Can You Get FFS Twice?

Understanding the Nuances of Revision Facial Feminization Surgery

As a facial feminization surgeon with years of experience, one of the most frequently asked questions I encounter, particularly from individuals who have undergone prior facial gender-affirming procedures, is: “Can you get FFS twice?” The answer, in the vast majority of cases, is a resounding yes. However, the decision to embark on a second, or even a third, round of facial feminization surgery (FFS) is a complex one, requiring meticulous surgical planning, a deep understanding of anatomical limitations, and a realistic expectation of outcomes.

This comprehensive guide will delve into the intricacies of revision FFS, offering a surgeon’s perspective on the indications, challenges, and potential benefits. Our aim is to demystify the process, empower patients with knowledge, and provide a clear roadmap for those considering this transformative journey.

The Landscape of Primary FFS and the Emergence of Revision Needs

Primary FFS aims to modify facial features to align with a more feminine aesthetic, addressing bony and soft tissue structures that contribute to perceived masculinity. This typically involves procedures such as forehead contouring (including frontal bossing reduction and orbital rim reshaping), hairline advancement, rhinoplasty, cheek augmentation, lip lift, and jaw and chin recontouring (genioplasty and mandibuloplasty). While primary FFS yields deeply satisfying results for many, several factors can lead to the consideration of revision surgery:

• Incomplete Feminization: Sometimes, initial FFS may not fully address all aspects of facial masculinization, leaving residual features that a patient wishes to refine. This can be due to a conservative initial approach, limitations of the previous surgeon’s technique, or the patient’s evolving aesthetic goals.
• Asymmetry: Even with the most skilled primary surgery, subtle asymmetries can persist or become more noticeable post-operatively. Facial asymmetry is inherent to human anatomy, but significant or bothersome discrepancies can necessitate revision.
• Unfavorable Scarring: While surgeons strive for inconspicuous incisions, individual healing responses can lead to hypertrophic (thickened) or keloid scars, which may require revision.
• Undercorrection or Overcorrection: Bony recontouring, in particular, requires precise execution. Undercorrection means not enough bone was removed, leaving a masculine appearance. Overcorrection, while less common, can result in an unnatural or overly “scooped” appearance.
• Patient Dissatisfaction with Aesthetic Outcome: Aesthetic preferences are deeply personal. What one patient considers a successful outcome, another might find dissatisfying, even if technically proficient. This subjective dissatisfaction is a significant driver for revision.
• Healing Complications: Though rare, complications such as infection, hematoma (blood collection), or seroma (fluid collection) can affect the final aesthetic and necessitate corrective surgery.
• Evolving Aesthetic Goals: As individuals progress in their gender affirmation journey, their understanding of their desired feminine aesthetic may evolve, leading to new surgical goals that were not part of the initial FFS.

Understanding these reasons is crucial for both the patient and the surgeon, as they guide the diagnostic process and the formulation of a revised surgical plan. It’s important to note that the desire to get FFS twice is not a sign of failure in the initial surgery, but rather a testament to the dynamic and highly individualized nature of facial gender affirmation.

The Surgical Principles of Revision FFS: A Deeper Dive

Revision FFS is fundamentally different from primary FFS. It’s not simply repeating the previous operations. Instead, it’s a more intricate dance with altered anatomy, scar tissue, and often, compromised tissue planes. My approach emphasizes a meticulous understanding of the pre-existing surgical alterations and a conservative, yet effective, strategy.

Navigating Altered Anatomy and Scar Tissue

One of the most significant challenges in revision FFS is the presence of scar tissue. When tissues heal after surgery, they form fibrous adhesions that can obscure anatomical landmarks, limit tissue mobility, and complicate dissection. This scar tissue can also affect blood supply to the area, necessitating careful planning to preserve vascularity and promote optimal healing.

• Dissection Through Scarred Planes: Unlike primary surgery where virgin tissue planes are easily identified, revision surgery often requires careful, sharp dissection through fibrotic tissue. This increases the operative time and demands a higher level of surgical precision to avoid damage to nerves, blood vessels, and adjacent structures.
• Compromised Tissue Elasticity: Scar tissue is less elastic than normal tissue, which can impact the ability to redrape skin and soft tissues smoothly after bony recontouring. This is particularly relevant in areas like the forehead and hairline.

