Recovering from Facial Feminization Surgery

Facial feminization surgery (FFS) is a complex set of procedures that often involves a difficult recovery. Most people have many questions after they have undergone surgery and it is important for people to stay informed. Dr. Mittermiller has put together this page to help patients in their recovery stage after surgery. Some of the details will vary based on individual situations. It is always important to discuss specific details with your surgeon.

Recovery Timeline for Surgery

Prior to Surgery

The key to a successful recovery is entering surgery with a clear understanding of the recovery phase after surgery. Prior to surgery, you should prepare yourself with food, supplies, and knowledge. Here is a link to a page that lists some of the supplies that may be helpful during the recovery phase of surgery. It can be helpful to have a week’s worth of food and supplies in case you do not feel comfortable traveling the store. During the months leading up to surgery, take stock of what you use on a regular basis and make sure you have enough of these supplies for after surgery. Read all the information provided to you by your surgeon’s office, and read about the recovery so you know what is coming.

Day of Surgery

You just came out of surgery. Congratuluations! You have likely been waiting a while for this point and it is finally here. On the day of surgery, it is most important to simply relax and try to be comfortable. If you are in the hospital or at a nursing facility, the nurses will help increase your comfort level. If you are staying at home, ideally a friend or a family member can assist you with basic needs.

Pain Immediately after Surgery

The pain following surgery will likely start increasing within the first few hours following surgery. It is usually a dull, throbbing pain in the surgical areas. It is likely you will have multiple medications available for pain control. If you are in the hospital, the nurses will be able to choose and provide the best available medication. If you are staying at home, the medications will have the recommended dosing written on the bottles. Pain after surgery usually reaches a maximum on the night of surgery or the day after surgery and begins to subside after that point.

Nausea Immediately after Surgery

Not everybody experiences nausea after surgery. It can be mild or severe depending on individual experiences. If you are in the hospital, the nursing staff can help you with the available medications. If you are at home, you will likely have been prescribed an anti-nausea medication. If nausea occurs, it usually only lasts 1-2 days following surgery.

Swelling Immediately after Surgery

The amount of swelling one experiences after FFS depends dramatically on the types of procedures performed. Swelling of the forehead is usually minimal following surgery. If swelling does occur from brow work, it usually manifests around the eyes with swelling of the upper and/or lower eyelids. This usually peaks around 1-2 days following surgery and then starts to subside. If cheek augmentation was performed with fat grafting or implants, the swelling will usually peak around 3-5 days before it starts to decrease. If a lip lift or lip augmentation was performed, the swelling usually peaks around 3-5 days and then begins to subside. Chin and jaw reduction surgery results in massive swelling of the lower face. This swelling is usually the most distressing part of the swelling during surgical recovery. The swelling in this areas is dramatic and can worsen symptoms of dysphoria. The chin and jaw swelling usually peaks around 3-7 days and can take multiple months to resolve. Swelling of the face can be reduced through multiple methods. Icing or cold compresses should be used during the first 48 hours following surgery. Head elevation while awake and while sleeping is important to help limit and reduce swelling. The facial bandages or compression bandages can also help following surgery.

Activity Immediately after Surgery

If you are feeling up to it, you should try to take a few short walks around the house, nursing facility, or hospital floor on the night after surgery. This should be done carefully and possibly with the assistance of another person.

Bandages Immediately after Surgery

If brow or jaw work was performed as part of surgery, you will likely have a large facial wrap or bandage in place. If a rhinoplasty was performed, you may have splints on the outer surface of your nose and on the inside of your nose. You may also have a piece of gauze placed underneath the nose to catch any drainage from within the nose. The gauze underneath the nose can be changed as needed to keep the area clean. If you had a tracheal shave with an incision underneath the chin or on the neck, then you may have either stitches with a piece of tape or skin glue on the incision. Do not remove this until directed by your surgeon. If fat grafting was performed, you may have a small piece of gauze over your belly button (aka umbilicus).

