I laid down on a cold, steel table in the operating room and looked up at the fluorescent lights beaming down into my eyes. While taking a few shallow breaths, I began to graze the hard contours of my face with my fingers, knowing it would be the last time I would feel the square of my jaw, my long chin, the protruding bones in my forehead. For a moment, and only for a moment, I grieved the face of the girl who was forced to endure a male puberty. The girl who watched her face gradually masculinize over the years and who cried every day when she looked in the mirror. She was beautiful in her own way.
A sudden sense of calm coursed through my veins. My heart rate slowed and my thoughts stopped racing, a welcome change from the months of indescribable anxiety that preceded this moment. The anesthesiologist, his hand on my shoulder, told me to count back from 10. Uncertain but hopeful, I drifted off.
It was just over a year ago that I underwent facial feminization surgery, a radical procedure that some trans women undergo to eradicate the effects of testosterone on the skull that one experiences while undergoing a male puberty. The entire ordeal was transformative, but not in the earth-shattering manner that one might expect. It was a more gradual change that took many months to fully reveal itself.
Facial feminization surgery is an umbrella term to describe a set of procedures used to alter and soften masculine facial features to have a more feminine appearance. Depending on the needs of each patient, the cost of FFS can range from $30,000 to $50,000.
Like many trans women who have undergone FFS, prior to the surgery, one of my most pressing fears was that I would not be able to recognize myself following the surgery. But as Jeffrey Spiegel, a double board-certified facial plastic and reconstructive surgeon who specializes in FFS, explains in an interview with Allure, FFS is not about giving you a new face. It is about giving you the face you were always meant to have. Spiegel has a practice in Newton, Massachusetts and began his surgical career nearly 20 years ago as a facial and craniofacial plastic surgeon. At the time, transgender-specific surgeries had not yet gained consumer popularity or widespread medical recognition.
“Most people feel a great sense of relief — like a rebirth,” Spiegel says. “Patients are worried about looking completely different. When it’s done correctly, a transgender woman looks in the mirror and says, ‘I finally see my face.’ She sees her real face that has been hidden for her entire life. All the subconscious things that prevent her from being seen as the correct gender are fixed.”
For many trans women who undergo FFS, it's not to conform to cisgender female beauty ideals, but rather to alleviate feelings of gender dysphoria.
“A trans woman came to see me and asked me for help. She was very distraught and distressed about her face,” Spiegel recalls. “We discussed what could be done and we looked at the medical literature together. While there was information about sex-reassignment surgery, there wasn’t much information about facial surgery.” Spiegel began to research the skeletal differences between cisgender men and women, finding marked differences in their bone shapes and densities.
According to Spiegel, the forehead is the most prominent subconscious gender marker. Typically, cisgender women have softer and rounder foreheads while cisgender men have prominent brow ridges that shadow the eyes. During FFS, the forehead is commonly shaved down or reconstructed. Other feminizing procedures performed alongside forehead reconstruction can include hairline advancement, brow lift, jaw reshaping, chin reshaping, rhinoplasty, cheek augmentation, Adam’s Apple reduction, and lip augmentation.
Spiegel eventually operated with great success on the initial trans woman who came to him for help. She began referring others to him, and soon trans women from around the country began trickling into his practice through word-of-mouth marketing. “I realized this was uncharted territory and we’ve been helping thousands of women since then,” Spiegel said. “After FFS, trans women are able to move through the world more safely and avoid prejudice.”
Throughout his career, Spiegel has performed over 1,000 cases of FFS, and he’s not the only one who has taken on this specialty. In the past decade, FFS has become an industry of its own, with surgeons performing the procedure in many states and around the world. The number of clinics performing FFS is rapidly increasing every year, to the degree that most new patients must spend time on a waiting list.
But with its tremendous growth has come intense debate, particularly among members of the trans community whose beliefs about passing are varied and fraught. Conflicting ideas about FFS have also entered mainstream culture. In June 2015, it was revealed that trans celebrity Caitlyn Jenner underwent ten hours of FFS. Shortly after, trans actress Laverne Cox shared her own views on FFS, saying, “Years ago, I wanted really highly invasive surgical procedures to feminize my face. All these years later, I have the money to do it, but I don’t want it.”
