What is FFS and who is it for?
Facial Feminization Surgery (FFS) refers to a range of surgical procedures designed to modify facial features perceived as masculine to create a more feminine appearance. It is not a single operation but a personalised journey that may include bone procedures (forehead, jaw, chin reshaping) and soft tissue interventions (nose, lips, eyelids).
What FFS is — and what it is not
FFS is not "standard" cosmetic surgery aimed at beautifying according to arbitrary standards of beauty. It is gender-affirming surgery, with the goal of aligning physical appearance with felt gender identity. It does not seek to create a "perfect" face, but a face that is consistent with the person who carries it.
Studies show that FFS significantly improves quality of life, reduces gender dysphoria, and promotes psychological well-being. A systematic review of 1,302 patients confirms that FFS is safe and associated with high satisfaction among transfeminine patients.
Who is FFS for?
FFS primarily concerns:
- Transgender women wishing to feminise their face as part of their transition
- Non-binary individuals wishing to soften certain facial features perceived as masculine
- More rarely, certain cisgender women with masculinised facial features they wish to soften
There is no "typical candidate". Each face is unique, and FFS should be considered as an individualised project, tailored to each person's anatomy and wishes. The goal is not to conform to a standard of femininity, but to feel at peace with oneself.
For readability, the term "patient" is used throughout this guide, but it includes anyone concerned, regardless of gender.
How facial feminisation works: Principles, not just procedures
To understand FFS, it is helpful to grasp why a face is perceived as masculine or feminine. This perception relies on subtle visual cues related to bone structure and soft tissues.
Skeletal and soft tissue gender markers
The male facial skeleton typically presents:
- A more prominent forehead with marked supraorbital ridges (prominent brow ridge)
- A more acute nasofrontal angle
- A wider and more angular jaw
- A more projected and squarer chin
- A visible Adam's apple
The female face, by comparison, typically presents:
- A smoother and more rounded forehead
- Eyebrows positioned slightly above the orbital rim
- A finer nose with a more open nasofrontal angle
- More prominent cheekbones
- A narrower jaw and more pointed chin
- A smoother neck contour
These differences are largely influenced by hormones during puberty. Feminising hormone therapy modifies soft tissues (skin, fat distribution) but cannot reshape already developed bone structures.
Why some features matter more than others
Research on facial perception shows that the upper third of the face (forehead and eyebrows) plays a decisive role in gender identification. A study of 220 patients confirms that forehead and orbital reshaping has the most significant impact on femininity perception.
This is why forehead reshaping is the most frequently performed FFS procedure (67.5% of cases according to National Surgical Quality Improvement Program data), followed by orbital contouring (48%), rhinoplasty (44%), and mandibular reshaping (44%).
Why hormones alone are sometimes insufficient
Feminising hormone therapy produces significant changes in soft tissues: fat redistribution, skin refinement, changes in hair texture. However, bone changes that occurred during male puberty are permanent.
A study using the FACE-Q scale showed that patients who had FFS have significantly higher facial satisfaction scores than those on hormone therapy alone. This does not mean FFS is necessary for all trans women, but that it can be a relevant option for those whose dysphoria centres on skeletal features.
Facial analysis and surgical planning
FFS is not a catalogue of procedures to tick off. It is a bespoke surgical project, developed after thorough facial analysis.
The importance of individualised analysis
Each face presents a unique combination of features. Some patients have a very prominent forehead but a fine jaw; others present the opposite. Preoperative facial analysis identifies which features contribute most to masculine perception and which are already feminine.
This analysis relies on:
- A detailed clinical examination of the face (frontal and profile views)
- Standardised photographs
- Cephalometric analysis (angular and linear measurements of the facial skeleton)
- In specialised centres, a 3D scan (cone beam CT) enabling three-dimensional virtual planning
The role of CT scanning and 3D planning
3D CT scanning has become an essential tool in FFS planning. It allows precise visualisation of bone anatomy, particularly the thickness of the frontal sinus (crucial for forehead reshaping), and simulation of planned modifications.
Virtual planning reduces operative time, minimises risks of excessive resection, and improves result precision. It also allows the patient to visualise expected changes, facilitating realistic discussion of goals.
Single-stage or staged surgery?
FFS can be performed in a single procedure (single-stage approach) or in several stages spaced a few months apart.
The single-stage approach has the advantage of only one recovery period and ensures harmonious consistency of the entire face. Data shows that performing five or more procedures during the same intervention does not significantly increase the complication rate (3.9% in a US national study).
