On 21st January 2004 I underwent Facial Feminisation Surgery with Dr. Suporn at Aikchol Hospital in Chonburi, Thailand.

Contents

1. Why More Surgery?
2. What Needed Doing?
   
3. Which FFS Surgeon?
4. Planned Surgical Procedures
5. Costs
6. Diary
7. Other Accounts of Facial Feminisation Surgery with Dr. Suporn
8. Results and Reflections

Why More Surgery?

Before the event quite a few people asked me exactly why I was going through with a second major surgery. I think it's worth answering that question first before going into detail about the surgery itself.

Basically, the reason I decided to do this was to improve my "passability" and give me a better chance to rebuild my social life. Whilst I've been rather lucky in my appearance and incredibly lucky in my build, I do still get stared at on occasion (and it can be very uncomfortable when it happens), and I'm certain that's in large part due to the effects that male hormones have had on my face during my adult life. Whilst those changes have been stopped from proceeding further by hormone therapy, the damage already done is irreversible.

Facial Feminisation Surgery offers the promise of undoing some of that damage. It's major, specialised bone surgery, and as such there are few surgeons specialising in it and it's expensive - significantly more expensive than GRS. On the plus side, recovery is much quicker than from GRS (which is much more invasive) and the results are often quite striking.

What needed doing?

Most people I encounter see me wearing makeup, and with my hair down. That's deliberate, as I'm aware that my facial bone structure isn't particularly feminine.

When I sent the initial enquiry to the clinic, I attached several pictures of my face, without makeup and with my hair tied back. It was the first time I'd been photographed like this since my transition, and it brought it home to me how much I could benefit from FFS:

From these pictures there are several things that could really be improved:

• The profile was not what I'd like it to be - particularly the slope of the forehead and the size and profile of my nose
   
• The eyes appear a little recessed because of the overhang of the brows (this is known as "brow bossing", and is a typically male facial bone structure).
   
• My chin was fairly deep and square, although hormone therapy had fortunately masked that a little (if you look at earlier pictures such as this one, you can see the change rather clearly).

On the plus side, I didn't seem to need a tracheal shave, as my adam's apple is not at all prominent. As it turned out, I was wrong - but more on that later.
 

Which FFS surgeon?

To my knowledge, there are just four surgeons worldwide specialising in the sort of major bone work required for FFS:

• Dr. Douglas Ousterhout in San Francisco, US. He's the pioneer of facial feminisation surgery, but well and truly out of my price range!
  
  Lynn's Facial Feminization Surgery discusses her surgery with him in some detail, and is also a good grounding in what FFS involves and can and can't be done. Facial surgery with him (in theatre - and they showed a great deal!) is also featured in a documentary titled "Sex Change" shown in the UK earlier this year by Channel 4 (a terrestrial TV station in the UK).
  

• Dr. Suporn in Chonburi, Thailand. As I was planning to go to him for reassignment surgery anyway, it seemed sensible to seriously consider him for the facial work I wanted done.
   
• Dr. Brian Musgrove in Manchester, UK. In addition to Dr. Suporn, I sent the same enquiry to Dr. Musgrove (minus the GRS bit of course, as that's not something he does!). His response was:

  "Thanks for your enquiry and the photos.

  It is difficult to make a diagnosis by e-mail, but I suspect you have a Cl 3 malocclusion with a high FM angle, and a pseudoprognathism, to mention just a few. The possibilities are diverse and it would be worth your while coming to see me in Manchester. Phone my secretary Ann when she is back from leave next wed, to make an appointment."

  Whilst his conclusion was undoubtedly accurate, it wasn't at all understandable to me as I lack a medical background. Since he didn't feel able to indicate what may be required in his professional opinion, he also didn't give an indication of what costs might be involved - something I really needed as I had a limited budget to fund both GRS and FFS, and I strongly suspected that surgery in the UK would be out of my price range.

  To find out what he recommended and how much it would be likely to cost, I would have to pay for a consultation. Unfortunately, that seems to be the way things are done in the UK - but it wasn't what I was looking for.

