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Facial Gender & FFS:
• In a Nutshell
Hair and Hairline
• Forehead
Adam's Apple
• Facelifts
Hormonal Effects
• Ethnic Variations

• Virtual FFS FAQs
• General FFS FAQs

My Facial Feminisation Thesis

My Top Tips for FFS Patients

Disclaimers, Promises and My Qualifications

Body Dysmorphic Disorder and FFS



General FFS FAQ's


On this page I have tried to answer some of the many questions that FFS patients typically ask:


Will FFS make me passable?
Not necessarily. Passability is complex and involves a lot more than the face - your height, body shape, voice etc. can all have an effect. If your passability issues are partly or completely due to facial masculinities, then FFS should help, but the degree to which it will help will depend on whether the masculinities you have are ones that can be surgically altered (there are some things about the face which can't be changed though surgery).


Will I still look like me after FFS?
In my opinion, the key purpose of FFS is to remove the effects that testosterone had on your face during puberty. In other words, it's not about creating a "new" face - it's about taking you back to your original face. I call this principle "Puberty Reset".

In fact, it's actually quite difficult to change the central character of someone’s face and FFS will generally only make you look like a more feminine version of yourself. Of course, the more you have done, the more the face changes, and it is possible to take facial surgery to a level where you do start to look like a different person. This is more likely to happen when someone has cosmetic procedures repeated too many times or has extreme changes like large volumes of filler injected.


Is FFS dangerous?
All surgery carries a risk, but FFS is not especially dangerous. Many of the procedures involved are standard facial procedures like rhinoplasty. Some of the other procedures like brow bossing removal are more unusual but are no more risky. To minimise the risk of complications, be in the best health you can before surgery – the most important thing is to stop smoking well before surgery (I would advise several months) but also try to be reasonably fit and eat a healthy diet so your body has all the nutrients it needs to heal.


Is FFS painful?
Surprising as it may seem, most patients suffer relatively little pain with FFS. Breast implants and SRS are generally much more uncomfortable. This is very variable from person to person, so some people may have some pain, whilst others may have none at all. If there is pain, it is usually short-lived and fairly easy to control with painkillers.


How long will I need to take off work?
It depends on what procedures you have done and how quickly you tend to heal (everyone's different). For small procedures like lip filling or a lip lift you could typically return to work in a few days but for more invasive work like forehead, jaw and chin surgery, you may need at least 2-3 weeks off work, and longer if your job is physically demanding. A good rule is to not do anything too demanding for 6 weeks, but it does vary a lot from person to person and according to what you've had done.


How long will it take me to fully recover?
It depends on what procedures you have done and how quickly you tend to heal (everyone’s different). The worst of the swelling can last at least 6 weeks, bruising may only last 3 or 4 weeks, sensation may take several months or longer to fully recover, but it is all very variable from person to person, and very small changes can still be happening after more than a year. Typically though, within 4 to 6 weeks, you should look fairly normal to other people, even if you know there is still some swelling there.


Should I wait until I’ve been on hormones a while before I have FFS or Virtual FFS?
Waiting a year would be ideal. This allows the hormones to achieve most of their effect on the face, and if you find you start to pass reasonably well or feel a lot better about yourself, you might feel that you don't need as many procedures as you first thought. However, this is not always possible or practical, and if you have significant bone masculinities like heavy brow bossing or a big square chin, it is often clear that these will always be a problem. In that case, it might be perfectly reasonable to have FFS or Virtual FFS before you have started HRT. The area hormones affect most is the cheeks, so it's usually a bad idea to have any cheek enhancement until hormones have had their effect. And the chewing muscles can reduce a little on hormones if they are large, so that's another area to be cautious about. See my page on hormonal effects for more on this.


Is an aggressive approach to FFS better than a conservative approach?
When people talk about aggressive vs conservative FFS, they are usually referring to one of two different things:

1. The size of the change a surgeon makes to a particular feature. So, to give an example, whether the surgeon takes a large amount of bone from a chin (aggressive) or a small amount (conservative).

The best approach in this case depends on the size of the patient's chin, so if the chin is very large, then a big change might be necessary (aggressive), but if the chin is only slightly too large, then a smaller change might be appropriate (conservative). However, personal preference can play a part too, so a patient might choose to keep a little squareness or height in the chin for personal or aesthetic reasons, even if doing so compromises the femininity they could otherwise achieve.

