Choosing the right plastic surgeon to perform your facial feminization surgery can be a confusing and overwhelming process, for trans and cisgender women alike. Like any major decision in your life, it pays to do thorough research before making your final choice, because choosing the wrong surgeon could entail significant consequences. An inexperienced or unskilled surgeon may suggest procedures which are ill-suited for your facial features. Conversely, they may omit procedures that would be ideal for you simply because they are not comfortable performing what may be necessary. And of course, no one wants to seek out another surgeon to repair the work of the previous one, but unfortunately, that is a very common occurrence for FFS.
Facial feminization surgery, or FFS, describes a set of complex procedures designed to “feminize” the face. The concept and treatments were developed with transfeminine patients in mind in the 1980s, led by a San Francisco–based surgeon who devised measurements for a “normal” female appearance by surveying anthropological skeletal.
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Many people start out by searching for patient reviews online. However, these can be inconsistent and may also be completely inaccurate due to exaggerated reviews or comments. It has been brought to our attention by patients visiting our practice, for example, that some surgeons have offered cash incentives for promoting their practice online. It is wise to take a “buyer beware” approach so you can be fully aware of any pitfalls or red flags to look out for. To help make the process easier for you, we’ve put together a list of factors to avoid when choosing your FFS surgeon.
1. By Googling “best facial feminization surgeon” or a similar search term
If you start your search for an ideal FFS surgeon by googling “best facial feminization surgeon” or “best FFS surgeon in the world” don’t expect to get trustworthy results. This is because these kinds of Google rankings are very easy to manipulate. It’s better to start your research based on meeting surgeons in person and understanding the volume and quality of their work.
2. Making your decision solely based on “Before and After” pictures on the Internet
Many FFS surgeons display “Before and After” pictures of patients on their websites and on social media. However, it’s important to remember that image manipulation via Photoshop is a common marketing tactic. So keep in mind that although “before and afters” may seem impressive, you need to be wary of what you are seeing. Photos presented as representative of a surgeons work should be taken with the same camera, with the same lighting, against the same backdrop, and preferably with minimal makeup in both the before and after photos, with the hair pulled away from the face. Patients who share Instagram-worthy “after” photos with makeup from unusual angles and flattering lighting are only promoting their own vanity and provide little insight into the skill of the surgeon who performed the work.
3. Does the surgeon have an overabundance of positive reviews on social media?
Just to reiterate, it’s important to take all online reviews with a healthy dose of skepticism. If you see a surgeon being overly praised, tread carefully. Listen to your gut instinct. If a review feels overly positive, or not authentic, it probably isn’t. Social media and online “influencer campaigns” are becoming more and more common.
4. Alternatively, does your surgeon spend a lot of time on social media?
If your surgeon appears to be spending more time on social media rather than operating on patients that may be a red flag. Ideally, if your surgeon has a good reputation and is in high demand they should be too busy operating on patients, rather than commenting on Facebook.
5. Does your surgeon spend a lot of time flying around to conferences all over the world?
You may think it’s a good sign that your surgeon spends a lot of their time flying around the world to provide local patient consultations. How convenient. However, your surgeon likely isn’t very busy if they need to travel in order to solicit your business. The best surgeons are generally too busy operating to do that sort of thing.
6. How many FFS patient procedures does your surgeon perform in a year?
Your surgeon’s workload is a good indicator of the actual demand for their facial feminization practice. Ask them how many FFS surgeries they perform within a year. Top facial feminization surgeons will typically undertake 2-3 facial full feminization procedures a week, this equates to at least 100 or more a year. When it comes to facial feminization there is no substitute for experience. Beware, however, because you likely cannot be sure that your surgeon is telling the truth about how busy they are. We have personally seen surgeons misrepresent their experience at academic medical conferences to their peers, so there is nothing really stopping them from misrepresenting their experience to you.
7. Is your FFS surgeon just a plastic surgeon? Or are they also a qualified craniofacial/maxillofacial surgeon?
Most plastic surgeons are capable of performing the sum of the soft tissue procedures included in facial feminization. But for a successful and long-lasting facial gender confirmation surgery, ‘bone work’ on the facial skeleton needs to be performed by a highly skilled surgeon with craniofacial/maxillofacial training. Only surgeons cross-trained in both plastic surgery AND craniofacial surgery should perform the cluster of procedures that are typical for FFS. For example, forehead contouring involves the reshaping the bones of the skull to a more feminine shape so your surgeon must know how to work with the underlying skeletal structure of the face as well as the soft tissues. Your surgeon must also have a thorough understanding of how to manage complications when they occur.
Along with the technical skills of facial plastic and craniofacial surgery, your chosen FFS surgeon must also have the keen eye of an artist and a deep appreciation of facial aesthetic harmony to ensure a truly feminine and beautiful result. This may be an obvious factor but is sometimes forgotten when choosing an FFS surgeon.
8. Making your decision based on geographic location.
Top facial feminization surgeons are spread out across the world. So depending on your budget and needs you may want to travel to find the best surgeon for you. If you choose a surgeon based solely on geographical proximity you may be seriously limiting the quality of your choices. For most people, FFS is a major, one-time life event with significant expenses and major sacrifices made in terms of money spent and time needed for recovery. The quality of the work is something that should not be compromised. It makes no sense to arrange your FFS as if you were buying a new car. But unfortunately, many people do just that and end up seeking out another surgeon in a different city to revise the previous surgeon’s work.
