A testosterone puberty reshapes the face, growing the brow ridge, nose, jaw angles and chin, and forming an Adam's apple in the neck. Oestrogen softens skin and moves fat into the cheeks but cannot reverse bone changes, which is where facial feminisation surgery comes in.
What does a testosterone puberty do to the face?
Quite a lot, and almost all of it happens in the bone. The frontal sinus, which is an air space behind the forehead, grows and pushes the bone forward. That is what creates the brow ridge. The forehead then slopes back more, and the eyebrows end up sitting lower and flatter than they would otherwise.
The nose grows larger. The jaw becomes wider at the angles, the corners just below your ears. The chin becomes taller and squarer. Lower down, the thyroid cartilage in the neck grows to form an Adam's apple.
None of this is a fault or a failure on anyone's part. It is simply what testosterone instructs a growing face to do. If you went through that puberty and it never felt like yours, the discomfort you feel when you look in the mirror has a physical explanation, and it makes complete sense.
What does oestrogen change in the face?
Oestrogen later on does lovely things to the face. I'm a woman, so I would say that, but it really is true. Skin softens and fat moves into the cheeks, which can make a big difference to how a face looks and how it is read by other people.
What oestrogen cannot do is reverse changes to bone. Once the brow ridge, the jaw angles and the chin have grown, hormones will not shrink them back. That is not a reason for despair, and it is not a sign that treatment is not working. It is just the limit of what a hormone can reach, and it is the reason a surgical option exists.
If you want to explore the hormone side, GenderGP can help with access to affirming medical care, including hormones, prescribing and monitoring.
What is facial feminisation surgery?
Facial feminisation surgery, often shortened to FFS, is a set of procedures that reshape the bone and soft tissue of the face. It is not one operation. People choose the parts that matter to them, and plenty choose none at all. Here is what each part does.
Hairline and forehead
Hairline surgery can bring the hairline forward and round off the corners. Forehead contouring reduces the brow ridge. If the bone is thick enough, the surgeon can simply shave it down. If the sinus sits right behind it, the front wall of the sinus is carefully removed, reshaped and fixed back in a flatter position.
Brows, cheeks and lips
A brow lift can raise the eyebrows into a more arched, feminine position. Cheeks can be enhanced with fat grafting or implants. A lip lift shortens the space between the nose and the upper lip, which testosterone tends to lengthen.
Jaw, chin and neck
The angles of the jaw can be reduced, and the chin can be narrowed or shortened. A tracheal shave reduces the Adam's apple.
Is facial feminisation surgery only for trans women?
No, and this is the part I love. Every one of these procedures is also performed on cis women who want a softer brow, a smaller nose or a more delicate jaw. Faces sit on a spectrum, and the bones underneath are just the same bones.
That matters because trans women are sometimes told that wanting facial surgery is vanity, or proof of something, or somehow different in kind from what any other woman might want. It is not. A woman who wants her brow softened is a woman who wants her brow softened, whoever she is. Surgery simply undoes some of the instructions that testosterone gave the face.
Do I need facial surgery to be a woman?
You do not. Your gender is not decided by the shape of your brow, your jaw or your Adam's apple, and no face is the wrong face for a woman. Some people have surgery because the way their face looks causes them real distress, or because it affects how they are treated every time they leave the house. Some are perfectly happy with the face they have. Both are right, because there is no right way to transition. There is only your way.
It is also worth asking what you are actually hoping the surgery will change. Is it how you feel when you look in the mirror? Is it being misgendered by strangers? Is it something about a particular feature that has always felt wrong? Knowing which of those is driving the wish will help you work out which procedures, if any, are for you. If you want to think it through out loud, that is something you can do with Sammy here.
What does it cost, and who pays?
This is the hard part. In many places, public health services treat facial feminisation surgery as optional or cosmetic, which means that for many people the cost falls on them. Surgeons who do this work well are relatively few, waiting lists can be long, and the price of a full set of procedures is considerable. I can't give you a figure that would hold across countries, so check what applies where you live.
That is an injustice, not a reflection of how much the surgery matters. For someone whose face is a daily source of distress, this is not a luxury. It is care that people are being asked to fund themselves because the system has decided their need is less real than other people's.
Does it matter when puberty care happens?
Yes. Everything above describes what happens when a testosterone puberty goes ahead and is later undone in part by surgery. Trans young people who are able to go through the right puberty at the same time as their peers do not develop these bone changes in the first place. It is one of the clearest practical reasons that delay in care does harm: puberty does not pause while a process runs, and bone growth is permanent.
Puberty blockers are medications that pause puberty, and they have been used for decades, including in care for precocious puberty. Access to them has been narrowed severely in the UK, where private supply to trans young people has been banned, and NHS prescriptions are close to impossible to obtain. The people who pay for that are trans young people and their families, sometimes for the rest of their lives. If it applies to you or someone you love, GenderGP can talk through what is available from a doctor who understands this area.
Where do you go from here?
Look at your own face with curiosity rather than judgement, and ask which parts, if any, you would like to change. Hormones can soften skin and move fat. Surgery can work on the bone. Neither is compulsory, and neither makes you any more or less who you are.
If there is a topic that you would like me to cover, just let Sammy know.
Dr Helen Webberley
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