The sex reassignment process from male to female (MTF) involves a host of feminisation procedures, including breast surgery, facial feminisation surgery and voice surgery, as well as MTF sex change surgery and hormone therapy. This article discusses the many feminisation procedures involved in an MTF transition. 

For biological males wanting to transition to females, sex reassignment is a complex process involving a number of therapies and sex reassignment surgeries. The goal of all surgical procedures is to reduce “male” characteristics, making the body look more “feminine” or even androgynous, according to personal preferences. Sex change surgery is a big part of the transition process, but it does not end there. You can read a detailed account of sex change genital surgery from male to female in the procedures section of this website. The article covers the complete range of MTF genital surgical operations, including the removal of testicles (orchiectomy), the penis (penectomy), and the surgeries involved in creating the vagina (vaginoplasty), the labia (labiaplasty) and the clitoris (clitoroplasty).

The goal of this article is to discuss all the other feminisation procedures, including facial feminisation surgery (FFS).

Non-genital surgeries in male to female transitions

Are the bodies of women so different from those of men that a whole host of procedures are necessary to make a trans woman appear more feminine or less masculine?

Yes. Male and female bodies have very different structures that we rarely think about. Here is a list of feminisation procedures that can be used to enhance the impact of hormone therapy and genital surgery, together with the expected outcomes.

  • Breast augmentation surgery or augmentation mammoplasty is typically achieved by inserting silicone breast implants to make the breasts larger.
  • Facial feminisation surgery makes surgical changes to the nose, forehead, chin, jaws, cheeks, lips, eyes and ears. A close examination of male and female facial structures shows significant differences between the sexes. Each of these procedures attempts to make the masculine features less prominent and highlight or enhance the feminine aspects.
  • Thyroid cartilage reduction is commonly referred to as shaving down the Adam’s apple. The technical terms of tracheal shave or chondrolaryngoplasty are also used for this procedure. In some cases this cosmetic procedure can be combined with voice surgery.

There are a number of other surgeries not considered essential, but that individuals may feel are important for their transition. This list is by no means exhaustive.

  • Voice surgery is intended to raise the voice pitch to more closely resemble a female voice. It involves surgery on the vocal cords or the surrounding cartilage.
  • Abdominoplasty or abdominal lipoplasty may be necessary in some cases to remove fat and excess skin from the stomach.
  • Hip or thigh implants are inserted to make these areas more rounded and feminine.
  • Scalp surgery treats male-pattern baldness, a common condition among men. It involves various surgical procedures such as hair transplants, grafting and removal of the bald skin in strips.

The rest of this article provides more detailed accounts of the above procedures.

Breast augmentation

Breast augmentation, or augmentation mammoplasty, is a key part of the feminisation process. The procedure is very similar to surgery performed on females wanting to enhance their breast size. However, since the chest of a male transitioning to female is structurally different from that of a non-trans woman, it is necessary to work with a breast surgeon who has experience and expertise in working with trans women.

We are not discussing breast augmentation here in detail because a detailed article on the topic (not, however, transgender specific) is in the procedures section of this website.

Facial feminisation surgery (FFS)

It is hard to distinguish male and female infants by looking only at their faces. During puberty however, testosterone causes many changes in the male body that affect the development of the skull, facial bones and cartilage in the face and neck. These changes make the male face distinctly different from the female face. By the end of puberty, the basic structure of the face and neck is completely formed, and any further changes can only be achieved with surgery. While hormone therapy can make facial skin softer and cause minor changes in the soft tissue of the face, hormones cannot change basic structures.

Not everyone wanting a MTF transition undergoes face and neck surgery, but many feel these procedures allow them to reduce their gender dysphoria. The choice is up to each individual, as are the extent and the number of procedures they undergo seeking more feminine features.

Surgery on the bones or cartilage of the skull is one type of FFS. Another is surgical work on the soft tissue that covers the bone and cartilage structure. The first type deals with changing the basic structure of the face to make it look more like a female skull and involves invasive surgery. Once the basic structure is changed, less invasive soft tissue work allows for fine-tuning to suit personal preferences. Sometimes, if only small changes are needed, soft tissue changes alone may suffice.

Facial feminisation surgery involves changes to the forehead, chin and jaws, cheeks, lips and ears.

Forehead surgery

Foreheads of men and women differ in three key aspects. Men have a flat slope between the hairline and brow while women’s skulls are rounder. Men have a heavy bony ridge above the eyes; women do not. The distance from the eyebrows to the hairline is longer in men, even without male pattern baldness, which makes it more pronounced.