Specific Considerations for Common Revision Procedures

Let’s explore how revision principles apply to some of the most frequently requested FFS procedures:

Revision Forehead Contouring

The forehead is a cornerstone of facial feminization. In revision cases, addressing residual frontal bossing or an inadequate orbital rim reduction is common.

• Bone Management: If bone was previously removed, there’s less available bone to work with. The surgeon must carefully assess the remaining bone thickness and quality. Sometimes, small amounts of residual bossing can be burred down. In cases of significant under-correction or if the anterior table of the frontal sinus was previously removed (Type 3 forehead reconstruction), further recontouring might involve carefully burring down the remaining bone or, in rare instances, considering alloplastic implants to create a more feminine convexity.
• Hairline Management: If hairline advancement was performed, scar tissue can make a second advancement more challenging. The elasticity of the scalp may be reduced. In such cases, alternative methods like hair transplantation to fill in areas of recession or to soften the hairline might be considered in conjunction with or instead of further advancement.
• Orbital Rim Refinement: Reshaping the bony orbits for a softer, more open appearance is crucial. Revision here often involves meticulous burring to smooth any remaining supraorbital prominence or to subtly recontour the lateral orbital rims.

Revision Rhinoplasty

Rhinoplasty is notoriously complex, and revision rhinoplasty even more so.

• Cartilage and Bone Grafting: If too much cartilage or bone was removed in primary rhinoplasty, creating an overly “scooped” or pinched appearance, revision often necessitates the use of grafts. These can be harvested from the patient’s own septum (if available), ear, or rib cartilage. These grafts are used to rebuild nasal structure, improve projection, refine the tip, and correct asymmetry.
• Scar Tissue and Airway: Internal scarring can affect the nasal airway, necessitating careful release of adhesions during revision to improve breathing function.
• Defining the Feminine Dorsum: In revision, the goal is often to create a smoother, more refined nasal dorsum (bridge) and a slightly upturned, delicate tip, avoiding the masculine characteristics of a prominent dorsal hump or a drooping tip.

Revision Jaw and Chin Contouring (Genioplasty and Mandibuloplasty)

These procedures aim to reduce the angularity of the lower face and create a softer, more oval or heart-shaped contour.

• Bone Resection Limitations: If significant bone was already removed, there are limits to how much more can be taken without compromising mandibular integrity or facial aesthetics. Revision might focus on refining any remaining angles or asymmetry.
• Soft Tissue Redraping: After bony recontouring, the overlying soft tissues need to redrape smoothly. In revision, scar tissue can impede this, potentially leading to residual soft tissue laxity or irregularities. Surgical techniques to tighten the soft tissues, such as suspension sutures or even limited submental liposuction, might be considered.
• Symmetry and Proportionality: Achieving perfect symmetry is an elusive goal, but significant asymmetry can be addressed by further selective bone reduction or, rarely, the use of custom implants to augment a deficient side. The overall proportionality of the lower face to the rest of the face is paramount.

Revision Lip Lift

A lip lift shortens the philtrum (the area between the nose and the upper lip) and subtly evert (turn out) the upper lip, creating a more feminine appearance.

• Scar Revision: If the initial scar is hypertrophic or visible, revision often involves re-excising the scar and meticulous re-suturing with careful attention to skin tension.
• Amount of Lift: If insufficient lift was achieved, further removal of skin can be performed, provided there is enough philtrum length remaining and it won’t lead to an overly short or unnatural appearance. Overcorrection can be challenging to address and may require filler or fat grafting to restore volume.

The Comprehensive Consultation: Your Roadmap to Revision FFS

A thorough and honest consultation is the cornerstone of successful revision FFS. This is where both the patient and the surgeon establish realistic expectations and develop a personalized surgical plan.

Detailed Medical History and Previous Operative Reports

Before I even begin a physical examination, I request detailed medical records from previous FFS procedures. This includes operative reports, pre- and post-operative photographs, and any imaging studies (e.g., CT scans). This information is invaluable for understanding:

• What was done previously: Knowing the extent of bone reduction, the types of implants used (if any), and the location of previous incisions is critical.
• Potential Complications: Any history of complications, such as infection or nerve injury, needs to be thoroughly discussed and assessed.
• Healing History: How the patient healed from previous surgeries can provide insights into their general healing capacity and potential for scar formation.

