A Comprehensive Guide to Facial Masculinization Surgery (FMS)

Medically reviewed by Jennifer Richman on June 6, 2024.

Facial masculinization surgery (FMS) is a specialized set of procedures designed to enhance and accentuate masculine facial features for transgender, non-binary and gender non-conforming patients. Here we discuss specific procedures, benefits, costs, insurance coverage and more topics that patients commonly ask about when it comes to FMS. This gender-affirming surgical process aims to create greater harmony between a patient’s appearance and their gender or internal sense of self. If you are interested in undergoing surgery, you can request a free virtual or in-person consultation to create a unique surgical plan that meets your needs.

What is Facial Masculinization Surgery?

FMS refers to a series of procedures that patients can choose from to modify any of the three following parts of the face: the lower third (the neck, chin and jaw), the middle third (the nose, lips and cheeks) and the upper third (the eyebrows, forehead and hairline). The procedures that patients can choose from are very similar to the options for Facial Feminization Surgery (FFS). In most cases, FMS procedures seek to augment and/or make features more angular, as opposed to giving the face a softer, more conventionally feminine appearance. 

The following procedures are most commonly associated with FMS. That said, patients can choose to undergo any of the gender-affirming facial surgery procedures we offer and will not be limited to just the following list:

  1. Brow bone augmentation & hairline repositioning: The presence of a prominent, protruding brow bone is a common effect of a first, testosterone-dominant puberty. Patients who have a flat forehead or brow bone can elect to have the shape of their forehead augmented with implants. Augmenting the brow bone can result in a more conventionally masculine look. This procedure can be done by creating an incision at the hairline or the scalp. The hairline incision may create a visible scar at the top of the forehead, but this incision location can allow your surgeon to bring down a receding hairline. Creating an incision in the scalp, on the other hand, does not leave a visible scar on the forehead.
  2. Rhinoplasty: A rhinoplasty can augment or diminish the size of the nose bridge and the tip of the nose. Rhinoplasties can also help patients achieve a more symmetrical nose and alter its structure to correct any functional (i.e., breathing) issues.
  3. Jaw contouring and augmentation: Patients can opt to have the jaw contoured and/or augmented through the placement of implants. Your surgeon will create incisions inside of your mouth, at the base of your bottom gums, to insert the implants. Once you have healed from surgery, these will give the jaw a larger, more prominent and more angular appearance. If you have preferences about the specific shape or angles you would like your jawline to have, you can communicate them to your surgeon in a free consultation.
  4. Buccal fat removal: By removing the fat pads in the cheek using small incisions in the mouth, patients can achieve a more sculpted and angular contour to the cheeks. This may be a good option for patients wishing to reduce the fullness in their midface region.
  5. Genioplasty or chin augmentation: Similarly to a jaw augmentation, your surgeon can also augment your chin.
  6. Tracheal Augmentation:  A thyroid cartilage enhancement (also known as Adam’s Apple Augmentation) is a technique that involves making the appearance of an Adam’s Apple. This is achieved by taking cartilage from the ribs to create a natural cartilage implant that mimics the appearance of an Adam’s Apple. This procedure is performed in a way to not alter the vocal cords. Also, this procedure often involves creating a small incision in the neck or under the jaw. The latter creates a far more concealable scar.

The specific combination of procedures will be tailored to each your unique facial structure and gender-affirmation goals. You can create a unique surgical plan with Dr. Ley or Dr. Facque by requesting a free consultation with them today.

Which FMS procedures should I choose?

Given the number of options available for facial surgery patients, it can sometimes be overwhelming to figure out which ones would be right for you. Our practice offers the following tips for patients who are having difficulty deciding which procedures they would like to undergo:

  • Many of our patients find it helpful to come into the consultation with pictures of people whose facial features they would like to have–for example, a family member. Having a visual representation can help your surgeon figure out which surgical options can best help you accomplish your goals.
  • Some patients find it helpful to reflect on what features of their face bring them dysphoria and/or what changes would bring gender euphoria. Having a sense of which parts of your face you would like to alter can help your surgeon figure out which options might best suit your unique needs.
  • After a consultation, some surgeons offer their patients the option of creating a 3-D digital rendering of what your facial surgery results could look like. Digital renderings are never completely accurate, but they can help you gain a sense of what facial surgery can do for you.
  • If cost is a limiting factor for you, you can request a cost-specific breakdown of each procedure after your initial consultation to see which procedures will fit in your budget.
  • In the informational video below, Dr. Facque (he/him) gives some tips for how you can make the most out of your free surgical consultation, where you and your surgeon will create a plan for FMS.

Who is eligible for FMS?

Both Dr. Ley and Dr. Facque use the informed-consent model to determine surgical eligibility for legal adults. Informed consent determines eligibility based on a patient’s ability to make a decision about whether or not surgery is the right choice for them once they have had the proper education about its risks and benefits. This model is designed to prevent providers from unnecessarily gatekeeping access to medically necessary, gender-affirming care. 

