Eve was created from the rib of Adam
matron asked Rabbi José: "Why did God steal a rib from Adam?"
Rabbi: "Steal? If one were to take away from your house an ounce of silver, and give you in return a pound of gold, that would not be stealing from you."
Matron: "But what need was there for secrecy?"
Rabbi: "It was surely better to present Eve to Adam when she was quite presentable, and when no traces of the effects of the operation were visible."
There is no ambiguity about the goals of feminisation surgery - it is to change an externally male physical appearance into an externally female physical appearance. However, although it’s possible to achieve a more feminine body through a variety of surgical and lifestyle choices, there are serious limitations as to what is possible. Also, some transwomen use surgery to excessively emphasise adjustable female physical characteristics to the extent that they become implausible and unnatural looking.
This article looks at such surgery, deliberately excluding sex-reassignment surgery and breast augmentation surgery which are major topics in their own right.
Puberty, Skeleton and Hormones
Pubertal development determines an adult's general bone structure. Alterations in the bony framework thereafter are unlikely with hormone therapy and surgical modification of the pelvis comes with significant risks that can outweigh the benefits based on current surgical techniques.
Typically, persons assigned as female at birth and who go through an estrogen-influenced puberty tend to store fat more easily and in regions of the body such as the hips, buttocks and thighs. This can give a curvier and more voluptuous appearance which is something many transgender women seek.
For the male-to-female transsexual, continuous hormone treatment will slowly help to feminise their subcutaneous tissue (i.e., redistribution, less muscle, more fat), but it will barely affect the skeleton of an individual already past puberty when treatment is commenced. However, in some cases, surgery can help feminise the appearance of the underlying skeleton.
Waist and Hips
Although the greatest male and female skeleton differentiation can be found in the pelvic girdle, unfortunately there is nothing that can be done to directly feminise the pelvis of an adult male to female transsexual woman. A combination of wide hips with substantial fat deposits, and a narrow waist with minimal fat deposits results in the average western woman having a hip-to-waist ratio of about 0.84, whilst for the opposite reasons men are around 0.95.
Long term hormone treatment by a transwoman will help to round out her hips due to an increase in subcutaneous fat deposits, whilst exercise can help to reduce the waistline. But the effects are slow to appear, and the final development is unlikely to be dramatic. Since the 1980's, some transsexual women have had implants (usually silicone) to their butt, hips and/or thigh regions to improve their curves. The results can be excellent, but the implants are often removed as the woman moves into middle age.
Some transwomen use silicon or hydrogel injections as a cheaper method of augmentation than surgery. Sadly, these injections have proved to be very dangerous, with life threatening cancer an all too common outcome.
Since about 2006 an increasingly popular procedure with transwomen has been body sculpting and contouring - commonly called the Brazilian butt lift. The procedure involves removing fat from the abdomen by liposuction and transferring it to the buttocks, hips and thighs. Approximately a third of the loss/gain quickly disappears, but the remainder persists in most patients. Body sculpting is preferable to the silicone and other implants to the hip and buttock regions that have been used since the 1980's - the short-term effect is less dramatic and satisfactory, but safer and less likely to cause problems in the long term.
Skull and Face
Relating the absolute measures of the male and female face, several surgically correctable differences which will make a dramatic difference in the perceived gender can often be identified to the benefit of a male-to-female transsexual.
[Note: An excellent article by Dr. D.K. Ousterhout on the differences between male and female skulls, and the feminisation of the face of a transsexual woman can be found here.]
Common procedures include:
reduction: involves advancing forward the scalp between 1.0 cm and 2.5
cm to correct for the receding masculine pattern hairline and to
approximate, when possible, a more feminine 'oval' pattern hairline.
Forehead contouring: involves shaving the brow bossing and, if necessary, contouring via shaving across the forehead.
Forehead augmentation: involves the use of 2, 3, or 4 implants (Gore-Tex Subcutaneous Augmentation Material).
[Not strictly skeletal, but worth listing here!]
The nose is the most prominent feature of the face. Many transwomen find nasal refinement to make one of the most marked improvements in their female facial appearance and it's the most common procedure after breast augmentation.
Nasal surgery or rhinoplasty alters the appearance of the nose by shaping and repositioning the nasal bones and trimming the bone and cartilage as needed to create the desired appearance. As example, rhinoplasty is used to correct a large hump, or a broad or round nasal tip. Small changes, such as subtly lifting the tip of the nose will often create a more youthful and feminine appearance.