Comprehensive Physical Examination

A meticulous physical examination of the entire face, paying close attention to both bony and soft tissue contours, is essential. This includes:

• Palpation: Feeling the underlying bone structure to assess the extent of previous reduction and identify any remaining prominences or asymmetries.
• Soft Tissue Analysis: Assessing skin quality, elasticity, and the presence of any irregularities or scar tissue.
• Nerve Function: Testing for any sensory or motor nerve deficits, particularly in areas like the forehead, jaw, and chin.
• Facial Proportion and Symmetry: A critical assessment of overall facial balance and the relationship between different facial features.

Advanced Imaging: The Role of 3D CT Scans

For most revision FFS cases, particularly those involving bone, a 3D computed tomography (CT) scan is indispensable. This imaging provides a detailed, three-dimensional view of the underlying skeletal structure, allowing me to:

• Visualize Previous Bone Work: Precisely identify areas of prior bone removal or augmentation.
• Assess Bone Thickness and Quality: Determine if there’s sufficient bone for further reduction or if bone grafting might be necessary.
• Identify Residual Masculine Features: Clearly pinpoint any remaining bony prominences that contribute to a masculine appearance.
• Plan Precise Bone Resection: Use the 3D data to plan the exact amount and location of bone removal with millimeter precision, minimizing the risk of overcorrection or damage to vital structures.
• Assess Soft Tissue and Airway: While primarily for bone, CT scans can also provide some information about soft tissue swelling and, in rhinoplasty revisions, the nasal airway.

Realistic Expectations and Psychological Preparedness

One of the most critical aspects of the consultation is establishing realistic expectations. Revision FFS can achieve significant improvements, but it’s vital for patients to understand:

• Limitations of Revision: There are anatomical and physiological limits to how much further feminization can be achieved, especially after previous extensive surgery.
• Potential for Complications: While striving for perfection, all surgeries carry risks, and revision surgeries can sometimes have slightly higher risks due to altered anatomy and scar tissue.
• Healing Time: The recovery process for revision FFS can be similar to primary FFS, and sometimes slightly longer due to the more complex dissection.
• Emotional Preparedness: Undergoing multiple surgeries can be emotionally taxing. I ensure that patients are psychologically prepared for the journey and have a strong support system. Referral to a mental health professional specializing in gender-affirming care is always an option if needed.

The Surgical Strategy: Precision and Patience

Once the comprehensive assessment is complete, a meticulous surgical strategy is developed. My approach emphasizes precision, patience, and a deep respect for the patient’s individual anatomy and aesthetic goals.

Anesthesia Considerations

Revision FFS, like primary FFS, is typically performed under general anesthesia. Given the potential for longer operative times and more complex dissection, a highly experienced anesthesiology team is crucial to ensure patient safety and comfort throughout the procedure.

Incisions and Access

Whenever possible, I utilize existing incisions from the previous surgery to minimize additional scarring. For example, if a coronal (headband-like) incision was used for forehead contouring, it will likely be reopened. Similarly, intraoral incisions for jaw and chin work can often be re-utilized. However, in some cases, new or extended incisions may be necessary to gain adequate access to the surgical field.

Sequential Approach to Procedures

I often perform revision FFS in a sequential manner, addressing the most critical areas first. For example, if both forehead and jaw require revision, I might focus on the forehead initially, as it significantly impacts overall facial perception. This allows for a logical progression and helps to maintain symmetry and balance throughout the various stages of the surgery.

Bony Recontouring Techniques

The techniques for bony recontouring in revision FFS are similar to primary FFS but are executed with enhanced caution and precision due to the altered anatomy.

