When I wrote my essay on puberty blockers, I didn’t mention anything about facial masculinization surgery (FMS). I am unsure whether I should revise the essay to mention FMS. I can confidently recommend facial feminization surgery (FFS). FFS is not something to take lightly, I know several trans women who have gotten FFS. They have good results, without long-term complications. Conversely, I do not know any trans men who have gotten FMS. I believe this is because FMS is more novel and experimental than FFS. The cost might be prohibitive as well. Moreover, FMS is additive while FFS is subtractive. This creates additional challenges for FMS, with respect to longevity and aesthetics. Here is all I know and can advise about facial masculinization procedures.
There are three types of facial masculinization procedures:
In my honest opinion, I do not think FMS is a good choice for the vast majority of trans men. Fillers are only temporary, and can become addictive. Filler addiction increases the risk of serious complications, such as tissue death and blindness. Implants involve screwing foreign objects to your skull, and carry the risk of infection and/or tissue damage. There is only one surgery that can be recommended. It would only benefit patients with a certain facial structure, and it only alters the chin. It is invasive, and can go wrong.
If you are considering FMS, do read the message from the supposed "first-ever successful case of FTM facial masculinization." He was horrifically botched, and urges others to "Love yourself, give yourself a chance, know that you are worth it." Not to be corny, but I recently watched Robert Hoge's "Own Your Face" TED Talk. I would encourage you to do the same, at least once, if you are considering FMS. It is truly an inspirational talk. Own your face!
Additionally, it may not be necessary to undergo these procedures. It is not uncommon for a biological man to have an unmasculine facial structure (i.e., a smooth brow, a slim jaw, a small nose). The textural cues associated with testosterone can override the structural cues, allowing one to pass for male. Diet and exercise can also make the face appear more chiseled.
....But yeah. At the same time, I believe in the capacity for adults to make decisions for themselves. The most responsible thing for me to do is explain the benefits and risks associated with each procedure. That way, you can truly make an informed choice. I don't think you should get any facial surgery or implants before age 25. Here is more information about fillers, implants, and surgeries:
Fillers are only temporary, lasting a limited number of months or years. They are not very good at achieving a chiseled facial appearance. Fillers can create “fat face”, where the face looks soft and wide, not rugged. They appear most natural when used to achieve subtle changes. If you have obsessive or compulsive tendencies, beware. Fillers can become addictive. Excessive use of fillers can lead to an unnatural, bloated appearance. They also multiply the risk of serious complications (e.g., blood clots, necrosis, scarring, loss of nose/lip, blindness).
Fillers can contain the following materials:
Hyaluronic acid (HA)
Semi-permanent fillers (e.g., hydroxyapatite or PMMA bone cements)
Hyaluronic acid (HA) is the best option for cheeks, chin, and jaw. HA is naturally produced by the body, while semi-permanent fillers are not. As a result, semi-permanent fillers carry greater risk of foreign body reactions and granuloma formation. Moreover, HA fillers are significantly more reversible than semi-permanent fillers. HA can be easily removed by dissolving it with hyaluronidase. On the other hand, semi-permanent fillers cannot be dissolved. They can require surgery to remove. Sometimes, it is impossible to completely remove semi-permanent fillers without damaging facial structures.
Reversibility is important for two reasons. For one, it allows you to undo an unsatisfactory cosmetic result. For two, it can save you from serious complications. Sometimes, fillers are accidentally injected into blood vessels, forming blood clots. These clots can choke off the blood supply to various parts of the face, causing disfiguring scars, necrosis, loss of parts of the face (e.g., nose, lips), or blindness. The risk of blindness increases when fillers are injected into the “dermal filler danger zones”. Two key danger zones are the glabella and the nose. Clotting in these areas can cut off blood supply to the eye(s), causing blindness. Semi-permanent fillers should only be considered for the nose. Because the nose is a danger zone, multiple filler injections increase the risk of clotting. Semi-permanent fillers can last longer than HA, thus requiring fewer injections. The nose should only receive filler injections from a cannela, in the hands of a very experienced practitioner. Filler injections to the forehead or brow are not recommended, because the glabella is a danger zone. A misplaced injection can cause blindness in one or both eyes.
An alternative to man-made fillers is a fat graft. A fat sample is harvested via liposuction, then injected into the face. I would advise against this. Fat grafts are more permanent than HA, and the cosmetic outcome is less predictable. If things go wrong, fat is difficult to remove. If things go wrong, they are difficult to remove. Moreover, the long-term cosmetic appearance is unknown. They could shift as the patient ages, causing an unnatural appearance that is difficult to reverse.
