Choosing a facial surgeon

Deciding on What to Have Done and Choosing a Surgeon

Go about this the same way you look for any doctor, your therapist, your endocrinologist, etc. First, research. This will help you decide what you should have done. Some people don't need a trachea shave, or their nose is fine, etc. Everyone's different. Different doctors will offer different solutions. For instance, some doctors said they recommended a brow lift but did not think I needed a brow shave. I decided they were wrong, but it's good to understand your options based on a number of opinions.

Look in magazines. Women's fashion magazines, your city's local lifestyle magazine, and other upscale publications tend to have articles and ads concerning surgeons. Look in the yellow pages. Ask your physician, therapist, and other health professionals. Visit or write to local and national transgender groups. Read transgender publications and go to their meetings and conventions. Dr. Ousterhout, the surgeon I chose, frequently travels to major transgender conventions, where he has a slide presentation and lecture (which I have not seen).

Call the referral numbers at the end of this document. Read the books I listed. Use your computer. Many transsexuals are happy to talk about their cosmetic surgery experiences, especially through the anonymity of the Internet. Post questions to bulletin boards. Email people who post something pertaining to your questions. If you have access to IRC or chat rooms, ask around. You'll be amazed how helpful everyone is.

Most large cities have a couple of facial plastic surgeons who are experienced with T*people. Some, however, sort of specialize. When I was researching. the most well known were Toby Mayer in Los Angeles and Douglas Ousterhout in San Francisco. I had seen both these doctors' names on other transgender resource lists, so I wrote to them along with several midwestern doctors.

Writing to Doctors for Information

On September 1, 1996, I wrote to several surgeons requesting information on these procedures. By the 15th of September, it was clear that I should discontinue hair transplants until I had consulted with a few plastic surgeons. None of the Chicago doctors I contacted sent along any transsexual-specific information.

Dr. Mayer sent along a very professional-looking package filled with extensive information about hair loss solutions and about a dozen other procedures he performs. There were a lot of photos and thorough descriptions of each procedure. I found this package very helpful in giving me a general sense of what I could expect. Some was transsexual-specific, and perhaps most interesting was a copy of an article from Chrysalis Quarterly describing two transsexuals' surgical outcomes: a best case and a worst case. I only had the funds to visit one out-of-state surgeon, and I decided on Dr. Ousterhout for reasons listed below.

Dr. Ousterhout sent along a brief but very informative brochure called "Feminization of the Transsexual" that outlined his philosophy, credentials, and services he performed. I was most impressed by Ousterhout's information because he clearly explained with texts and illustrations the differences in male and female skull structure, with great specifics on the importance of the jaw and forehead in gender identification. Basically, all the curves on a female forehead are smooth and convex, meaning it gently rounds outward both vertically and horizontally. Males often have a wide flat area beneath the hairline that often slopes forward more than females. This sloping is often interrupted by a ridge above the eyes and bridge of the nose. I hadn't thought much about brows until my therapist mentioned I should think about a brow shave. Once I started closely observing friends and co-workers with Dr. Ousterhout's information, it became very clear to me how much difference a brow shave could make for me. His information on the jaw was just as good, and I will discuss that when I write about my jaw and nose modifications.

Dr. Ousterhout was the only surgeon who requested radiographs (x-rays) and photos before he discussed what he could do for me and give me prices. This made a lot of sense, since everyone's different. I talked to my dentist, who helped me arrange to have the three radiographs done in Chicago: a full skull profile, a full skull frontal view, and a panoramic of my jaw. The radiologist puts an aluminum filter behind it, which causes a faint silhouette of your face to be superimposed over the bones on the radiograph. I got a copy of the radiographs for myself, and I mailed off the others with about a dozen photos and my wish list of modifications. Dr. Ousterhout wrote back within the week on what procedures he recommended.

Dr. Ousterhout classifies foreheads by Type I, which requires minimal reduction (shaving the bone); Type II, which requires moderate reduction and smoothing by filling in depressions and concave areas with a layer of acrylic filler that fuses to the bone; and Type III, which requires repositioning the bone in the forehead to set it back, plus extensive bone reduction, but no filler. Often he will also round out the upper area around the eye (the supraorbital rim), which adds to the femininity of the face.

I set up a couple of consultations in Chicago, and made an appointment with Dr. Ousterhout in San Francisco as my final consultation.

Consultations

Good surgeons will answer every single question you have to your complete satisfaction. They won't try to rush you out the door, and they won't make you feel bad for asking. Usually you discuss your goals with the doctor, who then takes measurements and makes recommendations, and then an assistant or office manager puts together an estimate of the price.

Some questions to ask:

  • What boards are you certified with?
  • How long have you been doing this procedure?
  • How many patients have you performed it on?
  • May I see pictures of your patients (not just ones in brochures)
  • Are there any of your patients I can talk to?
  • Describe the procedure.
  • What sort of recovery time should I expect?
  • When will bruising and swelling subside?
  • Can I expect any temporary or permanent change in sensation?
  • When will I be able to return to work?

In addition to travel costs to get there, most consultations are about $100, usually refundable with surgery if you choose that doctor. When you are comparing cost estimates from several doctors, be sure to consider the doctor's location and then budget accordingly for travel, food and lodging expenses. Different procedures call for different lengths of stays. If you cannot spare the time or money to stay in the town you came to for surgery, ask the surgeon if he or she is comfortable with having a doctor in your town remove the sutures. Sometimes they are willing to do this. In my case, I felt it was important to remain in San Francisco and have Dr. Ousterhout remove all the staples and sutures himself. Obviously, this is the best way to do things. Some procedures, such as the jaw reshaping, have dissolvable sutures, so you could be free to leave within a few days of surgery.

