The term “facial feminization surgery” refers to a number of procedures that can be performed to give the face a softer, more traditionally feminine appearance. These can include both bony and soft tissue surgeries of the face, neck, and thyroid cartilage, often complimented by laser hair removal. While each patient will have unique needs, typical FFS procedures include brow lift with bossing, scalp advancement, nose reshaping, blepharoplasty, tracheal shave, cheek implants, lip lift, lip and cheek implants, cheek softening, and face/neck lift. Combined, these procedures can offer the transwoman a greater degree of harmony between her inside and outside self, increase her self-esteem, and allow her to “pass” more effectively.

There is no one feature that defines a “feminine” or “masculine” face. Rather, the degree of femininity expressed in a human face is typically the result of the combination of multiple facial features, and the ratio of feminine to masculine features. Facial features traditionally considered masculine include brow bone bossing, a prominent nose and chin, thick eyebrows, a square jaw, a long face, and a visible Adam’s apple. In short, men tend to have chiseled, more angular features. In contrast, women usually possess softer, rounder facial characteristics—a smooth forehead without bossing, a pointed chin, a more delicate nose, fuller cheeks, and an arched brow. Generally, facial feminization is achieved through bone reduction and changes to the skeletal framework.

Because every patient is unique, Dr. Antonetti doesn’t believe in a “one-size-fits-all” approach. Instead, we opt to work with each patient to design a unique treatment plan tailored to your individual needs. Dr. Antonetti is not only highly skilled technically, but has the aesthetic and artistic awareness to know what constitutes a feminine face. During a consultation appointment, he will meet with you to assess your facial structure, discuss your needs, and answer any questions you have about FFS and the recovery process. Most transwomen elect to have all facial feminization procedures performed at once, or in two phases (upper face and lower face). If performed all at once, FFS usually takes between 6-12 hours. In general, patients who undergo FFS will stay overnight after their procedure and return home the following day. Some swelling and discomfort is expected, but this typically resides after about 7 days, with full recovery expected within 3-4 weeks.

During the breast augmentation procedure, which is also known as augmentation mammoplasty, implants are placed either over (sub-glandular placement) or under (sub-muscular placement) the chest wall muscle. Placing the implant under the muscle can create a more natural look, but recovery time and pain tend to be a bit more with this method. In order to place the implant, the surgeon will make a small incision near the breast area, then create a pocket that will hold the implant. Possible locations for the incision include the areola, axilla (armpit), or the bottom of the chest muscle. Dr. Antonetti can help you to decide which technique is best suited for your unique anatomy.

Breast augmentation is a very common and safe procedure. Typically, the surgery takes about one to two hours to complete. It is usually performed on an outpatient basis using general anesthesia, which means that the patient is asleep during the procedure. Dissolvable sutures are placed during the surgery, and the patient will wear an ace bandage around the breasts until the first post-op appointment.

Several types of implants are currently available, including both saline and silicone options. Dr. Antonetti prefers to use smooth, round, moderate or high profile implants. Mentor, the maker of these implants, offers a 10-year warranty in case of rupture and guarantees them for life. While both saline and silicone implants can offer excellent results, silicone implants tend to look a bit more natural compared to saline implants. This type of implant can be a good option for transwomen, who tend to have less breast tissue. However, silicone implants do require a larger incision for placement, which means that any post-surgery scarring will also be more significant. Dr. Antonetti will work with you to weigh the pros and cons and choose the best implants for your needs.

Many breast augmentation patients have questions about what they’ll experience during the recovery period. Fortunately, recovery time tends to pass fairly quickly with this procedure. Most patients are able to return to work in about one week. During the first few days post-surgery, rest is extremely important. Use of the arms should also be limited during the first week, which means no driving, lifting, or reaching. The breasts will likely feel tender and swollen, but most patients report that their pain is mild to moderate. You’ll be sent home with a prescription for medication to address any pain issues. Breast massage is an important self-care technique that will improve your body’s ability to heal from the surgery—you’ll be taught this technique at your post-op appointment.

