that develop are more prominent than feminine features. Men have vertically longer and less pointed chins, with less tapered jaws, than women. Male noses are also larger than those of females. Men also have what we call bossing, a rounded prominence of the lower forehead behind the brows. It extends from the mid-forehead outward to the outside of the bony eye sockets. A woman's forehead, on the other hand, is continually convex or curving outwardly with considerably less forward projection than a man's forehead. (See Figures 1–1, 1–2.)

As you move through this book you will learn just how feminization surgery can erase each of these differences. By significantly reducing and contouring the skeletal structures underneath key facial features, a surgeon well versed in the techniques I describe can remodel a male face into a female face. He or she can turn the massive size, angles, and proportions found in men into the smaller size, angles, and proportions found in women.

But as helpful to you as facial feminization might be in being perceived as a woman, you may wonder if it is as important or more important than sexual reassignment surgery, especially if you cannot afford both. Let's take a closer look at the two options. It may help you weigh your choices.

FFS or SRS

Many individuals believe that sexual or gender reassignment surgery is the quintessential step in becoming female. Certainly turning male genitalia into female genitalia is an obvious, significant alteration for someone who wants to change gender. My sense, having worked for more than two decades in this arena, is that more transgender individuals select SRS over FFS than the reverse. They have decided, for whatever financial or personal reasons, that having sexual reassignment is more desirable than having a feminine facial structure. For them it is indeed a giant step forward.

Yet to my mind, being seen as a female is the most important step in transitioning. Yes, even more important than gender reassignment. I know there are people who argue against facial feminization (for starters, some see it as an expensive, misdirected act), but I strongly disagree.

Changing your masculine features to reflect the smaller angles and proportions of a female face has many positive benefits. First, it eliminates or markedly reduces any remnant of masculinity. Unfortunately, even after undergoing SRS, transsexuals still retain their male facial features, making it difficult for them to assimilate into society as women. Second, it eases the real-life test required by most sexologists and psychologists prior to SRS. If you choose to have sexual reassignment, facial feminization helps pave the way. Finally, it helps you feel more like a female when you're walking down the street. I know. I have met many patients who found great satisfaction in transforming their faces, whether or not they did anything else to their bodies.

Choosing FFS Alone

Just as some individuals are adamant about having SRS, either with or without FFS, others want to look feminine for whatever reason and don't feel the need to change their genitalia to be socially accepted. Or perhaps they wish to remain in the masculine world at least part of the time but still want to pass in the feminine world. Several of my patients over the years have worked as men during the day and dressed as women at night without any problems whatsoever.

They have managed well because unlike genetic females, who may have difficulty with their gender identification if they appear too masculine, genetic males can have a feminine or feminized face and still be accepted. I am not sure why, but it is true! These individuals move comfortably between the two worlds, functioning as men when dressed as men and as women when dressed as women. If you desire this type of living arrangement, a feminized face should not be a problem for you in your otherwise male world.

Undergoing Facial Feminization Surgery

Facial feminization is a collection of aggressive facial-bone surgeries designed to reduce the masculine areas of your skull to feminine proportions. By re-contouring the forehead, eye sockets, nose, jaw, and chin while reducing the Adam's apple, the lips, and any baldness, your surgeon can give a look and profile that befits a woman.

Patients often ask me why a facelift will not garner the same positive results as FFS. I remind them that just as you can't change the shape of a house with a coat of paint, you can't feminize the skull by just lifting the skin. In other words, as with a building, you have to address the underlying foundation, in this case the bony structures, to affect the outside or overlying contours. Even though a facelift may be a desirable add-on, altering the skeleton is the only way to move someone from distinctly male to distinctly female.

As you will learn, feminizing some facial areas is more important than feminizing others, even though all of the procedures (including information on recovery, potential complications, and results) are detailed in this book.

Also, although modifying every area of the face can be key to a feminine appearance, people do not always need to change everything. In fact, facial feminization is a very individualized process. Because each person has a unique face and, more important, a unique bony structure underlying that face, what a surgeon does for one transgender individual may be totally different for another transgender individual. Obviously, as I mentioned earlier, there are similar male characteristics that need to be eliminated or refined for any transsexual to pass or blend in society. Yet each change is targeted to that person's face. There are no cookie-cutter procedures in this process!

Sequence of FFS Procedures

Once you have decided on FFS, the next big choice you will make concerns the timing of your procedures. Will they be before or after SRS, if you are having both? Will you have all of your facial feminization surgeries in one setting or in separate surgeries?

Among my male-to-female (MTF) patients who undergo both gender reassignment and facial feminization, more individuals than not seem to want FFS first. Since I treat only a certain percentage of the transgender community, however, I am not certain how this plays in the larger transsexual population. I have no national statistics.

Parenthetically, a number of these individuals had gender reassignment procedures ten to twenty-five years ago and now want a more feminine look. I can only guess that they passed very well in their twenties and thirties, but as they enter their forties are no longer content with the way they look. Also, since very little was known about facial feminization two decades ago, they had no choice in what procedures were available initially.

If you see FFS as complementary to your gender reassignment surgery, you may want to put any genital procedures behind you before addressing your facial concerns. But then again, it is perfectly appropriate, and possibly even preferable, to alter your facial features prior to SRS. Considering you must undergo the aforementioned one-year real-life experience before gender reassignment, having a new face during that period may help you look and feel more feminine.

As to sequencing your procedures once you have made your decision, you do not need to do them all at one time, even though I like to fold everything into one surgery if it works for you.

Five percent of my patients start out with only a reduction of their thyroid cartilage or Adam's apple, one of the most prominent masculine characteristics and a dead giveaway as to your status. Many patients divide the procedures into at least two sessions, for whatever monetary, job, family, or relationship reason. For the most part, it makes no difference. The only time I insist on combining procedures is when I am doing both the nose and forehead. They must be feminized together for reasons that I explain in chapters 4 and 7.