Sutures from Surgery

There will be sutures or staples at multiple locations following surgery. If any brow procedures were performed, these will either have been performed through an incision within the hair (coronal incision) or along the hairline (if a hairline lowering was performed). If a coronal incision was used, then there were be staples within the hair. If a hairline lowering was performed, you will have staples within the hair and sutures along the hairline. If a rhinoplasty was performed, there will be sutures within the nose and possibly on the columella, which is the part of the undersurface of the nose between the nostrils. If a lip lift was performed, you will haves sutures at top part of your upper lip along the base of your nose. If cheek implants were placed, there will be dissolving sutures placed on the inside of the upper lip. If chin or jaw surgery was performed, there will be dissolving sutures on the inside of the lower lip. If an incision was placed on the undersurface of the chin or neck for a tracheal shave, there will be sutures in this location that may or may not need to be removed by the surgeon at a follow-up appointment. If fat grafting to the face was done, there will be a small incision near the umbilicus (belly button) that has been closed with sutures.

Eating or Drinking Immediately after Surgery

Surgeons have many different approaches to eating and drinking after surgery. It is important to clarify these instructions with your surgeon before surgery. If you underwent surgery that did not involve any incisions on the inside of your mouth, you can usually resume a regular diet immediately following surgery. If incisions were placed on the inside of the mouth, your diet will likely be modified immediately following surgery. In any case, you should try to remain hydrated immediately following surgery by drinking water or a sports drink. If you are staying in the hospital, you may have an intravenous catheter (IV) that is providing you with supplemental fluid to prevent dehydration. On the day after surgery, Dr. Mittermiller is usually okay with patients advancing their diet as tolerated. If jaw reduction surgery was performed, it can often be painful to eat hard or chewy foods. In these situations, soft or liquid foods can be more comfortable to consume.

Bathing Immediately after Surgery

It is usually not necessary to bathe on the night of surgery. You will be severely fatigued and likely will not want to move around much.

Days 1-7 after Surgery

The first few days after surgery can be particularly rough for most people. At this point in time, swelling will reach its maximum and the pain may still be somewhat intense.

Pain 1-7 Days after Surgery

Pain should always be tolerable, so if it is not, then one should contact their physician to discuss potential changes in the medication regimen.

Activity 1-7 Days after Surgery

You should try to leave their house, apartment, or hotel for a few brief walks during the first week after surgery. This can help with reducing the risks of blood clots, it can help maintain a positive mindset, and it can help with reducing facial swelling.

Bathing 1-7 Days after Surgery

Dr. Mittermiller suggests patients take a shower on the day after surgery to start gently cleaning their hair. This helps to remove any clots that are still in place from surgery and it helps people feel better. Any gentle shampoo should be okay, but if there are any uncertainties, then this should be reviewed with the surgeon. The face can be gently cleaned while bathing. If a nasal splint is in place, try not to wet the splint since this can cause it to fall off sooner than desired.

Oral Care 1-7 Days after Surgery

Gentle tooth brushing can start soon after surgery. If any concerns during brushing arise, do not continue to brush and instead contact your surgeon for further instructions. You likely will have also been provided a prescription mouthwash with instructions on how to use the mouthwash after surgery. This should be used multiple times during the day to keep the mouth clean.

Weeks 2-4 after Surgery

The patient will usually meet with their surgeon 1-2 weeks after surgery. At this point, the sutures and staples will be removed and all the incisions and surgical sites will be evaluated. After the sutures and staples are removed, it is helpful to be particularly gentle with the surgical sites. The sutures and staples provide strength for the incision, so once they are removed, the incisions are slightly weaker than they were with the sutures and staples in place. During the first month after surgery, people should still avoid strenuous exercises or any uncomfortable activities.

Months 2-6 after Surgery

After the first month, patients can usually start reducing the number of restrictions they need to follow. At this point, people can usually start resuming their regular activities and exercises. Sports that can potentially involve trauma to the face should usually be avoided until about 4-6 months following surgery.

Frequently Asked Questions

How do I take a shower or bathe after surgery?

After FFS, you may have multiple bandages on your face. Any facial compression wraps can usually be removed in order to shower. If there is a gauze placed underneath the nose, this can also be removed while showering. People may have a hard splint placed over the top of the nose after a rhinoplasty. This splint should remain in place while bathing. It is usually best to avoid wetting the nasal splint since this can cause the splint to loosen and fall off. A shower hand piece can be helpful for directing the water towards the hair while not wetting the nasal splint. Cleaning the face can be performed gently with a wash cloth.

What products are necessary after surgery?

There are a variety of products that can be helpful prior to surgery. Specific product recommendations can be found on a separate page (here) on this site. Not all the products are necessary for every patient. It is important to review the procedures you will be having and evaluate whether specific products match your needs.

