This article was reviewed by Andrea Gersh, MSN, FNP-C.
For this article, we are going to be using anatomical language to refer to body parts, but we celebrate any words you use to self-identify. The language we use for our bodies matters, just like how we ask others to touch and experience our bodies, and respecting this is a part of healthy and active consent.
Before the popularization of gender-affirming surgeries, many transgender people had no other options other than to dress as the gender they knew they were and hope for the best. These days, while access to surgery is still difficult for many trans people given the financial barriers, lack of insurance or proper coverage, gatekeeping in the medical field, and difficulty accessing affirming healthcare providers, advancements in the field of transgender health mean that a variety of surgeries are now available that were historically difficult or impossible to access.
Now there is a wide range of gender reconstructive surgeries, beyond bottom surgery, to help transgender people alleviate gender dysphoria and feel aligned with their bodies. Facial Feminization Surgery (FFS) or Facial Gender Conforming Surgery (FGCS) is one of these procedures and is commonly sought out by transgender women, transfeminine people, and other non-binary folks who are looking to change their facial appearance.
What is Facial Feminization Surgery?
Facial Feminization Surgery refers to a broad range of surgical procedures that give the face a softer and what some would call more traditionally “feminine” appearance. This can include anything from hairline lowering, augmented lips and cheekbones, jaw and chin reshaping and resizing, Adam’s apple reduction, and more. Combined, these procedures can help many transgender women create more harmony and ease between their inner self and outer form and greatly reduce the dysphoria that comes from being misgendered or read incorrectly.
Some trans women choose to undergo FFS for safety reasons, to make it easier to move through the world without being read as trans. Unfortunately, many insurance plans still do not cover the surgery as it is often considered cosmetic and therefore not medically necessary. However, in some cases, FFS can have a greater impact on transgender people’s mental health and wellbeing, even more so than bottom surgery can. Hopefully, as transgender health and access start to be taken more seriously, insurance will recognize the necessity of surgeries like FFS for the livelihood of trans people.
Who is Facial Feminization Surgery for?
Mostly transgender women, transfeminine people, and other non-binary folks undergo Facial Feminization Surgery. However, FFS is not solely for trans women, as some cisgender women also undergo similar procedures (more routinely known as plastic surgery) to change the appearance of their facial features. But in comparison to cosmetic aspects of plastic surgery, FFS is an essential part of the health and wellbeing of transgender people, and studies have shown that trans people’s quality of life after this surgery drastically improves.
While we know that things like “masculinity” and “femininity” are often subjective, this does not change the way that trans and gender non-conforming people are often treated in the largely cis-centric, binary world we live in today. While some transfeminine people have no desire to change their face, others often benefit from the physical, emotional, and psychological changes such as improved self-worth and self-esteem, that this surgery can provide.
What are the different procedures performed in Facial Feminization Surgery?
There are many different types of procedures that go into gender-affirming FFS and each surgery is highly tailored to the individual needs of the person. The overall goal of FFS is to soften the face into a shape that is more typically recognized as ‘feminine.’
This typically includes focusing on bone structure and nose shape, although it can encompass every aspect of the face and neck including forehead reduction (contouring and reshaping), hairline lowering, browplasty (otherwise known as brow lift), rhinoplasty (nose reshaping), lip lift and augmentation, cheek implants, chin reduction and recontouring, jaw shave and reduction, tracheal shave (reduction of the Adam’s apple), and/or earlobe reduction. Soft tissue work such as facelifts and necklifts can also be incorporated. These procedures aren’t exclusively for transfeminine people, as many cisgender women also get a variety of the same procedures from plastic surgeons.
The surgery usually consists of a long-form set of gender confirmation procedures performed in either one or two sessions. Here are descriptions of the different procedures that can be involved as one or many parts of FFS.
Forehead reduction and contouring consist of reducing the prominence of the brow which can be more common in people assigned-male-at-birth (AMAB). This requires shaving down hard angles to make the brow bone less protrusive. If you have a smaller brow protrusion, this can be accomplished by simply shaving down the brow bone. However, if not done carefully, this can result in a hole in a sinus cavity. Therefore it is common for people with bigger brow protrusion to have the bone removed, reshaped, and then replaced so that it lies flat on the face.
Hairline alterations and scalp advancement
Hairlines can differ depending on the levels and presence of estrogen and testosterone in the body. Forehead work is typically paired with procedures that alter the hairline to reduce the effects of pattern-baldness and receding hairlines. Transfeminine people might have a more M-shaped hairline, while people assigned female-at-birth are typically born with a hairline shaped like an inverted U.