Those individuals who want to separate their feminization surgeries often ask me which area, the upper or lower face, should be addressed first. I usually suggest beginning with the most masculine features. If they are equally male, I leave it to my patient but I also may make suggestions.

Recovery/Follow-up Care

Facial feminization may be elective surgery, but it is surgery all the same. The truth is that you will look worse before you look better. Expect to be swollen, black and blue, and probably in enough pain to necessitate medication, even though 25 to 30 percent of my patients never take a pain pill postoperatively. You won't be able to step out the day after your operation. You won't be running a marathon or doing any vigorous activity for the next several weeks. In addition, you'll have to adjust your diet if your mouth needs to heal.

It will take weeks before you see the complete results of your surgery. Generally, I say three to four months even though some patients continue seeing improvement six to seven months and, in rare instances, a year later. In any case, eventually you will be able to return to your usual activities, sporting a fresh, feminized face.

Returning to work is a very important issue for most people. I always tell my patients that if they can stay at home and work from a computer, they can start as soon as they feel up to it, even if it is just a few hours a day. If, however, they must go to a workplace and mingle with other people, they may want to wait two to four weeks, depending on their age. If they do heavy labor, they should probably plan on a month off.

What will you look like then? My primary objective, no matter which facial feminization procedures you undergo, is that you pass easily as a female. What constitutes "passing"? It is being able to function in the world as a female without question. It is answering the door early on a Saturday morning, without your lipstick, makeup, and hairdo intact, and hearing the person on the other side say, "I am very sorry to bother you, ma'am ..."

Will You Look Beautiful after Surgery?

Beauty is the one thing I cannot promise you from facial feminization, in part, because beauty is a very elusive concept, difficult to describe and even harder to deliver. Although plastic surgeons have wrestled with the notion ever since they began resculpting faces, no one has come up with the ultimate ah- ha-this-is-it definition by which we can set the perfect measures or standards.

That's not to say that some haven't tried. Scientists, for instance, have used all sorts of devices to quantify what they think is a beautiful face. A colleague of mine tried averaging the cephalograms of beauty queens to produce the most perfect facial skeleton. Did it work? Not particularly well.

But the truth is, "beauty is in the eyes of the beholder." We all have our own perceptions of handsome or pretty. If 10 men were asked to pick the most beautiful among 100 attractive women, most likely none of them would make the same choice. That is the subjective nature of beauty.

Our perceptions are defined in large part by ethnicity and the experiences of everyday life. Although people often think of beauty in terms of the Caucasian face, Latinos, African Americans, Middle Easterners, Chinese, Japanese, Koreans, and all other ethnic groups are truly beautiful in their own unique features.

Moreover, the media, peer pressure, and sexual mores influence what we find attractive and what we do to make ourselves appealing, especially to the opposite sex. From haute couture to hairstyles, we choose based on our own personalities and what looks good on us, dictated by our complexions, bone structures, and even facial fat.

Beauty Is Still Important to Feminization

Not surprisingly, beauty is such an important concept that people want a great aesthetic result from facial feminization. Clearly, not everyone desires to look Caucasian (certainly not all of my patients have northern European roots), but everyone hopes to look her very best. Achieving that goal involves each step of the operation, from evaluating a patient to planning and executing surgery with a specific end point. It necessitates skills, experience, and the kind of artistic license I take during surgery if I think it is in the best interest of my patient.

Surgeons, like me, must keep two mathematical concepts in mind as we're reconstructing any patient's face: proportion, the relationship between individual features and the whole face, and symmetry, or sameness between corresponding sides of the face.

Proportion Is a Key Guideline

Facial proportion is perhaps the single most important issue in producing a beautiful result. Some people suggest that all beauty is a matter of proportion, expressed especially by an ancient mathematical concept called the Golden Mean, the square root of 5 plus 1 divided by 2 or 1.618. It quantifies the proportional relationship between the whole and its parts. No matter where you look in nature, architecture, art, and the anatomy, so goes the theory, you will find the same ratio of 1.618 to 1.0 in the most beautiful examples. That includes women! In fact, I do not believe I have ever seen an attractive woman who did not express this constant ratio.

Feminization can markedly improve the proportions of an MTF individual. How so? By reducing the height of several facial areas, a surgeon can alter the dimensions and proportions dramatically to fit a smaller feminine face.

When the scalp and hairline are advanced, for instance, forehead height is reduced. When the chin is shortened, the entire face length is decreased. Similarly, when the nose, which is longer and wider in men than women, and the upper lip, which is higher in females than males, are both reduced, so are the heights of these facial areas.

Must every transgender face be made vertically shorter? Not necessarily, even though that is usually the case. The point is, whether your features must be shortened or lengthened, your surgeon's goal must be to establish correct proportions in your finished face. I regularly rely on an instrument developed by the late Dr. Robert Ricketts, an orthodontist who believed fervently in this concept, to ensure that my MTF patients exhibit the same constant ratio in their faces as appears in other women. Doing so adds greatly to someone's overall aesthetic results. (See Figures 1–3, 4.)

Symmetry Is a Key Guideline

Some individuals believe that the faces of all beautiful people are perfectly symmetrical. I agree that models and other very attractive individuals exhibit lots of symmetry. I am not sure if anyone is perfectly symmetrical, but some people may be very close. I have never evaluated my patients based solely on the harmony of their features, but I can assure you that the opposite is true: men and women who are obviously facially asymmetrical are usually not attractive and certainly not beautiful.

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Excerpted from Facial Feminization Surgery by Douglas K. Ousterhout, Jeanne Koelling. Copyright © 2009 Douglas K. Ousterhout, M.D.. Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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