The concept

    By Dr Frans Noorman van der Dussen, pioneer of FFS surgery, and mentor of many other FFS surgeons.

    • Performing multiple bone- and soft tissue procedures in all facial anatomical units in one surgical intervention.

     

    • To work out the procedures in the right sequence for the best possible harmonious facial feminine expression.

     

     

Core options

    • Opening the view, reduce the “Hooding Factor”, take the eyes out of the shade.

     

    • The shape and outline of the forehead-nose-cheek and upper lip must fit in the average 3D harmonious proportional quotation range.

     

    • Reduce the width of the lower jaw and the squareness of the chin and fit the lower facial height in the average (or smaller) proportional quotation range.

     

    • Redrape the overlaying soft tissues and fatpads to highlight the definition of the flow and shade of the cheekbone.

     

 

Facial Feminization Surgery

He is well known around the world for his achievements in Cranial Facial Aesthetic Surgery and especially Facial Feminization Surgery, in which field he developed procedures that have been adopted by many of his colleagues. His target is remodeling the face into average female proportions in a natural harmonious way without exaggerations.

 

Clinics in Antwerp, Belgium

In the Singelbergclinic and in the hospital he implements surgical procedures which combine bone structure and soft tissue operations preferably in one session.

Highly Individual

The procedures are highly individual and depend on the archetype of the client’s face. The archetype dictates the limits in which the facial feminization procedure can be performed.

Passing at first glance appraisal

What is passing? This is the day you throw your male outfit in the bin and step out as a woman into the outer circle of your social life as discrete as possible. The goal is male to female gender reassignment in the face, so that you will pass at first glance appraisal.

 

The procedures

Dr. Frans Noornan van der Dussen developed surgical procedures that do not leave any visible scars at all and also result in a swift recovery. The procedures are a combination of bone structure and soft tissue operations in only one surgical intervention. The advantage is that all anatomical units in the face can be mutually fine tuned in a harmonious way.

Three pillars of beauty

All procedures are founded on the three pillars of beauty: Proportions, Symmetry and Clarity. This results in delicate jaws, nice pronunciation of the cheekbones, small chin, large eyes, full lips and a nice dental show.

 

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Craniofacial

Craniofacial surgery is a surgical subspecialty of maxillofacial surgery, plastic surgery, and ENT that deals with congenital and acquired deformities of the skull, face, and jaws. Although craniofacial treatment often involves manipulation of bone, craniofacial surgery is not tissue-specific, i.e., craniofacial surgeons deal with bone, skin, muscle, teeth, etc. Craniofacial surgery does not, however, include surgery of the brain or eye.

Defects typically treated by craniofacial surgeons include craniosynostosis(isolated and syndromic), rare craniofacial clefts, acute and chronic sequellae of facial fractures, cleft lip and palate, micrognathia, Treacher Collins Syndrome, Apert’s Syndrome, Crouzon’s Syndrome, hemifacial microsomia and many others.

 

FFS

Facial feminization surgery (FFS)refers to surgical procedures that alter the human face to bring its features closer in shape and size to those of an average female human. FFS includes various bony and soft tissue procedures (see below) though the term “FFS” is generally not regarded to include facial hairremoval. FFS techniques are derived from maxillofacialand reconstructive surgery as well as general plastic and cosmetic surgery. Douglas Ousterhout and Frans Noorman van der Dussen pioneered what is now called FFS during the 1980s and 1990s in the U.S.A and Europe . There are only a small number of surgeons globally who specialise in FFS.

 

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FFS has become increasingly sought after by transsexualwomen and many feel that it is just as important or even more important for them than sex reassignment surgery(SRS) because it helps them integrate socially as women. While most FFS patients are transsexual women, some non-transsexual women who feel that their faces are too masculine will also undergo FFS. FFS is occasionally sought by cross-dressersand drag queens.

To be considered a candidate for gender reassignment surgery, a person must have a psychological evaluation and be diagnosed with Gender Identity Disorder from the Diagnostic and Statistical Manual, published by the American Psychiatric Association.

They must have signed letters from a psychiatrist and another mental health care provider; must live as a woman — or man — for a year before surgery; and must make a commitment to undergo psychotherapy throughout the process if they want to have genital surgery.

 

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“Not everyone wants genital surgery and not everyone needs facial surgery” Dr Noorman van der Dussen says, but most patiens want one or more things in their face changed.

 

Surgical procedures

Here is a list of the surgical procedures most frequently performed during FFS and the reasoning behind them:

 

Hairline correction

 

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In males the hairline is often higher than in females and usually has receded corners above the temples that give it an “M” shape. The hairline can be moved forwards and given a more rounded shape either with a procedure called a “scalp advance” where the scalp is lifted and repositioned or with hair transplantation.

 

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Hair transplants can also be used to thicken up hair that has been thinned by male pattern baldness. If too much hair has been lost, it will not be possible to correct hairline problems.