Commons tasks include:
Septal Surgery - The strip of cartilage which separates the two sides of the nose is called the septum. It is sometimes bent and interferes with breathing; if so, it may need to be straightened. If it is too long, it is often shortened.
Shaping the Profile - Many women complain of a hump on the bridge (dorsum) of the nose. This is usually made of both bone and cartilage. It is removed with scissors or a saw. When the nose is flat, the profile may be augmented with grafts of bone or cartilage.
Refining the Tip - If the tip of the nose is large or boxy, much of the tip cartilage may be removed or reshaped to refine the shape.
Reducing Nostril Flare - If the nostrils are flared, they may be reduced by removing a small wedge of tissue from the base of the nose.
Common tasks include:
reduction: involves an intra-oral incision which requires an extended
recovery period (with severe facial swelling/bruising for about 10 days).
Chin and Jaw
Possible tasks include:
Jaw reduction: involves a 1.0cm extra-oral incision under the jaw line to cut the bone (on average, by 1.0cm depth) and thus reduce the sharp angle of the back corner of the jaw where it rises up to the ear.
Alternatively, an intra-oral incision can shave (but not cut) the bone. Although this technique prevents external scaring, it is less effective, has more risk of infections, and requires an extended recovery period due to severe facial swelling/bruising.
Chin reduction: involves an intra-oral incision to shorten and narrow the chin (if necessary, including contouring with a hard silicone implant). The technique involves: (1) shaving the bone; (2) cutting the bone; or (3) sectioning out the mid-section of chin and joining the upper and lower sections via steel screws.
genioplasty: involves an intra-oral incision and sliding forward or
backward the lower section of chin (if necessary, including contouring
with a hard silicone implant).
In 2015, age 30, Carmen married her Adrian Torres whom she had been dating since 2009, and became the stepmother of his two daughters. Contemporary press reports claimed that by the wedding she had spent $100,000 on cosmetic surgery, but with no confirmation that this included GCS.
Next is Maggie. She has had undergone very extensive FFS with Dr Bart van de Ven, including: forehead recontouring and shaving, brow lift, rhinoplasty, chin recontouring, jaw reduction, a face lift, Adams apple removal and a lip lift. Undoubtedly she faced serious risks (as well as considerable cost) seeking such extensive surgery, but the results are exceptionally good and shown below as an example of a best case result:
Saga from Sweden is shown before and four months after extensive facial feminsation surgery by the 'Facial Team' in Spain This included work on her forehead, jaw and chin, a rhinoplasty and a tracheal shave. Unfortunately, the photo's are excessively edited as evidenced by the implausibly narrower neck.
In Iran it's illegal to be a homosexual man, but you can change your sex from male to female. After having SRS you are legally considered to be a woman for everything from having to wear the hijab in piblic to marriage to a man. A large number of surgeons offer SRS and other feminisation surgeries for men that (often reluctantly) decide to become a woman. Surgical procedures have evolved that are barely known outside the country but the results can be excellent, as shown below.
Finally, a another patient who wishes to remain anonymous. She had FFS by Dr Eric Bensimon which involved significant changes to her jaw, a recontouring of the forehead, hair lowering (scalp advancement), and the removal of any visual Adam's apple.
A search for the term 'Facial Feminization Surgery' using Google will produce a vast number results. A few examples include:
Other Surgical Procedures
Removal or Adjustment
In the first technique, one or two of the floating ribs at the bottom of the rib cage are taken out to have a smaller waist, typically by 1 - 2 inches unclothed. Corsets also become far more effective as they can act upon a greater area of soft tissue rather than rigid bone - although a reduction of more than 4" reduction is likely to soon cause damage to internal organs. The resulting back scars, the vulnerability of exposed internal organs to damage from bangs and bumps, and the possibility of unsightly rib re-growth makes this a very problematic procedure which is rarely performed by reputable surgeons. Actresses Raquel Welch and Elizabeth Talyor; singers Cher and Janet Jackson and celebrity businesswoman Kylie Jenner are reported to have had this procedure - although there is no supporting evidence other than the fact they suddenly had fabulous hour-glass figures in a dress with a tight waist. In 1988 Cher gained ridicule when she sued Paris Match magazine for claiming that she had had extensive cosmetic surgery (including the removal of two ribs); against common sense and photographic evidence she won the case!