Because breast augmentation is such a safe procedure, complications are infrequent and tend to be minor. However, possible complications include hematoma (a collection of blood under the skin), sensory changes of the breast or nipple, firming of the breasts due to scar tissue, infection, poor healing (often related to tobacco use), and reactions to the anesthesia. Additionally, there is the potential for leakage or rupture of the implant itself—about a 1-2% chance of rupture per year.

While breast augmentation is similar for trans and cis gender women, transgender women do have some special considerations to keep in mind. Generally, the transgender woman has a broader chest and shoulders, so a larger implant may look more natural and proportional. Additionally, transwomen tend to have slightly lower nipples, which means that the natural breast crease may need to be lowered during surgery so that the nipple is properly centered on the implant. Finally, compliance with after-care measures is particularly important for the trans patient. Transwomen typically have a larger pec muscle that causes the implant to be held higher on the chest wall, but diligent breast massage and compression will allow the implant to “drop” into a more natural position.

In order to obtain the best possible results from surgery, the transwoman will ideally have taken hormone therapy for at least 12 months before undergoing breast augmentation. Initiating hormone therapy will result in nipple growth and the development of some breast tissue, which means that the surgery is likely to be more successful, with better cosmetic results.

As the patient, it’s very important to have realistic expectations going into breast augmentation surgery. While your breast augmentation will result in fuller, more feminine breasts, the results may not be perfect. Augmented breasts tend to look and feel somewhat different than natural breasts, particularly in transwomen who undergo breast augmentation in middle-age or beyond. The breasts may be firmer, rounder, and slightly further apart. Transwomen who are considering breast augmentation can try out implant sizers to get a better idea of how their breasts might look and feel after surgery. Additionally, patients should keep in mind that some scarring is inevitable with breast augmentation, as this procedure requires that a surgical incision be made. Good self-care measures after surgery can help to minimize scarring.

Due to genetic variation and the effects of sex hormones like estrogen and testosterone, men and women tend to have different facial characteristics. In contrast to the average woman’s facial structure, men usually have longer, larger, and more angular faces. Men typically also display a more prominent and protruding brow bone, which is known as “bossing”, along with a larger and higher chin. Other facial features that are generally perceived as masculine include a prominent nose, thick eyebrows, a square jaw, and a visible Adam’s apple. In contrast, facial features that are considered more feminine include an absence of bossing, a smaller chin and nose, fuller cheeks, and an arched brow. No one facial feature defines a traditionally masculine or feminine face; rather, these traits are achieved through the combination of various features and the ratio  of male to female characteristics. With FMS, the goal is to achieve a masculine appearance while taking the patient’s overall facial proportions and anatomy into consideration. Facial masculinization surgery typically involves a combination of procedures tailored to the individual patient’s unique needs and goals. Procedures that may be performed during FMS includes rhinoplasty, chin implants, blepharoplasty and mastectomy. Dr. Antonetti will work with you to choose the ideal combination of procedures in order to achieve the very best possible results.

There are a number of surgical techniques that may be utilized to accomplish the desired breast tissue removal. The most common technique is called a “bilateral mastectomy with free nipple grafts”. This technique allows for the removal of essentially all of the breast tissue (including milk ducts) and excess skin, along with proper placement and downsizing of the nipples. This technique is utilized most frequently because the majority of patients present with a combination of excess skin and a naturally low nipple position.

The peri-areolar, or “keyhole”, technique consists of breast tissue removal through a small incision around the nipple. This technique carries the advantage of significantly reduced scarring. However, a relatively small number of patients are considered good candidates for this procedure. The suitable candidate for this type of mastectomy is typically the young, slim patient with a small amount of breast tissue, no excess skin, and a nipple position that does not require modification. Dr. Antonetti will perform a physical examination and work with you to choose the best mastectomy technique for your anatomy and unique needs.