• Forehead:
  • Burring: For subtle contouring of residual bossing or orbital rims, high-speed surgical burrs are used to meticulously sculpt the bone.
  • Osteotomies and Repositioning (Type 3 Revision): If a significant portion of the anterior frontal sinus wall was previously removed, or if there’s substantial remaining bossing, careful osteotomies (bone cuts) might be performed to reposition or reshape the bone. This requires immense precision to avoid the posterior sinus wall and brain. In some cases, a custom implant (e.g., PEEK or PMMA) can be designed based on the 3D CT scan to provide the desired forehead convexity and fill in any depressions, minimizing the need for extensive further bone work.
• Jaw and Chin:
  • Sagittal Split Osteotomy: For chin reshaping, a sagittal split osteotomy allows for precise repositioning of the chin bone (genioplasty) to achieve desired projection, height, and width. In revision, this might involve refining previous cuts or adjusting the bone segments for better contour.
  • Angle Reduction: For jaw reduction (mandibuloplasty), careful burring or ostectomies (bone removal) are performed to reduce the mandibular angle. In revision, this might involve addressing any remaining flare or asymmetry. Again, the 3D CT scan is invaluable here to avoid over-resection.

Soft Tissue Management

Beyond bone work, effective soft tissue management is paramount in revision FFS.

• Scar Tissue Release: Careful release of fibrous adhesions is performed to allow for better redraping of the skin and soft tissues, minimizing tension and promoting a smoother contour.
• Redraping and Suspension: After bony recontouring, the soft tissues are meticulously redraped over the newly shaped bone. In some cases, internal suspension sutures may be used to elevate and secure the soft tissues, especially in the midface or neck, to counteract gravitational effects and optimize the aesthetic outcome.
• Fat Grafting: Autologous fat grafting (transferring a patient’s own fat from one area to another) can be a valuable adjunct in revision FFS. It can be used to:
  • Fill Depressions: Address any residual contour irregularities or hollows.
  • Enhance Volume: Augment areas like the cheeks or temples to create a softer, more feminine fullness.
  • Improve Skin Quality: Fat grafting has regenerative properties that can improve the overlying skin texture and appearance, potentially even aiding in scar improvement.

Closure and Post-Operative Care

Meticulous layered closure is essential to minimize tension on the incisions and promote optimal healing and scar aesthetics. Post-operative care for revision FFS is similar to primary FFS, involving:

• Pain Management: Appropriate analgesia to manage post-operative discomfort.
• Swelling Reduction: Use of cold compresses, head elevation, and sometimes compression garments to minimize swelling.
• Drainage: Temporary drains may be placed to remove excess fluid and prevent hematoma/seroma formation.
• Activity Restrictions: Patients are advised to limit strenuous activity and heavy lifting for several weeks to allow for proper healing.
• Follow-up Appointments: Regular follow-up appointments are crucial to monitor healing, assess results, and address any concerns.

Potential Challenges and Risks in Revision FFS

While the prospect of getting FFS twice can be exciting for patients seeking further refinement, it’s crucial to acknowledge the potential challenges and risks that are often heightened in revision surgery.

Increased Operative Time and Complexity

As discussed, revision surgery is inherently more complex due to altered anatomy and scar tissue. This often translates to longer operative times, which can marginally increase anesthetic risks and post-operative swelling.

Scar Tissue Management

Managing scar tissue remains a primary challenge. While careful dissection and meticulous closure can help, the body’s individual healing response to prior surgery can influence the outcome of new incisions and the remodeling of existing scar tissue. In some cases, scar revision procedures may be required as a separate stage.

Risk of Nerve Injury

The facial nerves are intricate and delicate. In revision surgery, scar tissue can obscure nerve pathways, making them more difficult to identify and protect. While rare, the risk of temporary or, in extremely rare cases, permanent nerve injury (leading to numbness or weakness in facial muscles) can be slightly higher in revision settings. My priority is always meticulous dissection and constant vigilance to preserve nerve function.

Hematoma and Seroma Formation

Bleeding (hematoma) and fluid accumulation (seroma) are general surgical risks, and they can be slightly elevated in revision cases due to increased tissue dissection and altered vascularity. Careful hemostasis (controlling bleeding) during surgery and the use of drains post-operatively help to mitigate these risks.

Infection

Any surgical procedure carries a risk of infection. While rare with prophylactic antibiotics and sterile technique, the presence of scar tissue can sometimes make an area more susceptible to infection.

