The face communicates important social information. In the first contact with others, it is through the face where we subconsciously categorise someone as a man or as a woman, based on socially constructed frames of reference. For many trans persons, nothing is more important than being seen by the outside world, as they feel and identify inside.
FGCS, or “facial gender confirmation surgery”, is a term that encompasses a whole bundle of procedures in which the face of a person is adjusted to match the gender of that person. . After all, on average and when accounting for a variety of racial and ethnic variations, there are a number of anatomical differences between the skulls of those assigned male or female at birth.
With most aesthetic procedures, patients want to improve their appearance, but mainly want to remain and feel like themselves. With interventions for facial feminization or masculinisation, the patient undergoes some drastic changes. Various surgical procedures exist in this context that can change these characteristics. FGCS focuses on both the facial skeleton and the soft tissue (skin, muscles, connective tissues) and includes a whole range of different techniques that originate from oral surgery and reconstructive surgery, but also from plastic and aesthetic surgery. We discuss the options below for facial feminization techniques.
The forehead
Facial feminization of the forehead offers the possibility of removing frontal bossing, enlarging the eye sockets and positioning the eyebrow higher, as well as giving the eyebrow a more typically feminine shape. Finally, the forehead can be made smaller by sliding the hairline forward.
The chin
The chin on those assigned female at birth is typically more pointed, narrower and lower. With facial feminization, the chin can be adjusted through intra-oral access through corrective osteotomies. The detached bone fragments are moved to adjust this shape and are fixed again with titanium plates.
The jaw angles
The jaw angle of a cis male is typically more prominent due to thicker chewing muscle that engages there, but especially due to a more pronounced bony structure of the lower jaw at that location that is more extensive both backwards, downwards and outwards. The jaw angle can be reduced by means of corrective osteotomies whereby the excess bone is removed.
Orthognathic surgery
By combining a displacement of the bone structures of the upper and lower jaws, the volumes can be changed in the middle and lower thirds of the face. These changes can give the middle face more volume and make the face rounder. With this operation the chin also becomes less prominent, the jaw angles become less pronounced and the upper front teeth can be made more visible.
The nose
The nose is usually larger in cis men than in cis women. The nose is right angled and the corners to the forehead and upper lip are sharper. When the forehead is adjusted, the angle between the nose and forehead is already made more obtuse, and the angle between the nose and upper lip can also be made more obtuse by orthognathic surgery. If the effect on the nose of these procedures proves to be too little, a correction of the nose can be carried out in a second procedure, making the nose smaller, the nose less prominent and the tip raised a little more.
The cheekbones
Often, cis women usually have slightly more prominent cheekbones than cis men, but adjusting the cheekbones alone does not have a very large feminising effect. Prominent cheekbones are found attractive generally and are mainly performed for this reason.
The above procedures can be performed without any long-lasting visible scars.
Reduction of the Adam’s apple
If the trans person assigned male at birth has a pronounced Adam’s apple, it can be reduced through surgery. The Adam’s apple correction is a simple operation in which a forward-looking and striking Adam’s apple is corrected via a small incline across the Adam’s apple. This harmonizes the proportions in the neck and creates a better neck contour. The scar is small and almost invisible, because neck skin generally heals nicely. The procedure can be performed in combination with the voice feminisation procedure and/or in combination with GFCS. Please note – if a voice-feminisation operation is desired, it is recommended that the Adam’s apple reduction is not performed before the voice-feminisation procedure.
Usually a combination of procedures is performed during facial feminization surgery, depending on what is needed to give the patient’s face a more feminine appearance. The entire procedure normally takes between 4 and 8 hours, depending on the extent of the operation. It is advised to stay in the hospital for 1 or 2 nights after a facial feminisation operation.
It is important to also note, that as yet these surgeries are not provided through the NHS. Anyone seeking pre- or post-intervention counselling can access this at the Gender Wellbeing Clinic. Trans people seeking these procedures are encouraged to go to specialised professional clinics.