Gender-Affirming Facial Surgery

The hairline is critically important for many people seeking GAFS. Masculine hairlines tend to be squared or M-shaped, with recession at the temples, and set further back.

An angled (beveled) incision is made a few millimeters behind the hairline, so hair can grow through it and camouflage the scar. It runs within the hair-bearing scalp, then turns down toward the ear. A strip of skin is removed from the top of the forehead, and the hair at both temples is rotated toward the middle, turning a square forehead into a rounded, lower one.

The most common side effects are temporary hair loss and scalp numbness. The hair loss is a temporary “shock” shedding (telogen effluvium); hair usually starts to return after a few months. A few hairs may be lost around the incision or in areas under tension, but this is usually mild if it happens at all. Numbness is common, because the nerves supplying much of the scalp travel up from the eye sockets and are largely cut during hairline advancement and open brow lifts. They need time to regrow.

Many people consider the forehead and brow the biggest contributor to their dysphoria, and many surgeons agree it's often the feature that differs most between typically male and female faces. A feminine forehead is more rounded, with a gentle S-shaped slope into the top of the nose.

In forehead contouring, the frontal bone is shaped with a drill. About 80% of patients also need a setback (type III cranioplasty): the lower middle part of the frontal bone, which covers the sinus, is removed, shaped, set back, and secured with titanium hardware so it can't shift. Bone dust collected during contouring is then placed around and over the hardware to create one smooth contour without bumps you can feel.

Masculine faces have more bone around the eyes, including a bony hood over the eye itself. Dr. Kinkhabwala takes an additional step that not every surgeon includes: he reduces the upper rim of the eye socket, the bone that creates the brow hooding typical of men. This opens up the eyes and draws more attention to them. Combined with a brow lift, it has a significant feminizing effect on the upper face.

During FFS, the brow lift uses an open approach for the most dramatic lift and contouring. Through the same incision as the hairline advancement, a small strip of skin below the hairline is removed, raising the brow while lowering the forehead. The tissue above the eye sockets is also released, freeing the brows to settle higher, and a layer at the temples is used as a third way to raise and stabilize the brow.

For a small group of patients who need neither a large central brow lift nor much central forehead contouring, the brow lift and brow-rim contouring can be done through an upper eyelid incision instead.

A feminine nose is typically smaller, less projected, narrower, slightly scooped, refined at the tip, and slightly upturned. Feminizing rhinoplasty usually involves narrowing the bony base, lowering the hump to slope the bridge, and refining the tip. Some patients also need a septoplasty or turbinate reduction at the same time if breathing is a concern.

More about rhinoplasty

Feminine cheeks are fuller toward the center of the face; masculine faces are wider at the sides. Dr. Kinkhabwala most often uses fat transfer for a natural, volumizing effect in the central cheeks, and also uses fat for lip augmentation. The fat is taken from the thighs or the abdomen. In some cases, he'll consider cheek implants.

Feminine lips have more volume, a shorter upper lip, more teeth showing at rest, and more gum showing with a smile. A lip lift shortens the skin between the lip and nose while turning the lip slightly outward, increasing tooth show and giving the look of slight augmentation. A small strip of skin is removed through an incision under the nose that extends slightly into each nostril to hide the scar.

Feminine faces tend toward a heart or V shape, compared with the boxier masculine face. If the cheeks are overly full and wide, partially removing the buccal fat through a small incision inside each cheek can create more V-shaped contouring. During a facelift, the buccal fat can be removed through the facelift incision instead.

The masculine lower face is squarer, partly because the side of the jaw (the ramus) is taller. Dr. Kinkhabwala takes a conservative approach to reducing the jaw angles, as many surgeons now do, because overdoing it can blur the transition from the neck to the face. Good candidates have jaw angles much wider than their neck; if the neck is moderately thick and already softens that transition, he typically avoids angle reduction.

A neurotoxin such as Botox in the masseter (chewing) muscles is another option, and can dramatically reduce the squareness of the jaw when much of the width is muscle. The downside is that it lasts 3–4 months and must be repeated.

