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."

Born a boy, Tonya's appearance and physique is the result of 20 years on female hormones and a lot of surgery.

Introduction
As described in the article Male and Female Skeleton, there are several basic differences between the adult male and the adult female skeleton, and also post puberty there are substantial differences in the overlying tissue (depth and type).   It is the combination of these factors that differentiates the physical appearance of men and women. 

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.

Ava Glasscott came out as a girl age 12, transitioned age 15, and had SRS age 22.  After facial feminisation surgery she competed in beauty pageants and has worked as showgirl, model and actress.  Shown age 32.

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

A transwoman with silicone hip implants, their outline is just visible.

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.

In the 21st century, high quality surgery and hormones can go a long way towards transforming the body
on  the right to the body on the left and vice versa.  Major skeletal changes such as reducing height or
feet size have been attempted but are still impossible to do satisfactorily, regardless of budget.

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.]

Forehead
Forehead recontouring involves rounding the forehead to approximate a female shape, often by shaving bone from the brow of filling in flat areas to round them out.  Reducing brow ridges, if excessive, can considerably improve the feminine appearance. 

Common procedures include:

Scalp 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.

SMAS/platysma (deep plane) rhytidectomy: involves lifting the cheeks, jowls, jaw line, and neck and their underlying muscles. 

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).

Transwoman Robera Close was considered one of Brazil's most beautiful women in the 1980's. However photo's of her face were almost from the front, profile shots were rare as they revealed her large nose. She eventually had rhinoplasty.

Nasal Surgery (Rhinoplasty)
[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.

In 2005, MTV featured 26-year old transsexual Gia on I Want a Famous Face, who wanted to look like Pamela Andersen.  She had already had a dozen operations since her teens (inset left), but surgeon Dr Mayer (right) gave her a new breast implants, liposuction on her abdomen and chin, another nose job, micrografts to her hairline and fat transferred to her smile lines.  The result (centre) is a vague resemblance to Pamela.

Narrowing the Nasal Bones - If the bridge of the nose is wide, the surgeon will narrow it by fracturing the bone on each side and moving it closer to the centre.

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.

Cheeks
Cheek implants, also called submalar implants, can make the face look less flat, which can enhance its feminine appearance.  Like any implant, there is a danger of rejection.

Common tasks include:

Cheekbone reduction: involves an intra-oral incision which requires an extended recovery period (with severe facial swelling/bruising for about 10 days).

Cheekbone augmentation: involves an intra-oral incision to augmenting the bone with a hard silicone implant.

Lip contouring: involves lifting the upper lip via a shallow 'v' incision below the nose or by an incision inside the lip. If necessary, the lower lip can be made fuller via an incision inside the lip.

 
Nikohl Spearman was born in January 2000 and transitioned at a young age.  In 2019 she appeared (left) in the TV series Crazy Fast as 16-year old Beanie.  In 2020 she had FFS - a chin jaw reduction, forehead shave and brow lift.  She posted the results online (centre) and has since started to work as a model (right). 

Sara Randall after FFS on her chin and jaw. She also had extensive dental work (she was a dental student!) and describes this on her website.

Chin and Jaw
The chin is an extremely important area in gender recognition.  Although the potential benefits can be great, the difficulties involved in re-shaping a "robust" lower jaw sufficiently to make a significant improvement in overall facial feminization prevents this being a very common surgery.

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. 

It's hard to find any feminisation surgery that Amanda Lepore has not had - beginning with rhinoplasty at 15 and SRS at 19.

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.

Sliding 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).

Chin augmentation: involves an intra-oral incision to advance a short or/and receding chin with a hard silicone implant.

Neck
A trachea shave is a common procedure undertaken to reduce a transwoman's "Adams's Apple".  

Carmen Carrera
Carmen Carrera (born Christopher) became famous for her appearances in 2011, age 26, as a male drag queen on the third season of the TV series RuPaul's Drag Race.  She regularly appeared in the next few series as a guest, but was now openly transgender and her appearance was radically changing due to taking female hormones and surgical operations.  In early 2014 it was reported that she had had sex-reassignment surgery but in a TV interview she said "I don't want to talk about it; it's really personal ... People [can] speculate whether I've gotten SRS [but] I fixed up a couple things.”  The 'few things' included dental work, rhinoplasty, chin and jaw reprofiling, breast augmentation, liposuction, a tummy tuck, buttock and calf augmentation, and fat transfers.