When can I start activities?

This question has many answers depending on the type of activity. Dr. Mittermiller usually prefers patients to be up walking starting immediately after surgery. Movement allows the body to recover faster and it makes people feel better! It is difficult to walk too much in the recovery stage. If you are feeling lightheaded after surgery, do not push yourself through any activities. At that point, sit down, relax, and wait until you have fully recovered before trying to stand up again.

Strenuous exercises should often be avoided at least during the first 4-6 weeks after surgery. Strenuous activities are ones that cause your heart rate to increase or cause perspiration. There is usually no need to engage in strenuous activities immediately after surgery. Recovery from surgery requires a significant amount of resources from the body, so one’s focus should often be to allow the body to obtain all the resources it needs.

What can I eat after FFS?

The types of food and drinks that are allowed after surgery often depend on the specific procedures that were performed. If no incisions were placed inside the mouth and there were no manipulations of the jaw muscles or bones, then a regular diet can often be continued after surgery. In these scenarios, it is simply important to make sure people eat a nutritious diet.

For patients who had incisions placed within the mouth, the diet can vary slightly. Surgery on the lower jaw often results in tenderness of the muscles that help with chewing. In these scenarios, it can be helpful to have foods that fall within a “soft” diet for after surgery. This includes liquid foods such as soups and smoothies, but can also include foods that are mashed or solid foods that can easily be broken down between the tongue and the roof of the mouth. If there are any questions about specific foods, these should be reviewed with your surgeon.

Foods that can be uncomfortable to eat following surgery include hot or spicy foods. These can aggravate incisions that are inside the mouth.

Drinks that are dense in protein and nutrients can be helpful for patients who have a difficult time holding down food following surgery. It can be helpful to have drinks such as Ensure, Boost or Gatorade in these scenarios to stay hydrated and to make sure that enough nutrients are being ingested following surgery.

After eating, one should try to make sure the mouth and incisions are clean. This can be done with a gentle rinse using water, salt water, or prescription mouthwash.

When can I swim after surgery?

Swimming should be avoided until all incisions have healed. This includes swimming in pools, lakes, rivers, and oceans. These areas can often have slightly elevated amounts of bacteria and may increase the risk of infection after surgery.

When should I shower after surgery?

Dr. Mittermiller usually prefers patients to shower starting the day after surgery. This includes washing one’s hair. It is important to be gentle around any staples or sutures that are placed on the scalp. Patients should never aggressively pull on their hair or on any of the incisions since this can cause a disruption of the incision and bleeding.

When can I exercise or be active after surgery?

There are many ways that one can exercise or be active following surgery, so it is difficult to provide a recommendation that applies to all types of exercise. Gentle activities such as walking are usually okay starting immediately after surgery. At any point, if lightheadedness occurs, one should gently sit down or lie down and rise with caution or assistance.

Activities that elevate one’s heart rate or increases ones metabolism to the point of sweating should usually be avoided for the first 2-4 weeks following surgery. These activities may increase the risk of bleeding or injury. These include common activities such as running or bicycle riding.

One should also be careful with lifting heavy objects, since this can increase one’s blood pressure and cause bleeding. A soft rule of thumb is to avoid lifting objects that are more than 5-10 pounds for the first few weeks following surgery.

Sports that can involve physical contact usually should be avoided for a longer period of time. Depending on the exact procedures that were performed, these sports should be avoided for as much as 4-6 months. Sports that can occasionally involve impacts to the surgical sites include soccer, basketball, and baseball.

There are some sports that intentionally involve powerful impacts to the face such as boxing or martial arts. It is necessary to discuss the specifics of these sports with the surgeon to determine if and when one may return to these sports.

The procedures one undergoes during facial feminization surgery are also affected by the degree of allowable physicality. For example, a rhinoplasty or frontal sinus setback has some components of inherent instability. An impact to the nose or frontal sinus setback may destabilize the surgical result. Other procedures such as jaw contouring may allow for earlier commencement of physical sports since there are fewer concerns of destabilizing the underlying structures. Nevertheless, it is always important to discuss specific activities with the surgeon if there is any confusion or uncertainty.

How should I sleep after facial feminization surgery?