Some surgeons cut across the hairline, move the hairline and scalp physically forward, remove the excess forehead skin, preserving the healthy hair follicles, so your hair can continue to grow. Hair follicle transplants may also be used to add ‘feathering’ to the hairline because ‘feminine’ hairlines are usually less defined. However, in more recent years, coronal incisions (across the top of the head) have become more popular, which allows the scar to be hidden by a person’s head hair. A coronal incision can be paired with simultaneous hair transplants because the incision is far from the hairline. If hair transplants are something you are interested in, talk to your surgeon about a coronal incision.
One of the most common FFS procedures is rhinoplasty, otherwise known as a nose job. The goal of rhinoplasty is to reduce the overall size of the nose and round out its angles while maintaining proportion with the other features of the face. Rhinoplasty is the virtually same procedure for transgender women as it is for cisgender women. It can involve reshaping the width of the nose as well as reshaping the bridge and tip to create a smoother aesthetic. Rhinoplasty is usually performed at the same time as forehead contouring and hairline lowering to ensure that the end result is proportional and aesthetically balanced.
Lip and cheek procedures
Depending on your facial features or desired outcomes there are a range of lip and cheek procedures that are available. Lip lifts are also common procedures that shorten the distance above the upper lips and reorient the lip to curl slightly upwards. Lip augmentations (or lip fillers) also plump up the lips through injectable fillers or fat transfer injections to make them appear fuller or more ‘feminine.’
Cheek augmentation is a less common procedure, although some surgeons may recommend it. This procedure involves creating cheek implants usually from fat grafts taken from elsewhere on the body (such as inner thighs). However, if you are on estrogen hormone replacement therapy, your cheeks may have become fuller already which might render this type of surgery unnecessary.
Chin and jaw procedures
Genioplasty (or chin contouring) can reduce the height and width of the chin, creating a less angular or chiseled look. This happens through shaving down any bone protrusion or through a chin augmentation in which the bottom part of the chin is sliced into a wedge, slid forward away from the jaw, and then reattached. Sometimes, the V-line surgery is also recommended to revise the angles of the jaw and chin and create a more triangular shape.
Chin procedures can also go alongside jaw contouring or jaw tapering. This works to reduce the overall width of the face creating a more narrow shape. The back corner of the jaw can be reshaped to become rounder and smoother and bone can be shaved off to create a less visible jawline. These procedures happen through an incision inside your mouth which means that there are no visible scars.
A tracheal shave is also a common procedure that significantly reduces the size and appearance of an Adam’s apple, This procedure typically involved an incision that is made just under the chin, so that scarring is less noticeable. The thyroid cartilage will be shaved down to reduce the size of the trachea to create a smoother neck and throat area.
How much does FFS cost?
Despite improved insurance coverage for a range of gender-affirming surgeries, FFS continues to be difficult to get covered. However, this does not mean it’s impossible. Oftentimes getting coverage for FFS requires multi-level appeals to insurance companies to prove the necessity of the procedures.
If you are looking to get FGSC covered by your insurance, you will want to start with an understanding of your coverage. Check if you have out-of-network benefits or if your insurance plan is limited to providers in the network, as well as your deductible and out-of-pocket max. Read your insurance plan for any explicit inclusions or exclusions for transgender care. Lastly, see if there are any support groups or local LGBT advocacy groups in your area who might be able to help you navigate this process.
Unfortunately, the current version of the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) criteria do not provide sufficient discussion on Facial Feminization Surgery. Insurance companies routinely look to the Standards of Care to determine which gender-affirming surgical procedures are medically necessary to treat gender dysphoria, and the lack of specificity in the current version of the SOC often leads to the denial of coverage for FFS. Out of pocket costs for FFS can range from $20,000 to $50,000 and above, although the cost depends on both the surgeon and which procedures are selected.
Is FFS safe?
Facial Feminization Surgery, if performed by an experienced and skilled surgeo, is a very safe and low-risk set of procedures that draw upon surgical techniques and procedures already widely being utilized by plastic and reconstructive surgeons. However, it’s important to note that all surgery comes with some degree of risk. This often includes the risk of infection, bleeding, difficulties with wound healing, and/or aesthetic outcomes that may be different from what was hoped. It is important to choose a surgeon who is experienced in performing FFS specifically, and one who is operating in a medical environment that is experienced in caring for transgender and non-binary patients.
For help finding a surgeon who performs FFS, check out this resource guide. You can also see Trans Healthcare’s FFS Surgeon Directory or MTFSurgery. See if your insurance has a list of covered providers or reach out to trusted friends for recommendations. Transbucket is also a great community resource for before and after photos of all different types of gender-affirming surgeries (note: you have to identify as transgender and/or nonbinary to access the site).
Know that FOLX clinicians can help write letters of recommendation from a hormone provider, and our member support can provide resources for local surgeons if needed. If this is something you are interested in, please do not hesitate to get in touch with your clinician. If you are interested in scheduling a virtual consultation with an affirming clinician here at FOLX, you can do so here. If you are interested in getting started on an estrogen membership, that process begins here.