The diagram above depicts the common surgical procedures offered for facial feminization, which soften masculine craniofacial anatomic features that cannot be changed with hormone therapy.  Note the sex-specific differences between male and female sex skulls. Male sex skulls have flatter forehead inclinations with prominent supraorbital ridges, while female sex skulls have a smoother frontal bone and rounded supraorbital ridges. (Source: the Mayo Foundation for Medical Education and Research.)

The diagram below better illustrates the desired results.

. This transwoman received forehead contouring through a hairline incision, browlift, hairline advancement, rhinoplasty, chin contouring with a sliding genioplasty and a tracheal shave.

Reducing the height of the radix of the nose is often the single most visually effective element of facial feminization surgery.  It is the junction between the forehead and the nose and therefore requires careful contouring and coordination. This transwoman also received forehead contouring, scalp advancement and feminization, browlift, cheek implants, and mandible contouring with sliding genioplasty.

Nose Surgery (Rhinoplasty)
[Not strictly skeletal, but worth listing here!]
The nose is the most prominent feature of the face.  Many transwomen find nasal refinement to make one of the most marked improvements in their female facial appearance and it's the most common procedure after breast augmentation.

Nasal surgery or rhinoplasty alters the appearance of the nose by shaping and repositioning the nasal bones and trimming the bone and cartilage as needed to create the desired appearance. As example, rhinoplasty is used to correct a large hump, or a broad or round nasal tip.  Small changes, such as subtly lifting the tip of the nose will often create a more youthful and feminine appearance. 

Commons tasks include:

Robera Close was considered one of Brazil's most beautiful women in the 1980's. However profile shots were rare as they revealed a large nose. She eventually had FFS, most obviously rhinoplasty to reduce and reshape her nose.

Septal Surgery - The strip of cartilage which separates the two sides of the nose is called the septum.  It is sometimes bent and interferes with breathing; if so, it may need to be straightened.  If it is too long, it is often shortened.

Shaping the Profile - Many women complain of a hump on the bridge (dorsum) of the nose. This is usually made of both bone and cartilage.  It is removed with scissors or a saw. When the nose is flat, the profile may be augmented with grafts of bone or cartilage.

Refining the Tip - If the tip of the nose is large or boxy, much of the tip cartilage may be removed or reshaped to refine the shape.

Narrowing the Nasal Bones - If the bridge of the nose is wide, the surgeon will narrow it by fracturing the bone on each side and moving it closer to the centre.

Reducing Nostril Flare - If the nostrils are flared, they may be reduced by removing a small wedge of tissue from the base of the nose.

 
Nikohl Spearman was born in January 2000 and transitioned at a young age.  In 2019 she appeared (left) in the TV series Crazy Fast as 16-year old Beanie.  In 2020 she had FFS - a chin jaw reduction, forehead shave and brow lift.  She posted the results online (centre) and has since started to work as a model (right). 

Sara Randall after FFS on her chin and jaw. She also had extensive dental work (she was a dental student) and describes this on her website.

Jaw and Chin
The chin is an extremely important area in gender recognition - basically men have a large, square and robust jaw whilst women have a smaller, less prominent and more triangular jaw.  Although the potential benefits can be great, the difficulties involved in re-shaping a "robust" lower jaw sufficiently to make a significant improvement in overall facial feminization makes this an expensive and risky procedure.

Possible tasks include: 

Jaw reduction: involves a 1.0cm extra-oral incision under the jaw line to cut the bone (on average, by 1.0cm depth) and thus reduce the sharp angle of the back corner of the jaw where it rises up to the ear.  

Alternatively, an intra-oral incision can shave (but not cut) the bone.  Although this technique prevents external scaring, it is less effective, has more risk of infections, and requires an extended recovery period due to severe facial swelling/bruising. 

It's hard to find any feminisation surgery that Amanda Lepore has not had - beginning with rhinoplasty at 15 and SRS at 19.

Chin reduction: involves an intra-oral incision to shorten and narrow the chin (if necessary, including contouring with a hard silicone implant). The technique involves: (1) shaving the bone; (2) cutting the bone; or (3) sectioning out the mid-section of chin and joining the upper and lower sections via steel screws.

Sliding genioplasty: involves an intra-oral incision and sliding forward or backward the lower section of chin (if necessary, including contouring with a hard silicone implant).

Chin augmentation: involves an intra-oral incision to advance a short or/and receding chin with a hard silicone implant.

A text book example of facial feminisation surgery - with changes to the nose, chin and jaw line

Forehead Reconstruction
Forehead recontouring involves rounding the forehead to approximate a female shape, often by shaving bone from the brow of filling in flat areas to round them out.  Reducing brow ridges, if excessive, can considerably improve the feminine appearance. 