 

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Forehead recontouring

Males tend to have a horizontal ridge of bone running across the forehead just above eyebrow level called the brow ridgeor “brow bossing” while female foreheads tend to be smoother, flatter and have less bossing, or bossing that project just below eyebrow level. The outer segments of the bossing that the eyebrows sit on are called the “supraorbital rims”.

 

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The section of bossing between the eyebrows (the glabella) sits over a hollow area called the frontal sinus. Because the frontal sinus is hollow it can be more difficult to remove bossing there. If the bone over the frontal sinus is thick enough the bossing can be removed by simply shaving down the bone, however if the wall of bone is too thin it may not be possible to shave the bossing away completely without breaking through the wall into the frontal sinus. FFS surgeons have taken 3 main approaches to resolving this problem:

 

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The 3 main approaches to solve the problem, are divided in 3 types :

Type 1 : shaving

 

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Type 2 : shaving and closing the small perforations in the anterior wall of the frontal sinus with little flat pieces of bone (bone chips), sometimes fixed with miniscrews

 

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Type 3 : most commonly done in Dr Noorman van der Dussen’s hands :

 

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    • sliding osteotomy (cutting) of the whole anterior wall of the frontal sinus  including the supra-orbital rim.

     

    • remodelling of the anterior ‘wing’-shaped bone plate

     

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    • repositioning of the bone plate in a posterior position (endorotation of the lower part)

     

    • fixation with mini titanium screws

     

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    • remodelling of the lateral part of the supra-orbital rim, also at the inside of the superiorior part of the orbit in order to open the view

     

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Brow lift

 

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After the bony procedure for opening the view and the shape of the supra-orbital rims, we redrape the soft tissue of the forehead and the brows .

 

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This involves not only upward pulling of the brows , but may also be oblique pulling. This vector of pulling will be decided before and during the procedure.

This is done with dissolvable sutures fixed on the bone and deep temporal fascia.

 

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Females tend to have higher eyebrows than males so a brow lift is often used to place the eyebrows in a more feminine position.

 

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Hairline recontouring

    In many males there is a temporal recession of the hairline  and the forehead in much higher.

    To make this more female, we use several procedures (4).

    1. rhomboid skin excision and temporal lift
    2. temporal advancement flap and resection of non-hair bearing skin of the recession
    3. hemline incision on the hairline and advancement of the hair bearing scalp up to the recession
    4. expander placement under the hair bearing scalp; in a second stage after 3 months , removal of the expander, excision of skin, and redraping of the scalp

    My preference is using number 1 and 2.

    Many  other FFS surgeons use number 3 but my argument against this is : there always will be a scar at the hairline that needs hair transplant.

     

Rhinoplasty

Cheek implants

The goal : increasing the Zy-zy distance in long faces.

Females often have more forward projection in their cheekbones as well as fuller cheeks overall. Sometimes cheek implants are used to feminise cheeks. They come in different sizes and can be placed in different positions depending on the needs of the patient. Sometimes bone cement (hydroxyapatite cement) is used instead of silicone implants but various other materials (like medpor) are also used. Another possibility is a fat transfer where fat is removed from another part of the body and injected into the cheeks to make them fuller. And also a subperiosteal facelift is possible in case of saggy tissue.

 

Keep 3 things in mind

    • never exaggerate

     

    • never too much volume

     

    • never on the wrong places (not too low, and not too median – it has to be a lateral flow, to  underline the Ogee curves )

     

There is also a possibility to widen the arch and body of the zygoma (cheekbone) with an osteotomy , and putting a wedge (piece of bone) in between the gap.

Advantages of Hydroxyl apatite granules : placed in a subperiosteal pocket : this is our preference , through an intra-oral approach because molding is easy and smooth edges at the border of the implant regions (zygomatic area, lateral orbital rim, lateral infra orbital rim area).

The maximum point of augmentation must be more lateral than infra-orbital in the direction of the arch, in order to avoid the ‘miss-piggy’ look.

 

Lip lift

The distance between the opening of the mouth and the base of the nose tends to be longer in males than in females and when a female mouth is open and relaxed the upper incisors are often exposed by a few millimeters. To feminise a mouth an incision is usually made just under the base of the nose and a section of skin is removed. When the gap is closed it has the effect of lifting the top lip, placing it in a more feminine position and often exposing a little of the upper incisors. The surgeon can also use a lip lift to roll the top lip out a little making it appear fuller.

With this procedure , we respect the nasal sill with a waveline incision accoring to Cronin.

The orbicularis muscle is fixed to the interior nasal spine with strong sutures in order to create a nice dimple at the filtrum. There must be an excision of skin , and muscle till the oral mucosa layer.

There is a vestibular approach possible with a push-up of the skin around the anterior nasal spine, without an external scar. But the lift is less spectacular, without an outroll of the upper lip, and with less definition of the upper lip.

I don’t like combining this with a rhinoplasty. First nose, then lip surgery in a second stage.

 

Lip filling

Females often have fuller lips than males so lip filling is often used in feminisation. There are many methods of lip filling from injecting fat , fillers and V-Y flaps.