Some patients have inquired about the possibility of using a “pedicled” technique to preserve sensation to the nipple; however, this technique is often unsuccessful in maintaining nipple sensation. We generally do not recommend this technique for transmen because it necessitates leaving a fair amount of breast tissue and does not result in an optimal male chest appearance.

Patients who have a very large amount of breast tissue or chest wall fat tissue may benefit from combining lateral chest wall liposuction with their mastectomy. The decision as to whether or not this is needed will be made at the time of the consultation, or as determined by pre-operative photos in the case of our out-of-town patients.

While our patients are usually very happy with the outcome of their procedure, it is important to have realistic expectations going into surgery.  While top surgery can help you to gain a more traditionally masculine appearance, your chest may not look “perfect” following surgery.  Swelling and bruising are to be expected after mastectomy, so final results may not be evident right away.  Ultimately, your results will depend on the specific mastectomy technique used, along with your individual anatomy and body characteristics.  Dr. Antonetti will work with you to ensure that you obtain the very best possible results.  Additionally, performing weight-training exercises to build muscle mass both before surgery and after recovery can enhance your results.

Patients who have undergone top surgery often wonder if their breasts will “grow back” if they gain weight.  Because this procedure removes the actual breast tissue (rather than just fat tissue), patients would have to gain a substantial amount of weight for the chest to recover a feminine appearance. Keep in mind that the results of top surgery are considered permanent and are not reversible.

As with any surgery, there are potential complications associated with cosmetic mastectomy.  However, this is considered a very safe procedure, and most patients feel that the benefits outweigh the risks.  Possible complications include bruising, swelling, nausea and vomiting, blood clots, infection, seroma (i.e., fluid build-up), and poor reaction to the anesthesia. Top surgery is generally performed under general anesthesia, which means that you’ll be asleep during the procedure.  It is common to experience diminished nipple sensation post-surgery, but typically patients do retain some sensation and most transmen actually report increased sexual satisfaction following their procedure (likely due to enhanced body confidence).

A pre-operative appointment will typically be scheduled one week prior to surgery for local patients, and one to two days prior to surgery for out-of-town patients. It is essential that our office staff have all your health information at the time of scheduling in order to determine if any special requirements are needed (such as lab work or medical clearance). In addition, we follow the WPATH guidelines for transgender care, which means that a letter from your therapist is required prior to surgery. Patients who are over fifty years of age and those with significant underlying medical problems are required to obtain a medical clearance.

Out-of-town patients generally arrive two days before surgery. Please inquire with our office regarding area hotel accommodations, as we do work with a number of hotels to provide special pricing to our patients. The pre-operative visit is scheduled the day before surgery. At that time you will receive all necessary instructions, undergo the full nursing workup for surgery, and be examined by Dr. Antonetti.  This is an ideal time to ask any specific questions you might have about the procedure itself. It is also important to have a support person with you at the time of your pre-op visit. This person will help in assimilating the extensive amount of information and instructions given to you, and will typically be the person staying with you after surgery.

A special dressing will stay on the nipple graft for one week, but drainage tubes are no longer needed for this procedure. We have developed meticulous quilting techniques designed to reattach the skin flaps to the chest wall, thus eliminating the need for uncomfortable drain tubes. Postoperative discomfort is typically mild to moderate and is controlled by pain medication. Arm use should be restricted during the first week. This includes driving, lifting, or reaching. At one week normal daily activities may be resumed; vigorous exercise and weight-lifting can be resumed at 6-8 weeks post-surgery. Scars are permanent, but they should fade gradually over the first year after surgery; do not tan incisions during this time period. Dr. Antonetti can also provide you with instructions on techniques to speed the scar healing process.

We understands that each patient has his own unique needs and expectations, which is why we take an individualized, patient-centered approach to gender transition services.   During the preoperative consultation, Dr. Antonetti will take the time to discuss and understand your goals for gender transition.  Additionally, he’ll thoroughly explain each procedure and answer any questions you might have.  We want you to feel comfortable and happy with your decision to pursue top surgery with us, so please do not hesitate to let us know how we can be of assistance.