The staged approach may be preferred for complex cases, patients with medical comorbidities, or those who prefer gradual recovery. In this case, structural bone procedures (forehead, jaw) are generally performed first, followed by soft tissue interventions.
FFS procedures by facial region
FFS comprises a set of procedures targeting different areas of the face. Here is an overview by region, with an explanation of each intervention's feminising effect.
Upper face
Forehead contouring (brow ridge reduction)
The most emblematic FFS procedure. It involves reducing the bony prominence of the forehead (frontal bosses and supraorbital rim) to create a smooth, rounded contour. According to Ousterhout's classification, 82% of patients require an osteotomy with repositioning of the anterior wall of the frontal sinus (type III). This intervention feminises the profile silhouette and "opens" the gaze.
Hairline advancement
The male forehead is generally higher with a more receded hairline. Hairline advancement, performed by skin excision or Hair Transplant, reduces forehead height and creates a more rounded shape. This procedure is often combined with forehead contouring via a trichophytic incision.
The feminine eyebrow is positioned slightly above the orbital rim with a more pronounced arch laterally. The Brow Lift, performed through the same incision as forehead contouring, repositions the eyebrows and opens the gaze.
Orbital contouring
Reduction of the lateral orbital rim increases the light entering the orbit and creates more "open" eyes — a typically feminine characteristic.
Upper Blepharoplasty and Lower Blepharoplasty
Eyelid surgery may be indicated to correct excess skin or fatty pouches, particularly in older patients. It is not systematically feminising but contributes to harmony and rejuvenation of the gaze.
Midface
The male nose is generally wider, more projected, with a higher dorsum and a more acute nasofrontal angle. Feminisation rhinoplasty aims to refine the nose, reduce the dorsal hump, increase the nasofrontal angle — making the transition between forehead and nose smoother (changing on average from 133° to 149°) — and create a more delicate tip with a slightly open nasolabial angle. Studies report high satisfaction (4/5 on the nose feminisation scale).
Cheek augmentation
Feminine cheekbones are generally more prominent and more anterior. Augmentation can be performed with silicone implants or by Facial Fat Grafting (Facial Lipofilling) (autologous fat transfer). Fat grafting offers a more natural result but may require touch-ups.
The distance between the base of the nose and the vermilion of the upper lip (philtrum) is shorter in women. The Lip Lift shortens this distance and increases vermilion visibility, creating a fuller upper lip and more feminine smile.
Lip augmentation
Hyaluronic acid injection or fat transfer can increase lip volume. This procedure is considered adjunctive and not systematic.
Lower face
Jaw contouring (mandibular angle reduction)
The male jaw is wider with more pronounced gonial angles. Mandibular contouring, performed via an intraoral approach, involves reducing the angle and body of the mandible to create a finer, more oval line. A study of 837 patients reports a femininity score increasing from 47.86 to 76.41 after the procedure.
The male chin is often wider and squarer. Feminisation genioplasty can reduce chin width and height, or reposition it as needed. This procedure is frequently combined with mandibular contouring ("V-line surgery").
Masseter reduction
Hypertrophied masseter muscles can give the face a square appearance. Reduction can be surgical or by botulinum toxin injection, the latter being less invasive but temporary.
Neck
Adam's apple reduction (chondrolaryngoplasty)
The prominence of the thyroid cartilage (Adam's apple) is a highly visible male marker. Chondrolaryngoplasty involves reducing this prominence through a small cervical incision or, more recently, via a transoral approach (with no visible scar). The procedure does not modify the voice. Studies report that 60% of patients are "very" or "completely" satisfied with the result, and no permanent voice changes have been observed.
Which procedures are most common in FFS?
Not all FFS procedures are necessary for every patient. Procedure frequency reflects their relative impact on gender perception.
Core procedures (very frequent)
- Forehead and brow ridge reshaping (67.5% of cases)
- Orbital contouring (48%)
- Rhinoplasty (44%)
- Mandibular contouring (44%)
- Chondrolaryngoplasty (35%)
Adjunctive procedures (case-dependent)
- Genioplasty (14%)
- Brow Lift (12%)
- Cheek augmentation (12%)
- Lip Lift (9%)
Optional refinements
- Upper Blepharoplasty / Lower Blepharoplasty
- Facial Fat Grafting (Facial Lipofilling)
- Lip augmentation by injection
- Hair Transplant (to complement hairline advancement)
It is essential to understand that FFS is modular. One patient may only need one or two procedures, while another will benefit from a more comprehensive plan. The goal is not to "do everything", but to target the most relevant interventions for each situation.