Implants are more permanent than fillers. With all implants, you have to worry about foreign body reaction, anaphylaxis, infection, revisions, and aging. Contrary to popular opinion, implants are not necessarily permanent. The skull changes shape as you age. This causes implants to lose their fit and aesthetic with age. In other words, you might have to get them removed or replaced -- especially if you get them at a young age. You also have to consider infection. Cheek and chin implants are often inserted through incisions in the mouth, in order to reduce visible scarring. This increases the risk of bacterial infection, where pathogens travel through the cut in the mouth to colonize the implant. Because implants can get infected at any point in time, they can require surgical removal in one’s lifetime. Additionally, it is common for patients to seek revision after getting implants. Even with customizable implants, it can be hard to get the shape right.
Before getting implants, consider your lifestyle choices. Implants are not a good idea if you participate in combat sports and similar activities. That said, I believe that implants can be a viable option -- at least, for cheek, chin, or jawline augmentation.
Facial implants are generally made from these materials:
Porous polyethylene (e.g., Porex, Medpor)
Silicone’s key advantage over porous polyethylene is reversibility. Silicone can be safely removed and replaced when necessary. It’s key disadvantages are aesthetics, bone resorption, and capsule formation. Similar to fillers, silicone can have a “fat face” effect. Because it is a soft material, it isn’t very good at creating a chiseled appearance. That said, well-placed silicone can create subtle but significant improvements. Bone resorption can occur when the implant is not placed or secured properly. It can also be caused by capsular formation, and inflammation. In addition to bone damage, fibrous capsules can cause an unusual lumpy appearance around the implant.
Conversely, porous polyethylene integrates into bone more easily. This reduces the risk of bone resorption, but makes it harder to remove the implant. Additionally, the material is harder than silicone, which can create a more chiseled appearance. This trade-off makes it difficult to decide which material is superior.
There are a couple of other things that trans men should consider. The first is age. If you get implants at a younger age, it increases the likelihood that you will have to get them removed. The second is fit. Stock implants come in two styles: masculine and feminine. Masculine styles are designed to fit the faces of biological men, while feminine styles are designed to fit the faces of biological women. Would a stock masculine implant fit correctly on a trans man’s face? An improper fit could create an unusual cosmetic appearance, and increase the likelihood of bone or tissue damage. I would hope this is not an issue. If it is, you might have to opt for custom implants, which are more expensive.
Forehead and brow implants are another story. These regions can be augmented with bone cement or a pre-formed implant. I am not an expert on these techniques, but I am wary of both. For one, I have concerns about the cosmetic result. The forehead and brow play important roles in facial expression. They crease and crinkle, and get wrinkled with age. I would expect facial implants to appear unnaturally smooth -- especially on a man's face. In terms of materials, I have a handful of concerns about the use of bone cement, namely:
Bone/tissue damage associated with in situ polymerization
Foreign body reaction
Bone cement implantation syndrome
Bone damage associated with implant loosening
Degradation of cosmetic appearance, with age
Difficulty removing the implant
Bone cement contains polymethyl methacrylate (PMMA). Prior to implantation, it comes as a kit containing copolymer powder and a liquid containing methyl methacrylate (MMA) monomer. Shortly before implantation, the powder and liquid are mixed together, forming a PMMA putty. The putty is then applied to the skull, where it hardens and sets. The process of PMMA polymerization gives off heat and free radicals. These can damage the bone and surrounding tissue. As described before, the implantation can also cause foreign body reaction or infection. Furthermore, PMMA implants can break down or fail to polymerize correctly. Unpolymerized MMA is toxic to the body, and can cause severe allergic reactions. In orthopedics, PMMA is associated with bone cement implantation syndrome (BCIS). BCIS is a rare but sometimes deadly condition, characterized by heart attack, hypoxia, hypotension, and cardiac arrhythmia. I am not sure whether there is any risk of BCIS when PMMA is applied to the forehead or brow. Additionally, I am concerned about implant loosening. Polymerization-related bone/tissue damage, residual monomers, poor adherence, and immune responses can cause the implant to loosen. Loose implants can create fine, microscopic scratches on the skull. This can irritate, damage, and/or destroy the underlying bone. Moreover, the face skull volume, and the brow angle recedes with age. This can lead to an unnatural appearance and loosening of the implant. If you regret the implant, bone cement can be more difficult to remove than silicone. I am not sure if the inclusion of hydroxyapatite improves the result. Hydroxyapatite improves the biocompatibility of PMMA bone cement. However, it also increases adhesion to the bone. This could make it more difficult to remove when needed.
