It was during the fall of 1982 that Ed Falces, a now deceased San Francisco plastic surgeon, referred a patient named Lucy (remember that name) to me for feminization of her forehead. I had been doing craniofacial surgery at the University of California San Francisco Medical and Dental Schools for nearly ten years (I trained with Dr. Tessier in Paris, 1972–73); however, I had never thought about the differences between male and female skulls. Why should I have? Most of my patients were younger than 15 years, several years before development of the secondary sexual characteristics of the skull is completed.
I needed to know a lot more about Lucy's skull shape and what I should do before leaping blind-folded into an operation to alter her skull. I read 5 books on physical anthropology of the male and female skull as a start. Perhaps most importantly, I studied somewhere around 1200 to 1300 dry skulls. The University of the Pacific, located in Stockton, CA, has its dental school in San Francisco. They have a magnificent skull collection, mostly normal, but many pathologically involved skulls as well. Well worth visiting.
Based on my impression of these skulls and knowledge acquired through reading, I devised 4 operations that I believed would correct any secondary sexual characteristics of the male–female skull. Although I had read the separate articles by Tony Wolfe and Mutaz Habal, I did not feel that their methods sufficiently corrected all of the differences in the male and female skulls. It is important to understand that in addition to the different contours of the forehead in male and female skulls, there is in some ways an even larger difference in the projection, that is, the amount that the male forehead is further forward than the females’. My way of reconstructing a Crouzon or Apert patient, as an example, was always a forehead augmentation. For numerous good reasons, I never advanced the forehead bone. Rather I always used methyl methacrylate. Although not part of this introduction, I did many of these and never had even one problem of which I am aware. One of the questions before proceeding with the augmentation was how far to advance the augmentation. Probably starting in 1975 or so, just for kicks, it seemed like a good thing to do, I started measuring the forehead projection of my noncraniofacial cosmetic and other patients, male and female, and recorded it. I also read Dr. Farkas book on physical anthropology, after it came out in 1981.1 It is just one of those basic differences that in the great majority of individuals, the male skull is on average 3 to 6 mm further forward than that of the female. Therefore, to properly transform the male to female skull, the surgeon, in my opinion, must correct this projection difference. In the great majority of cases, just burring down the bossing a millimeter or two is not sufficient.
I operated on only a few transgender patients during the next 3 to 4 years. However, there was then and now a transgender network, and the volume of cases began to increase. Sometime during those years, I started doing sliding genioplasties on transgender patients to correct the several differences between the male and female chins. During my time at the university, I had done a considerable number of sliding genioplasties on our clinic patients. We had a large collection of hemifacial microsomia patients almost all of whom needed chin surgery. To adapt this operation to the differences that were present in the transgender patient was not a difficult stretch of the imagination. The same was basically true for the nose, almost all male transgender patients have a larger nose than that of a similar size female. A reduction, feminizing rhinoplasty became a standard procedure.
Around 1987, an American Airlines captain came to me for feminization. After I had operated on her forehead, nose, and chin, she asked me what I could do for her big lower jaw. There are significant differences between the male and female lower jaws. Bingo. Again, just like with the chin, I had done a considerable number of jaw procedures on hemifacial microsomia patients trying to provide as much symmetry as possible. By this time, I had also completed a large number of jaw procedures on patients with various maxillofacial issues which required advancements and setbacks. The experience was there, it was just a matter of modifying the procedures to the problem at hand. These lower jaw procedures, chin and body, became standard procedures in the vast majority of my patients. Atlas of Craniofacial Growth, a textbook I had worked on as a dental student at the University of Michigan in the late 1950s, has many measurements that are extremely important in planning of the chin and jaw surgery.2
Shortly after the beginning of my work on transgender patients, I also began correcting the masculine thyroid cartilage. Ed Falces taught me how to do that procedure. This was first described in the early 1960s and generated some controversy. Ed also did some male to female genital procedures; however, I never did any genital procedures and cannot comment on that work.
