Michelle is a patient of Dr. Dwight Ellerbe in Anchorage, AK. She has had a feminizing rhinoplasty in combination with a reverse genoplasty, to bring the nose and chin into semetry.  The chin has been set back over 5 mm. The result is dramatic.

Square jawlines and brow ridges have been the bain of MTF TGs likely since humans first began experiencing Gender Identity Disorder. However, through the miracle of modern surgical techniques, even a very masculine face can be reshaped into a beautifully feminine one!

Here we discuss the anatomical differences between male and female faces, what can currently be done about changing them, and which doctors are excelling in this area of medicine.

FFS, or Facial Feminization Surgery, is actually a series of surgical procedures performed to feminize a masculine face. Since every face is different, some of these procedures may or may not be neccesary, depending on individual needs.

Reshaping the masculine face into a more feminine one often requires recontouring of the underlying bony structures of the skull and jaw, as well as the soft tissues of the face.

This type of surgery yields very dramatic results that are permanent and irreversable. Any person considering such a combination of procedures, should be certain that they want to permanently present as female.

Just how different are female faces from that of males?

There are several basic differences between a male and a female skull. Females typically have a more pointed chin and less nasal prominence than males. The forehead is quite different, as males tend to have more pronounced brow ridge and a larger, more prominant forehead.

The shape of the skull affects the shape and contour of the skin. Changing the shape of the skull will assist in changing one from distinctly male to female. Modifying the angle of the lower jaw and the prominence of the cheeks and/or chin can also help improve femininity.

SCALP ADVANCEMENT AND BROW POSITION                                                           

In physical anthropology studies, it has been shown that men have a longer distance from the brows to the hairline than do women. This is true even without any evidence of male hair loss. The average for women is approximately 5.0 centimeters (2.0 inches), as opposed to men's 7.0 centimeters (2.6 inches). In actuality, Dr. Douglas Osterhout found that in the majority of the transsexuals that he has seen, this distance is actually between 7 to 8 centimeters (2.7 to 3.1 inches).

A long forehead is generally acceptable for the male, but not for the female. Women with long foreheads will generally either wear bangs or will comb their hair in a way such as to hide some of their forehead. Small hairpieces have also been used. This routine is not a decision based on forehead length, but rather the finding by women that they just "look better" with their hair farther down on their forehead. Women with long foreheads rarely wear their hair back as in a ponytail.

In general, we like the position of the brows in the female to be higher - over the superorbital rims - while in men it is quite normal to have the brows slightly under the supraorbital rims. In fact, if they are higher in the male - like in a female - they may look surprised or effeminate. Elevation of the brows can be nicely completed in a standard forehead lift. This is also routinely completed in the forehead feminizing procedures.

Combining the forehead bony feminization, brow lifting, and scalp advancement, has for years been a very concerning problem; the fear being that the scalp would pull back farther, thus elevating the brows into a very abnormal position and causing the appearance of extreme surprise. Dr. Osterhaut has developed a method whereby both procedures can be completed simultaneously with excellent results. This has now been completed in many patients, both male and female. The net result of this procedure in the MTF transsexual who has this particular hairline and forehead length, is considerable feminization.

Forehead and/or scalp advancement are generally completed under general anesthesia, but can be completed under local anesthesia and sedation (in selected cases). The procedures are completed through an incision just at the hairline in the middle two thirds of the forehead, and then extend laterally more posteriorly into the hair and down to the superio-posterior of each ear.

The pre-hairline scar heals very nicely, but, depending upon one's preferred hairstyle and the quality of the healed scar, may benefit from a few micro hair grafts in front of the scar. As you probably know, the male hair pattern is generally nicely maintained while on female hormones.

 RECOVERING FROM FOREHEAD SURGERY

This surgery is generally completed on an inpatient basis, and most patients will spend one night in the hospital following surgery. A dressing is placed around the forehead after surgery, and left in place during the first night. It can be removed the day following surgery.

After removal of the dressing, showering and gentle washing of the hair is completed daily for a few days. If chin surgery has been completed at the same time, there will be a tape supporting dressing. This must stay dry, in which case the hair will need to be washed by someone else while lying down.

There will be some pain for a few days, which will require pain medications. While infections are extremely rare, antibiotics are utilized to avoid any potential infection. Swelling and any black and blueness that occurs around the eye will generally be gone within 10-12 days following the surgery. There may be some forehead numbness lasting several weeks to possibly years. Other nerve injuries that might rarely occur will be discussed by your doctor during consultation.

Many patients are able to go back to work at their usual activities (especially if they can work at home) within 2-4 days following surgery. It is not advisable to do anything that would require exertion sufficient to cause you to sweat or to have a rise in pulse or blood pressure for 8 days following surgery. The sutures and staples utilized to close the scalp incisions are generally removed by 9 days following surgery.

The results from this portion of the surgery are generally very dramatic, and offer tremendous psychological support. With a greatly improved femenine appearance, the transwoman will find greater social acceptance, and have much improved self-confidence.