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.

   

 

Examples of FFS
One of the most successful FFS procedures I have seen is that of Jordan Bellina.  Age 30 she underwent two extensive procedures with Dr. Mayer, including scalp advancement, brow contouring, rhinoplasty, a lip lift and chin augmentation.  It cost her about $29,000.  She has documented this "life changing" experience on her YouTube channel.

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:

Patrícia Araújo (born Felipe Silva de Araújo) in 2009. Her exceptional legs, augmented by procedures such as fat transfer, made her a top model in Brazil. Tragically she committed suicide in 2019, age 35.

It is important to realise that not all facial feminisation surgeries are a huge success.  Some are clearly "botched" and in other cases the patient is unlucky and has serious complications.  Unsurprisingly these results are not publicised by the surgeons and including "negative" photos on this page might result in legal problems.  However, a search of the Internet will quickly reveal a few of the more appalling stories.

 

If the patient has enough money and will accept the risks, a lot is now possible.

Other Surgical Procedures

Rib Removal or Adjustment
These are uncommon procedures which are undertaken to improve the figure. 

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!

Amanda Lepore, the left picture shows where her lower ribs were broken.  The right photo shows her wearing a corset with a 22-inch waist.

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.

Long Bone Shortening
It is possible to shorten the bones of the legs (most commonly the femur) and arms by resection in order to reduce physical size and height.  This procedure is considered dangerous and is very rarely performed on transsexual women.  Excessive reduction of limb length will also destroy the proportions of the body, causing new problems such as an oddly large body on short legs.

 

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.

Lisa spent a relatively modest $20,000 on facial feminisation, breast implants, and SRS with Dr Ousterhaut and Dr Watanyusakul.

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.

Jamie Clayton, age 30 - after eleven years on hormones, SRS, small breast implants, and a few other bits of work!

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.  SRS is a notable omission from the list, but an online-only Playboy pictorial of her shot in 2008 shows that she was post-op by then.

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.  

Procedure Description	Cost ($/€)
Facial Feminisation Surgery
Blepharoplasty (tighten upper and lower eyelids areas)	6,700
Blepharoplasty (tighten upper or lower eyelids areas)	4,400
Rhinoplasty (nose reduction)	7,500
Rhinplasty with Septoplasty (nose reduction and adjust airway)	8,800
Facelift (Rhytidoplasty)	7,800 - 10,600
Liposuction of neck	2,600
Chin augmentation	3,600
Cheek augmentation	5,200
Forehead/brow lift with brow bone reductions and hairline advance	6,200
Thyroid cartilage reduction / tracheal shave (Adam's apple)	3,600
Upper lip shortening	4,400
Top (Breasts) and Body Surgery
Breast Augmentation	8,200
Liposuction	1,000 - 1,500
Abdominopslasty (tummy tuck)	5,300 - 8,500
Buttock augmentation (implants)	9,500
Buttock augmentation (fast transfer)	6,500
Calf augmentation (implants)	6,700
Bottom Surgery (GRS/SRS)
Orchiechtomy (castration)	4,600
Vaginoplasty (one-stage with penile inversions, clitoroplasty and labiaplasty)	19,700

Transwoman Chantelle Stodden at the beginning (left) and end of a decade long surgical journey, including SRS and rib removal.

It is quite possible to find medical practices (particularly in Asia) quoting half these amounts, but potential clients should be very wary of a "bargain" - as a minimum  check the clinics reputation on-line and make sure there are no hidden costs. 

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.

As shown in this 1999 graphic, by age 21 Maxine had undergone 35 operations and procedures in 10 body areas.  They cost about €26,000 ($32,000).	Kelly-Anne (formally Michael Tanham) spent $50,000 feminising her body by age 30, as shown in this 2000 picture.  In 2016, now called Kelly Star, she claimed that she had spent $250,000 on surgery.	Transwoman Barbie spent $80,000 on plastic surgery to look like ... Barbie!

A group of Brazilian transsexuals, including the most famous of them all - Roberta Close.  Between they will have had dozens of feminising surgical procedures.

Web links

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