Gorgeous, Dahling: Are You In The Zone For Facial Surgeries

Welcome back to our series on gender affirming surgeries and procedures. We started with prepping for bottom surgeries and will end with office visit procedures such as fillers and botox. Last week we talked about implants for augmenting hips, butts, and pecs. This week, we’re discussing facial surgeries. The next two pieces in this series are on botox and fillers, which can also be used to in gender affirming ways.

Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.

Facial Surgeries – Zones of the Face

We don’t expect to be able to cover all of the possible surgeries available, nor do we think we’ll be able to provide more depth than some of the dedicated resources for facial surgeries. What we think we can do is talk about what facial structures can be changed in gender affirming surgeries.

Facial surgeries are categorized by where on the face they occur:

• top third – hairline to brow
• middle third – the skin between the eyebrows to the point where the nose meets the skin above the lip
• bottom third – just beneath the nose to the jaw and bottom of the chin

Feminizing facial surgery is well-known in the community. Masculinizing facial surgeries are also available but are less well known. We’re psyched to spread the word!

A note on language use at QueerDoc:

We believe that there’s no one way to be trans. We also believe that there’s no one way to be masculine, feminine, or non-binary, and that what these terms mean has a lot of overlap for individual people. When we talk about the effects of estrogen on bodies, we like to use wording like “gettin’ curvy” We use “angles” or “gettin’ square” for the effects of testosterone.

On that note, let’s dive in to some of the current options for “facial features remodeling surgery” (shout out to the surgeons who coined this term that can apply to anyone who seeks to change their visage.)

The Top Third

But First, Some Facial Surgeries Vocabulary

In case the surgeon brings out some unfamiliar words at your consultation or you’re dowloading articles from SciHub.

supra-orbital ridge – this is just above the eye socket and separates the forehead from the eye socket. Eyebrows generally sit on top of this ridge. The brow bone.

bossing – unfortunately, not QueerBoss! Skull bossing is when some of the bones of the head push out. Prominent ridges above the brow may be described as bossing.

frontal sinus – a sinus cavity in the skull bones between and above the brow ridge. May add bulk to the forehead shape, but not everyone has one.

osteotomy – the medical term for cutting bone in a surgery.

Your genetics determine much of what your face will look like after puberty. The hormone mix that you experience in first puberty plays a big role, too. Facial dimensions and cultural beauty standards vary between populations and between individuals. The below charts of estrogen’s and testosterone’s influences on facial structures are generalized. They are also likely to have been gathered from studies on white people by white doctors: they are limited. Any one person may also have a mix of characteristics that are broadly associated with either estrogen or testosterone exposure in first puberty. For example, my family genetics tend towards a long forehead with an M-shaped hairline in everyone, not just those who experienced a testosterone-based puberty.

Many surgeons now offer visual imaging with dynamic graphic capabilities to help visualize changes to your face. If you have photos of people who share facial characteristics that are similar to your goals, we recommend bringing those photos with you to consultations.

Common Procedures

Foreheads may be changed by reducing, augmenting, or re-shaping the bones of the skull.

There are four types of foreheads according to surgeons:

• Type I: has no frontal sinus or bone thick enough that reducing the thickness of the bone will not risk the frontal sinus cavity. About 3% – 5% of people.
  • Remodeleling a Type I forehead is usually done by buffing away bone with the surgical equivalent of a burr grinder
• Type II: has a dip in the skull above the brow bone. There might be bossing of the brow bone. About 3% to 5% of people have Type II foreheads.
  • Altering a Type II forehead is often done by filling in the dip to create an even curve, with or without altering the brow.
• Type III: has a frontal sinus cavity and bossing above the brows. This creates a projected brow, but the bone on top of the sinus cavity may be thin. About 90% of people have Type III foreheads.
  • Altering a Type III forehead may cutting the bone in addition to reshaping it with a burr. There may be a risk of damaging the frontal sinus cavity.
• Type IV: a Type IV forehead is smaller all over
  • Type IV forehead remodelling is done through augmentation

Augmentation materials include:

• polymethylmethacrylate – an acrylic-like resin that is common in dental and medical applications, including joint replacements
• hydroxyapatite granules – hydroxyapatite is very similar to bone in the body. It can be used to create a structure where bone will eventually grow into and around and fill in.
• calvarial bone graft- not cadaveral! Calvarial bone is a bone graft from a non-facial part of the skull.
• silicone implants

Injected fillers are also commonly used to augment facial characteristics, and we’ll talk more about those in a couple of weeks.

Hairlines may be brought forward and the shape of the hairline altered at the same time as brows are lifted to shorten the forehead. Generally, eye sockets will be shaped at the same time foreheads are remodeled. For individuals wishing for a softer appearance, eye sockets are enlarged by reducing the top rim of the eye socket and changing the angles of the orbit.