Can FFS be combined with other surgeries?
FFS can be performed alone or combined with other procedures, depending on the patient's needs and wishes.
Common combinations
Rhinoplasty (Nose Surgery) is almost systematically combined with forehead contouring, as the nasofrontal angle depends on both the nasal root and the forehead. Performing these two procedures together ensures optimal harmony.
Jaw contouring and Chin Surgery are generally performed during the same operation to ensure a smooth transition between different facial areas.
Combination with orthognathic surgery
Some patients have functional skeletal abnormalities (malocclusion, retrognathia) that can be corrected by orthognathic surgery. In these cases, FFS and orthognathic surgery can be planned together, sometimes during the same procedure.
Interaction with previous surgeries or treatments
Patients who have previously received filler injections or undergone facial surgeries must inform their surgeon. Permanent fillers (silicone) can complicate certain procedures, and surgical history influences the operative plan.
Recovery and timeline after FFS
Recovery after FFS is a gradual process that requires patience. Understanding the different phases helps manage expectations and navigate this period calmly.
Immediate postoperative phase (days 1-7)
The first days are marked by significant oedema (swelling), bruising, and a sensation of facial tightness. These symptoms are normal and expected. Pain is generally moderate and well controlled by analgesics — most patients describe discomfort rather than frank pain.
An enhanced recovery after surgery (ERAS) protocol significantly reduces pain, opioid consumption, and hospital stay. According to one study, average pain scores are 2.5/10 with such a protocol.
Patients are generally allowed to return home the same day or after one night of observation. Home support is necessary during the first few days.
Swelling resolution phase (weeks 2-6)
Swelling begins to decrease significantly from the second week. It generally resolves "top to bottom": forehead first, then nose and cheeks, and finally jaw and chin.
Most patients can resume sedentary professional activity after 2 weeks. Bruising gradually fades and can be camouflaged with makeup.
A sensation of numbness or tightness is common at this stage. It corresponds to transient nerve inflammation and resolves progressively.
When does the face start to look feminine?
This is a frequent and psychologically important question. Due to swelling, the face may appear "puffy" or "strange" during the first weeks — this is not the final result.
From 4-6 weeks, most swelling has resolved and feminised contours become visible. This is often when patients begin to recognise themselves and appreciate the changes.
When are results final?
Complete stabilisation of soft tissues and bone contours takes 6 to 12 months. Some elements (scar maturation, skin adjustment) may continue to evolve up to 18 months.
For patients who have had rhinoplasty, the definitive nasal result is generally not visible until after one year, due to progressive tissue retraction.
Results and realistic expectations
What FFS can change
FFS can significantly modify:
- The shape and projection of the forehead
- The position and arch of the eyebrows
- The openness and expression of the gaze
- The shape and size of the nose
- The contour of the jaw and chin
- The prominence of the Adam's apple
Prospective studies show significant improvement in facial femininity scores: the median score increases from 47.2 before surgery to 80.6 after six months or more. Gender appearance is rated as "feminine to very feminine" by external observers.
What FFS cannot change
FFS does not modify:
- The voice (a separate voice surgery exists)
- Skin texture (hormone effects are complementary)
- Facial hair (laser or electrolysis hair removal remains necessary)
- The size or shape of the ears (unless Otoplasty (Ear Surgery) is specifically performed)
FFS also does not guarantee systematic "passability" or absence of discrimination. It is one tool among others in a transition journey.
The role of perception and self-image
Satisfaction after FFS depends not only on objective results but also on psychological factors. Studies show that patients who had surgery younger and with shorter waiting times have higher overall satisfaction scores.
It is normal to go through a period of psychological adjustment after surgery. Recognising oneself in a new reflection takes time. Psychological support can be beneficial during this period.
Long-term stability
Bone FFS results are permanent. Once bones have consolidated, modifications are definitive. Only the natural effects of ageing on soft tissues may slightly modify appearance in the very long term.
Soft tissue procedures (fat grafting, fillers) may require touch-ups over time.
Risks and safety in facial feminisation surgery
Like any surgical procedure, FFS carries risks. It is important to know them to make an informed decision, while placing them in context.
