Facial Feminization

What is Facial Feminization Surgery?

Facial Feminization Surgery, or FFS, is the cosmetic procedure that aims to add or enhance feminine features of the face. Through Facial Feminization Surgery, masculine features of the face can be modified to appear more feminine and delicate. The surgery can involve one or many procedures and is uniquely tailored to each individual.

The goal of Facial Feminization Surgery is to modify the facial features just enough to give the impression of femininity, without altering the uniqueness of each individual. Under the care of a skilled and experienced surgeon, such as Dr. Toby Mayer, the results can be awe-inspiring.

Facial Feminization Surgery can be performed as a collection of staged or solitary procedures. Each area of the face is addressed separately, and various procedures may be performed depending on the desired outcome, the surgeon’s experience, and the individual’s needs.

 History of Facial Feminization Surgery

Although its popularity has dramatically increased over the past two decades, male to female surgeries can trace their origins back to the 1930s. Einar Wegener, a Danish artist, was making a successful career out of being a female impersonator. Born with two sets of reproductive organs, Wegener decided to undergo surgery to remove the male organs and make her physically just female. Einar Wegener then became Lily Elbe. Surgeons were successful in removing the male gonads and creating an artificial vagina for Lily. Next, Lily requested the addition of a womb, but unfortunately, she did not survive the procedure.

It wasn’t until the 1950’s that advancements in the field of plastic surgery and the knowledge of sexual hormones enhanced the growth of male to female surgeries, including Facial Feminization Surgery. Transgender individuals were able to take feminine hormones to soften their skin, develop breast tissue, and enhance more feminine body contours. In 1952, the U.S. print media covered the successful transgender surgery of Christine Jorgensen. The publication increased awareness and the popularity of hormonal and surgical options for transsexuals grew.

The 1980’s and 1990’s were the most influential for Facial Feminization Surgeries. Pioneered by facial plastic surgeon Toby G. Mayer of Beverly Hills, Facial Feminization became an integral part of male to female surgery.

Dr. Mayer started his practice in Beverly Hills in 1976. During this time there were no other facial plastic surgeons performing Facial Feminization in southern California. At this time these patients were having a difficulty coming out as transgender as this prevented them from further employment opportunities.

Not realizing how prevalent this demand was, as he had only heard of Christine Jorgeson and Dr. Renee Richards, Dr. Mayer began receiving referrals. In performing the Fleming and Mayer Flap Dr. Mayer was able to develop a means of doing forehead reconstruction along with hair replacement surgery. His transgender consultation rate increased. This led to the development of the hairline lowering surgery, forehead lifting and contouring of the supra orbital bone using the Irregular Trichophytic Hairline Incision. This trademarked incision allows the hair to grow through and in front of the incision area thus hiding the scar.

One of Dr. Mayer’s transgender patients asked if he knew of a way to raise the pitch of the voice. He said at this point he was not aware of techniques but would research it. After speaking with a famous laryngologist and running his ideas by him, he was told “this would not work”. Dr. Mayer and his patient decided to proceed with a new technique he developed as long as the patient signed a waiver in case it didn’t work or there was a problem. The surgery was performed and they were both amazed as the result was beyond their wildest dreams. Since his training was in ear, nose and throat he began performing the thyroid cartilage shave along with the Mayer Voice Feminization procedure. Dr. Mayer began doing more of these along with other Facial Feminization surgeries.Facial Feminization Beverly Hills

Today, the work of Dr. Toby Mayer of Beverly Hill, CA, and a few others, continues to take the world of transgender procedures to new heights. Dr. Mayer, specifically, has perfected many of the best techniques providing the most effective and attractive Facial Feminization results worldwide.  It’s no wonder that individuals from all over the globe travel to Beverly Hills for Dr. Mayer’s skilled and experienced touch.

His concept is easy – create a facial balance. Smaller features don’t necessarily equal femininity; everything needs to fit together. For example, if you made a small tiny nose on someone with a big head you would create something that patients and their friends would notice as being abnormal or strange. Dr. Mayer’s solution was to create a harmonious blending of all of the parts, i.e. create a nose that fits in a natural female fashion on someone with a larger skull. This knowledge came from what was originally stated by Da Vinci more than 500 years ago – that certain parameters of beauty would need to be maintained.