2. The number of procedures. So, whether a surgeon recommends a large number of procedures, including ones which will only make a very small difference, (aggressive), or whether they recommend a smaller number of procedures, leaving out procedures that will have a minimal effect (conservative).

Again, it's about what's appropriate for the particular patient, but the number of procedures can be more difficult to judge. Basically, surgery is a controlled injury and you always have to weigh risks against gains. So, using the chin as an example again, if you have a feminine face overall with only a hint of squareness to the chin, one surgeon might recommend leaving it as it is, because they feel it's not worth the trauma, risks and expense for a change that even you will struggle to see clearly and that won't impact noticeably on things like passability, while another surgeon might recommend doing it anyway because they feel that every little feminisation helps.

And remember, some surgeons will recommend procedures you don't need at all and will have no effect on your femininity. This is an "aggressive" approach but also an erroneous approach, so don't assume "aggressiveness" will always lead to a more feminine result.


Do I need to stop hormones before surgery?
Different surgeons have different protocols, so your particular surgeon should advise you. For genital surgery you should expect to come off hormones before the operation, but you are much less likely to need to come off them for FFS procedures.


Can any face be feminised?
Technically, almost any face be feminised to some extent, however, it is important to understand that it is not possible to make every face look completely female. This is because there are some masculinities that cannot be altered with surgery. For example, women tend to have larger eyes in proportion to their skull than men, and no surgery can give you bigger eyes. You can emphasise the size of them with make-up, and through procedures like brow lifts, blepharoplasties and forehead recontouring, but the eyes themselves will stay the same size.


Is the size of your head important in FFS?
You may have seen an idea spreading on the internet that head size is a significant factor for trans women. Here is a brief fact check:

1. Men, on average, have larger heads than women because men, on average are larger than women. This makes it very easy to find pictures of trans women next to cis women showing the trans woman with a larger head. This proves nothing - it's not science and is highly vulnerable to confirmation bias.

2. However, men also have *proportionately* larger heads - this means that given a man and woman of the same height, the man will, on average, have a larger head, however, the science suggests the difference in cranium diameter is small (1.38 cm which would be 2 to 3% larger). See this link for more details.

3. There is currently no evidence that head size is a significant factor in gender recognition. That doesn't mean it isn't a factor, but we will have to wait for the science on it before we know.

4. If you have a large head, you can't make the cranium smaller, but you can usually do things that make it *seem* smaller by choosing the right hairstyle, and procedures like jaw reduction can make the face smaller (do be aware though that the size of the jaw must still balance with other features).


I have seen a masculine feature on a cis woman - does that mean I can get away with the same masculine feature myself?
If your goal is passability, then it will probably depend on how masculine your face is overall - a square chin on an otherwise feminine face might not be much of a problem, especially if you are small and have a feminine voice etc. But for another patient, that same chin squareness might be in the context of a lot of other masculinities and only adds to the problem.


How feminine is feminine enough?
I have written a whole page on this issue for my thesis. Here's a link.


Who is the best FFS surgeon?
There is no “best” FFS surgeon and people choose their surgeon for different reasons. There are several factors involved like whether the surgeon offers the actual procedures you are looking for; whether you personally like the look of the surgeon’s work; whether your budget limits your choice of surgeon, or whether you are able to travel abroad. There are not many surgeons who specialise in FFS but I believe it is generally best to search out a surgeon who does, and it is best to be prepared to travel, even halfway across the world for the right surgeon for you.


Why do different surgeons recommend different procedures for the same face?
There are 4 main reasons that you can get different assessments from different surgeons:

1. Some surgeons don't do good assessments.

2. Some surgeons try to sell as many procedures as possible.

3. Some surgeons only do a limited number of procedures.

4. Some of your needs are borderline - so one surgeon judges that a particular procedure probably is worth doing, while another is not quite convinced.

One of the main purposes of my work is to help you work out which is which.