Feminine chins are more tapered and less projected. Dr. Kinkhabwala uses an ultrasonic instrument to finely contour the jaw and chin to the goals set during photo morphing. If the chin is already recessed, an augmentation genioplasty, with precise cuts that let the chin narrow significantly while moving forward, creates a V shape and better defines the jawline and the angle into the neck. For augmentation genioplasty, he often uses imaging and virtual surgical planning beforehand.

He performs all jaw procedures, and the tracheal shave, through a small incision under the chin, the same one used in face and neck lifts, which hides well with good scar care. In his experience, it has lower rates of lip numbness, less swelling around the jaw, and less infection than going through the mouth, where natural bacteria and saliva are present.

A tracheal shave reduces the prominence of the Adam's apple. The traditional approach uses an incision directly over the cartilage. Dr. Kinkhabwala uses a higher, more hidden incision in the crease under the chin, which heals very well, and is the same incision used for neck lifts and jaw and chin contouring.

Will it change my voice? No facial procedure directly changes the vocal cords or voice. After a tracheal shave, a rare subset of patients have a temporary voice change in the first month from swelling around the larynx.

As faces age, the differences between masculine and feminine faces actually shrink. In women, jowling and midface descent create a boxier look, unlike the V or heart shape of a young feminine face, and sagging adds length, which reads as more masculine. A facelift in an older woman is therefore a feminizing procedure. Patients who previously had jaw reduction for feminization are also prone to earlier jowling and may benefit from an earlier facelift. Many insurers cover face and neck lifts for gender dysphoria when they follow jaw reduction.

More about the deep plane facelift

Though usually not covered by insurance, laser treatment can soften the texture of testosterone-exposed skin and can also remove hair. For many trans women, it's an extra step toward reducing misgendering.

For most patients, the brow is a primary concern. Dr. Kinkhabwala addresses it with a custom implant that spans the lower forehead and brow and extends slightly into the temples to add width, tailored to your goals and anatomy.

A small number of patients have a particularly low forehead and want more recession at the hairline. For them, hair excision can create a higher forehead.

To masculinize a nose, Dr. Kinkhabwala most often builds up the bridge significantly (adding projection and a slight hump) and turns the tip slightly down. For patients who need a wider nose, bone cuts open the base of the bony pyramid.

Many patients are masculinized enough with brow and jaw implants alone. Some also benefit from cheek implants that add volume mainly at the sides, widening the face and making the eye sockets look slightly smaller, which also reads as more masculine. If the cheeks are very full, buccal fat removal can make them more angular.

The feminine jaw is smaller in every dimension. Augmenting it uses three implants: one over the chin, joined to one on each side of the jaw, creating one continuous jawline without steps or irregularities. They're placed through one incision under the chin and two small incisions inside the cheeks, adding height, projection, and width.

Fillers are an option for people who don't want implants. They're relatively simple and can be done in the office. There are two kinds:

• Hyaluronic acid filler is the easiest to place and can be dissolved if there's a problem or you don't like the look. What you inject is close to what you get.
• Your own fat is permanent and carries natural growth factors and stem cells, but it requires liposuction from another area, costs more, and “takes” less predictably. Anywhere from 50% to 90% survives, the final effect takes 3–4 months to see, and touch-ups may be needed.

Fillers are most often placed at the sides of the cheeks and along the jawline. Dr. Kinkhabwala avoids injecting large amounts around the brows because of a higher risk of vascular complications. Filler is typically not covered by insurance.

Temporary shedding around incisions (telogen effluvium) is common. Permanent loss is very rare, and is usually caused by sutures passing through hair follicles or heat from nearby cautery. Dr. Kinkhabwala places sutures beneath the follicles and avoids cautery along the incision to minimize trauma to the hair.

Besides infection, implants carry a risk of asymmetry and, very rarely, extrusion. Uncommonly, an implant can stretch or press on a nerve and cause numbness nearby. This is almost always temporary; if it isn't improving, the implant may need adjusting.

Feminizing the upper rim of the eye socket carries a risk of double vision. It's common in the first 72 hours, from swelling. In a small number of patients it lasts a few weeks. Dr. Kinkhabwala has not had any patients with lasting vision problems.