Dr. Mayer takes all features into consideration to make sure that changing one thing does not throw something else out of balance.  His goal is to make the patient happy with their surgery. They are the ones that will look at it every day, not the surgeon.

Candidates for Facial Feminization Surgery

Facial Feminization Surgery can be the ideal procedure for a variety of individuals depending on their goals, expectations, and overall health. Facial Feminization Surgery can be a life-changing procedure. A thorough consultation and evaluation with Dr. Mayer will help determine if you are a good candidate for Facial Feminization Surgery.

The Human Face

Society recognizes certain facial characteristics as feminine or masculine based on what is commonly expressed by the specific sex hormones. While basic differences exist between female and male faces, the degree of femininity or masculinity can vary greatly. Differences can be seen in practically every area from the shape of the skull to the contour of the skin. Rarely does one feature make a face feminine or masculine. Rather, it is the overall image and collection of features that creates the general impression. Here, we’ve outlined some basic features that can help guide individuals who want to know what characteristics will create a more feminine appearance of the face.


The masculine face tends to be more square with a wide, chiseled jaw, whereas an oval shaped face with a rounded hairline and more pointed (less square) chin is more feminine and soft. The feminine profile also tends to be more flat, while a backwards sloping forehead and longer, protruding lower half of the face is more masculine in appearance.


A male typically has a receding hairline while females have a more rounded hairline without future hair loss.


The forehead tends to be a distinguishing feature when it comes to masculinity or femininity.

The feminine forehead has a more rounded shape with a slightly flat front. The masculine forehead on the other hand, has a pronounced ridge above the brow, known as “brow bossing”.


Arched, thinner eyebrows positioned higher on the brow bone have a more feminine appearance compared to the thicker, straighter brows that typically sit lower on male faces.


Eyes in females appear larger due in part to the shape of the brow above and the cheek bones below. Collectively the structures of the upper face create a larger appearance to the eyes, which are typically considered more attractive and feminine.


Cheeks that are full and round are considered more feminine due to the higher and more pronounced cheekbones often seen in females. The leaner cheekbones of males tend to give the cheeks a hollowed look because they also carry less fat than female cheekbones.


One of the most common and useful changes during Facial Feminization Surgery is the modification of the nose. Feminine noses tend to be smaller with a narrow bridge, refined tip, upsloped profile, and less prominent nostrils compared to the masculine version. The feminine nose also typically has a greater angle between the lip and tip of the nose (more upturned).


A puckered, backward slope of the area between the upper lip and nose is considered feminine and is often and a desired look for those hoping to give a more youthful and sensual appearance to the mouth. Males tend to have a longer space above the upper lip. Full lips are desirable and attractive for men and women alike.


Another distinguishing facial feature with regards to femininity and masculinity is the jaw. Many believe that it is necessary to reduce or shave the jawbone to achieve a feminine look. However, in doing so, you create an imbalance or “light-bulb” appearance which again looks abnormal and strange. In reality, many female celebrities have strong jawlines and chins, such as Sandra Bullock, Savannah Guthrie, Keira Knightley and Angelina Jolie.


Masculine chins tend to be wide with a flat base and two corners that create a square. They are tall and thick, and it is not uncommon for masculine chins to have a vertical cleft in the middle. The feminine chin, on the other hand, is more diminutive, soft, and rounded.

Adam’s Apple

Probably the most masculine feature of the face is the Adam’s Apple. In males, the thyroid cartilage of the trachea is much more pronounced, creating a visible bump in the lower neck region. It is a very masculine feature but is sometimes seen in females.

Voice Feminization

Males have a deeper voice. The Mayer Voice Feminization Procedure was developed 40 years ago by Dr. Mayer to raise the pitch of the voice. The goal is for patients to be called “ma’am” on the telephone instead of “sir”. It is successful 90% of the time. Dr. Mayer has performed hundreds of these procedures and has had no breathing or airway problems or a negative change in the voice. The other procedure done in Korea works by fusing the vocal chords and is not done by Dr. Mayer.

The Consultation

An important part of Facial Feminization Surgery is the consultation to discuss desired expectations, goals, and any other concerns. During the consultation, Dr. Mayer will be interested in the details of your journey and your reasons for pursuing Facial Feminization Surgery. It’s important for your surgeon to have a good understanding of YOUR goals, desires, and expectations.

