How to Evaluate Facial Feminization Surgical Results Using Preoperative and Postoperative Photographs

Publication date: 4/29/2025

Facial feminization surgery (FFS) encompasses a range of procedures designed to soften masculine facial features and create a more feminine appearance. For both patients considering FFS and those who have undergone it, analyzing preoperative and postoperative photographs is a crucial step in understanding the potential and actual outcomes. These images serve as a visual record of the journey, highlighting the subtle yet impactful changes achieved.

Simply looking at before-and-after pictures is not enough. To truly appreciate the transformation and understand the nuances of FFS, a detail-oriented and focused approach is key. Here is a guide on how to analyze these important visual documents.

Understanding the Goals of FFS

Before diving into the details, it is essential to remember the overarching goal of FFS: to create a more feminine appearance by addressing specific masculine features. This often involves

Softening prominent, masculine bone structures: Reducing the brow bone prominence, reducing the chin and jaw

Enhancing soft tissues: Creating feminine lips with a lip lift or lip augmentation, augmenting the cheeks, feminizing the nose with a rhinoplasty, elevating the eyebrows with a brow lift, lowering the hairline, and reducing the size of the Adam’s apple

Keep these goals in mind as you analyze the photographs.

A Focused, Detail-Oriented Approach to Analyzing Photo

To gain a comprehensive understanding, analyze both the preoperative and postoperative photos using the following framework

Standardized Photograph Conditions

One key component to evaluating preoperative and postoperative photographs is to determine whether the photographs are taken under similar conditions. The outcomes can appear dramatically different based on the conditions in which a photograph is taken.

Lighting: The lighting in preoperative and postoperative views should be the same. Before and after photographs can sometimes be taken under dramatically different lighting conditions.. This is sometimes due to benign issues such as a surgeon changing his studio or clinic lighting. In some situations, this can be intentionally manipulated to produce a specific result. For example, harsh overhead lighting can produce shadowing on the eyes that makes the brow bone appear more prominent whereas front-on lighting can produce less shadowing of the eyes and make the brow bone appear less prominent.

Makeup: In an ideal world, patients should remove all makeup before photographs. However, this is not standard practice and in most situations, a patient’s makeup will be left as it is. Since this is often the reality, the viewer should specifically try to identify any makeup being worn. Then, the viewer can determine how the makeup affects the patient’s appearance and the apparent surgical outcomes.

Positioning: Ideally, a patient’s head should be in the same orientation for every photograph series. This is the responsibility of the photographer to direct the patient and to take standardized views. Head tilt can dramatically alter the overall appearance and significantly change the appearance of specific areas like the neck.

Standardized Photograph Views

Front: A front view should show the patient looking directly at the camera with their eyes and head in a neutral position. This view allows evaluation of how a person appears during normal conversation.

Lateral (Side Profile): This view should be a pure lateral view. It is crucial for assessing changes in forehead projection, nasal profile, lip fullness, chin projection, and jawline angle definition. The head should have a similar tilt in the before and after photographs.

Three-Quarter Views (Left and Right): These angles offer a dynamic perspective, allowing viewers to see how the facial contours flow and blend. This view is particularly helpful for assessing cheek fullness, chin corners, and nasal dorsum contours.

Mouth Open in Repose: A gentle opening of the mouth allows one to see the amount of tooth show visible with a slight opening. This is particularly helpful to evaluate lip lift results since a good result will often have a youthful, feminine amount of tooth show.

Smile: Smiling can produce subtle changes to the face when seen in any direction. One can observe how the soft tissues, including the nose, respond to facial movement.

Front View with Head Tilted Upward: An upward gaze is helpful for neck evaluation. This can better demonstrate Adam’s apple prominence in both lateral and front views. This view is also helpful for evaluating the undersurface of the nose.

Front View with Head Tilted Downward: The downward gaze is most useful for evaluating the hairline, nose, and chin. It provides a direct view of the hairline, which is helpful for evaluating hairline lowering or hair transplant procedures. It is helpful to evaluate the straightness of the nasal dorsum following rhinoplasty. It is the best view for evaluating the anterior shape of the chin.

Lateral View with Head Tilted Upward: This view is useful for evaluating tracheal shave results. Tilting the head upwards accentuates the thyroid cartilage prominence. Minor changes are more easily assessed with these views..

Close-Ups (Specific Areas): Close-up shots of specific areas like the eyes, nose, or lips can sometimes highlight subtle but significant changes.

Focus on Key Facial Features and Their Feminization

Hairline lowering
Hairline lowering is best viewed with the hair pulled back in both preoperative and postoperative photographs. However, many patients choose not to pull their hair back before or after surgery. In these scenarios, allowing the hair to fall naturally can be best to observe its effect on the overall facial appearance. Reducing the hairline alters the vertical proportions of the face, making less forehead skin visible. Evaluate the shape of the resulting hairline and note any particularly distracting scars. The hairline lowering scar is best seen by pulling back the hair to reveal the scar’s full extent.

Brow Bone Reduction and Orbital Contouring
The goal of this procedure is to note any prominent forehead bossing, a sloping or heavy brow, and the eyebrow position in both preoperative and postoperative views. This procedure is often best evaluated in the front, three-quarter, and lateral views. In the front view, one can see the overall effect of the procedure on the patient at conversational distance. The lateral view provides a much better understanding of the degree of reduction. The three-quarter view allows the best evaluation of the lateral orbital rim reduction.