Overall safety profile
US national data (NSQIP) on 77 patients shows a 30-day postoperative complication rate of 3.9%. This rate is comparable to other elective facial surgeries.
The number of procedures performed during the same intervention does not significantly increase complication risk, which validates the combined approach when medically appropriate.
General risks
- Bleeding and haematoma: rare, but may require drainage
- Infection: infrequent, generally responds to antibiotics
- Anaesthesia reaction: evaluated during pre-anaesthetic consultation
- Unfavourable scarring: risk of widened scar or alopecia at scalp incision sites (observed in approximately 10% of patients, treatable with hair grafting)
Nerve risks
Procedures on the forehead and jaw carry a risk of nerve injury:
- Sensory disturbances: a temporary decrease in sensitivity of the forehead, lips, or chin is common and generally resolves within weeks to months
- Motor injuries: the facial nerve (frontal branch) may be affected during forehead contouring, causing transient brow weakness. Permanent damage is rare with an experienced surgeon
Asymmetry and revisions
Slight asymmetry may persist or appear after consolidation. Revision rates vary between studies: approximately 15% of patients who underwent forehead contouring require additional intervention (brow lift revision, scar revision, bone touch-up).
The importance of surgeon experience
FFS is a highly specialised surgery. The best results are achieved by surgeons with craniofacial surgery training and significant experience in gender-affirming surgery. Surgeon choice is one of the most decisive factors for safety and result quality.
Cost of Facial Feminization Surgery
Why do prices vary so much?
FFS cost varies considerably depending on several factors:
- The number and complexity of procedures performed
- The surgeon's experience and reputation
- The country and city where the procedure is performed
- Facility fees (clinic, anaesthesia, hospitalisation)
- Whether postoperative follow-up is included in the package
Price ranges in Belgium and Europe
In Belgium, the cost of comprehensive FFS generally ranges from €15,000 to €35,000, depending on the extent of procedures. Belgian clinics are recognised for their technical expertise and personalised approach.
For comparison:
- Spain: €10,000 to €25,000
- Western Europe generally: €15,000 to €50,000
These fees usually include surgical fees, anaesthesia, clinic stay, and osteosynthesis material. Preoperative consultations, imaging studies, and postoperative follow-up may be charged separately depending on the facility.
Per-procedure vs global pricing
Some clinics offer "à la carte" pricing (per procedure), while others work with global packages. The package approach may offer better financial predictability and encourages coherent planning.
It is essential to request a detailed quote including all foreseeable costs.
Reimbursement and coverage
In Belgium, as in most European countries, FFS is generally not covered by mandatory health insurance when performed for aesthetic purposes.
Some mutual funds or supplementary insurance may offer partial coverage, particularly when FFS is performed as part of a documented transition pathway. Conditions vary considerably between organisations and evolve regularly. Verification with your insurer is essential.
FFS cost represents a significant investment. A transparent discussion with the surgical team allows evaluation of options and realistic financial planning.
Is FFS right for you?
The decision to undertake FFS is deeply personal. This section offers some points for reflection.
Personal motivations
Ask yourself these questions:
- Which aspects of my face generate dysphoria?
- Are my expectations realistic relative to surgical possibilities?
- Do I have enough information to make an informed decision?
FFS can be transformative for people experiencing dysphoria related to specific facial features. However, it is not an obligation in a transition journey, and some people choose not to pursue it.
Psychological readiness
The period surrounding surgery can be emotionally intense. Anticipation, recovery, and adaptation to a new reflection require psychological resources.
Studies show that 75.9% of FFS candidates have a mental health diagnosis (mainly anxiety and depression). Psychological support before and after the procedure can promote a better overall experience.
The importance of specialist consultation
A consultation with a surgeon specialising in FFS allows:
- Objective evaluation of facial features
- Discussion of the most relevant procedures
- Visualisation of expected results (3D simulation)
- Obtaining a personalised quote
- Asking all necessary questions
This consultation is an exchange, not a commitment. It helps clarify whether FFS corresponds to your needs and expectations.
A multidisciplinary approach
FFS generally fits within a broader transition journey. Coordination with other professionals (endocrinologist, psychologist, GP) allows coherent and safe care.
The decision to consider facial feminisation surgery is personal and deserves complete, honest information tailored to each situation. A specialist consultation allows evaluation of the procedure's relevance, discussion of expected benefits, and understanding of its limitations in a safe medical environment.