Common procedures include:

Scalp reduction: involves advancing forward the scalp between 1.0 cm and 2.5 cm to correct for the receding masculine pattern hairline and to approximate, when possible, a more feminine 'oval' pattern hairline.

SMAS/platysma (deep plane) rhytidectomy: involves lifting the cheeks, jowls, jaw line, and neck and their underlying muscles. 

In 2005, MTV featured 26-year old transsexual Gia on I Want a Famous Face, who wanted to look like Pamela Andersen.  She had already had a dozen operations since her teens (inset left), but surgeon Dr Mayer (right) gave her a new breast implants, liposuction on her abdomen and chin, another nose job, micrograft's to her hairline and fat transferred to her smile lines.  The result (centre) is a vague resemblance to Pamela.

Forehead contouring: involves shaving the brow bossing and, if necessary, contouring via shaving across the forehead.

Forehead augmentation: involves the use of 2, 3, or 4 implants (Gore-Tex Subcutaneous Augmentation Material).

Cheeks
There are multiple procedures which can enhance a transwoman's feminine appearance. 

Cheek implants: also called submalar implants, can make the face look less flat. Like any implant, there is a danger of rejection.

Cheekbone reduction: involves an intra-oral incision which requires an extended recovery period (with severe facial swelling/bruising for about 10 days).

Cheekbone augmentation: involves an intra-oral incision to augment the bone with a hard silicone implant.

Lip contouring: involves lifting the upper lip via a shallow 'v' incision below the nose or by an incision inside the lip. If necessary, the lower lip can be made fuller via an incision inside the lip.

Ava Glasscott began hormones age 15.  Shown age 30 - 8 years after SRS and 4 years after BA and FFS.  Height 5' 10", Weight 145 lbs, Figure 34-27-38, Cup size DD.

Neck
A trachea shave is a procedure undertaken to reduce a transwoman's "Adams's Apple".   It's both expensive and risky.

Born a boy, Tonya's appearance is the result of 20 years of hormones and a lot of feminising surgery.

Body Sculpting

A significant development since 2000 has been the development of medical techniques to "sculpt" a transwoman's soft tissue and thus her body shape by removing fat from some areas and adding it to others.  Procedures that was once the preserve of the rich have now become relatively affordable and commonplace.

Fat removal procedures remove unwanted tissue. The procedure may be invasive, as with grafts or liposuction, or non-invasive using laser therapy, radiofrequency, ultrasound or cold (cryoablation or cryolipolysis) to reduce fat, sometimes in combination with injections.  The removed fat is sometimes added to another location, e.g. to augment breasts.  At the conclusion of the procedure, the patient is placed in a compression garment.

Transwomen patients face particular challenges as they often request fat grafting or transfer to their buttock and hip areas.  For the first two weeks after the procedure they can't sit normally and must sleep on their side or preferably abdomen to avoid pressure to the buttocks or hips which will dissipate the enlargement. This is further complicated if the patient also has fat breast augmentation, in which case the transwoman can only sleep on her side.

The before and after results of 'body sculpting' on a transwoman   

Carmen Carrera
Carmen Carrera (born Christopher) became famous for her appearances in 2011, age 26, as a male drag queen on the third season of the TV series RuPaul's Drag Race.  She regularly appeared in the next few series as a guest but was now openly transgender and her appearance was radically changing due to taking female hormones and surgical operations.  In early 2014 it was reported that she had had sex-reassignment surgery but in a TV interview she said "I don't want to talk about it; it's really personal ... People [can] speculate whether I've gotten SRS [but] I fixed up a couple things.”  The 'few things' included dental work, rhinoplasty, chin and jaw reprofiling, breast augmentation, liposuction, a tummy tuck, buttock and calf augmentation, and fat transfers.

In 2015, age 30, Carmen married her Adrian Torres whom she had been dating since 2009 and became the stepmother of his two daughters.  Contemporary press reports claimed that by the wedding she had spent $100,000 on cosmetic surgery, but with no confirmation that this included GCS.

   

 

Examples of FFS
One of the most successful FFS procedures I have seen is that of Jordan Bellina.  Age 30 she underwent two extensive procedures with Dr. Mayer, including scalp advancement, brow contouring, rhinoplasty, a lip lift and chin augmentation.  It cost her about $29,000.  She has documented this "life changing" experience on her YouTube channel.

