Tag Archives: FFS

Nasal Shapes and Related Differences in Nostril Forms: A Morphometric Analysis in Young Adults – Review

The authors of this study analyzed the nose and nostril shapes of 173 young white people. They studied the noses to find differences between male and female noses. Their goal was to make sure that during plastic surgery on the nose, men are not given noses that are too feminine.

The authors provide data on average differences between male and female noses that may be helpful to anyone preparing to get facial feminization surgery. Reading about the differences might cause dysphoria for some people.

It is interesting to note that there was no nostril type that was found only in males or only in females. In addition, the differences between the average measurements for males and for females is small. Noses do not fit into simple male and female categories.

The authors were not able to find all nose types that have been identified previously and they say this is a limitation to their data. Some of the subgroups of noses were smaller than others which might also limit their results.

The data was collected in Turkey and might not apply to populations in other countries. It is also limited by the fact that they only looked at white people.

Original Article:

Nasal Shapes and Related Differences in Nostril Forms: A Morphometric Analysis in Young Adults by Etöz, Betül Çam MD; Etöz, Abdullah MD; Ercan, Ilker PhD in Journal of Craniofacial Surgery Issue: Volume 19(5), September 2008, pp 1402-1408.




Dr. Paul Tessier and Facial Skeletal Masculinization – Review

The article is partly a tribute to Dr. Paul Tessier who trained Dr. Ousterhout and mostly a description of techniques use to masculinize the face. So far, the author has only performed facial masculinization on six men, but he has performed some of the individual techniques involved many times.

The article discusses the various techniques used and some of the possible complications. There are good before and after photos – the person is posed the same way. I can easily see the differences in the faces. The faces are more masculine after surgery, but they were also clearly men’s faces before surgery.

Chin masculinization has sometimes resulted in facial numbness that is usually temporary, but there have been cases where it was not. The author says he has reduced this problem over time.

As in most of this research, the study is written by the person who performed the operations and might therefore be biased in favor of the work.

Original Article:

Dr. Paul Tessier and Facial Skeletal Masculinization by Ousterhout, Douglas K. MD, DDS, in Annals of Plastic Surgery Issue: Volume 67(6), December 2011, p S10–S15.


Forehead Augmentation with a Methyl Methacrylate Onlay Implant Using an Injection-Molding Technique – Brief Review

This is a technique for augmenting the forehead that is used to make the forehead more attractive. Most of the patients in this study were cis women, but a few were men. It is not clear if the men were trying to feminize their foreheads.

The authors were surgeons who used the procedure on 547 patients over a 13 year period; 516 of them were included in the study (the others did not return for the three-month follow-up). 45 of the patients were male, 471 were female.

Most of the patients were satisfied with the procedure and there were no major complications. 60 patients (12%) were not satisfied with the result, 28 people (5%) returned for a reoperation to fix things. The authors use the reoperation rate to evaluate the procedure. The authors modified their technique over time and the reoperation rate in 2008-2011 was lower than the rate in 1999-2002.

The article does not say if the people who were dissatisfied with the operation were female or male.

As in many studies, the authors of the paper are the surgeons who performed the operations. They may be biased in favor of their own work.

Original Article:

Forehead Augmentation with a Methyl Methacrylate Onlay Implant Using an Injectin-Molding Technique by Dong Kwon Park, Ingook Song, Jin Hyo Lee, and Young June You in Arch Plast Surg. Sep 2013; 40(5): 597–602..

Surgical modifications of forehead and orbital area in facial feminization – Brief Review

This is an abstract of an oral paper. They presented clinical cases and seem to have discussed surgical techniques.

Original Article:

Surgical modifications of forehead and orbital area in facial feminization by A. Lemaitre, W. Waskiewicz, S. Medin Rey, S. Duvigneaud, M. Shahla, K. Keiani in International Journal of Oral & Maxillofacial Surgery, Volume 40, Issue 10 , Page 1084, October 2011.


Case Report: Feminizing the Male Face – Review

This is a study of facial feminization surgery given to ten Iranian trans women during the years 1990-2007. It provides a good description of the various procedures they used to feminize the face, although not all of the patients needed all of the possible surgeries.

The authors talk about the importance of having standards for FFS. They present a staged surgical protocol and parameters to consider before surgery.

