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Putting Your Best Face Forward:
Feminizing the Face,
Soft Tissue Techniques


By Sheila Kirk, M.D.



(This is the second of a three part series that will deal with discussion of the surgeries available to those who desire facial feminization. In January, Part 3 will deal with the bony remodeling and re-sculpturing surgical techniques available.)

Plastic and Reconstructive surgeons today have such great capacity to project, plan, revise and remodel the human boday that it is no wonder that so many are considering this surgical approach early in transition and before moving toward genital reassignment.

As much as I understand the need for some to have anatomic congruity with one's mind, it is understandable that some would like to have facial and skull cosmetic surgery before undertaking genital change. I also believe that facial and body contouring can make sense for those of you who never will seek GRS.

In this second of three articles dealing with facial feminization, I want to concentrate on soft tissue procedures and save discussion of bone alterations until my January column. I don't want you to think that bone and soft tissue procedures are not often combined. They certainly are and have to be, to accomplish the plan designed for each individual. And keep in mind my last remark. In the consultation visit, a plan should be formulated by you and your plastic surgeon to reach a satisfying and successful set of results. To feminize - not just to demasculinize you - is the plan and to accomplish this feminization by making you unique, not like the other Transwoman before you or the one the surgeon does after you. A "tranny" face should NOT be the result of your surgery experience. In that I mean, you should not receive an obviously sculptured face that is as likely to draw as much negative attention as one who has never had facial feminization surgery. I am afraid we have all seen examples of what I am talking about.

Please be cautious of those surgeons who push a "cookie-cutter" approach and supply you with the same standard list of procedures that they supply to your friends. This "laundry list" approach with no consideration to the uniqueness of your face (or your friend's for that matter) is not in your best interest and frankly, in my opinion, is adopted by surgeons who have become complacent and have more interest in their bottom line than supplying you with what is best for you.

When evaluating the face, it helps to divide it into three segments, upper, middle and lower. In that division, however, it is most vital to project how changes in the upper third will affect the rest of the face and how changes in the lower third will have influence on decisions about alterations of the rest of the facial structures-and so on. Changes in soft tissue can be somewhat extensive like, for example, face and neck lifts. But subtle and simple procedures such as accentuation of cheek pads or elevation of the upper lip are important considerations as well. After healing those subtle changes can have powerful effect, even more than extensive alteration.

Let's look at some of these soft tissue remolding procedures. The eyes are the very first structures that people focus on in looking at you. Procedures to "open" the eyes change their shape and erase wrinkles and fat collections around them are often utilized. Blephosoplasty or surgical change in the eyelids, upper and lower, is a procedure that must be very carefully carried out so as not to produce too wide an appearance or too restricted lid activity. Often one can spot the person who has too vigorous an approach to the eyes. Their eyes look unnatural and not a part of their face. Delicate liposuction can take away the bulge appearance in the lower lid and slight elevation of the outer position of the eyes, the lateral canthus, can change the shape. The result is the almond shape eye we see in many of the most beautiful models.

In conjunction with those approaches to the eyes, one can soften greatly the ridges of bone above the eyes that are so thick and prominent in men. By making a small incision within the hairline of either side of the head, the surgeon can dissect down beneath the forehead tissue to expose these heavy bone ridges and allow for high-speed instrumentation to be applied to shave down the bone. The overall effect is two-fold. One, to soften these structures to appear as they are in genetic females. And two, to de-emphasize the concave appearance of the forehead as it is characteristically in men. With this approach often there is no need to actively correct the concave appearance although when that concavity is marked it will need special attention. That technique we will deal with in the next article. When we consider bone-shaving methods, another very simple technique is to make incision inside the lower lip and with dissection down to the chinbone a burr revolving at high speed can smooth down the bone thickness and prominences to make a female chin shape. While other bone removing methods are employed to soften and thin the jaw line, this very efficient surgery in particular is highly useful to feminize. Pain afterwards is minimal and ability to function fully, including eating, in a day or so is usual.