Preferred technique is Fat Transfer
HA-fillers , but not lasting .
Fascia strips
V-Y flaps in order to outroll the red part of the upper lip.
Goretex sheets : never done in our practice
Silicone implants : never done

 

Chin recontouring

Males tend to have taller chins than females and while female chins tend to be rounded, male chins tend to be square with a flat base and two corners. The chin can be reduced in height either by bone shaving or with a procedure called a “sliding genioplasty” where a section of bone is removed. The square corners can usually be shaved down. Sometimes liposuctionis also used to remove some of the fat that some people have underneath the chin.

The goal is to create a V-shape in a frontal view and a proper lower facial height.

The genioplasty is a main tool to reshape the face in the proper proportions.

 

3 goals

    • frontal vertical view : changing lower facial height (reduction in long faces, augmentation in short faces) (better proportion in regards to forehead, midface/nose, and lower face

     

    • frontal horizontal  : removing of a central piece of bone (better V shape)

     

    • lateral view : advancement or setback : a nicer profile

     

The main problem of many sliding genioplasties , is that many surgeons create a STEP deformity at the lower border of the lower jaw. This may be visible , and one may be able to feel it as well upon touching your cheek.

We avoid this through a genioplasty which is starting as far back as possible on the lower border of the lower jaw, starting with a very fine cut, and then increasing the thickness of the cut, while sparing the mental nerve, which supplies the sensitivity of the lower lip.

In the midline of the chin, when this is very masculine and square , a central piece of bone can be removed which will reduce the width of the chin .

This is an intra oral procedure without scars. The slding osteotomy (bone cut) is performed with an oscillating saw is performed in a lateral tunnel under the mandibular nerve. This is a 100 % sensible nerve , so there will never be a problem with the function of your lip, but initially there may be numbness of your lower lip.

The fixation of the chin will be rigid with titanium screws and plates.
There is no need to remove these when everything has healed.
The first week soft food is recommended. You can drink and eat immediatly after the procedure.

 

Jaw recontouring

Males’ jaws tend to be wider and taller than female jaws and often have a sharp corner at the back. The back corner can be rounded off in a procedure called “mandibular angle reduction”; bone can also be shaved off along the lower edge of the jaw to reduce width and height and the chewing muscles (masseter muscles) can also be reduced to make the jaw appear narrower.

The mandibular angle is usually flaring outwards.

For lower jaw width reduction at the angle we use an intra-oral approach. The masseter (chew) and pteryogoid muscles are undermined. Then the flaring bone is shaved off and the incision is neatly closed with dissolvable sutures. There is almost no risk for nerve or blood vessel damage.

When the angles are shaved off, the lower jaw border can be shaved off in an anterior direction, finishing in a genioplasty.

 

Adam’s apple reduction = Tracheal Shave

Males tend to have a much more prominent Adam’s applethan females although small Adam’s apples are more common in males than many people realise. The Adam’s apple can be reduced with a procedure called a “tracheal shave” or “thyroid chondroplasty”. It is not always possible to make a large Adam’s apple invisible with this procedure, rather the intent is to change it from the masculine 90 degree angle to the feminine 120 degree angle.

We use the submental approach, creating a tunnel over the platysma , underneath the skin.

Then over the thyrohyoid muscles , dissecting the wings of the thyroid bone, and removing the protruding cartilage of the wings.

 

Associated procedures

Beautification and rejuvenation procedures are often performed at the same time as facial feminisation. For example, it is common for eye bags and sagging eyelids to be corrected with a procedure called “blepharoplasty” and many feminisation patients undergo a face and neck lift (rhytidectomy). It is often necessary for older patients to have a lower face-lift after jaw and chin surgery because the reduction in bone and the effects of swelling can leave sagging skin.

 

Limitations

FFS is a very powerful set of procedures but there are limits; for example: a wide jaw can be feminized by surgical narrowing but it may not be physically possible to narrow a very wide jaw enough to make it fully female. There are also some masculine facial features that can’t be surgically feminized at all like the relative size of the eyes to the skull (females tend to have proportionately larger eyes).

FFS can be expensive too, often costing $10,000 to $25,000 USD depending of course on which particular procedures the patient undergoes and which surgeon they go to. Although many patients do not spend much time hospitalized, specialized expertise by the surgeons’ support staffs may be required during the immediate post-operative period and it may be several weeks before the patient can resume work.

As far as can be ascertained, FFS is currently ( 2011 ) unsupported by any published, peer-reviewed studies of its “clinical effectiveness.” As a result, the UK National Health Service (NHS) will not provide public funding for it or, indeed, revisions to privately obtained surgery if things go wrong or are otherwise unsatisfactory. Clinical effectiveness studies are urgently needed.

 

Transgender Face Feminization (FFS) | Transgender Plastic Surgery (Breast Augmentation and Body Contouring) | Transgender Hormone Therapy | Male to Female Sex Reassignment Surgery (SRS) MTF | Cosmetic Procedures