Can I go to a normal plastic or cosmetic surgeon for FFS?
It depends on what you are having done but I generally advise against it because plastic surgeons don’t usually offer the type of bone surgery many of us need for FFS, and they don’t have the specialised understanding of male/female facial differences. I have seen inappropriate advice given by cosmetic surgeons to people needing FFS on several occasions. I don’t mean to show any disrespect to cosmetic surgeons in general – on the whole they are highly skilled people, and just the people to go to if you need a procedure like a facelift, but in my experience, many don’t have the deeper understanding of facial feminisation that most of us need for FFS


Will I have visible scars?
Some FFS procedures do leave visible scars. For example: scalp advances can leave a visible scar at the hairline and a lip lift can leave a visible scar just under the nose. Scalp advances can generally be avoided altogether because better results can be attained with transplants, but the lip lift scar is inescapable. In many cases the scar is not very noticeable, but there is no sure way to avoid lip lift scarring altogether, other than not having a lip lift. Many people assume that if the surgeon is good then they will not scar but this is not true - a good surgeon will do everything possible to minimise scarring but and incision always leaves a scar, and some people scar more easily than others. It is also possible to be left with a strong scar even if the surgeon’s work was perfect. Dark-skinned people such as those of African descent are at greater risk of scarring than light-skinned people.


Will I look “plastic” after FFS?
The short answer is that you shouldn't. A plastic look typically results from procedures being overdone, particularly procedures like brow lifts, cheek filling/implants, lip filling, and procedures that try to change the shape of the eyes. Over-lifted eyebrows for example, can give you a rigid and surprised expression, while too much lip filling can cause the lips to look like an inflated tyre. There is nothing wrong with the procedures themselves - they all have their uses - the problems arise if they are overdone or you have them when you don't need them.


Will my surgeon charge me for revisions?
Different surgeons have different rules so discuss this with them during your consultation and don't wait until you need a revision to find out. Some surgeons do charge, others don’t charge for their work but do charge for the anaesthetist and hospital facilities, and some will revise completely fee of charge. It will usually vary according to the nature of the revision - if, for example, there has been a surgical error - perhaps an asymmetry that should not have happened, then the revision should be free, but if there is no error or complication, but you would like to try a slightly different approach, then you will probably have to pay for that.


How do I know what sort of forehead procedure I need?
The type of forehead procedure you need depends on 2 things: firstly on the kind of result you want and secondly on the underlying structure of your particular forehead. It is not possible to tell from the outside what the underlying structure of your forehead is like - for that you will need to see inside the forehead with an MRI scan, CT scan or x-ray. Please see the page on foreheads for more detailed information on this. Essentially, to remove brow bossing, the vast majority of FFS patients need a forehead reconstruction, so assume you will need one, and seek out a surgeon who does them.


Which is better - a scalp advance or hair transplants?
Hair transplants look more natural than a scalp advance and you don't end up with a scar along the hairline. How visible the scar is after a scalp advance will partly depend on luck, partly on the skill of the surgeon, and partly on your own tendency to scar. Some patients with a faint scar feel that it is not a problem, but for many others, it is clearly visible and they are very conscious of it.

Some people combine both procedures - they start with a scalp advance during their forehead surgery, then a few months later, they finish the hairline and fill the corners with transplants. However, it can still be difficult to hide the scar this way because transplants don't take as well in scar tissue, and the scar is only a little way into the new hairline meaning you may still be able to see it through the transplants. See the page on hair and hairline for more on this.


Will I need a face lift after FFS?
Jaw and chin surgery can cause some slackness in the soft tissues around and under the jaw and chin. This is partly because you are losing a volume of bone and also because the surgery causes a lot of swelling and this swelling can stretch the soft tissues of the lower face. If you are relatively young, the skin is very elastic and will easily contract again when the swelling goes down to fit the new smaller bone structure snugly. But if you are older (typically over about 40 but very variable) the skin may no longer be elastic enough to fully contract, and in that case you may need a face lift to take up the remaining slack. The face lift should not be done during the jaw and chin surgery - it should be done several months later. See the jaw and chin pages for more on this.


Should FFS surgeons take an aggressive or conservative approach?
Sometimes when some people talk about aggressive vs conservative surgery, they are talking about the size of the change a surgeon makes to a particular feature, so for example, whether the surgeon takes a large amount of bone or a small amount of bone off a chin. At other times they are talking about the number of procedures so for example, whther a surgeon only recommends . Aggressive might mean making a large change, There are a lot of conversations on FFS forums about aggressive vs conservative FFS and people get confusedYour surgeon should take whatever approach the feature they are working on needs.


Will I pass without make-up after FFS?
This depends on many factors including the degree to which your particular face can be, or has been feminised, but also things like your stature, your voice, your clothing and hair etc. In other words, it has to do with a lot more than your face.