Much is spoken of in ways to emphasize more the cheekbones. The most prominent bone in this area, the zygoma, can be augmented with malar implants placed through the mouth into the cheek and this is a common approach. Often, however, the cheek pad can be emphasized to accomplish a very female appearance and this maybe a very worthwhile approach without placing a foreign body. A non-absorbed suture is placed in a very clever manner in the circumference of the cheek pad to elevate this structure. It is then attached to the scalp tissue above the hairline-simple and effective. When there are depressions in the temple area on each side various substances can be placed to fill and soften those depressions.

An area that is also commonly considered, is the middle third of the face and particularly the nose. Surgical techniques to remove the dorsal hump and change shape are utilized. The nasal openings can be made smaller and softened and a very important feature of the nose, the tip, can be fashioned to be petite and with a slight elevation as is fitting for the individual's whole face. In men, the lips are frequently thin and in a straight line -- the upper lip in particular. A very imperceptible incision made just beneath the nose, through which precise suturing is done will raise the upper lip to reveal more of the vermillion, and it can be shaped as well to have more contour. This lends allure and femininity to the mouth. Liposuction techniques to the chin, the neck as well as to the tissues under the eyes are exceedingly valuable. Removal of small deposits of fat can enhance other features to make for a most beautiful appearance.

When considering much more extensive procedures, one that comes to mind, is when hairlines are changed with deliberate and involved surgery. The frontal hairline in women is much closer to the eyebrows than in men. The forehead is not as broad or extensive in women. Placement of an expander through two, less than one-inch, incisions within the hairline on either side of the head, allows for stretching the hair bearing scalp. This is done under IV sedation and after 8-10 weeks of periodic injection of sterile saline into the expander by the patient, the stretched segment can be mobilized into a flap. This flap will be so placed with appropriate incision and suturing that the hairline is natural, lower, and the hair is growing in the proper direction. This technique is used to create parietal or side of the head flaps as well to eliminate male pattern baldness and other types of hair loss. This technique is very specialized and not utilized by many who work with various hair transplant operations. Dr. Ernest Manders, has refined this procedure with pioneering techniques that produce excellent results.

Sometimes to accomplish the most ideal results, various surgical procedures are staged. A certain few are done first. Then others are combined in a second stage to complete the plan after appropriate time has elapsed and healing has taken place. Not always is it possible to put too much together and at times it's inadvisable because in a second stage there could be the possibility that one technique can be eliminated or another one added or modified to accomplish a better result. Keep in mind, you also have an input to the plan to surgically alter the face and skull. Don't believe it is all the decision of the plastic surgeon. Very often what you desire is very easily implemented into the surgical plan. Still, I caution you, sometimes it is not and while marvelous changes are possible some unrealistic approaches may never be a consideration for you.

There is much to consider and to discuss when considering face and skull re-modeling. Keep an open mind-evaluate techniques, surgeon's philosophies, their costs and compare, compare, compare! Once again, please don't accept a set of procedures pushed by some surgeons as the only way to feminize a T face. It's a cop-out on the surgeon's part. A surgeon should always keep your individualism in mind and work with you to improve and enhance your best traits while feminizing you. Your face is often the first physical impression of yourself seen by others, consider carefully what you want and who you want to help you "put your best face forward."

Next month, I will concentrate on the bone (osteotomy) operations for the face and skull and some of the body contouring operations available to you.


Sheila Kirk, MD recently made Trans-history by forming the first Transgender Surgical & Medical Center (TSMC Center) developed and directed by a Trans surgeon. In addition, Dr Kirk is the first Trans-surgeon performing MTF GRS surgeries, breast augmentation and related surgeries. Together with her partners she also performs rib removals, male pattern baldness correction, craino-facial feminization, body and facial contouring and corrective procedures. You can receive more information about the TSMC Center or ask Dr. Kirk questions on your treatment and care, by contacting her at TSMC@aol.com, by phone (412) 781-1092, fax (412) 781-1096 or snail mail: TSMC P.O. Box 38366, Blawnox, PA 15238.

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