Additionally, general medical questions and concerns will be discussed, as well, along with any psychiatric history or emotional concerns. Your surgeon should also be informed of any allergies, medications, and supplements to avoid adverse reactions or interactions. Lifestyle, diet, activity, pre-existing health conditions and/or risk factors will also be discussed.

The size and shape of your face along with details of your facial structures and skin quality will also be evaluated. Photographs, and likely x-rays, of the facial bones will be taken to know what options exist and what approach would be best to accomplish the desired goals.

This is also the ideal time to ask questions and take in all that is involved in Facial Feminization. It’s normal to be excited as well as apprehensive for a surgery of this magnitude. Don’t hesitate to share your concerns, good or bad, with Dr. Mayer. Facial Feminization is so much more than just a cosmetic procedure. It has emotional and life-changing effects and should not be taken on without careful thought and consideration. All details of the procedure, risks, and potential complications will also be discussed before surgery takes place.

Once the decision has been made to undergo Facial Feminization Surgery, a pre-op evaluation will be performed, and some routine lab tests may be done to guard against any medical complications. You’ll be advised to stop smoking if you smoke, take or stop taking certain medications or supplements, and avoid taking any aspirin, anti-inflammatory drugs or certain herbal supplements, as they can increase bleeding.

The Procedure

The procedure for Facial Feminization Surgery may be performed under conscious sedation or general anesthesia in a hospital or ambulatory surgical facility. Since each Facial Feminization Surgery that Dr. Mayer performs is uniquely tailored to each individual, the steps may vary slightly. The steps below are generalizations to give an idea of the process:

Step 1: Anesthesia

For your comfort and the success of the procedure general anesthesia is administered through an IV. Some procedures, such as the thyroid cartilage shave and voice feminization, can be performed under local anesthesia or intravenous sedation which is enough to make you calm and probably sleepy but not full anesthesia.

Step 2: Surgery

As mentioned before, Facial Feminization Surgery refers to a collection of procedures that involve modifying facial features in order to create a more feminine appearance. Several procedures can be performed in conjunction with one another, or only one may be necessary; full Facial Feminization is not necessary for everyone. Procedures most commonly performed in Facial Feminization Surgeries include: hairline lowering (advancement), Fleming Mayer flap, brow lifting with forehead contouring (shaving of the supra orbital bone), cheek augmentation, rhinoplasty, lip augmentation (and/or lip lift), chin reduction and contouring, and thyroid cartilage shave (Adam’s apple reduction), with or without the Mayer voice feminization procedure.

Altering the Hairline

Since the forehead and hairline are two of the more distinguishingly masculine features of the human face, altering the hairline is typically the starting point for most Facial Feminization Surgeries. Paired with forehead length adjustment, the hairline advancement procedure helps give the forehead a softer appearance, while also counteracting the effects of male pattern baldness and a receding hairline.

The process begins with an incision of the scalp at the hairline which allows the scalp and hairline to physically be moved forward, immediately lowering the hairline, and elevating the brow. The hairline advancement may require tissue expansion in patients with male pattern baldness. The coronal incision method is very rarely done by Dr. Mayer since he feels the Irregular Trichophytic Forehead Incision is a superior result. Dr. Mayer feels that in patients who have significant hair loss the best result for hair replacement is the Fleming Mayer Flap method. Having done both transplants and the Fleming Mayer Flap for over 40 years he feels patients are most happy, if given the choice, with the Fleming Mayer Flap.

Incorporating hair transplants into the hairline lowering surgery also allows surgeons like Dr. Mayer to target areas of the hairline that need reinforcement without unnecessarily advancing parts that may not need advancing.

Forehead Modification

The masculine forehead can be made more feminine by surgically reducing the brow bossing and shaving down any hard angles. If the forehead bone is thick and the brow protrusion small, sometimes the brow bone can be directly shaved down to create a softer more rounded and feminine shape. Dr. Mayer’s procedure does not necessitate removing and replacing the bone.

Caution is taken to avoid shaving the bone down to much which can create a hole in the sinus cavities under the forehead bone. To avoid this, a lateral skull x-ray is performed.