• Dr. Noorman van der Dussen in Antwerp, Belgium. I only came to hear of him relatively recently. Again, a lack of publicly available information on procedures, indicative prices and results on the web discouraged me, although he does (like Brian Musgrove) have a very good reputation.
  

In the event I chose to go back to Dr. Suporn. In my case, that also offered the opportunity to have a "3 month check-up" on the results of my reassignment surgery.

Planned Surgical Procedures

When I contacted the clinic, they suggested the following procedures as a "worst case":

• Forehead bone contouring/resetting ('compression technique') and forehead lift
   
• Dermalive to treat furrows (creases) rising above nosebridge
   
• Feminising rhinoplasty or (if necessary) reconstructive rhinoplasty (osteotomy)
   
• Sliding genioplasty, chin and jaw reduction

They also made the following observations (which I've precied):

"Without seeing x-rays, we cannot tell if shaving the brow bossing will completely remove it.  It is possible that you may still have a very slight brow bossing remaining afterward.

The only way to remove the rising deep crease above each corner of nosebridge is to use Dermalive injections.  The treatment should last at least 7 to 10 years.

The hump on the nose can be shaved down to give a smoother contour as viewed from the profile. Feminising rhinoplasty can give a somewhat smaller and better contoured shape - but for a considerable reduction in size, you would need the reconstructive technique.  This involves breaking the nose and resetting it to a smaller shape.  You would need to wear a cast for 2 weeks.

The chin can be reduced in vertical length and also width to a smaller more feminine shape. As your chin protrudes rather forward, you would most likely require a sliding genioplasty together with chin reduction. As we suspect that reducing your chin together with sliding genioplasty would give an unnatural bent angle between your chin and jawline due to the unusually large vertical length of your chin, we also recommend scheduling jawline reduction.  This is the only way to ensure that you will not have a 'notch' between the junction between the chin and jawline.  Now that Dr. Suporn does jawline reduction intra-orally, you would not have any external incision scars after surgery.

Finally, your left ear protrudes more than your right, but this is something (otoplasty) which you could just as easily correct closer to home in the U.K."

I asked a friend with some experience of FFS to comment on Dr. Suporn's recommendations, and she observed:

"After looking at your pics I definitely think they are wrong - a sliding genioplasty will just make your face look out of proportion. I can see what they mean as you have a slight underbite but I don't think that would be addressed by that anyway. Though I think they are right about the actual jawline reduction as this will shorten the gap between the bottom lip and chin meaning that you get a shorter face, thus giving the appearance of wideness which will definitely help out with the feminising effect.

Having looked at the photos now I don't think a shortening of the top lip to nose would work, perhaps it might be something that may need looking at after you have had the nose re-done but I think it should be ok.

Perhaps looking at having the hairline brought down again might be an idea too, once you have the brow done it might seem that your hair is slightly receding and bringing the hairline down just a fraction would soften the look of the forehead further."

While arranging my reassignment surgery for November 2003 with Dr. Suporn, I asked for a consultation to be held while I was in Thailand. When I was admitted to Aikchol Hospital for my surgery on the following day and an X-Ray was taken of my chest, X-Rays (front and profile) were also taken of my face so that Dr. Suporn could confirm the clinic's assessment.

At my first check-up following my GRS, he told me that he'd had a chance to study the facial X-Rays taken at the hospital when I was admitted, and that I have rather thick bone in my forehead - so the Type II "compression" approach would definitely work for my forehead - I didn't need the more major "Type III" reconstructive technique - definitely good news!

I also asked about the need for the sliding genioplasty and jaw reduction and he explained why it was necessary in my case (basically because of the shape of my jaw, which the X-Rays undoubtedly confirmed). I don't pretend to understand all he told me, but I'd already put my life in his hands once by then trusted him totally.

Finally, having also met patients who've undergone most of these procedures while in Thailand for my reassignment surgery I was completely happy with my choice and confident of the outcome. That confidence proved to be well placed.

