In short: every face is unique, and the order is decided at the consultation. But in general, if your budget does not cover everything, the order Dr. Javier Gutiérrez recommends is forehead, nose (only if it is indicated) and Adam's apple. Before any surgery, look at the secondary features: if you have beard shadow, laser hair removal or electrolysis will feminise your face more than jaw surgery. Hair transplant and hair removal can be done near home. The jaw and chin can usually wait, unless they are your most masculine feature.
Most of the people who write to us do not have the budget to do everything at once. The question we hear most is which procedure to do first: if I can only have one or two, which will make the most difference?
The answer has a clear order. And one part is worth saying plainly: sometimes what feminises most is not an operation, and not something we do.
Before surgery: the secondary features
We do not only recommend what we offer. Some features do not depend on bone, and they weigh a great deal in how a face is read. The clearest example is beard shadow.
Dr. Gutiérrez's clinical view is clear: if you have beard shadow, have laser hair removal or electrolysis before jaw surgery. It will feminise your face much more. No study has compared the two directly. What has been studied is the effect of hair removal on wellbeing: in a survey of trans people in the United States, severe psychological distress was 21.6% among those who had had gender-affirming hair removal and 40.7% among those who wanted it and had not had it (Lee et al., 2021).
There are two methods. Laser hair removal works mainly on dark hair. Electrolysis works on blonde or white hair, which laser does not remove, and on stubborn dark hairs that do not respond to laser.
If you are going to have surgery afterwards, plan the timing: laser hair removal or electrolysis in the areas to be operated on stops three weeks before surgery. We explain it in our guide to surgery day.
Not every feature needs surgery: some weigh more than others in how a face is read, and some change with hormone therapy. We cover this in how to choose an FFS surgeon.
Beyond beard shadow, your voice weighs in how you are read. Mannerisms, the way you dress and make-up count too. None of this needs an operating theatre.
1. The forehead
In general, if you can only have one procedure, make it the forehead. The gender reading of a face starts at the eyes, and the forehead is the roof of that region. We explain why in our post on the upper third of the face.
But there is no rule that fits everyone, because every face is unique. For some patients, the only masculine feature is the chin, the jaw or the Adam's apple, and then that feature is the priority. That is why the order is decided individually at the consultation.
Studies of facial perception point the same way. People looking at a face they read as masculine spend longer on the forehead (Gupta et al., 2022). And in a study of 303 patients, the area between the brows and the top of the nose was the single region that weighed most in how gender was read (Choe et al., 2023).
If there is also hair loss, more hair counts too. But you can have the hair transplant near home and save: you do not need to have it with us. If you have it later at another clinic, wait at least 4 months after forehead surgery. If you prefer it in the same operation, FUS is done through the same approach and costs €6,000. Forehead feminisation costs €8,500.
2. The nose, if it is indicated
The shape of the nose changes how a face is read (Bruce et al., 1993). That does not mean every nose needs surgery. Rhinoplasty comes second only if it is indicated. Some people already have a nose that fits a feminine face, and then there is no need to touch it. Whether yours needs it is decided at the consultation.
At ARQÉA, rhinoplasty is performed by Dr. Ramón Tarragona, a plastic surgeon, and costs €7,000.
3. The Adam's apple
Third is the Adam's apple. In a survey with 1,026 raters, a more prominent Adam's apple made the neck read as more masculine, especially in profile (Kiessling et al., 2022).
A tracheal shave is a day-case procedure of about an hour, and you can go about normal life the next day. It costs €4,500. We cover it in our post on tracheal shave surgery.
What can wait
In general, the jaw and chin are not in the first three. They add to the result, but they are not where the reading of a face begins. The exception is when they are your most masculine feature: then they can be the priority.
With the cheekbones, it is also worth waiting for the effect of hormones: at least 6 months of treatment, and ideally a full year, before deciding. For the jaw, time on hormones does not make a difference.
What to do near home and what in Barcelona
On a limited budget, it helps to split the plan:
- Near home: electrolysis or laser hair removal, voice work, the follow-up of your hormone therapy, and a hair transplant if you need one (at least 4 months after forehead surgery).
- In Barcelona: the bone and cartilage surgery, that is, the forehead, the nose if it is indicated and the Adam's apple.
- Afterwards: the four check-ups included, at 7 days, 1 month, 3 months and 12 months, in person or by video call.