Compromised Blood Supply

Extensive previous dissection can, in very rare instances, compromise the local blood supply to certain tissues, potentially affecting wound healing. This is particularly considered in procedures involving large flaps of skin or bone.

Limitations of Further Correction

It is vital for patients to understand that there are limits to how much more correction can be achieved, especially if significant bone or tissue was removed in the initial surgery. Over-resection can lead to an unnatural or skeletal appearance. The goal is always to achieve a harmonious and natural-looking result, not simply to remove “more” bone.

The Psychological Impact and Long-Term Outlook

The journey of facial feminization, whether primary or revision, extends beyond the operating room. The psychological impact is profound, and the long-term outlook for revision FFS is generally positive, provided realistic expectations are maintained.

Addressing Body Dysmorphia and Dysphoria

For many trans individuals, FFS is a critical step in alleviating gender dysphoria. However, it’s important to differentiate between realistic aesthetic goals and body dysmorphia. If a patient exhibits signs of severe body dysmorphia, where their perception of their appearance is significantly distorted, further surgical intervention may not be the most appropriate solution without concurrent psychological support. A surgeon’s role extends to recognizing these patterns and referring to mental health professionals when necessary.

Patience with Results

The final results of revision FFS, like primary FFS, take time to mature. Significant swelling can persist for weeks or even months, and soft tissues will continue to settle. Patience is paramount during the healing process, and regular communication with the surgical team is encouraged.

The Importance of a Supportive Environment

A strong support system, including family, friends, and mental health professionals, can significantly contribute to a positive surgical journey and outcome. Having individuals who understand and affirm your gender identity and surgical goals is invaluable.

Lifelong Commitment to Self-Care

Maintaining the results of FFS, whether primary or revision, involves a lifelong commitment to self-care. This includes a healthy lifestyle, sun protection, and a good skincare regimen. While FFS is a permanent change to bony structures, the soft tissues will continue to age naturally.

Conclusion: Can You Get FFS Twice? Absolutely, with Expertise and Prudence.

To reiterate, the answer to “Can you get FFS twice?” is unequivocally yes. For individuals seeking further refinement or correction after initial facial feminization surgery, revision FFS offers a powerful pathway to achieving more harmonious and satisfying feminine facial features. However, it is a complex undertaking that demands a highly skilled and experienced surgeon who possesses a deep understanding of facial anatomy, the intricacies of previous surgical alterations, and the potential challenges of working in scarred tissue planes.

As a surgeon, my commitment to patients considering revision FFS is to provide:

• Thorough Assessment: A comprehensive evaluation, including detailed history, physical examination, and advanced imaging (3D CT scans), to meticulously plan the revision.
• Realistic Expectations: An honest and open discussion about the achievable outcomes, potential limitations, and inherent risks associated with revision surgery.
• Meticulous Surgical Technique: Precision, patience, and a nuanced approach to navigating altered anatomy and scar tissue, prioritizing patient safety and optimal aesthetic results.
• Comprehensive Post-Operative Care: Dedicated support throughout the healing process, ensuring close monitoring and addressing any concerns.

Revision FFS is not merely a second chance; it is an opportunity to refine and perfect the artistry of facial feminization, empowering individuals to embody their authentic selves with greater confidence and comfort. While the path may be more intricate, the transformative potential for those who seek it remains profound, offering a tangible step forward in the lifelong journey of self-affirmation. The journey to a truly harmonized facial aesthetic is often a multi-stage process, and with the right surgical guidance, getting FFS twice can indeed lead to a remarkably positive and fulfilling outcome.

Visit Dr.MFO Instagram profile to see real patient transformations! Get a glimpse of the incredible results achieved through facial feminization surgery and other procedures. The profile showcases before-and-after photos that highlight Dr. MFO’s expertise and artistic vision in creating natural-looking, beautiful outcomes.

Ready to take the next step in your journey? Schedule a free consultation with Dr. MFO ( Best Facial Feminization Surgeon for You) today. During the consultation, you can discuss your goals, ask any questions you may have, and learn more about how Dr. MFO can help you achieve your desired look. Don’t hesitate to take advantage of this free opportunity to explore your options and see if Dr. MFO is the right fit for you.