DR. SHERMAN LEIS, PROMINENT TRANSGENDER SURGEON, DISCUSSES THE PROCESS OF FACIAL FEMINIZATION.

Facial feminization procedures are often a first step in the transitioning process towards gender reassignment, but should they be?
(Bala Cynwyd, PA USA)   At the recent IFGE conference in Alexandria, Virginia, hosted by the Transgender Education Association (TGE) of Washington DC, Dr. Sherman Leis, renown surgeon and transgender specialist spoke about facial feminization.  Facial feminization is the process of surgically modifying the human face to give its shape, size, and features a look that is more like a typical female and helps the person more easily socialize as a woman.  “Facial feminization is frequently the first surgical phase of transitioning in male-to-female gender reassignment,” noted Dr. Leis.  

 Facial Feminization can include bone, soft tissue, and aesthetic procedures including hair removal, brow and forehead modification, chin and Adam’s apple refinement, and others.  Some of the most frequently performed procedures include rhinoplasty (nose), hairline alteration, cheek contouring, and lip fill and lift.  Some cosmetic surgery is also done at the same time to give eyes, neck, and chin an uplifted, more youthful appearance.

Some patients schedule complete facial feminization in one procedure, while others select multiple surgeries to be performed one at a time, for economic or social reasons.  

Notes Dr. Leis, “Facial feminization is a wonderful first step because it gives the transitioning person a more obvious and immediate feminine appearance and to become comfortable with many of the the social and psychological aspects and issues.

From decades of experience, Dr. Leis has developed a unique outlook on the transitioning process that is highly sympathetic to the needs and feelings of the patient.  It is the underlying reason why he founded The Philadelphia Center for Transgender Surgery.  “Anyone can contact any plastic surgeon and request a certain medical procedure.  However, our extensive experience specializing in the needs of the transgender community has demonstrated that much more is going on here than a simple nose job or brow lift,” said Dr. Leis.  

“The transgender candidate has many unique questions and concerns requiring a more complete understanding of the patient and their mindset, on the part of the specialist.  Transitioning is a journey that is touched on by surgical, psychological, hormonal, aesthetics, legal, and other issues.  Even the initial facial feminization step for the most committed trans patient requires a significant mental leap, one that must be supported by experienced people who understand and support it.  Procedures done in a more nurturing environment will greatly enhance the patient’s comfort level and increase the prospect for a successful outcome,” said Dr. Leis

For example, at The Philadelphia Center for Transgender Surgery, it is recommended that the gender reassignment candidate’s first step is to meet with an experienced mental health specialist to assure ones mental readiness to begin the transition.  The psychologist or therapist will also provide information about what to expect from family, friends, co-workers, associates, and the general public during this experience and how to successfully deal with those aspects of transitioning.  Next, they will consult with an endocrinologist to evaluate the candidate’s hormone levels and general health, as well as recommend safe and appropriate dosages of hormones.  Then, within this knowledgeable and supportive environment, the surgical procedures be more successful psychologically and medically.

Observes Dr. Leis, “Most transgender candidates have many, many questions along the way.  This is normal.  One does not want to have an impatient doctor, or worse, having to connect with someone half way around the world to answer a question or concern. “   It is for this reason that, in addition to his busy surgical and speaking schedule, Dr. Leis can be found working late into the night, personally answering calls and emails from those who feel challenged by their circumstance, seeking comfort and information from someone who cares.

Observed Dr. Leis, “Thanks to remarkable advances in technology, psychology, and aesthetics, together with the improving social acceptance for the transgender community, more and more people can live their dream freely instead of living in denial and frustration.”  He said, “More resources,

physicians, and institutions are needed to support this community, which is why I created The Center as a complete, comprehensive resource in the United States.  My vision is to provide an oasis where a transsexual contemplating the transition process, can come for information, limited or total surgery, aesthetic services, and an environment of support and compassion.” 
Dr. Sherman Leis is Board Certified in General Surgery and Plastic and Reconstructive Surgery.  He is Professor and Chairman of Plastic & Reconstructive Surgery and Director of Residency Training in Plastic Surgery at Philadelphia College of Osteopathic Medicine.  As part of his aesthetic surgery practice, Dr. Leis has performed many feminization and masculinization procedures of the face and body. He has more than 30 years of experience providing the highest quality care for the trans community.

The Philadelphia Center For Transgender Surgery is recognized as one of the premier facilities in the world for sexual reassignment because of its extensive experience and comprehensive links to Dr. Leis’ team of dedicated specialists - surgeons, psychologists, endocrinologists, aestheticians, speech therapists, legal experts, and others.  The Center offers a variety of surgical and non-surgical procedures for GLBTI individuals.  Its discreet, serene headquarters is located in suburban Philadelphia at 19 Montgomery Avenue, Bala Cynwyd, PA  19004.  Phone:610-667-1888.