I consulted with a couple of surgeons in Chicago who made some good suggestions and gave me useful information, but they left me basically unimpressed, so I was very pleased when I consulted with Dr. Ousterhout on November 19, 1996.

You Can Learn From My Big Mistake

In my case, since I essentially just had a really high forehead, I assumed hair plugs were the way to go. My plan was to take care of my hairline and then do the plastic surgery I wanted done. I reasoned that since hair transplants take a while to grow out, I should get them done as soon as possible so they'd start growing. As soon as I settled on a hair transplant doctor and had my first session, I started looking into cosmetic procedures. It quickly became clear that if I planned to get a brow shave and lift that I should have that done before completing transplants. Meeting several cosmetic surgeons confirmed this, so I stopped getting transplants after my first session and started an intense search for a plastic surgeon. Several doctors suggested that if I got a brow lift, I could combine it with a scalp advancement and save a ton of money on hair transplants. All I might want is a few micrografts in front of the scar I would have along my hairline. One doctor I consulted with had a woman working in his office who had this procedure done, and that was what convinced me to get the brow lift and scalp advancement. This hair transplant mistake cost me about $2,000, as my transplants were all removed during the scalp advancement procedure. Ouch.


A reader sent the following excellent piece to me in 2000:

When Everything Doesn’t Work Out Perfectly

Based on my very stressful and lengthy post-surgical experience, I have some suggestions for any future patients who undergo cosmetic surgery for "feminization":

1. Make sure that all risks and complications are explained to you in full prior to making any decisions about whether or not to have surgery. Insist that the major risks and possible complications (within reason, of course) are given to you in writing. Ensure that you have enough time to reflect upon the risks and an extended length of the recovery if there are any complications.

2. Get as much as you can in writing: surgeon’s fees (remember: clarify what might be added to your bill at the last minute), responsibilities in case there is a need for subsequent revisions of the procedures, nature and quality of post-operative care (especially important if you live at a distance from the place of surgery).

3. Ask to be shown a copy of the consent form before booking your surgery. Make sure that, as a legal document, it is explained to you in full. If the document doesn’t go into much detail, ask for further documentation to be sent to you, possibly from the surgeon’s lawyers. Know what the surgeon’s medical and legal responsibilities are before undergoing the operation. It is much more difficult to sort things out afterward, especially if you are dealing with complications. I don’t think there is any such thing as too much information.

4. Ask for the phone numbers of at least 3 people who have undergone procedures similar to those that you are contemplating. If you are made to feel that such a request is unnecessary, do not drop the matter. While the Internet can provide valuable guideposts, it is NOT a good place for reliable surgical references and accounts of the everyday reality of recovering from very, very invasive surgery. You do not know the people who have posted their stories—as detailed as they are they may be unrepresentative of what might happen to you. Remember there are relatively few full accounts of these procedures when you think of all the surgical candidates that have had operations. As we know from television, before-and-after pictures can be deceiving, and what works for one person won’t necessarily work for another.

5. In keeping with #4, do not accept the claim that they have operated on so many people that your surgery will be just another in a long string of successful surgeries. While the number of successful patients might well give you confidence, this is your surgery, you are paying dearly for it, and you have a right to have your individual case treated as if it were the first. Remember, you are not going to do this again so unless they are willing to start at square one with you and take you through the whole process, from pre-consultation to post-surgery, I would consider looking for another surgeon. You deserve to have your questions answered.

6. If you feel that you are left in waiting rooms for too long, especially at the pre-op just before your surgery, make it clear that you feel it is unprofessional and ungracious to schedule individuals for appointments at times that are not even close to the time that you eventually see the surgeon. You must be ready to walk away from your surgery, even at the very last minute, if you feel that you are not being treated well. Obviously no one wants to do this when they get to this point—but it’s your body that you are entrusting to a surgeon. Take care of yourself; do not assume that others will do it. You are the one who will live with the consequences of this momentous decision.

7. You must at least consider the possibility that you will be one of the 6% (the figure that was quoted to me by the surgeon) of patients who will suffer some form of nerve damage. Are you willing to take those risks with your body? Can you live with a lower lip which drools constantly and a mouth that can no longer can form the letters "b" or "p"? Are you willing to risk the loss of your hair? Only you can answer these questions, and it is best that you do so when you can reflect seriously and quietly on the whole picture.

8. If you do decide to undergo surgery (especially an extensive set of procedures), I would strongly suggest bringing a partner or advocate with you to make sure that you are well taken care of, and that there is someone who can make your needs known to both the hospital and the surgeon. A beeper number, however quickly it is answered, is not the same as a live person, especially when you are dazed and hurting. It seems to me that surgeons might be well advised to consider employing a full-time patient care assistant for post-operative patients. Some surgeons are already doing this, especially with the current uneven standard of nursing care in many hospitals.

9. If you feel uncomfortable with any part of the process, remember that you are in control. If you do not feel that you are receiving due consideration of your questions, remember that there are other surgeons and that you don’t need to make a decision right on the spot. I would go home and reflect on what you have been told, how you have been treated, and what some post-surgical patients have told you about the entire process, not just the result.

10. Being obsessed with the results is understandable when you have lived your whole life in the wrong gender and a surgeon offers a very tempting physical surgical program for "feminization." However powerful this promise is for transgender people , you still have the right to expect the kind of explanations that any other surgical candidate would be given. Get facts about your surgery as if you had cancer—don’t get lost in a world of "I will be so pretty!" You very well may be—that’s why you’re there—but keep a level head about you. This is no magic wand—this is very, very invasive surgery which is elective. You are taking a body which is perhaps otherwise healthy and putting it at risk. You will be living with the consequences, both good and bad, for the rest of your life. Think about it.