Facial feminization

Techniques used in modern plastic surgery enable many modifications to be made to the face and neck in order to achieve the most desired effect for the patient and to eliminate a number of strongly marked male features. They are often complementary to genital correction surgeries. A person who undergoes this process may feel uncomfortable in social situations because of some characteristics pointing to their previous gender identity. They often complement genital gender-affirming surgery. A person undergoing this process may feel uncomfortable in social interactions because of facial cues associated with sex assigned at birth.

Facial feminization procedure

Facial feminization consists in modification of bone and cartilage structures of the facial skeleton and adaptation of soft tissues. Appropriate bone sculpture is the basis of craniofacial surgery in the context of gender affirmation. Plastic surgery deals with many problems faced by transgendered persons. Problems that often cannot be sufficiently corrected with makeup or hair, especially if the patient wants to achieve a fully natural result. Sometimes a correction of one feature is sufficient to achieve this.

The complexity of the procedure requires specialist knowledge of maxillofacial, facial, reconstructive and of course plastic surgery, which allows for optimal softening of facial features. The male facial skeleton differs apparently from the female one – the differences include larger bone volume. For this reason, the forehead, temples, orbits, supraorbital region with their characteristic massive structure, wider nose than in a genetic woman, strongly outlined mandible, and laryngeal elevation may be reduced during the medical procedure. There are many possibilities of surgical gender affirmation in the area of the facial skeleton and neck, so it is worth to familiarize yourself with them.

Forehead, hairline

Zabieg w obrębie czoła jest jednym z podstawowych sposobów feminizacji twarzy. Treatment of the forehead is one of the fundamental ways to feminize the face. Preparation includes removal of a skin fragment – a narrow striped scalp according to the course of the coronary suture. Then the frontal lobe of the skin is separated while protecting the anterior branch of the facial nerve. A fragment the periosteum of the edge of the frontal-nasal region of the orbit is also separated. An osteotomy is performed within the anterior wall of the sinus to gain access to it. A fragment of the anterior sinus wall is kept in saline solution. Then the bone tissue of the frontal-nasal region of the orbit is modelled and the anterior wall of the sinus is smoothed out, which returns to its place by way of osteosynthesis. Precise periosteal placement is essential. This is done with the use of systems supporting correct eyebrows positioning on the newly formed bone structure. This procedure allows work on several areas – forehead and temporal elevation and upper supraorbital edges, thus alleviating the prominent protruding forehead, which is often associated with massive eyebrow ridges.

Softened features allow for typically feminine expression.

The hairline for men and women is fundamentally different. The treatment allows you to complement the effect of feminization and achieve natural results in the upper third of the face. There are two methods of hair line correction. The first one is a surgical hairline reduction, recommended only for patients whose natural hairline is even (without strongly marked temporal hair loss). Therefore, it can be said that the a heavily receding hairline is a contraindication to the procedure. The scalp hair loss in the temporal area is not compensated for after the hairline reduction procedure, which is why this method is rarely used.

The treatment is performed by removing a striped skin fragment with a maximum width of 2 cm around the hairline. The incision is made on the hairy part of the scalp (at a depth of about 2 mm) to avoid leaving visible scars. A new hairline is created using positioning aids – the same as those used for surgical forehead area development. Their use not only makes it possible to facilitate the procedure, but also reduces the tension of tissues caused by the closing of wound edges.

Hairline correction using a hair transplant is the second method that can be used in this area to achieve optimal feminisation results. Patients with an M-shaped hairline (commonly found in MF transsexuals), with no current androgenic alopecia (usually reduced by appropriate hormone therapy) and sufficient hair density may be eligible for transplantation. There are two ways to obtain hair follicles. The hair follicle unit can be surgically extracted from a small, narrow scalp belt or by direct extraction (FUS and FUE techniques). The second method usually requires more experience and takes longer. If you are also undergoing the forehead reconstruction procedure described above, you can sometimes combine the two procedures by using a previously removed scalp fragment for a FUS hair follicle transplant. After the forehead surgery, a new hair line is formed (immediate hair transplant technique – IHT). The big advantage of the combination of treatments is the development of the entire upper 1/3 of the face and the simultaneous achievement of the full effect of feminization of this part. It is necessary to modify the course of anaesthesia due to the adverse effect of the prolonged duration of general anaesthesia.