9. Your friend’s FFS surgeon worked for her, so you’ll choose the same one.
You might go to a hairdresser that a friend recommends but the same is not true for facial feminization surgeons. Your friend may have had a positive experience but because everyone is different your facial feminization needs will not be the same as your friend’s. For example, if you need a specialized procedure such as a feminizing rhinoplasty (nasal surgery or “nose job”), you want to be sure that your surgeon has a good track record of performing rhinoplasties for men and women in general and also specifically for feminization. In fact, this procedure is one of the most-often requested FFS revision procedures because the ‘new nose’ needs to sit in harmony with your newly feminized features and unless your surgeon has had ample experience in performing rhinoplasties, the result may be less than optimal. It is easy to assume that an “FFS surgeon” will have comprehensive experience in all aspects of FFS but that is often not the case.
10. Have you checked your surgeon’s qualifications, credentials, training, or associations?
Often we assume too much about doctors who call themselves ‘surgeons’. Make sure you check all relevant education, training, qualifications, and certifications to confirm that your surgeon is legally qualified to undertake the plastic and craniofacial surgical procedures that are included in facial feminization surgery. They should have these qualifications clearly and proudly listed on their website and should not hesitate when you ask to see them or have them explained to you.
11. Is your FFS surgeon “Board Certified”?
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If your facial feminization surgeon is here in the US, you want to ensure that they are US Board Certified. This means that they have Board-certified status by The American Board of Plastic Surgery.
Alternatively, if your FFS surgeon is located overseas, do a bit of research and find out what the top plastic and craniofacial qualifications and associations are in that specific country, and make sure that your chosen surgeon has these attained credentials.
12. Do they treat you as a real human being or just a set of FFS procedures?
You’re about to make one of the most important decisions of your life, if not THE most important decision, so it can at times feel quite emotional and overwhelming. You want to make sure that your surgeon has a good “bedside manner”, is personable, and treats you like a human being and not just a set of surgical procedures. The same is also true for their clinic staff, ranging from the Physician’s Assistant to the front desk. You want to feel welcome and cared for every step of the way. You’ve already undertaken a significant effort to get to the point of making this momentous decision and their entire staff should support you in the continuation of your gender confirmation journey.
13. Does the surgeon perform FFS in a state-of-the-art hospital or private clinic?
Make sure you know the answer to this critical question. It’s all too easy to just assume that the surgery will take place in a hospital, but that may not always be the case. Ask your surgeon if your surgery is going to be performed in a state-of-the-art hospital or a private clinic. Although small clinics can make you feel as though you’re getting a more personalized level of service, they often may lack the specialized medical facilities that may be necessary in the event of an emergency. To ensure your FFS is done safely by a highly experienced dedicated FFS surgeon be sure to confirm the surgery will be performed in a hospital operating room.
14. Is the surgeon willing to operate on you without a consultation first?
Make sure that you meet your surgeon in person before going ahead with your FFS surgery. Not just on Skype, email or the phone. Especially if you’re traveling to another state or country, it may seem like an extra expense to visit their office for an in-person consultation beforehand but any surgeon with integrity would always want to meet you first for an in-person consult. The best FFS surgeons will want to do a complete interview and physical examination beforehand in order to recommend which specific FFS procedures will work for you.
A responsible surgeon will also want to determine the personalized scope of your FFS and what, if any, variances will be needed. Is this the best procedure for you at this time? Are there any non-surgical alternatives (for example reduction of the Masseter muscle)? Will you need more than the one surgical session? Or any specialized equipment or implants? Do you need corrective jaw surgery first for a misaligned bite?
Reluctance to have an in-person consultation beforehand should be a big red flag.
15. Does your surgeon actually specialize in FFS? Or is it something they do “on the side”?
As you may already know, facial feminization surgery is a highly specialized skill set and not something that just any plastic or craniofacial surgeon can perform. It takes years of studying, specialized training, and then obtaining a large experience in facial feminization surgery (FFS) – hundreds of surgeries- to do this type of surgery with success. If your surgeon does FFS “on the side” to their other general plastic or craniofacial surgery, we’d advise you to keep searching for a facial feminization specialist. You should also ask your prospective surgeon detailed questions about their practice. What procedures do they do? How much of their weekly work is specifically FFS? Another common issue is that surgical residents in training may suggest that they were trained in FFS surgery when in reality they simply assisted the primary surgeon. Watching a procedure and doing them on your own are very different things.
16. Does the surgeon undertake thorough pre-op planning and x-ray imaging?
The key to a successful FFS outcome is pre-op planning. Your FFS surgeon should order a full set of x-rays and measure every feature of your face down to the millimeter. Additionally, your surgeon should have access to the latest in imaging technologies such as Virtual Surgical Planning (VSP), a pre-operative planning method that is sometimes used when certain anatomical details are involved. It involves the visualization of a surgical procedure using 3D imaging software. The central benefit being that VSP assists in predefining each step of the procedure including goal planning and bone segment navigation to ensure a symmetrical and aesthetically beautiful result. Do not hesitate to ask your prospective surgeon about their pre-op planning procedures. Poor or inadequate planning procedures are a good indicator of an inexperienced surgeon.
Dr. Deschamps-Braly is a board-certified plastic and craniofacial surgeon specializing in facial plastic surgery, orthognathic (jaw) surgery, and craniofacial surgery for adults and children. He is also one of the world’s foremost leaders and innovators in facial gender confirmation surgery.
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