Brow lift
A brow lift is often best evaluated in the front view. The viewer should evaluate the overall shape and arch of the eyebrows. They should also try to determine where the eyebrows are located in relation to the eyeball and the orbital bone. The viewer should take note of the degree of elevation, any change in shape of the brow, and whether the results appear natural.

Blepharoplasty
Blepharoplasty is a procedure that removes excess upper eyelid skin. It is a less-commonly performed procedure in facial feminization. This procedure is often best evaluated in the front view. The viewer should assess the amount of upper eyelid skin preoperatively and the change that occurs between the preoperative and postoperative photographs. The viewer should take note of the symmetry of the location of the eyelid show both before and after the operation. The symmetry or asymmetry may either improve, stay the same, or worsen.

Nose (Rhinoplasty)
Rhinoplasty is one of the most complicated procedures to assess in surgical photographs. It often requires evaluation of every available view to evaluate results. The front view allows assessment of the overall size and appearance and how it harmonizes with the rest of the face. The lateral views allow the viewer to see the slope of the nose from the side and how the bridge of the nose (dorsum) interacts with the tip of the nose. The three-quarter views provide a better assessment of the shape of the dorsal aesthetic lines (straight, curved, bowed). The three-quarter views are the best views for observing any minor asymmetries between the two sides of the nose. Evaluation of the nose with downward tilted head provides a better viewpoint for assessing any dorsal or nasal tip deviation. The worm’s eye view provides the best view for evaluating the symmetry of the nostrils and the columella.

Cheeks
The cheeks are often best assessed in the three-quarter view. When taken properly, the photograph should show the contour of the cheek without obscuration by the nose. In this view, one can assess the degree of volumization achieved by cheek augmentation and where on the cheek the augmentation is most visible. The curve should extend from a concave curve at the eye/orbit into a covex curve at the cheek.

Lip Lift
The front, lateral, and front with gentle mouth open views are best for evaluating the lips before and after a lip lift. The front view shows the overall effect of philtral shortening on the face. The view with gentle mouth opening is best for evaluating the change in tooth show resulting from the lip lift. The front, three-quarters, and close-up views are best for evaluating the lip lift scar. The lateral view shows the change in lip pout and the upper lip skin’s curvature. Overall, an ideal lip lift is one that produces a noticeable change, appears natural, has a fine scar, gently increases tooth show, and is not overly short.

Lip augmentation
The front and lateral views are best for evaluating lip augmentation. The front view shows the general increase in lip volume, while the lateral view shows any change in volume distribution between the upper and lower lips.

Chin and Jawline
The chin and jawline can be assessed in all views. The frontal view shows the general change in the chin and jaw appearance. The jaw is often narrower in the back towards the ear and should lead to a gentle taper or point at the chin. The lateral view can demonstrate any change in the chin’s forward projection. The three quarter views are helpful for viewing the corners of the chin. The front view with head tilted downward can be the best view for assessing the chin’s anterior contour. Ideally, chin and jaw reduction results in a softer, more tapered jawline, with a chin that is narrower or less square. The chin can be vertically shortened or the forward projection can be shortened for a more feminine appearance.

Tracheal shave
Tracheal shave results can be seen from multiple views. The front, lateral, and views with upward tilted head are often best for evaluating the results. In the front and lateral views, check the visibility and prominence of the Adam’s apple. This should show a reduction from the operation. The front and lateral views with upward tilted head can accentuate the prominence of the Adam’s apple, making a subtle prominence more visible. One should also check the position, size, and visibility of the tracheal shave scar.

Overall Harmony and Balance

While focusing on individual features is important, step back and assess the overall harmony and balance of the face in the postoperative photos. Do the changes in individual features work together to create a more cohesive and feminine aesthetic? Are the proportions of the face more balanced? On first glance, does the patient appear more feminine?

Consider the Patient’s Goals

Ideally, the postoperative results should align with the patient’s desired outcomes discussed during the consultation. While you may not know these specific goals, try to discern the overall direction of feminization achieved. Ultimately, patients decide whether they want to undergo certain procedures. They may not want all available procedures, or certain procedures may not be appropriate for every patient. If there are questions about why certain procedures were performed for a patient, that should be discussed with the surgeon.

Important Considerations

Timeframe: Understanding the timeframe between preoperative and postoperative photos is important. Swelling and bruising are common immediately after surgery and will subside over time, revealing the final results. Many patients do not continue seeing their surgeon for follow-up after their first or second postoperative visit. Therefore, obtaining photographic documentation of long-term results is frequently difficult. Since swelling can take 6-12 months or even 2 years to subside, longer-term photographs are best for evaluating these long-term results.
Professional Interpretation: While self-analysis is possible, a qualified and experienced facial feminization surgeon is best equipped to interpret the images and explain the nuances of the transformation.

Conclusion

Analyzing preoperative and postoperative photographs of FFS patients is a valuable tool for understanding the impact of these procedures. By adopting a systematic approach, focusing on key facial features, and evaluating the overall harmony, you can gain a deeper appreciation for the artistry and precision involved in creating a more feminine facial appearance. These visual records serve as a testament to the transformative power of facial feminization surgery.

Citations