The new hairline is created to maintain its natural appearance by keeping the right proportion of density in each area and leaving a slight unevenness (both women’s and men’s hairline is not perfectly even).

Cheeks, nose, upper lip

The middle 1/3 of the face is also a major challenge for surgery and provides further possibilities to modify some of the features necessary to achieve the most feminine appearance.

There are different methods of correction within the cheeks. Usually the aim of the procedure in this area is to mark and enhance the zygomatic bones. Porous polyethylene implants are attached to the bone by osteosynthesis using appropriate fastening screws for stabilization. The porous structure of implants allows bone tissue cells to implant and adapt. Access to the treated area is possible through the oral cavity. It is important to skilfully choose the size of the implant, because it easy to accidentally achieve an exaggerated, artificial effect.

Fat transplantation is often chosen as a cheek volumetric enhancement method. It consists in taking fat from the abdomen or thighs and preparing it for application to the supraocostal zone, taking care that the application is not too shallow. The use of this method by a skilled specialist gives a natural look. The transplanted fat is partially absorbed, reducing the visible final effect, so remember that it is often necessary to repeat the procedure.

The nose as the central part of the face influences its general appearance, therefore it is one of the most frequently operated areas not only among transgender patients. (…see source?) Appropriate nose correction can make the whole face appear more gentle and the profile more regular. Much depends on the type and quality of the patient’s skin. The relatively thick layer of skin covering the nose, which is observed in genetic men, can minimize the visible effects on the tissues underneath it. A lot also depends on the surgical technique, which, in order to avoid late complications, should focus not only on the aesthetic aspect, but also on the nose structure. Surrounding areas particularly at risk of complications in the form of tissue collapse are the area of the back and tip of the nose. To avoid this, the cartilage transplantation method is used.

The distance between the upper lip and the nose is longer in genetic men than in women. In order to feminize this area, the upper lip is raised. The surgeon performs a small incision of the skin just below the nose (bullhorn technique), a narrow strip of skin with subcutaneous tissue is removed in such a way as not to disturb the circular muscle of the mouth, then meticulous sewing is performed.

Mandible, chin

The mandible and chin are the lower 1/3 of the face. Plastic surgery procedures in this area have a huge impact on the feminization process. A thick mandible outline is reduced by reducing its dimensions in width and height, softening the line of the mandible, including the modification of the shape and size of the chin and the mandible-chin transition line. Since a clear jaw line and highly visible angles are not an unambiguously male trait – and because there are many women look good with these traits – a proper assessment of the needs of the patient should be carried out. Modifications in this area of the face do not affect the functionality of the occlusion.

The mandible and chin are accessed through the mouth to prevent visible scars. Access to the mandible requires two parallel incisions (at the base of the vestibule) to the end of the molars. However, access to the chin is obtained through an incision in the area of the lower lip, keeping a distance from the teeth and gums. It is important that the chin nerves on both sides are preserved. These incisions allow for a very visible surgical field and any scars after the healing process are undetectable for the patient.

Adam’s apple

The commonly called Adam’s apple is actually thyroid cartilage, which in genetic men, through more strongly emphasized laryngeal elevation, creates a very characteristic feature, which is not easy to hide under clothing. A meticulous shaping of the area allows the removal of this feature. In order to gain access to the Adam’s apple, the incision is made relatively far from the cartilage itself, preferably in the neck and chin region. This prevents the accretion of thyroid cartilage with the upper layers and reduces the risk of visible scars. The incision should not exceed 2 cm. Excess tissue can be removed with a scalpel or diamond drill. The diamond drill is well suited for shaping cartilage, as it does not significantly damage adjacent soft tissues. Detailed and accurate anatomical knowledge is required to manipulate the surgical area, as there is a risk of damaging the vocal cords, which may adversely affect their function. One layer of sewing is enough to close the access to the laryngeal cartilage, which is an obvious aesthetic advantage.

Surgical speech modification

This procedure is performed within the vocal cords in order to soften the male timbre of the voice. There are several surgical techniques that can be used for this purpose.

Indications and contraindications for the procedure

This procedure may not be appropriate for people whose expectations do not account for the possibility of an incomplete voice shift (e.g., limited or no change in pitch/resonance toward a typically feminine range).