Costs

Facial Feminisation Surgery is an expensive procedure - far more so than reassignment surgery. Here's how the costs worked out in practice:
 

Description	Cost in Thai Currency	Cost in UK Currency	Comment
Surgery	720,000 Baht	£10518	Rather than take cash, I transferred the funds electronically from my own bank. The process was quick and easy, the exchange rate good and the charges far more reasonable than those for currency exchanges.
Hotels	50393.49 Baht	£752	This includes not only the cost of the room but phone/internet calls, meals etc. The room cost in the Mercure was 1100 Baht/night (about £17), and meals/drinks typically added 500-1000 Baht to that. The Royal Twins Palace was cheaper (900 Baht), but we often ate out which added to the cost.
Flights	-	£655
Cash	21,400 Baht	£351
Total		£12,276

FFS Diary

As I did following my reassignment surgery on 14th November 2003, I kept a detailed diary of my feelings and experiences, which I gradually wrote up as a set of illustrated web pages:

1. The trip to Thailand and my consultation with Dr. Suporn
   (18th - 19th January, 2004)
    
2. The surgery and my immediate recovery in Aikchol Hospital
   (20th - 25th January 2004)
    
3. Recovering in the Mercure Hotel
   (26th January - 6th February, 2004)
    
4. Partying in Pattaya, the return to Chonburi and my journey home
   (7th - 17th February, 2004)
   

If you have any questions about my surgery or anything connected with it, I'll be happy to answer them, so feel free to send me an email via the Contact page.

Other Accounts of Facial Feminisation Surgery with Dr. Suporn

• Kelly Novak's FFS page discusses the very issue I may have to unexpectedly confront - the risk that the skin around the chin/jaw may not adhere to the bone and that I may require follow-up work. If you're planning to have chin or jaw work done I strongly recommend you read her account.
   
• SRS & FFS with Dr. Suporn Watanyusakul [MD]
  

Results and Reflections

Undergoing FFS proved to be an eye-opener for me, as after the incredible pain I suffered following my reassignment surgery in November I thought that FFS would be easier. Although in one respect I was right - there was very little pain - I wasn't at all prepared for the dent my self confidence took while my face was healing. Although the clinic state that a stay of 3½ weeks is enough for FFS, I stayed a full 30 days and I'm glad I did, as by the time I left Thailand my face looked more presentable than it would otherwise have been.

Aside from all the bandaging, the work I had on my jaw meant that for the first couple of weeks I had great difficulty eating, and even a month after surgery I still had to choose my meals carefully! It'll probably be several months before my jaw is fully recovered and I'm able to eat without cutting my food up smaller than I usually do.

As you'll see in the pictures on the right, the changes are subtle but noticeable:

• My forehead protrudes notably less.
   
• My brows look much better (although they couldn't be lifted as much as I would have liked due to the tightness of the skin).
   
• The profile of my nose has been vastly improved (even though it's still quite swollen in these pictures)
   
• Although the change in my jaw is subtle the difference in the size of my chin is truly astonishing.

There are two things I didn't expect which I wish I'd been aware of while planning my surgery - both associated with chin reduction:

1. You may notice that I didn't list a tracheal shave amongst the surgical procedures I had planned. That wasn't because I'd already had one, but because it wasn't noticeable. Unfortunately, after my chin had been reduced it became noticeable. Had I known that was a risk, I'd have scheduled a tracheal shave. As it is, a return visit to Thailand in a year or so is quite likely (any excuse to see my friends again!).
    
2. The removal of such a large quantity of bone from the chin and jaw carries a significant risk that a lower facelift will be necessary sometime in the future. Only time will tell...all I can do is be prepared for that eventuality if it proves to be necessary.

Despite these issues - and although it will be several months until I can see whether everything has turned out the way I hoped - so far I'm very happy with the results:

Of course only time will tell how much of a difference undergoing FFS will make in my day to day life, but so far it looks very encouraging. Although the changes are subtle (I still look like me), friends who've seen me since returning have been astonished by the difference!