An only slightly less dramatic and dangerous procedure is to break the lower ribs, bend them inwards to reduce the waistline, and force them to mend in the new position by the continuous wearing of a tight and rigid corset for a month or more. Amanda Lepore - who claims to have the most expensive surgically enhanced body in the world - underwent this procedure. She also claims to now have the perfect female figure - 38-22-38 - and combined with her petite 5ft 2in height the result is indeed impressive if you can cope with her excessively feminised facial appearance.
Cost of Surgery
It's worth ending this article by noting the very high cost of feminisation surgery.
Basic procedures such as a "nose job" are widely available, and good quality surgery can be economically obtained from clinics that don't otherwise deal with transsexual women.
But more extensive feminisation surgery is a specialist field in which there are only a few reputable surgeons practicing. In 2000, facial femisation surgery from a top surgeon such as Dr. Ousterhout would start at about $10,000 and soar upwards from there. There are cheaper options emerging, particularly in Thailand, but carefully check out the surgeon's references and make enquires about them on the Internet. Poor quality surgery is far worse than none.
An example of the benefits of good quality surgery is Jamie (formerly James) Clayton. When just 19 she transitioned and moved to New York, where her make-up skills won her a job as a beautician. Her first surgery was a subtle breast augmentation which barely took her to a 'B' cup - although hardly noticeable it was enjoyed by her boyfriends and helped her to pass physically. Next, she paid $16,000 in 2003 to have sex re-assignment surgery by the highly rated Dr Meltzer when 25 - she wanted her revised genitalia to both look pretty good and to work. She was very happy with result and soon experienced vaginal orgasms. With "tweaking" to her genitalia, and other "touch-ups", by age 30 she had spent about $50,000 on surgery to get near where she wanted to be appearance wise. Famously, a magazine article published in 2008 called her (only slightly generously) "The Second Most Beautiful Girl in New York", which stirred considerable debate as to whom the first girl was!
In 2011, Larissa Summers (pictured right) - born Darren Pratt - featured in several UK newspapers with a claim that she had spent €500,000 on plastic surgery. She apparently has had 50 operations, including eight breast procedures, seven nose jobs, three Brazilian butt lifts, ear corrections, cheek and lip filler, chin and jaw contouring, lip lifts and lipo-freezing. Her GCS in 2003 is a notable omission from the list. She was outed in 2005 as being a post-surgery transwoman but refused to acknowledge this publicly and subsequently slipped back to near stealth with considerable success, e.g. a Feb 2009 online-only Playboy pictorial of her makes no mention of her being transgender.
The table below includes some indicative costs (c. 2016) of private surgery in Europe or the USA by a well-regarded practice and/or surgeon for the indicated procedure. These include only surgery, anaesthesia and immediate hospital care, they exclude taxes (e.g. some UK practices now apply VAT), medications and any post-operative care or procedures. If there are complications, the cost can soar. Incidental expenses such as travel must also be added.
The increasingly common practice of bundling of multiple procedures (e.g. GCS/SRS, breast augmentation and facial feministion) makes post-operative complications almost inevitable. Having these occur when you are thousands of mile from home is both mentally depressing and financially very expensive. Also, there is no return from a botched SRS procedure with a low-cost but inexperienced surgeon. Gender confirmation surgery is a "one-shot" surgical procedure. Follow-on remedial procedures can never compensate for tissue removed and nerves destroyed in the radical first procedure.
When arranging surgery, it's impossible to better a 2,000 year-old Roman saying: "Caveat emptor... ", its commonly translated as just "Buyer beware!" but the full saying is that a buyer should not to be ignorant of the nature of what they are buying from another party.
Obviously the cost of multiple procedures starts to add-up, and many middle-age transwomen readily admit to having spent £/$/€50,00 plus on surgery - it's almost a required badge.
A good, if now dated, starting point is Lynn Conway's informative article on Facial Feminisation - based on her personal experiences - at: http://ai.eecs.umich.edu/~mirror/FFS/LynnsFFS.html
For more information on facial feminisation surgery I highly recommended Sally's Resource Morsal at: http://tsresource.info/
For more links, check out the Transsexual Women's Resources website at: http://www.annelawrence.com/facialindex.html
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