Other considerations we take into account for surgery include:

  1. Overall health: You will be asked to disclose your medical history to your surgeon to help us create a plan that will keep you safe through surgery. This includes any medications you are currently taking, your drinking and smoking habits, if you have a disability, if you have any medical conditions and if they are being monitored and/or treated.
  2. BMI: There are no strict BMI requirements for facial surgery. Your surgeon will create a unique surgical plan to minimize the risk of complications based on your medical history. For example, patients with certain health conditions might need to stay the night in the hospital after surgery.
  3. Hormone replacement therapy (HRT): We have no HRT requirements for facial surgery candidacy as many of our patients do not undergo HRT. That said, per WPATH’s Soc 8 recommendations, many providers recommend that patients who are undergoing testosterone HRT wait until 1-2 years of treatment are complete before pursuing facial surgery. This is because it can take 1-2 years for physical changes in the face (like fat redistribution) to peak. Patients who have undergone testosterone HRT may see changes in the shape of their jaw and the volume of their cheeks, for example. This could influence their decision about which FMS procedures would be right for them.
  4. Have a strong support system: A strong support network of family, friends, support groups and/or mental health professionals can be invaluable during the recovery and healing process. Especially for more intense surgeries like FMS, we strongly recommend that patients have a strong support network going into surgery
  5. Have realistic expectations: It’s crucial to have realistic expectations about the potential outcomes and limitations of the surgery, as well as an understanding of the recovery process.
  6. Insurance coverage: If you would like insurance to cover your FMS, you will need to meet certain support letter requirements. These are discussed below.

Costs and insurance coverage

The cost of FMS can vary, depending on which procedures you choose to undergo. Patients who are able to secure insurance coverage for their procedure can drastically reduce their out-of-pocket costs.

Patients who are interested in paying for surgery with insurance will be assisted by our free insurance concierge service. Our insurance advocacy team has successfully helped over 90% of interested patients secure full or partial coverage for their gender-affirming procedure. In order to prove that FMS is medically necessary, you will need to present a support letter from a licensed, mental health professional. Likewise, if our surgeons are outside of your plan’s in-network providers, you will need a referral letter from your primary care provider. For more information, click here.

Cash-pay patients are those who will not be using insurance to cover the costs of surgery. These patients may pay all surgical costs out-of-pocket, use medical credit to finance their surgery and/or be the benefactor of a gender-affirming surgery grant. For more information about these resources, click here.

The total price for FMS can range from $4,500 to $100,000 for cash-pay patients. For a more detailed cost-breakdown of gender-affirming facial surgery, click here.

The good news is, insurance has been covering gender-affirming facial surgery more than ever before. In the video below, Dr. Facque describes how you can figure out if your plan will cover the costs of surgery.

https://www.youtube.com/watch?v=G9lqSSJN4DI&ab_channel=GenderConfirmationCenter

Benefits of Facial Masculinization Surgery

Undergoing FMS can provide numerous physical and psychological benefits for patients. These include:

  1. Improved psychological and emotional well-being: Various studies have shown that gender-affirming procedures, including facial surgery, can significantly improve mental health outcomes by reducing anxiety, depression, and overall distress related to gender dysphoria.
  2. Increased Self-Confidence: By achieving a facial appearance that better aligns with your gender identity, patients often experience a significant boost in self-confidence and overall self-esteem.
  3. Reduced Gender Dysphoria: FMS can help alleviate the feelings of gender dysphoria associated with having certain facial features, promoting a greater sense of congruence and well-being.
  4. Improved Social Interactions: With a more masculine facial appearance, individuals may feel more comfortable and confident in social situations.

Recovery from Facial Masculinization Surgery

Recovery from facial surgery can vary greatly from patient to patient, depending on the specific procedures they undergo. Below are some general guidelines you can keep in mind for the FMS procedures listed above. For a more detailed guide on recovery, click here.

  • Leaving the hospital: While FMS can be an out-patient procedure for some patients, others might need to stay the night in a hospital after surgery. Regardless of when you are discharged, you will need to be picked up by someone who will take care of you.
  • Around-the-clock care: Generally speaking, for the first 72 hours after surgery, you should be accompanied by someone around-the-clock. You will need help administering medications and icing your face every hour to keep down inflammation. 
  • Pain and inflammation: Pain and inflammation will be at its peak during the first week after surgery. Depending on the procedures you undergo, you will likely leave the hospital with gauze over your incisions and bandages wrapped around your face as compression helps contain inflammation. Patients will likely be taking prescription pain medications for the first few days after surgery, during which they should not operate a vehicle. We recommend keeping your head elevated at all times and keeping snug compression garments or bandages on the face as much as tolerable for the first week after surgery. Swelling around the eyes, mouth and neck can be uncomfortable to tolerate, but patients can expect swallowing, opening the eyes wide, and other tasks to get easier as swelling improves.
  • Diet: We recommend that patients follow a low-to-no-sodium diet to reduce swelling during the recovery period. If there are any incisions in the mouth–from a jaw or chin augmentation–you will need to maintain a soft food diet for at least two weeks. Eating hard or sharp foods can pre-maturely open the incisions and delay healing.
  • Emotional recovery: Facial surgery not only involves an intense recovery process, but also requires great patience as you wait for one of the most visible parts of your body to heal. The physical toll and long healing timeline sometimes give patients temporary feelings of post-operative depression and even regret. For this reason, we encourage patients to lean on their loved ones and mental health professionals for the emotional hardships that may come up during recovery. 
  • Physical activity: It is important to go on daily walks to reduce the risk of blood clots. For the first week, just walk around your house. Take care to avoid stairs, cluttered areas, loose rugs, and any other obstacles that could result in slips, falls, or injuries while you’re taking narcotics or have increased swelling around the eyes.
  • Final results: Facial surgery can be one of the most difficult gender-affirming procedures to recover from. Even after the first month of healing, inflammation will continue to decrease over the course of the first year. Likewise, it will take at least a year for scars to fully mature and for ligaments in the face to settle after surgery. For this reason, we generally tell patients that they will need to wait 12 months after facial surgery to see their final results.