For individuals seeking a more angular face, eyebrows can be straightened and lowered, hairlines can be re-shaped, and the eye socket rim can be filled and augmented.

The Middle Third

Yep, some words first

zygoma – where the outside of the eye socket meets the cheekbone and extends back along the cheek, where it becomes the zygomatic arch just about where you can feel your lower jaw move under your cheekbone. If the eye socket is a clock, the zygoma is between about 7 to 10. The zygoma is often the widest part of the face.

glabella – the space at the top of the nose, in between the eyebrows

nasion – the dip in the bone between the eyes

nasal-frontal angle – the angle where the glabella becomes the nasion

lateral canthus – the outer corner of the eye

canthal tilt – the angle difference between the inner corner of the eye and the outer corner of the eye

malar prominence – the point where the cheek is most forward compared to the rest of the face. This spot is generally about one-third of the distance from the outer corner of the eye to the jawline in height.

maxilla – the upper jaw

orthognathic surgery: surgery which repositions the upper or lower jaw, and sometimes the chin

Many people choose to alter the characteristics and proportions of the middle face by changing their noses. If multiple sections of the face are remodeled, the top and middle sections are often done together. We’ll repeat: facial dimensions and cultural beauty standards vary between individuals and populations, so these are, by necessity, generalized, and any individual person may have a mix of characteristics regardless of their first puberty.

Common Procedures

As in the top third of the face, bone shape can be altered through reduction and augmentation. Cartilage can be removed, or implants used create more height or width. Finally, tissue can be removed or orientation changed in surgery. Most of the characteristics of the face can be remodeled.

Eyes: the bones of the eye socket can be reshaped to change the angles of the orbit and how far forward the rim of the orbit is compared to the cheekbone. The inner and outer corners of the eyes can be moved to create a stronger angle to the canthal tilt. The space between the eyes can be narrowed or widened, and the angle/dip between the forehead and the nose can be made sharper or shallower.

Nose: reductions in nose dimensions are frequently sought. However, noses can be augmented, as well. Grafts may be used to both shape the nose and widen it.

Zygoma: (this is a great Scrabble word!) alterations can shave down the zygoma to decrease width at this part of the face, or bone can be augmented here to make the face wider. The width of the face at temple and jaw play a huge role in the overall proportions of the face.

Cheekbones: can be raised, shaped, and flattened

Upper Jaw: Dental surgery to change the alignment of the upper (and lower) jaw is fairly common. These same techniques can be used to move the jaw forward or backward. Orthognathic surgeries may require dental expertise to maintain (or improve) teeth alignment and jaw function. Augmentation of the upper jaw with filler materials can be done.

The Bottom Third

You guessed, it: more facial surgeries vocabulary!

nasolabial angle– the angle formed where the nose (naso) meets the lip (labial.)

alar base – the bottom of the nose from where the nose meets the face to the tip of the nose

subnasale – the point where the nose meets the upper lip

vermillion border – the line between facial skin and lip skin

mandible – the lower jaw

gonial angle – the angle at the back of the lower jaw, formed by the line up towards the ear and the line extending towards the chin. The meeting point is the gonion.

Common Procedures

Changing the nasolabial angle, the height of the alar base, and the length to the upper lip (as well as increasing or decreasing the amount of vermillion) are commonly done at the same time as remodeling the nose. However, it is often recommended that jaw remodeling be done separately from top or middle of the face procedures so that the individual has an easier time breathing during recovery. If both the mouth and nose are healing, breathing is harder!

Changing the gonial angle, or changing the size or shape of the lower jaw, as well as chin procedures are often done with incisions inside the mouth. This lowers the chance of visible scars, but may increase infection risk because mouths have bacteria.

Lower jaw surgeries can range from light remodeling through bone removal or augmentation to a complete u-shaped removal of the bottom portion of the mandible (for reduction) or augmentation to the entire jaw.

Chin procedures may involve removing a T-shape from the chin and then bringing the lower notched pieces back together to reduce the chin height and width or more subtle changes through burring rather than bone removal. Chin and gonial implants can be custom-made for enlarging the chin and the back of the jaw.

When: Preparation and Recovery For Facial Surgeries

Preparation is similar to other surgeries. If you smoke, you will need to stop for at least a few weeks before and after surgery. If you have diabetes, your blood sugars will need to be well-controlled. You will need to have a pre-operative physical evaluation and some lab work done to make sure that your health is optimized for surgery. Here’s our pre-surgery checklist for making sure you’re ready for surgery and recovery.

The American Society of Plastic Surgeons states that most individuals should plan for four weeks off of work, and can expect bruising and swelling for at least the first week after surgery. It may take several months for all of the swelling to go away. Activity restrictions may last up to eight weeks. If incisions have been made inside the mouth, expect to eat soft foods after surgery until those incisions heal. You may also have specific oral care instructions to prevent infection.