Below are the results of three successful facial feminisation surgery procedures performed by Dr Mardirossian (USA):

Patient A. Photos taken before and 6 months after FFS. Procedures performed include forehead contouring with browlift and hairline advancement, rhinoplasty, lip lift, mandible contouring and tracheal shave.

Patient B. Photos taken before and 5 months after FFS. Procedures performed include forehead contouring with browlift and hairline advancement, rhinoplasty, lip lift, mandible contouring and tracheal shave.

Patient C. Photos taken before and just 1 month after FFS.  Procedures performed were: forehead contouring with a browlift, hairline advancement, mandible contouring, rhinoplasty, and cheek implants.  Swelling was minimised by using before surgery a computed tomography (CT) scan to optimise the planned procuredure.

  

Below is Katerina Myers, before and after her facial feminisation surgery.

 

Next is Maggie.  She has had undergone very extensive FFS with Dr Bart van de Ven, including forehead recontouring and shaving, brow lift, rhinoplasty, chin recontouring, jaw reduction, a face lift, Adams apple removal and a lip lift.  Undoubtedly, she faced serious risks (as well as considerable cost) seeking such extensive surgery, but the results are exceptionally good.

 

Saga from Sweden is shown before and four months after extensive facial feminsation surgery by the 'Facial Team' in Spain.  This included work on her forehead, jaw and chin, a rhinoplasty and a tracheal shave.  Unfortunately, the acuracy and credibility of the photos is reduced by their excessive editing, e.g. the implausibly narrower neck.

 

In Iran it's illegal to be a homosexual man, but you can change your sex from male to female. After having SRS you are legally considered to be a woman for everything from having to wear the hijab in piblic to marriage to a man.  A large number of surgeons offer SRS and other feminisation surgeries for men that (often reluctantly) decide to become a woman.  Surgical procedures have evolved that are barely known outside the country but the results can be excellent, as shown below.

 

Another patient who wishes to remain anonymous.  She had FFS by Dr Eric Bensimon which involved significant changes to her jaw, a recontouring of the forehead, hair lowering (scalp advancement), and the removal of any visual Adam's apple.

  

A search for the term 'Facial Feminization Surgery' using Google will produce a vast number results.  A few examples include:

It is important to realise that not all facial feminisation surgeries are a huge success.  Some are clearly "botched" and in other cases the patient is unlucky and has serious complications.  Unsurprisingly these results are not publicised by the surgeons and including "negative" photos on this page might result in legal problems.  However, a search of the Internet will quickly reveal a few of the more appalling stories.

 

Other Surgical Procedures

Rib Removal or Adjustment
These are uncommon procedures which are undertaken to improve the figure. 

Before and after photos of transwoman patient posted by a medical clinic after lower rib removal surgery.   Amanda Lepore, the left picture shows where her lower ribs were broken.  The right photo shows her wearing a corset with a 22-inch waist.

In the first technique, one or two of the floating ribs at the bottom of the rib cage are taken out to have a smaller waist, typically by 1 - 2 inches unclothed.  Corsets also become far more effective as they can act upon a greater area of soft tissue rather than rigid bone - although a reduction of more than 4" reduction is likely to soon cause damage to internal organs.  The resulting back scars, the vulnerability of exposed internal organs to damage from bangs and bumps, and the possibility of unsightly rib re-growth makes this a very problematic procedure which is rarely performed by reputable surgeons.  Actresses Raquel Welch and Elizabeth Talyor; singers Cher and Janet Jackson and celebrity businesswoman Kylie Jenner are reported to have had this procedure - although the only real supporting evidence is the fact they suddenly were wearing dresses showing off fabulous hour-glass figures with a tiny waist.  [In 1988 Cher sued Paris Match magazine for claiming that she had had extensive cosmetic surgery (including the removal of two ribs) and won the case.]

An only slightly less dramatic and dangerous procedure is to break the lower ribs, bend them inwards to reduce the waistline, and force them to mend in the new position by the continuous wearing of a tight and rigid corset for a month or more.  Amanda Lepore - who claims to have the most expensive surgically enhanced body in the world - underwent this procedure.  She also claims to now have the perfect female figure - 38-22-38 - and combined with her petite 5ft 2in height the result is indeed impressive if you can cope with her excessively feminised facial appearance.

Long Bone Shortening
It is possible to shorten the bones of the legs (most commonly the femur) and arms by resection in order to reduce physical size and height.  This procedure is considered dangerous and is very rarely performed on transsexual women.  Excessive reduction of limb length will also destroy the proportions of the body, causing new problems such as an oddly large body on short legs.

