“I saw the angel in the marble and carved until I set him free.” Michelangelo
The subspecialty of gender-affirming surgery is unique in that it represents much more than merely complex surgery confirming what many of our patients have often known their whole lives. It is often the end of a relentless journey of self-sacrifice, perseverance and a belief in that which cannot be seen. It is the ultimate culmination of marrying the physical self with their spiritual and psychological self after a lifetime of being consumed by the mismatch.
Perhaps the most personal and exposed part of one’s physical self is the face. It represents your identity, how you feel and perceive the world, and rightly or wrongly, how others perceive and receive us. A person’s face is far more difficult to align with one’s gender identity even with masterful makeup and hair artistry. There are often structural features that always remain as a sign of someone’s physically assigned secondary sexual characteristics.
The technique used to describe the alteration of facial proportions in order to feminise the face is called facial feminisation surgery or FFS. The main facial structures that are commonly altered in this procedure are as follows:
- Hair Advancement
- Forehead Contouring
- Filling Hollow Temples
- Cheek Contouring
- Jaw Contouring
- Laryngeal Shaving/Augmentation
Hair Advancement Techniques
Men have higher hairlines, lower brows and thinning temple hair. Conversely women have lower hairlines (±6cm), higher brows and fuller temple hair. By elevating the male brow and advancing one’s scalp, one is able to achieve a more female forehead.
By moving your hairline into a more feminine position, one is often able to transform how their face is perceived; many transgender patients are often very pleased merely by this rudimentary move. In conjunction with forehead contouring surgery and brow lift surgery, your entire upper face will appear more feminine and within the norms of the binary feminine phenotype.
Nowhere else in the male face is one more masculine than in the forehead region. Men have a distinct characteristic called frontal bossing – this is a prominence of the lower forehead just above the eyebrows and a steeper slope of the forehead compared with females. Women conversely have a more convex contour with more vertical height and a softer transition to their hairline. Men have a relatively sloped forehead compared with females in whom they are more rounded.
Temporal Fossa Augmentation (Filling Hollow Temples)
Often there may be recesses associated with one’s facial appearance. An area where this is often encountered is the temporal fossa. This is the area that lies to the side of your eye sockets and above your cheek bones. It is also called your temple. Improvements are made to this area to feminise and revitalize the facial region.
While there are no identifiable gender biases related to the size and position of one’s cheeks, all genders look healthier and facially balanced when their cheekbones look robust and elevated. It is important to emphasize that the size of one’s cheeks should be kept in proportion with the rest of one’s face, and that this area of facial aesthetics should be done as one of the last procedures after the forehead and cheek regions have been enhanced.
Male noses are generally larger than those of females. This is true of most of the dimensions assessed. Subtle and reproducible angles are also defined which, although very subtle, make for the stereotypical male and female noses. Gender specific nasal characteristics are as important as forehead dynamics in terms of facial recognition and identification of one’s chosen expression of gender if you wish it to be binary. Rhinoplasty can alter a masculine nasal appearance to align with more feminine characteristics.
Men have vertically longer and wider chins that are less pointed. This is a very common area of adjustment for transgender FSS due to the marked discrepancies and ease of correction as well as the very specific nature of differences between the genders. Men have chins that are approximately 20% taller than females and also are more square compared with female lower faces. Their chins are also wider and have lateral (side) prominences that gives one a chiselled look while females have a softer and more oval chin that has no chiseling at all. The midline of the jaw is also less prominent and the dimple is often less pronounced.
Jaw Contouring: Mandible Shaving/Lower Jaw Tapering/Angle Reduction
Men have a wider, fuller jaw and a taller and fuller mandible angle. Females have a smaller tapered jaw bone. Most importantly, men have significantly wider angles of their lower jaws from the side which are bowed out more prominently due to the much stronger muscles required during eating.
One’s Adam’s apple is for many people the very definition of masculinity. It is often the primary concern for many patients that approach me for help, and it heralds the dreaded pubescence that many transgender patients feel betray them.