The study includes a table summarizing some facial differences between males and females. It is interesting to note that the differences are measured in millimeters. This may be why some people can pass without surgery.

The authors mention the importance of cephalometeric radiography (this may refer to X-rays) and tracing in planning the surgery.

The authors make the interesting observation that the changes needed to feminize the face will vary by ethnicity and society.

The average age of the trans women in this study was only 23 (range 20-32). This is younger than in many of the other studies.

The before pictures are in black and white while the after pictures are in color. Nevertheless, it is easy to see that the face in the after pictures is much rounder. The after picture was taken four years after the operation, so there might have been other causes for the change (hormones or weight gain).

As in other studies, the authors are the surgeons who performed the surgery, thus they may have a bias to want to believe that the surgery was successful.

The article includes an interesting discussion of transgender history. Prior to 1991, there was no medical treatment for transgender people in Iran. In 1991 a religious decree was issued saying that transition was a permitted therapeutic procedure.

The authors conclude with an endorsement of further research:

Although our patients were satisfied with their improvement in appearance with these standard set of operations, conclusions as to these effects cannot be drawn. Even if feminization is considerable, the degree of improvement these procedures have on lifestyle remains to be assessed.

Original Article:

Case Report: Feminizing the Male Face by Mohammad Ghasem Shams, DMDa and Mohammad Hosein Kalantar Motamedi, DDSb in the Open Access Journal of Plastic Surgery, Eplasty. 2009; 9: e2.

The Surgical Suite – Review

This is an anthropological essay about behavior in the operating room. The author observed facial feminization surgery in two different operating rooms. He concludes that operating rooms are not just impersonal places, but can be both sterile and intimate.

I’m not sure what you can really conclude about operating rooms from observing two operations, especially when the presence of an anthropologist may change people’s behavior and make them talk more about what they are doing.

What he saw, however, was important to transgender patients.

In one operating room, the doctors and nurses discussed what FFS would mean to the patient. They seemed to be glad to be helping someone achieve their dreams.

In the other operating room, one nurse was completely unable to handle using the correct pronouns. At one point she put “it” on a chart.

This is a 2013 study, not something from the past.

For transgender patients, it is vital to have surgical and hospital staff who will use the correct pronouns. Everyone needs to be well educated in this area.

Patients seeking surgery need to look for understanding health care providers.

Original Article:

Facial feminization surgery: current state of the art – Review

This is an excellent overview of the current (2012) state of the art in facial feminization surgery (FFS). It provides detailed descriptions of the various surgeries, how they are done, and some possible complications. It seems to be aimed at surgeons, but would be useful to someone who is in the process of planning facial feminization surgery with a doctor.

The article goes into detail about the average differences between male and female faces; this might cause dysphoria for some people.

As with many articles in this area, the before and after pictures are confusing. Women in the after picture often have new hairdos and more make-up and jewelry. In one before picture, you can see a five o’clock shadow. This makes it harder to evaluate the effectiveness of the surgeries.

The author of the study is a surgeon who performs FFS. He is therefore an expert in the area, but he might also have a bias in favor of believing that FFS works.

The article provides some history of FFS. Altman states that Dr. Douglas Ousterhout popularized and pioneered the procedure in the 1980s and 1990s. Ousterhout analyzed an anthropological skull collection at the University of San Francisco to understand average facial shapes of men and women. (This article does not mention the work in the early 1990s at the Free University Hospital in the Netherlands. Becking et al wrote in the early 1990s that only Farkas had done anthromorphometric work on the differences between male and female faces.)

Altman discusses the purpose of FFS and how it fits into the process of transition. He offers some advice on discussing surgeries with patients.

Altman concludes with an extremely important call for more research in this area:

In terms of clinical effectiveness, there are no large studies looking at this aspect of care, but the author’s experience suggests that patient satisfaction is generally high following these procedures.


The future of FFS depends on further development of the procedures currently undertaken and possible changes in approaches to funding. For public funding to become available, clinical effectiveness will have to be audited and presented to health authorities to justify the health gain and requirement for patients undergoing this type of surgery.

Original Article: Facial Feminization Surgery: Current State of the Art by K. Altman in International Journal of Oral & Maxillofacial Surgery, 2012-08-01, Volume 41, Issue 8, Pages 885-894.

Note: This article contains photos of surgery and graphic descriptions of surgical techniques.