Facial feminization surgery encompasses a broad range of procedures to change masculine facial features into feminine features. Examples include having your hairline moved to create a smaller forehead, having your lips and cheekbones augmented, or having your jaw and chin reshaped and resized. You also might need skin-tightening surgery, such as a face-lift.

Facial feminization surgery might be done as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria). The techniques can help transgender women transition physically to their self-affirmed gender.

Many facial features, such as the eyes, jaw and brow, reflect gender differences. While other body parts can be covered or hidden, facial features are readily seen. For transgender people who have a gender identity that differs from the sex assigned to them at birth, altering these characteristics can be essential in their transition. Being seen as women can also help transgender women avoid harassment and discrimination.

However, facial feminization surgery isn't right for every transgender woman. Your doctor might recommend against these surgeries if you have:

• Unmanaged mental health conditions
• Significant health conditions, such as heart or kidney disease, a bleeding disorder, or a history of blood clots in a deep vein (deep vein thrombosis) or in a lung (venous thromboembolism)
• Any condition that limits your ability to give your informed consent

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection, damage to nearby structures, facial asymmetry and an adverse reaction to anesthesia. Other complications might include:

• Suture rupture along an incision line
• Visible scarring
• Fluid accumulation beneath the skin (seroma)
• A solid swelling of clotted blood within your tissues (hematoma)
• Dissatisfaction with appearance after surgery
• A facial nerve injury

Sometimes additional surgery is needed to correct facial asymmetry and improve the final outcome.

Feminizing surgeries are typically deferred until adulthood.

Before facial feminization surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in the procedures you desire.

Every person has a unique facial structure. Your surgeon will ask you about your own ideas about your face and recommend procedures that will most effectively contribute to the feminization of your face. Your surgeon will also describe your potential results.

To plan your surgery, you might need a CT scan. This will allow your surgeon to obtain detailed anatomical information. Your face will also be photographed before and at several intervals after your surgery.

The surgeon will refer you for an appointment to discuss your anesthesia. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking. Your doctor will also give you instructions to follow after your surgery to improve your results.

In addition, before you can have certain feminizing surgeries, you'll be required to meet specific criteria. To start, your doctor will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:

• A review of your personal and family medical history
• A physical exam, including an assessment of your internal reproductive organs
• Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes
• A review of your immunizations
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
• Discussion about contraception and future fertility

Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons and insurance companies will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:

• Your gender identity and dysphoria
• The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
• Mood or other mental health concerns
• Sexual health concerns
• Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
• Protective factors such as social support from family, friends and peers
• Your goals, risks and expectations of treatment and your future care plans

Consent

Since facial feminization surgery might cause irreversible physical changes, you must give informed consent after thoroughly discussing:

• Risks
• Benefits
• Cost
• Alternatives
• Social and legal implications
• Potential complications
• Procedure irreversibility

Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures might be essential to alleviating your gender dysphoria.

You might also consider talking to others who've had facial feminization surgery before taking this step. They can help you shape your expectations of what can be achieved and what personal and social problems you might experience during treatment.

During the procedure

Facial feminization surgery might include:

• Forehead contouring. In men, the bony ridge above the eye sockets tends to be more pronounced. In women, the outline of the forehead tends to be higher, smoother and more vertical. There also might be a rounded protrusion. To make the forehead appear more feminine, part of the forehead bone is cut, removed, reshaped and put back into place.
• Eye and lid modification (blepharoplasty). To feminize the upper eyelids, excess tissue can be cut away.
• Cheek augmentation. Women tend to have prominent round cheeks in the middle third of their faces. This is due to a greater concentration of fat in the area. To achieve a more feminine appearance, cheek augmentation can be done with implants. It can also be done by fracturing and moving the cheekbones into a different position or by taking fat from another part of the body, such as the belly or thighs, and placing it in the cheeks to alter their size and shape.
• Nose reshaping (rhinoplasty). Rhinoplasty done on transgender women typically involves reducing the overall size of the nose and its angles.
• Lip lift and augmentation. Female faces tend to have shorter distances between the base of the nose and the border of the upper lip. Male faces also have longer upper lips. A lip lift can shorten the distance between the lip and the nose and create a shorter, more curled lip. Lips can be augmented through the use of implants or fillers or by taking fat from another part of the body and placing it in the lips.
• Mandibular angle reduction. Male jaws are typically larger and broader than female jaws. The jaw can be reduced and narrowed by sculpting or removing outer layers from the lower jaw.
• Chin width reduction (genioplasty). The male chin is taller than the female chin and tends to be more square-shaped. To shorten and narrow the chin, a horizontal cut is made along the chin bone and a small wedge of bone is removed. Then the chin bone is reattached.

Other possible head and neck procedures include:

• Tracheal shave. This is a procedure to minimize your thyroid cartilage or Adam's apple. During the procedure, a small incision will be made under your chin, in the shadow of your neck or in a skin fold to conceal the scar. Your surgeon will then reduce and reshape the cartilage.
• Lowering the hairline. Female hairlines tend to be located lower than male hairlines. During hairline lowering surgery, an incision is made at the meeting point of the hair-bearing and non-hair-bearing skin. The scalp is then raised, placed back and fixed to the bone. Excess forehead skin is removed.
• Hair transplantation. Men might experience hair loss. They also tend to have an M-shaped hairline that recedes at the temples, while women tend to have a rounded hairline. Hair transplantation can create a more feminine hairline. In this procedure, hair follicles from the back and side of the head are removed and transplanted to balding areas of the head and the temples.

You also might need skin-tightening surgery, such as a face-lift or other treatments.

After the procedure

After surgery, expect to experience pain, redness and swelling in your face, most noticeably in your eyes, nose, jaw and chin. Avoid overexertion for one month. You can begin moderate exercise within three to six months.

Chewing and swallowing might be difficult due to incisions and swelling. Your surgeon might recommend that you work with a nutritionist to make sure you get enough nutrients following surgery. A healthy diet is an important part of your recovery.

Definitive and stable results might not appear until up to a year after facial feminization surgery. During your recovery period, you'll continue to talk to specialists involved in your treatment about the evolution of your facial features and any complications you experience.

Facial feminization surgery can be an important part of gender transition. Research suggests that these surgeries can dramatically improve the quality of life in transgender women.