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Facial feminization surgery (FFS) is mainly a reductive procedure of bony structures. This is done on such facial areas as the brow bones, cheeks and jawline/chin. To do so the subperiosteal stripping of the attached soft tissues is done. Between the soft tissue release and the subsequent bone reduction, the overlying soft tissues need to contract down and heal to the reshaped bone. How successful this soft tissue contraction is will vary based on the age of the patient, where they are in the aging process and how much bone reduction is done. Incomplete contraction and soft tissue laxity will occur in some patients as a result.

Experience in similar forms of facial bone reductions in non-gender affirming surgeries has a known association of undesired soft tissue laxity in some patients after surgery. Similar adverse soft tissue effects have been known for a long time in various setback orthognathic surgery procedures. It should be no surprise, therefore, that it will occur in some FFS patients as well.   

In the January 2022 issue of the journal Plastic and Reconstructive Surgery an article was published on this topic entitled ‘Face Lift after Facial Feminization Surgery: Indications and Special Considerations’. The authors discuss this topic by reviewing preoperative counseling, timing of facelift surgery, and operative details.

It is important to point out to FFS patients that some procedures can create loose tissue in the midface and along the jawline and neck. This is particularly relevant in cheek, chin and jaw reduction operations. The older the patient is the higher is that risk. It may eventually take some form for facelift for the patient to achieve an optimal facial reshaping outcome.

The implantation of facelift surgery has been done both at the time of FFS surgery as well as a delayed secondary surgery. It would be logical to presume that doing a facelift at the time of FFS surgery has greater application to the older patient who may already have jowling and loose neck tissues. In younger patients with good quality soft tissue and no preoperative laxity delaying any type of facial tissue tightening until it is determined a significant problem exists would make the most sense.

In doing an FFS facelift, it is important to recognize that the skin and tissues may be thicker than in traditional cisfemales. Hormone therapy and facial hair removal treatments may alter this to some degree but not completely. The location of the incisions around the ear should be retrotragal in front and high and back into the hairline posteriorly. Skin flap elevation may need to be more anterior to the nasolabial fold and aggressive forms of SMAS techniques are advised.        

Dr. Barry Eppley

Indianapolis, Indiana

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