Will I still be able to pass as male after FFS if I want to or need to?
It depends on your result and your overall femininity. If you pass for female easily, then passing for male might require some effort. For example: you might have to try things like keeping your hair very short and wearing very masculine clothes etc.


Can I do FFS in separate stages?
Generally yes but there are some exceptions: Face lifts should be done several months after Jaw and chin surgery, not before or during. The other area where exceptions may occur is with forehead and nose surgery (see next question), and if you are having a large number of procedures, it may be wise to separate them into 2 sessions so that you don't spend too long under general anaesthetic.


Can I have my forehead and nose done separately?
You might have heard people (including some surgeons) say that it is impossible to feminise the forehead without doing the nose at the same time. This is only sometimes true. There are patients who do not need rhinoplasty at all, and others who need rhinoplasty but no forehead work. In some cases though, you simply can't separate the procedures without making compromises (like not fully removing the bossing, or only doing a limited rhinoplasty).

It generally depends on the area where your nose meets the forehead which is called the "nasion" (also called the "radix"). If this area sits very far forwards of your eyes, then trying to reduce the nose down to an ideal feminine size, would leave an overhanging step where the forehead meets the new, smaller nose. Similarly, if you tried to fully feminise the forehead in a case like this without doing the nose, you would have a step where the forehead meets the nose - basically because the nose is too big for the new forehead.

Do be aware that brow bossing removal generally makes the nose look bigger, and conversely, rhinoplasty generally makes the brow bossing look stronger, so even when it is technically possible to separate the procedures, it might not always be helpful.


Do I need a psychiatrist’s referral letter for FFS?
Generally no. I have heard of one surgeon in the UK asking for one and the younger you are the more likely they are to ask but in most cases you will not need one.


Are there age restrictions for FFS?
Different surgeons will have different rules but generally you can expect surgeons to require you to be 18 or over before they will perform FFS on you. There are sometimes upper age limits too – some surgeons may set a maximum age like 65 or 70 but this will probably be flexible depending on your general health.


Are there weight restrictions for FFS.
Many surgeons will not operate on patients who are beyond a certain weight for their height, so you will need to ask you surgeon what their protocls are. If you want to check the healthy weight range for you height, look up your "Body Mass Index" (BMI) here.


Should I stop smoking before FFS?
All surgery has some risks associated with it, but nothing will increase your risk of serious complications more than smoking (including E-cigarettes). The main problem is that it shrinks the capillaries which are little blood vessels that carry blood to your surgical site and that basically means that the injury will not get a good oxygen supply. A lack of oxygen can mean that the tissue starts to die - this is called “necrosis” which can theoretically become gangrene. Smoking will also suppress the immune system which can make infections more likely. Some FFS surgeons will refuse to operate on patients who smoke and the same applies to vaginoplasty patients. I advise you stop smoking several months before undergoing any surgery. There is more information here.


How can I find a local FFS surgeon?
There are very few surgeons specialising in FFS in the world so it would just be a matter of luck if you happen to live either near one or even in the same country as one. I advise people to be prepared to travel for their FFS as the best surgeon for their needs could be on the other side of the world.


What happens if I have FFS abroad but have a complication after returning home?
Serious complications like infections will generally happen in the first few days after FFS. Most FFS surgeons will require you to stay nearby for at least 10 days after surgery, and after that complications that need immediate attention are rare. You may have to travel back at a later date though to fix a non-urgent complication like asymmetry.


If I travel abroad for FFS, can I get back home with my old passport picture?
Many people worry about this but I have never heard of there being a problem. If questioned, explain to the customs officers that you have had some facial surgery. You are likely to still be extensively bruised and swollen at this point and that should prove you are telling the truth. You can also get a note from your surgeon confirming that any change in appearance is due to extensive facial surgery. The note does not have to mention “feminisation” or that you are trans.


Will FFS affect my singing voice?
I am a singer myself and I did not notice any changes to my singing voice caused by nose or forehead surgery. However, tracheal shaves can cause voice problems if they are not done properly.


Will lip surgery affect my ability to play brass instruments?
I have been asked this more than once. I suspect it varies from case to case but it is best to assume that a lip lift or lip filling are likely to affect your embouchure. If you make your living as a brass player, you need to consider this very carefully.