How far your budget goes
| If your budget is around | What to prioritise | Cost at ARQÉA |
|---|---|---|
| €8,500 | Forehead | €8,500 |
| €13,000 | Forehead and Adam's apple | €13,000 |
| €20,000 | Forehead, nose (if indicated) and Adam's apple | €20,000 |
| + €6,000 | FUS hair transplant in the same operation as the forehead | €6,000 |
All prices include anaesthesia and the surgical centre. The quote we give you after the consultation is final and binding. You can estimate yours with our price calculator, and see every other price in our guide to FFS costs in Europe.
All at once or in stages?
Having everything at once means one anaesthetic, one hospital stay and one recovery. Rhinoplasty can be done in the same operation as the forehead and the Adam's apple.
The price depends on the combination. The three-procedure package (for example forehead, jaw and chin, and Adam's apple) costs €16,000; separately, those three would cost €20,000. Forehead and Adam's apple, or forehead, nose and Adam's apple, cost the same together as separately: €13,000 and €20,000.
In stages, each one has its own anaesthetic, hospital stay and trip. What you gain is spreading the cost over time and starting with what feminises most.
Frequently asked questions
If I can only afford one FFS procedure, which should it be?
It depends on your face, because every face is unique. In general, the forehead: the gender reading of a face starts at the eyes, and the forehead is the roof of that region. At ARQÉA it costs €8,500. Then come the nose, only if it is indicated, and the Adam's apple. But if your only masculine feature is the chin, the jaw or the Adam's apple, that feature is the priority. Before any surgery, if you have beard shadow, laser hair removal or electrolysis.
Is it cheaper to do FFS in stages or all at once?
It depends on the combination. The three-procedure package (forehead, jaw and chin, and Adam's apple) costs €16,000, compared with €20,000 separately. Forehead and Adam's apple, or forehead, nose and Adam's apple, cost the same together as in stages. All at once means one anaesthetic, one hospital stay and one trip.
Do I really need a nose job as part of FFS?
Not always. The shape of the nose changes how a face is read, but some people already have a nose that fits a feminine face. On a limited budget, rhinoplasty comes second and only if it is indicated. Whether you need it is decided at the consultation.
Should I finish laser hair removal or electrolysis before FFS?
If you have beard shadow, it is worth doing before jaw surgery: in Dr. Gutiérrez's clinical view, it will feminise your face much more. If you are having surgery, stop electrolysis or laser in the areas to be operated on three weeks before.
Is a tracheal shave worth it?
A prominent Adam's apple makes the neck read as more masculine, especially in profile. A tracheal shave is a day-case procedure of about an hour and costs €4,500 at ARQÉA. You can go about normal life the next day. That is why it is the third priority.
Can I get a hair transplant at home after FFS in Barcelona?
Yes. You can have it near home and save; you do not need to have it with us. Wait at least 4 months after forehead surgery. If you prefer it in the same operation as the forehead, FUS is done through the same approach and costs €6,000 at ARQÉA.
Can the jaw and chin wait?
In general, yes. They add to the result, but they are not where the reading of a face begins, unless they are your most masculine feature. And if you have beard shadow, laser hair removal or electrolysis will feminise your face more than jaw surgery. For the jaw, time on hormones does not make a difference.
How long should I be on HRT before deciding on cheekbone surgery?
At least 6 months of hormone therapy, and ideally a full year, before deciding on the cheekbones. For the jaw, time on hormones does not make a difference.
How much do forehead, rhinoplasty and Adam's apple surgery cost at ARQÉA?
Forehead feminisation costs €8,500, rhinoplasty €7,000 and a tracheal shave €4,500, with anaesthesia and the surgical centre included. The three cost €20,000, in the same operation or separately.
References
- Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope. 2011. PMID 21271570. PubMed
- Gupta N, White H, Trott S, Spiegel JH. Observer gaze patterns of patient photographs before and after facial feminization. Aesthet Surg J. 2022;42(7):725-732. DOI
- Choe J, Bregman D, Miller M, Bradley JP. Facial Feminization Surgery: Region-specific Importance Recognized by Artificial and Human Intelligence Gender Recognition Correlates with Patient Satisfaction. Plast Reconstr Surg Glob Open. 2023;11(4S):12. Meeting abstract. DOI
- Bruce V, Burton AM, Hanna E, et al. Sex discrimination: how do we tell the difference between male and female faces? Perception. 1993;22(2):131-152. DOI
- Kiessling P, et al. Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web-based Survey. Laryngoscope. 2022. PMID 36453533. DOI
- Lee MS, Almazan AN, Nambudiri VE, Keuroghlian AS. Association Between Gender-Affirming Hair Removal and Mental Health Outcomes. JAMA Dermatol. 2021. DOI
As we always say, this article is for general information and doesn't replace an individual medical assessment. What to prioritise in your case is decided at the consultation, with your face in front of us.
→ Book your free consultation now