Cox began the #TransIsBeautiful movement dedicated to embracing trans beauty in all of its glory. “All the things that make me uniquely and beautifully trans — my big hands, my big feet, my wide shoulders, my deep voice — all of these things are beautiful,” Cox said. “I’m not beautiful despite these things, I’m beautiful because of them.”
The complicated reality is that while FFS can provide trans women with remarkable relief, it also can produce the notion that there are essential differences between male and female faces. After all, when grouping together a specific set of cosmetic alterations as a means of “feminizing” certain features, there is, invariably, a troubling message that is communicated: that looking like a woman is uniform and that cisgender beauty standards are the norm from which transgender bodies deviate. For some trans people, this message reinforces restrictive stereotypes that ultimately fuel the same violence and discrimination that FFS is advertised as protecting trans women from.
Serving “realness,” as they say in the trans community, is often said to be the ultimate goal of transitioning, but in hindsight, I was real all along, regardless of what anyone thought about me.
And with the price tag of FFS often in the tens of thousands of dollars, there’s certainly an uncomfortable feeling that comes with contributing to an industry that profits from our pain. For the vast majority of trans women, FFS is not an attainable reality; in performing FFS procedures, surgeons are upholding an idealized notion of feminine beauty, but making it accessible only to a few.
That said, for many trans women who do undergo FFS, it is not for the purpose of conforming to cisgender female beauty ideals, but as a means of alleviating feelings of gender dysphoria. Gender dysphoria, as defined by the American Psychiatric Association, describes “a conflict between a person's physical or assigned gender and the gender with which he/she/they identify.” It is also important to note that for trans people, our feelings of gender dysphoria are not necessarily inherent to being trans. They are, at least partially, a side effect of living in a society that constantly tells us that being visibly trans is unacceptable.
Before undergoing FFS, I didn’t feel like I had a right to call myself a woman because I didn’t look cisgender. Whenever I would correct someone for misgendering me, I felt like I was asking a great deal of that person, to overlook their true perceptions in order to protect my feelings. I’ve since realized that I was wrong.
Serving “realness” is often said to be the ultimate goal of transitioning, but in hindsight, I was real all along, regardless of what anyone thought about me. Would I still have felt the need to have my face completely reconstructed if I lived in an ideal society that accepted me as a woman, regardless of my receding hairline, prominent forehead, and strong jaw? Perhaps not. But given the reality that there are oppressive systems and hegemonies of power currently in place that enforce narrow gender expectations and beauty ideals, undergoing FFS was the right choice for me.
Prior to having FFS, I had many questions about what I would end up looking like. During my various consultations, I was shown Photoshop renderings that predicted my results, but I knew that they were only partially accurate. Putting down a deposit and laying on the operating table was a remarkable leap of faith. I had to relinquish some of my bodily autonomy and trust that everything would turn out well.
When I woke up from the procedure, I was consumed by an unforgettable level of pain. All I wanted to do was scream, but I couldn’t open my mouth just yet because my jawbone had been shaved down and was being held together by screws. The recovery nurse handed me a mirror and reminded me that I was far from the final result.
“Don’t be frightened,” she said. “You have a lot of swelling and bruising.”
I begrudgingly looked at my reflection. My eyes were practically swollen shut and my face was covered in bruises and sutures. I looked like hell, to be honest. It was surreal to see myself so beaten and battered and even more surreal to accept that I had not only chosen to do this to myself but had also paid a substantial amount of money for it. Yet beneath the teeming anxiety, there was a quiet sense of relief as well. After a seven-hour operation, I would emerge as who I was always supposed to be.
After six months had passed and all of my swelling subsided, I was finally able to see how much softer and more refined my features were. It wasn’t a drastic change, but it was a powerful one. The greatest gift the surgery brought me was overwhelming peace of mind. Without the crushing weight of constantly wondering how I’m being perceived, I’m able to focus on more productive aspects of my life like work and relationships. I can now move through the world with my hair pulled back and without makeup and I don’t have to worry nearly as much about being gendered incorrectly. Ultimately, FFS didn’t make me more of a woman, but it did make the world more willing to accept me as one.
Read more stories about gender identity on Allure:
- What It's Like to Be Transgender and Face Dysphoria and Body Dysmorphia at the Same Time
- I Marked "F" as the Gender on My License Even Though I'm Nonbinary
- Coming Out as Transgender Only Made My Relationship Stronger
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