Vocal Feminisation Surgery

This topic really deserves a page of its own.  A female sounding voice isv ital when trying to pass or go stealth.  It is also a key advantage of starting female hormone treatment, or at least blockers, at an early age - before a male puberty leads a boys voice to 'break'.

To achieve a more feminine voice, a variety of surgical procedures can be performed in addition to speech therapy. These can be endoscopic, open or a combination of both. The underlying mechanisms of pitch elevation include increasing vocal cord tension, shortening vocal cord length and decreasing vocal cord mass.

The most popular technique due to its low cost is cricothyroid approximation, which increases vocal cord tension. The cricoid cartilage is pushed posterosuperiorly through a cervical incision and the thyroid cartilage anteroinferiorly resulting in the two cartilages being closer together. A disadvantage of this technique is that reducing or even removing the cricothyroid membrane and space can impact the airway, and make breathing more difficult.

At the other end of the cost scale is feminisation laryngoplasty - basically rebuilding the voice box to approximate a womans.  This involves removal of the anterior thyroid cartilage, thereby reducing the diameter of the larynx to raise the pitch of the voice. 

Finally, there is endoscopic Vocal Fold Shortening and Retrodisplacement of the Anterior Commissure (VFSRAC).  This surgical pocedure attempts to combine three pitch raising techniques, it aims to make the vocal folds thinner, shorter and tighter in just one procedure.

 

Cost of Surgery

It's worth ending this article by noting the very high cost of feminisation surgery. 

Lisa spent a relatively modest $20,000 on facial feminisation, breast implants, and SRS with Dr Ousterhaut and Dr Watanyusakul.

Basic procedures such as a "nose job" are widely available, and good quality surgery can be economically obtained from clinics that don't otherwise deal with transsexual women.

But more extensive feminisation surgery is a specialist field in which there are only a few reputable surgeons practicing.  In 2000, facial femisation surgery from a top surgeon such as Dr. Ousterhout would start at about $10,000 and soar upwards from there.  There are cheaper options emerging, particularly in Thailand, but carefully check out the surgeon's references and make enquires about them on the Internet.  Poor quality surgery is far worse than none.

Jamie Clayton, age 30 - after eleven years on hormones, SRS, small breast implants, and a few other bits of work!

An example of the benefits of good quality surgery is Jamie (formerly James) Clayton.  When just 19 she transitioned and moved to New York, where her make-up skills won her a job as a beautician.  Her first surgery was a subtle breast augmentation which barely took her to a 'B' cup - although hardly noticeable it was enjoyed by her boyfriends and helped her to pass physically.  Next, she paid $16,000 in 2003 to have sex re-assignment surgery by the highly rated Dr Meltzer when 25 - she wanted her revised genitalia to both look pretty good and to work.  She was very happy with result and soon experienced vaginal orgasms.  With "tweaking" to her genitalia, and other "touch-ups", by age 30 she had spent about $50,000 on surgery to get near where she wanted to be appearance wise.  Famously, a magazine article published in 2008 called her (only slightly generously) "The Second Most Beautiful Girl in New York", which stirred considerable debate as to whom the first girl was!

Left "Larrisa" age 27, centre Darren age 14 and right Laura age 34.

Laura Alicia Summers - born Darren Pratt in 1984 - has made a career out of her extensive feminisation surgery.  She had GCS in 2003 and then frequently appeared nude in mens magazines.  She was outed in 2005 but soon slipped back to near stealth with considerable success, e.g. a Feb 2009 online-only Playboy pictorial of her as "Larissa" makes no mention of her being transgender.

In 2011 she featured in several UK newspapers and magazines, claiming that she had spent €500,000 on plastic surgery.  She apparently had had 50 operations, including eight breast procedures, seven nose jobs, three Brazilian butt lifts, ear corrections, cheek and lip filler, chin and jaw contouring, lip lifts and lipo-freezing.  Her GCS was a notable omission from ye list!

The table below includes some indicative costs (c. 2016) of private surgery in Europe or the USA by a well-regarded practice and/or surgeon for the indicated procedure.  These include only surgery, anaesthesia and immediate hospital care, they exclude taxes (e.g. some UK practices now apply VAT), medications and any post-operative care or procedures.  If there are complications, the cost can soar.  Incidental expenses such as travel must also be added.  