Popularly known as a nose job, a rhinoplasty is the cosmetic procedure that contours the shape of the nose to a more feminine and attractive desired appearance. During a Facial Feminization Surgery, rhinoplasty aims to give the nose a more feminine profile in proportion to the rest of the facial features. While rhinoplasty performed during Facial Feminization Surgery does not differ from standard cosmetic rhinoplasty, a surgeon experienced in Facial Feminization can create better results because of their attention to the overall goal of the surgery, and creating a nose that is not too small for the skull and unbalances the face.

Cheek augmentation

In order to create the fuller, more rounded shape of the feminine cheek, cheek augmentation may be included in the Facial Feminization Surgery. Cheek augmentation is the cosmetic procedure that involves enhancing the cheeks by way of cheek implants or filler, such as Voluma. Dr. Mayer feels the results are too variable with fat grafting. Taking hormones may also result in mildly fuller cheeks.

Lip Lift

The amount of skin above the upper lip to the nose and below the lower lip to the chin can be adjusted to give a more feminine appearance. Shortening the space above the upper lip (the white part) can also give the lips a more puckered, pouty and feminine look. This small change can make a huge difference in the appearance of the face.

Lip Augmentation

The lips can be made fuller with fillers or with concentrated fat which is Dr. Mayer’s preference. This will make the red part of the lips fuller and more sensuous.

Chin Modification

Also known as a genioplasty, this procedure modifies the chin, whether it be to enlarge it or reduce it. The procedure usually involves making incision under the chin. If the chin requires a reduction, which is more common in Facial Feminization Surgery, the bone and protrusions are shaved down and contoured for a more feminine appearance.  If a chin augmentation is recommended, the chin bone can be modified by inserting a chin implant to make the chin more noticeable.

Jaw Surgery

An important nerve runs through the jaw bone, therefore there are limits to how much the jaw bone can be surgically reduced. A skilled and experienced surgeon such as Dr. Toby Mayer, however, can expertly smooth any strong angles of the jaw, producing a gentle, more feminine curve when the jawline requires it. Again, Dr. Mayer is hesitant in performing this procedure as it can create imbalances such as the “light-bulb” appearance.

Adam’s Apple Reduction

Also known as a thyroid cartilage shave, this procedure reduces the Adam’s apple, which is much more prominent in the masculine neck. Occasionally, an incision is made at the Adam’s apple or in a natural crease near it.

Voice Feminization

An incision is made in a natural crease in the neck. The sole purpose for this procedure is to change the pitch of a male voice into the female range.  It will not help you sing better or strengthen your voice.  It allows you to better conform to a female if your voice sounds female.  You will be pleasantly surprised to find that you can listen to patients who have gone through the Voice Modification procedure.

The Fleming Mayer Flap

This is the most magnificent form of hair replacement in the world – it is one of the few things in life that is actually better than you hoped it would be.  Our patients have total freedom of styling – they can comb their hair in any direction, go swimming, or put the top down on a convertible.  And that is total freedom!  Density, just like the rest of your hair, will grow forever.  This, of course, takes a real surgeon – an aesthetic surgeon that can design your hairline to go with your face.


Step 3: Recovery

Once your Facial Feminization Surgery is over, you will have bandages placed around the operated areas to minimize swelling and keep things in place. You will be taken to a recovery room or suite until sedation wears off. Prior to being released home or to wherever you will be staying after your procedure, you will be given specific instructions. These instructions often include the following:

  • Homecare of your surgical site(s)
  • Activity restrictions
  • Sleeping positions – with most facial surgeries, sleeping upright or reclined is typically recommended
  • Ointments to apply or medications to take orally in order to aid healing and reduce the risk of infection
  • Dates and/or intervals of follow up visits
  • Signs of infection or other concerns that warrant a call to your specialist or seek immediate medical attention for


The Results

Although the specific changes may be subtle, the overall transformation can be life changing. Facial Feminization Surgery can be a pivotal point in an individual’s life by helping them display their true identity to the rest of the world. Visit our Before & After photo gallery to see some of our inspiring photos and stories.

If you’re wondering if Facial Feminization Surgery is the right step for you, or if you are debating about which procedures to choose from, please call our office today. Dr. Mayer and his experienced and caring staff with be more than happy to hear your story, your desired outcomes and discuss what options are best for you. Together we can formulate a plan that is tailored specifically for you and your goals.