Facial Feminisation Surgery
On 21st January 2004 I underwent Facial Feminisation Surgery with Dr. Suporn at Aikchol Hospital in Chonburi, Thailand.
- Why More Surgery?
- What Needed Doing?
- Which FFS Surgeon?
- Planned Surgical Procedures
- Other Accounts of FFS with Dr. Suporn
- 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 (and so soon after the first, too), and 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", improve my confidence and give me a better chance to rebuild my social life. Whilst I had been fairly lucky in my appearance and incredibly lucky in my build, I did still get stared at (and believe me it could be very uncomfortable when it happened), and I'm certain that was in large part due to the effects that male sex hormones have had on my face during my adult life. Whilst those changes have been stopped from proceeding further by hormone therapy, the damage which had already been done was irreversible.
Facial Feminisation Surgery offered the promise of undoing some of that damage. It is major, specialised bone surgery, and as such there are few surgeons specialising in it and it is expensive - significantly more expensive than the reassignment surgery I'd just had. On the plus side, recovery from FFS tends to be much quicker than from reassignment surgery (which is much more invasive) and the results of FFS are often very striking.
What needed doing?
Back then most people I encountered saw me wearing makeup, and with my hair down. That was deliberate, as I was very conscious that my facial bone structure wasn't particularly feminine, and I could see echoes of my past whenever I looked in the mirror.
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 that since my transition, and it brought it home to me how I could potentially benefit from FFS:
These pictures helped me to conclude that there were several things that could be improved:
- My profile was not what I'd like it to be - particularly the slope of the forehead and the size and profile of my nose
- My eyes appeared 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 softened 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 was not at all prominent (as it turned out, I was wrong - but more on that later).
Which FFS surgeon?
To my knowledge at the time there were just four surgeons worldwide specialising in the sort of major bone work required for FFS:
- Dr. Douglas Ousterhout in San Francisco, US. Dr. Ousterhout is the pioneer of facial feminisation surgery, but was 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 what can and can't be done. Facial surgery with him (in theatre - and they showed a great deal!) was also featured in a documentary (badly) titled "Sex Change" shown 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 also consider him for the facial work I hoped could be done.
- Dr. Noorman van der Dussen in Antwerp, Belgium. I only came to hear of him relatively late during my research. Unfortunately a lack of (then) publicly available information on procedures, indicative prices and results on the web discouraged me, although he did (like Brian Musgrove) seem to have a very good reputation (among trans people he was nicknamed "The Artist").
- Dr. Brian Musgrove in Manchester, UK. In addition to Dr. Suporn, I sent the same enquiry to Dr. Musgrove (minus the reassignment surgery bit of course, as that's not something he does!). His response was as follows:
"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 that was conclusion was undoubtedly accurate, it didn't help me to get an idea of what he might be able to do or what the associated costs might be without travelling for an in person paid consultation.
I knew I had a limited budget, and strongly suspected that surgery in the UK would be out of my price range so didn't want to commit to a formal consultation if I was likely to be disappointed. A further factor was that I had heard he did not perform forehead reconstruction ("Forehead III"), which Suporn and Ousterhout definitely did.
In the event I chose to go back to Dr. Suporn. In my case, that would also offer 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 injections to treat furrows (creases) rising above the bridge of the nose
- Feminising rhinoplasty or (if necessary) reconstructive rhinoplasty (osteotomy)
- Sliding genioplasty, chin and jaw reduction
The clinic also made some observations (precied below):
"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 the following:
"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."
Having made up my mind, while arranging my reassignment surgery for November 2003 with Dr. Suporn, I asked for a consultation to be held while I was in Thailand. As a result when I was admitted to Aikchol Hospital for my surgery the following day and an X-Ray was taken of my chest, X-Rays (both 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 reassignment surgery, he told me that he had had a chance to study the facial X-Rays taken at the hospital when I was admitted, and that I had rather thick bone in my forehead. As such he believed that a Type II "compression" approach would definitely work on my forehead - I didn't need the more major "Type III" reconstructive technique, which was definitely good news!
I also asked about the need for the sliding genioplasty and jaw reduction and he explained why he considered it 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 so trusted him on that.
Finally, having also met patients who had 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.
Facial Feminisation Surgery is an expensive procedure - far more so than reassignment surgery. Here's how the costs worked out for me in practice (and please do remember that these are 2004 prices, subject to the exchange rates of the time):
Cost in Thai
Cost in UK
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.
This included 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.
In much the same way as during my reassignment surgery on 14th November 2003, I kept a detailed diary of my experiences and feelings, which I gradually wrote up as a set of illustrated web pages:
- The trip to Thailand and my consultation with Dr. Suporn
(18th - 19th January, 2004)
- The surgery and my immediate recovery in Aikchol Hospital
(20th - 25th January 2004)
- Recovering in the Mercure Hotel
(26th January - 6th February, 2004)
- 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 will 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 thought I may have to 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 are planning to have chin or jaw work done you could do worse than to 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 hit my self confidence took while my face was healing.
Although the clinic stated that a stay of 3½ weeks was enough for FFS, I stayed a full 30 days and I am very glad I did, as by the time I left Thailand my face looked much more presentable than it would otherwise have been, and equally my confidence had improved accordingly.
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 was several months before my jaw was fully recovered and I was able to eat without cutting my food up smaller than I used to.
No doubt because of the jaw work I also left Thailand 7lbs (3.2kg) lighter than I arrived!
As you can see in the pictures above, the changes are mostly subtle but very 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 was much improved (even though it's still quite swollen in these pictures)
- Although the change in my jaw was subtle the difference in the size of my chin was truly astonishing.
There are two things I didn't expect which I wish I had been aware of while planning my surgery - both associated with chin reduction:
- 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 more noticeable. Had I known that was a likely outcome, I would probably have scheduled a tracheal shave.
- 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*.
*As of 2020 (16 years later), it hasn't been an issue so far.
One further issue came to light about a decade later during a dental check-up when I discovered that the jaw reduction had left very little bone around one of my (impacted) wisdom teeth - significantly raising the risk of nerve damage (potentially leading to permanent partial facial paralysis) in the event of it having to be removed. That's a risk I may have to face one day, but not (so far) yet.
Finally, knowing what I do now, I wouldn't have had the Dermalive injections. Oh well!
Despite these issues - I am very happy with the overall results.
I'm pretty certain that that FFS has made a significant difference in how others now perceive me, but obviously I can't say for certain.
What I do know is that it's certainly helped with my self-confidence, and although the changes are subtle (I still look like me), friends who saw me after returning were a little surprised by how noticeable the difference was.