Procedure Description	Cost ($/€)	Two transwomen sent me this photo of the results of their GCS  (apparently by the same surgeon) and other surgery.  I've pixaleted to try to avoid the almost inevitable subsequent request to remove the photo! Fernanda (born Fernando) paid a professional photographer to do a "Playboy" style nude photo shoot after her GCS.
Facial Feminisation Surgery
Blepharoplasty (tighten upper and lower eyelids areas)	6,700
Blepharoplasty (tighten upper or lower eyelids areas)	4,400
Rhinoplasty (nose reduction)	7,500
Rhinplasty with Septoplasty (nose reduction and adjust airway)	8,800
Facelift (Rhytidoplasty)	7,800 - 10,600
Liposuction of neck	2,600
Chin augmentation	3,600
Cheek augmentation	5,200
Forehead/brow lift with brow bone reductions and hairline advance	6,200
Thyroid cartilage reduction / tracheal shave (Adam's apple)	3,600
Upper lip shortening	4,400
Top (Breasts) and Body Surgery
Breast Augmentation	8,200
Liposuction	1,000 - 1,500
Abdominopslasty (tummy tuck)	5,300 - 8,500
Buttock augmentation (implants)	9,500
Buttock augmentation (fast transfer)	6,500
Calf augmentation (implants)	6,700
Bottom Surgery (GRS/SRS)
Orchiechtomy (castration)	4,600
Vaginoplasty (one-stage with penile inversions, clitoroplasty and labiaplasty)	19,700

Patrícia Araújo (born Felipe Silva de Araújo) in 2009. Her exceptional legs, augmented by procedures such as fat transfer, made her a top model in Brazil. Tragically she committed suicide in 2019, age 35.

It's quite possible to find medical practices (particularly in Asia) quoting half these amounts, but potential clients should be very wary of a "bargain" - as a minimum check the surgeons and clinics reputation on-line.  Also, make sure that you have a good grasp of all the charges and costs, extras can appear from every direction - transport, tests, anesthetist, private room, wi-fi access, medications, dilation pack, taxes ... and some need to be paid in cash.  Of course flights and hotel's are on top of the medical costs.  In recent years the better clinics have greatly increased their prices and local regulations have become much stricter.  In 2016 it would be unrealistic and risky to expect to travel from Europe or the USA to Thailand for GCS without a budget of $20,000.

Transwoman Chantelle Stodden at the beginning (left) and end of a decade long surgical journey, including SRS and rib removal.

The increasingly common practice of bundling of multiple procedures (e.g. GCS/SRS, breast augmentation and facial feministion) makes post-operative complications almost inevitable.  I know one patient who due to complications ended up spending a month post-GRS in Thailand before she was able to fly home, she had to down-grade her hotel several times. Having these problems occur when you are thousands of miles from home is both mentally depressing and financially very expensive.  Also, there is no return from a botched SRS procedure with a low-cost but inexperienced surgeon.  Gender confirmation surgery is a "one-shot" surgical procedure.  Follow-on remedial procedures can never compensate for tissue removed and nerves destroyed in the radical first procedure.

When arranging surgery, it's impossible to better a 2,000 year-old Roman saying: "Caveat emptor... ", its commonly translated as just "Buyer beware!" but the full saying is that a buyer should not to be ignorant of the nature of what they are buying from another party.

Obviously, the cost of multiple procedures starts to add-up, and many middle-age transwomen readily admit to having spent more than £/$/€100,000 on multiple surgeries - it's almost a proud boast.

As shown in this 1999 graphic, by age 21 Maxine had undergone 35 operations and procedures in the shown 10 body areas.  They cost about €26,000 ($32,000).	Kelly-Anne (formally Michael Tanham) spent $50,000 feminising her body by age 30, as shown in this 2000 picture.  In 2016, now called Kelly Star, she claimed that she had spent $250,000 on surgery.	Transwoman Barbie had spent $80,000 on plastic surgery by 2001 to look like ... Barbie!
French transwoman Laura Balder (born in 1991) has documented on social media (e.g. her YouTube channel) her journey from young man to young woman.  In 2015 she began taking oestrogen and had laser hair removal; in 2017 she had breast augmentation, in 2021 facial feminisation, and in 2023 larger breast implants and liposuction.  Whilst still pre-SRS the change in her appearance is extraordinary, although - like most transwomen who transition after puberty - her voice doesn't match her female appearance.

A group of Brazilian transsexuals, including the most famous of them all - Roberta Close.  Between they have had dozens of feminising surgical procedures.

Web links

A good, if now dated, starting point is Lynn Conway's informative article on Facial Feminisation - based on her personal experiences - at:  http://ai.eecs.umich.edu/~mirror/FFS/LynnsFFS.html

For more information on facial feminisation surgery I highly recommended Sally's Resource Morsal at: http://tsresource.info/

For more links, check out the Transsexual Women's Resources website at: http://www.annelawrence.com/facialindex1.htm