What happens during Facial Feminization Surgery?

The answer to the question, “What happens during facial feminization surgery?” depends largerly on which facial features you will operate on and which technique is employed. Whatever types of surgeries you and your doctor agree on, you will most likely need to have the operation under general anesthesia in a hospital. This usually means spending one or two nights in the hospital for monitoring and to provide the correct post-op care.

What happens during Forehead Feminization Surgery?

The goal of forehead recontouring in facial feminization is usually to reduce the prominence of the bony ridge just above the eyebrows and create a more vertical forehead line. For more comprehensive feminization of the upper-third of the face, forehead recontouring is often combined with orbital bone shaving, hairline feminization and/or a brow lift, as needed, depending on the individual’s features.

Creating a more feminine forehead shape can be done in different ways depending on the objective result, patient’s bone structure and the surgeon’s judgment. One method is to grind the bony brow ridge down as far as possible, taking care not to perforate the frontal sinus cavity. The main problem with this method is that the sinus cavity wall is often left too brittle and therefore susceptible to fractures later on. Another common approach is a more complex cranioplasty. This requires an osteotomy, or bone cutting procedure, where the bone plate over the frontal sinus is completely removed, all bones reshaped within safe parameters for thickness after which the plate is replaced with the help of, ideally, titanium micro-screws, mesh or fixation plates if required.

These forehead feminization methods require access to the bone. Traditionally, this has been achieved through an incision at the hairline, with the inconvenience however of visible scarring or an unnatural-looking hairline in some cases. The skin and soft tissues of the forehead are pulled away so that the surgeon can reshape the underlying bone. After the reconstruction, the size-adjusted “flap” is replaced back over the newly feminized skull, and the incision is stitched directly along the hairline. Sometimes this is combined with a scalp advancement to lower the hairline, although a more modern understanding of facial gender tells us that a lower hairline may not always be feminizing yet may even have the opposite effect.

In more recent years, another well-known craniofacial approach has gained popularity since it allows for simultaneous forehead and hairline feminization in a single visit to the operating theater, without the risk of visible scarring. In this innovative procedure, the incision is made at the crown of the head, so that any scarring is hidden beneath the hair. At the same time, a thin strip of the scalp is removed from which the hair follicles are harvested for immediate grafting in the hairline feminization.

In both methods, an added benefit is that the patient may also notice a slight brow lift and smoothing of the forehead, which will subside with time as healing progresses (and the effects of aging return).

What happens during Jaw Feminization Surgery?

Like forehead recontouring, jaw reduction surgery removes and shapes the volume from the jaw and chin to create a more feminine appearance. The incisions are best made from inside the mouth so that there are no visible scars from the procedure. Although this may make accessing posterior areas of the jaw more difficult, experienced FFS surgeons are adept at this approach and may even employ specialized surgical instruments to reduce trauma to the surrounding tissues. The use of ultrasonic technology in intraoral approaches is proven to reduce postoperative complications like swelling and provide for an easier recovery.

It is contradictory to go under the knife to look better and be left with an unsightly scar.  Therefore, a series of specialized tools have been developed to be able to safely narrow and shape the mandible with more predictable results. The same goes for a chinplasty or genioplasty, which adjusts the volume and position of your  chin bones in order to create the desired effect–be it rounding, straightening, shortening, sliding forward or setting back–for a result that is as subtle or as aggressive as required.  As with the forehead osteotomy, these procedures involve fixation with biocompatible micro-screws and plates.

What happens during an Adam’s apple reduction?

Adam’s apple reduction, also known as a tracheal shave, is a procedure that in some centres is performed under local anesthesia if it is the only surgery being done. However, general anesthesia is needed when combined with forehead, jaw, or other facial feminization surgery. In this procedure, the incision should never be made near the bottom of the Adam’s apple on the throat, which would cause a highly visible scar, albeit a small one. The neck  is also an inconvenient spot if you develop tissue adhesion, resulting in an unnatural movement of the skin when swallowing.

Thankfully, many professionals are able to perform a reduction of this cartilage via an incision in one of the natural skin folds in the neck or under the chin in order to keep scars less noticeable. The underlying muscles are held apart while the surgeon reduces the excess cartilage that makes the Adam’s apple more prominent and masculine, taking care not to weaken the structures that support the vocal chords. Finally, a single suture may be used to close the incision. A small red line will be visible in most patients for about six weeks, but long-term scarring is usually minimal and easily reduced further with the use of silicone scar gels, micro-pigmentation or makeup.

In conclusion, as with any surgery, there are risks and complications that may–or may not–arise. FFS surgery is no exception although the most common problems, usually minor, are easily resolved thanks to modern medicine and experienced professionals. When performed with the assurance of the proper tried-and-tested protocols, methods and planning in place, FFS surgery is now more routinely considered a secure, controlled intervention with increasingly foreseeable results.

Patient Relations Manager Lilia Koss, presentator of Lilia's Livestreams
About the author

Hello world! I’m Lilia Koss and I use she, her, and they pronouns. What are yours? With a background in humanities and diverse professional experiences, I have been working with the Facialteam founders and directors since 2008. Involved from the ground up, so I’ve had hands in many pots: patient coordination, orientation events on 3 continents, social media, written and audiovisual content about our gender-affirming healthcare...but now life is more defined. Lately, I focus my energies on Public Relations, community management and live streaming to help raise the visibility of trans health. Life is pretty complete.