Like other facial implants, pre-formed forehead/brow implants are made of silicone or porous polyethylene. As described previously, silicone forehead implants can cause tissue damage and bone resorption, while porous polyethylene is hard to remove. The forehead and brow constitute a “danger zone” that contains important blood vessels and nerves. For these reasons, I am hesitant to recommend forehead or brow implants. It is entirely possible that my fears are unjustified, I just don’t know. Above all, do not go for cheap forehead/brow augmentation. The risk of nerve damage, vascular damage, and/or disfigurement is too high.
On the subject of implants, a certain Dr. Eppley is renowned for his customizable silicone implants. I don’t know much about Dr. Eppley, but I am leery of him. Many of his clients are young incels with unrealistic expectations. They think silicone implants can achieve “chadification” / “looksmaxxing”. A responsible surgeon would explain why extreme implants do not achieve a natural, masculine appearance. Instead, he performs whatever surgery his client asks for, which can result in freakish, cartoon-like faces.
Expectation vs. Reality
There’s another thing I found questionable. On one of his websites, Eppley describes how he “snap fit” a custom brow implant without any need for fixation. But the patient’s forehead shape is bound to change as he ages, and the silicone could cause capsule formation or inflammation. Doesn’t this pose a risk of bone resorption and/or removal of the implant? Eppley also has several negative reviews around the internet, accusing him of being a “salesman” instead of a surgeon. For all I know, he could have excellent surgical techniques. Just know that his extreme, customizable implants can have poor cosmetic results.
The final option for facial masculinization is surgery. The nose can be surgically augmented with a graft of rib cartilage. I do not know all of the risks associated with these operations. All I can offer is a word of caution about aesthetics. Being the center of the face, the nose is easy to screw up with plastic surgery. A bad nose job leaves your nose looking fake or damaged, and can throw off the entire aesthetic of your face. A really bad botch job can obstruct breathing. Be very careful with the surgeon you select for rhinoplasty.
The Adam’s apple can also be augmented with rib cartilage. I am leery of this operation. It was pioneered in 2017 by Dr. Deschamps-Braly. The patient he performed it on almost died, and suffers from several facial deformities. This former patient does not recommend Adam's apple augmentation -- at least, from Deschamps-Braly.
Some men seek maxillofacial surgeries, as an alternative to lower face implants. These surgeries include genioplasty, bilateral sagittal split osteotomy (BSSO) and double jaw surgery (bimaxillary osteotomy). These bone-cutting surgeries are more invasive and harder to reverse than silicone implants. Genioplasty can be performed as an alternative to chin implants. Genioplasty does not have the same risk of infection that implants do. The cosmetic result depends on the patient’s facial structure. In some cases, genioplasty can have a better cosmetic result than implants. In other cases, it does not improve cosmetic appearance. On occasion, genioplasty can cause jawline deformities called “step-offs”. Minor step-offs can be corrected, but major step-offs are disfiguring. The surgery also carries risk of damage to the mental nerve, and failure of the bone plate. Nerve damage is associated with lack of sensation and pain.
Bimaxillary osteotomy is a combination of two procedures: BSSO and Lefort I Osteotomy. BSSO involves cutting both sides of the lower jaw, while Lefort I Osteotomy involves the upper jaw. Either operation can be combined with genioplasty. Bimaxillary osteotomy and BSSO are both more serious than genioplasty. In addition to step-offs and nerve damage, these operations can impact your ability to eat, talk, and smile. They can be very disfiguring, if performed badly. I do not think you should pursue these surgeries if you don’t need them.
The face can be masculinized with fillers, implants, or surgeries. If you keep your expectations within reason, hyaluronic acid fillers are a safe, temporary option. Implants and surgeries are riskier. Skilled surgeons can place implants at the cheeks, chin, or jaw. Complications can occur, but I’ve seen good, long-lasting results. The only surgeries I would consider are rhinoplasty and genioplasty. I would think twice about bimaxillary osteotomy, BSSO, and brow / forehead augmentation. Be extremely careful about who you pick to perform these procedures. Avoid predatory surgeons who exploit their patients’ dysphoria for a quick buck.