Facial feminization surgery (FFS) is a group of surgical procedures; the aim of which is
to change the features of a male face to that of a female face
FFS was originally popularized and pioneered by Dr. Douglas Ousterhout of San Francisco, California, USA in the 1980s and 1990s.
Female and male faces are quite different in terms of size and shape, but in feminizing the male face it is important to appreciate that the size of the face has to be in proportion to the rest of the body.
Analysis of the female face demonstrates that it is more heart-shaped or triangular with the base of an inverted triangle being represented by a line drawn between the maximum prominence of each zygoma and the apex of the triangle being represented by the chin point. The female face is softer and more rounded or oval-shaped, with soft, round, curving forms.
Male faces are more square and angulated with a strong jaw and chin often with an M-shaped hairline. The chin and lower jaw is usually longer in the male by as much as 20% and is often, but not always, more prominent in profile.
The male forehead often exhibits significant frontal bossing, which may partly be due to a large frontal sinus, but may also be due to thick supra-orbital ridges. In addition, the angle formed at the glabella between the frontal area of the forehead and nose is often acute as opposed to in the female where it tends to be much more obtuse.
Female eyebrows are arched, especially in the lateral third area and sit well above the superior orbital rim, while the male eyebrow is straighter and tends to sit at the level of the superior orbital rim.
Female noses are smaller and shorter with narrow bridges and narrow ala bases, often with upturning of the nasal tip giving rise to a more obtuse naso-labial angle.
Male cheeks are flat whereas female cheeks can be quite prominent, being further anterior and higher with some cheek hollowing beneath, which provides further accentuation.
Female upper lips are fuller and shorter with good show of the vermillion and a well-formed Cupid’s bow. Maxillary tooth show is greater in females due to these features and characteristics.Male chins are often long, square and angulated as opposed to female chins, which are shorter, narrower and more pointed .
The male mandible has a prominent angle with lipping of the bone due to the masseter muscle attachments and it is wider than in the female. The external oblique ridge is thick and the masseter muscle is bulkier.
The thyroid cartilage is more prominent in the male and at the notch forms an angle of 90º as opposed to the female where it forms an angle of 120º, which is the reason for it being less pronounced. A prominent thyroid cartilage is an extremely masculine characteristic, hence the popularity of the thyroid shave in this group of individuals.
Group I patients has mild to moderate excessive projection of the brow and abnormal bossing. There are no frontal sinuses, or the bone anterior to the frontal sinuses is so thick that its reduction will not compromise the sinus air space. The reduction is achieved simply with an acrylic burr in order to achieve the desired contour.
In Group II the brows are normal, mildly or moderately projected and there is thick bone anterior to the frontal sinuses. This bone can therefore be reduced as in Group I patients, but may become quite thin. When the bossing is reduced there may be a forehead concavity superior to the bossing, which may require filling with bone cement to feminize this area of the forehead.
Group III patients have excessive brow fullness and the requirement for the anterior table of the frontal sinus to be set back into a more retruded position. The anterior table has to be osteotomized, reshaped and fixed with mini-plate osteosynthesis. Planning is undertaken by use of computerized tomography (CT). This group of patients forms the majority of cases requiring fore- head contouring.
In all cases access is via a coronal flap.
All groups of patients undergo orbital rim contouring in which the outer third of the superior orbital rim is reduced to increase the dimensions of the anterior orbital rim.
Brow lifting is undertaken to raise the eyebrows to a more feminine position. The female brow is located above the supra-orbital ridge, whereas the male brow is at the level of the ridge. Elevating the brow opens up and freshens the eyes and significantly feminizes this area. In conjunction with orbital rim contouring, this is very effective. Upper lid blepharoplasty may complement this procedure.
The procedure is carried out via the coronal access for the forehead reduction procedure placing sutures from brow dermis to bone in the desired position
Feminizing rhinoplasty (endonasal or open):
In most cases it is necessary to reduce any dorsal hump and to narrow the nasal bridge by in-fracture of the nasal bones. The dorsum can remain straight in the female nose, but some individuals may request more curvature to the dorsum or a retroussé nose. Large nostrils can be reduced by skin excision at the nasal sill. It must be appreciated that the nose must fit the face, in the sense that a small nose will not look harmonious or in place on a large face however well it has been feminized. Importantly, rhinoplasty is often combined with forehead reduction in order to reduce the acute angle seen in profile between the frontal sinus bossing and the take-off angle of the nose in the male. Read more about Rhinoplasty —>
The rhynomodelation is a technique which gives the possibility of good results, without the need to submit oneself to the risk and post operatory treatment of a common rhynoplasty. Read more about rhynomodelation —->
Lip lift and augmentation
Lip lift is commonly used in feminization of the face. Its aim is to shorten the lip in the area between the ala bases of the nose so the individual shows more of the maxillary tooth crowns. Additionally, the lip profile often changes in that a flat, long lip takes on a more curled appearance after- wards.
The procedure is accomplished by excising a pre- measured ellipse of skin immediately adjacent to the nasal sill and between the ala bases, ensuring that the incision does not extend beyond this point in order for the resulting scar to be acceptable. The width of the ellipse depends on the amount of lip shortening required,
Mandible angle shave and taper
The procedure is performed via the mouth through an incision from high on the external oblique ridge to the first molar area.
The cortical bone is significantly reduced, often exposing cancellous bone, with a high speed acrylic burr to reduce the prominence of the angle and external oblique ridge up to the mental foramen
When there is a significant mandibular angle present, the angle is osteotomized with reciprocating and oscillating saws to give this area a more rounded and softer appearance
The objectives of a feminizing genioplasty are to narrow an angulated masculine chin. It is often necessary to shorten the chin area vertically at the same time as narrowing it.
Chin osteotomies generally give far superior results than contouring the chin area.
This procedure is often combined with an angle shave, all throw mouth incisions with no visible scars.
Thyroid shave (chondrolaryngoplasty)
The approach to the cartilage is via a superiorly based 2 cm transverse neck incision in a suitable skin crease, based as high up as possible