Over the following years, other procedures were added, such as scalp advancement, hair transplants when possible (I generally farmed these out but not always in the beginning), cheek augmentations, otoplasties, blepharoplasties, rhytidectomies, among others. My co-author, Jordan Deschamps-Braly, has added fat grafting, which has been a magnificent addition, as well as we developed a thyroid cartilage augmentation procedure for masculinization of the thyroid cartilage.
Interestingly, although I completed nearly 1400 male to female feminizations between 1983 and 2014, it was not until after I had turned my practice over to Jordan that we masculinized a female to male patient. I had masculinized 6 nontransgender male patients whose complaint was that they looked too feminine.
The very last patient of my career, whom I operated on just before my 79th birthday, was once again Lucy. She was my first transgender patient and the final surgery of my long career. She asked me to correct some residual deformity left by Ed on her Adams apple. Alpha and Omega. A few days later Jordan took over.
One would think that in a city like San Francisco there would be an unending supply of transgender patients. This is partially true, but only a small percentage of these individuals become patients. Our patients came from every continent, and almost every country in 3 of these continents. Ages range from 17 to 73 years with the average age somewhere around 47. The average age since Dr. Deschamps-Braly carried on my practice has been somewhat lower, and probably now is in the mid-thirties.
But where are we now? Although the percentage of transgender patients born will not change, being that there are differences in the brain of transgender patients, there will be more “coming out” as their acceptance in the “community of life” is better. More will be requesting facial feminization. I do not know the percentage of transgender patients requesting feminization now, but in my experience, it was probably not >30%. That may be changing as there are more surgeons doing the surgery and to various degrees, they are busy. Many university medical centers now are starting transgender medicine programs. But I do not know whether these programs are doing a significant number of facial feminizations or more psychological support systems and perhaps top and bottom surgery. In the past, a much higher percentage of transgender patients underwent top and bottom surgery rather than facial feminization. Businesses are now making all aspects of sex care more available to their employees as well. Also, private and government insurance are now more involved. It has come to my attention that many hospitals are trying to capitalize on this and charging exorbitant fees for OR time and hospitalizations. The transgender political world is going a bit crazy at the moment.
But who is going to do the facial surgery? This is not routine surgery learned by watching one and then doing one. I have very strong opinions about the appropriate training necessary before even starting to learn the operations. I will use male to female surgery as an example but the same applies to female to male surgery. The basic issue is that the female skull is smaller than the male skull. So, in facial feminization surgery (FFS), the lower face requires reduction genioplasties, jaw and angle reductions, as well as occasional Le Fort I's, mandibular advancements and setbacks. Therefore, one must have significant maxillofacial training. In the upper face, I devised 4 operations for feminization. The Type I operation is the least commonly found situation and involves bony removal but no osteotomy. The Type III which is far and away the most common, requires extensive osteotomies, and sometimes requires harvest of additional cranial bone grafts. On rare occasion, the dura may be seen and even rarer there can be a dural leaks. On those occasional cases where there is a complete frontal sinus nasal cavity obstruction, one should better know how to correct these problems. They happen. In summary, I would demand, if it was up to me, that anyone doing upper facial FFS be craniofacial trained, not just watching 2 or 3 cases as a resident.
Being transgender is not the result of mother dressing Robert in too much pink one day and she became Roberta. There is a known and published difference in the brain of transgender patients. The great majority of my patients seem to have greater than average intelligence. Many have been very successful. Three of my patients have been put up for a Nobel prize, 2 should have gotten it. Some of the stories of their lives will bring tears to your eyes. But there are many stories that are extremely funny. Unfortunately, 6 of my patients have committed suicide, generally at least a few years after their surgery. My point in mentioning all of the above is that if you are really interested in doing this surgery, please do not do it just for the income. You and your staff must understand their issues, lives, and objectives. It can be very complex and you must have tremendous compassion for them.