Facial feminisation surgery in the UK: A plea to give it serious treatment

Abstract

Facial feminisation surgery (FFS) is a set of aesthetic gender-affirming facial surgical (GAS) procedures to make a face appear female. This type of surgery is largely undertaken in transgender women with gender dysphoria. However, some of these procedures may also be utilised in cisgender women who feel that some aspects of their faces are too masculine. The goal of FFS is to help the transitioning person gain social recognition as a woman.1 Historically, FFS was developed in the 1980s by Dr Douglas Ousterhout, a plastic surgeon in San Francisco, who examined several hundred dry skulls in the Atkinson skull collection at the University of San Francisco to characterise the differences between male and female skulls and distinguish these features in the adult skull. From this work he was able to develop surgical procedures that could feminise masculine adult skull features.2, 3 The principal surgical procedures available for FFS are: forehead and orbital contouring, hairline advance, brow lift, cheek augmentation, rhinoplasty, lip lift and augmentation, chin reduction, angle shave and taper, and thyroid cartilage shave, all of which are fully within the remit of the oral and maxillofacial surgeon. Additional procedures that may be offered include hair removal and hair transplantation.4 There is no doubt that in the United Kingdom (UK) and abroad, FFS is developing as a specialty of oral and maxillofacial surgery in its own right. However, provision and funding in the UK are extremely variable. There is no formal training or education for surgeons wishing to practise FFS, but over the last few years, interest in it and its popularity have been growing, and the number of patients wanting this surgery as part of their transition has increased significantly. It is important to appreciate that most patients presenting for FFS are self-referrals. Some, but not all, are under the care of a gender identity clinic (GIC), and if so, many will be on a long waiting list for treatment. However, there is no requirement for psychiatric consent before this surgery is undertaken. Notably, in recognition of the increasing interest in, and popularity of, FFS, the Annual Scientific Meeting of the BAOMS in July 2024 devoted a well-attended session to FFS, with talks on the treatment of the upper and lower third of the face and the role of orthognathic surgery, and on revisions and complications, along with a patient�s perspective.