Forehead surgery removes these differences or makes them less prominent. Potential forehead procedures include a brow shave to remove the bony ridge, forehead implants (bone fillers) to make it curvy and forehead reconstruction. A brow lift or forehead lift can tighten the skin of the forehead and raise the eyebrows. Scalp advancement brings forward the scalp and the hairline.

Surgery of the chin and jaw

Typically, male chins are wide and square; female chins are narrow and pointed. The distance between the bottom lip and the base of the chin is smaller in women. Backs of the male jaws are fuller and have a sharper angle, flaring away from the face. Women’s jaws are typically curvy from ear to chin and less square. Men also tend to have more prominent chewing muscles.

Chin and jaw surgery can make these differences less prominent, producing a more feminine shape. Chin and jaw procedures include removal of bone and some muscle to make the back of the jaw less prominent. Shaving and reshaping the chin bone make it tapered, less square and shorter. And surgically rotating the jaw can make the chin and back end of the jaw appear smaller. Implants (bone fillers) can help in cases of a receding chin. Liposuction can remove excess fat under the chin, making the lower face appear less heavy.

Nose reshaping surgery

Typical nose reshaping surgery or rhinoplasty involved in facial feminisation includes making the bony bridge of the nose flatter, making the nose thinner by reducing the width, shortening the nose by removing cartilage from the tip and making the nostrils narrower. Sometimes surgery on the bridge of the nose is recommended when forehead surgery makes it necessary to make the profile smoother.

Cheek augmentation

Cheek augmentation with bone grafts, fat implants or synthetic implants can emphasise the cheekbones, making them more prominent. This effectively makes the chin and jaw look smaller. It is also possible to cut and reposition the cheekbone.

Surgery on the lips

In facial feminisation surgery, the lips can be changed in a number of ways. Removing skin from between the nose and the top lip can raise the upper lip. The angle between the nose and upper lip can be changed. Lip implants can be used to make the lips fuller and more feminine.

Ear pinning and earlobe surgery

Ear pinning surgery or otoplasty and making the earlobes smaller are the ear surgeries involved in the facial feminisation process.

Voice surgery and the tracheal shave

Increase in testosterone at puberty has a great influence on the size and shape of the vocal tract. This influence is greater in males than in females and results in the cartilages of the larynx growing larger and thicker in males, increasing in height as well as front-to-back dimensions. The Adam’s apple is created with the thyroid cartilage getting tilted to a different angle in the neck. This tilt also changes the position of the vocal cords. In men, vocal folds grow longer and thicker. They vibrate more slowly than do female vocal folds.

Men develop more room in the mouth, nose and back of the throat, increasing the voice box’s capacity to resonate. Men have deeper voices than women due to changes in the larynx caused by higher levels of testosterone. Men’s laughter and coughs also carry a deeper sound than women’s do.

Because there is great variation among individuals, the differences between men and women can vary. How high or low-pitched the normal voice is depends on the individual. Because people have the hardware needed for a variety of pitches (whether they use them or not), speech therapy can help MTF trans people attain a pitch that they feel is appropriate for them. Voice changing surgery is necessary only if the change is not completely achievable with speech therapy.

Vocal tract surgery in MTFs aims to raise the voice pitch by shortening the vocal folds or reducing the total mass of the folds. Increasing the tension on the folds can also achieve this aim. This procedure is also known as pitch elevating surgery. Sometimes it may be possible to combine this surgery with the laryngeal shave, which reduces the size of the Adam’s apple.

The decision to have feminisation procedures

Whether you feel you need these procedures, and which ones you need are entirely personal decisions. Not every trans woman undergoes feminisation surgery. But, just as we say for everyone wanting cosmetic surgery, if you decide to go ahead with the above procedures you should do so for the right reasons.

It is important to thoroughly research your options. You may find the Costhetics article on Do Your Homework useful in this context.

Usually, trying to please others or trying to live up to their standards is not considered the right reason for seeking cosmetic enhancements. Practically all the surgeries discussed in this article are considered to be cosmetic. But in this instance, for trans women whose aim is passability, obtaining feminisation surgery can help make things easier.

Most of these procedures are considered cosmetic, rather than medically necessary, and therefore neither Medicare nor private insurance are likely to pay for them. You will have to check with your insurance provider to see which procedures, if any, are covered by insurance.

Other resources you may find useful

Here’s a time-lapse video or a trans woman who has undergone feminisation procedures as part of her gender change process.

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