Some recovery expectations:

• you’ll need to keep your head elevated: pillows, wedges, or sleeping in a recliner
• you may be told not to bend over
• may need to not shower for a couple of days
• you may need to wear a compressive garment for up to two weeks
• lifting restrictions for a couple of weeks
• you’ll be encouraged to walk right after surgery, but strenuous exercise should be avoided
• wear sunscreen/protective gear for at least 9 months after surgery to maximize your scar healing

The Gender Confirmation Center has a comprehensive guide to what to expect when planning facial surgery and recovery (note: it’s written using FFS terminology, not broader facial remodeling terminology.)

Yes, but what about specific facial surgeries?

The American Society of Plastic Surgeons also has detailed write-ups about several different surgeries:

Brow Lift

Chin Surgery (genioplasty or mentoplasty)

Nose Surgery (rhinoplasty)

Eyelid Surgery (blepharoplasty)

Cheek Augmentation

Cheek Reduction

How: Insurance and Surgeon Requirements

More and more insurance policies are covering gender affirming facial remodeling procedures. If your policy does cover facial surgeries, they will likely require prior authorization, consisting of:

• a supportive letter from a mental health provider within 6 months of surgery
• documentation of a diagnosis of gender dysphoria
• you are at least 18 years old
• pre-surgery evaluation by your surgeon documenting that you are healthy enough for surgery

Your surgeon will want a consultation with you where your wants and expectations are discussed. They may also want to know your post-surgery recovery plans for support and housing. They will likely want a referral from your gender care provider.

Who: Finding a Surgeon

• TransHealthCare.org
• findplasticsurgery.org
• WPATH Provider Directory
• OutCare Health
• mtfsurgery.net
• ftmsurgery.net
• The r/TransSurgeries wiki on Reddit

Many, many surgeons provide plastic surgery. Ones who have trained in gender affirming facial surgeries and work with gender diverse patient populations are likely to be better overall experiences. We recommend asking around within your communities for personal experiences, and asking your gender care providers for recommendations. If your area has a local Facebook group, LGBTQ+ Community Center, or other community resources, they may be great places to gather names of supportive and good surgeons.

Accessed Articles

Facque AR, Atencio D, Schechter LS. Anatomical Basis and Surgical Techniques Employed in Facial Feminization and Masculinization. J Craniofac Surg. 2019 Jul;30(5):1406-1408. doi: 10.1097/SCS.0000000000005535. PMID: 31299732.

Ousterhout DK, Deschamps-Braly JC. Special Edition on Transgender Facial Surgery. J Craniofac Surg. 2019 Jul;30(5):1326-1327. doi: 10.1097/SCS.0000000000005387. PMID: 31299711.

Salgado CJ, Nugent AG, Satterwaite T, Carruthers KH, Joumblat NR. Gender Reassignment: Feminization and Masculinization of the Neck. Clin Plast Surg. 2018 Oct;45(4):635-645. doi: 10.1016/j.cps.2018.06.006. Epub 2018 Aug 10. PMID: 30268248.

Habal MB. Gender Identification and Feminizazation of the Craniofacial Skeleton in the Presence of New Digital Biometrics. J Craniofac Surg. 2019 Jul;30(5):1323-1324. doi: 10.1097/SCS.0000000000005773. PMID: 31299709.

Lai C, Jin X, Zong X, Song G. En-Bloc U-Shaped Osteotomy of the Mandible and Chin for the Correction of a Prominent Mandibular Angle With Long Chin. J Craniofac Surg. 2019 Jul;30(5):1359-1363. doi: 10.1097/SCS.0000000000005126. PMID: 31299722.

Mandelbaum M, Lakhiani C, Chao JW. A Novel Application of Virtual Surgical Planning to Facial Feminization Surgery. J Craniofac Surg. 2019 Jul;30(5):1347-1348. doi: 10.1097/SCS.0000000000005090. PMID: 31299719.

Sayegh F, Ludwig DC, Ascha M, Vyas K, Shakir A, Kwong JW, Swanson M, Evans MW, Gatherwright J, Morrison SD. Facial Masculinization Surgery and its Role in the Treatment of Gender Dysphoria. J Craniofac Surg. 2019 Jul;30(5):1339-1346. doi: 10.1097/SCS.0000000000005101. PMID: 31299718.

Di Maggio MR, Nazar Anchorena J, Dobarro JC. Surgical Management of the Nose in Relation With the Fronto-Orbital Area to Change and Feminize the Eyes’ Expression. J Craniofac Surg. 2019 Jul;30(5):1376-1379. doi: 10.1097/SCS.0000000000005411. PMID: 31299725.

Deschamps-Braly JC. Approach to Feminization Surgery and Facial Masculinization Surgery: Aesthetic Goals and Principles of Management. J Craniofac Surg. 2019 Jul;30(5):1352-1358. doi: 10.1097/SCS.0000000000005391. PMID: 31299721.

Download our Questions To Ask Your Surgeon handout!