Facial feminization surgery frequently results in significant swelling of the face. Depending on the procedures that were performed, there can be swelling of the forehead, cheeks, nose, chin, jaw, lips, or neck. One of the best ways to reduce swelling after FFS is by continuing to keep the head elevated as much as possible. This is most relevant when sleeping during naps or overnight. One can nap upright in a recliner or in bed with head elevation. Some people prefer creating a ramp out of pillows underneath their back, neck, and head. Others prefer to purchase a wedge pillow. An example of a suitable wedge pillow can be found here: Postoperative Supplies for FFS. It can be helpful to keep the head elevated while sleeping for the first 1-2 weeks after surgery. The benefits start to decrease after that time.

How long should I place ice or cold compression packs on my face?

Icing a surgical site is done to help reduce swelling and bruising after surgery. The procedures that produce the most swelling after FFS tend to be genioplasty, jaw contouring, and cheek augmentation with implants. Rhinoplasty can sometimes result in significant bruising or swelling around the eyes. Placing ice or cold compresses over the surgical sites should start immediately after surgery and can continue for 48 hours after surgery. After the first 48 hours, ice packs become less effective at reducing swelling or bruising.

When can I dye my hair after a hairline lowering or coronal incision?

The hair dying process can potentially impair wound healing after undergoing a scalp incision. It is usually best to wait until after the incision has entirely healed before dying your hair again. This means that the incision should not have any open wounds or scabs. This often takes around 1 month, but it can be shorter or longer depending on your individual healing process. As always, it is best to check with your surgeon.

Can I cough or sneeze after FFS?

Coughing after surgery is allowed and sometimes recommended. Occasional deep breathing after surgery is important to fully expand the lungs and this can sometimes result in coughing.

Is it okay to have a sore throat after FFS?

There are a few reasons why one can have a sore throat after FFS. Most commonly, a sore throat is due to either the breathing tube placed during surgery or a tracheal shave operation. In both situations, the sore throat should improve after a few days and resolve after a few weeks. If the pain does not improve or if it suddenly worsens, then one should contact their surgeon for additional guidance.

When can I brush my teeth after FFS?

Surgeons often have differing opinions on whether tooth brushing should be allowed after FFS. Dr. Mittermiller is generally okay with people starting to brush their teeth immediately after surgery. The primary concern with brushing after FFS is that it can disrupt the incisions within the mouth that were used for genioplasty, jaw contouring, or cheek augmentation with implants. If there are no incisions inside the mouth, then one can start tooth brushing immediately after surgery with the same vigor as they did prior to surgery.

If there are incisions inside the mouth, it is important to brush teeth gently. This is usually easiest to do with a manual toothbrush instead of an electric toothbrush. One can usually start using an electric toothbrush again 2-4 weeks following surgery. If there are any concerns about disruption of an of the incisions inside the mouth, then the surgeon should be contacted for further advice.

Is it okay to have bloody sputum after FFS?

Bloody sputum (or spit) can occur for a variety of reasons after FFS. Occasionally, the breathing tube placed by the anesthesiologist can produce minor trauma to the airway. There are frequently incisions inside the mouth that are placed during FFS. These can sometimes ooze after surgery. The blood can mix with the saliva or sputum. If there is ongoing bleeding, then one should contact their surgeon.

When can I use a flat iron hair straightener after a hairline lowering or coronal incision?

A coronal incision is one that goes directly over the top of the head. This is a commonly used approach during facial feminization surgery for feminizing the brow bone. A coronal incision usually does not significantly affect the sensation on the top of the head. There may be some slight numbness around the incision following surgery. The scalp is also still healing at this point.

A hairline lowering incision is placed at the front border of the hair. The nerves that supply the sensation to the area immediately above the incision come from within the orbit, immediately above the eyes. Theses nerves are cut during the hairline incision, resulting in a dense area of numbness on the top of the head.

A flat iron hair straightener can be problematic to use immediately after surgery due to the heat and due to the pull on the hair.

When should I start to massage incisions or surgical sites after FFS?

Massage can be a helpful adjunct to recovery following FFS. Massage can help reduce swelling and it can help soften thick or firm scars. Massage is usually not recommended until at least 1 month after surgery since overly aggressive massage can disrupt incisions, break sutures, or move underlying structures in the early postoperative period. After about 1 month, it may be possible to start massage. This is usually most helpful for any visible scars. These frequently include scars that are the result of a lip lift or tracheal shave.

As always, if there are any specific concerns, please contact your doctor immediately.