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Facial Feminisation Surgery


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Facial Feminisation Surgery

  1. 1. Facial FeminisationSurgeryPatient information guide 1
  2. 2. 2
  3. 3. Content 3 Introduction 7 Surgical procedures 28 Practical information 34 Agave Clinic Facial Feminisation Surgery 3
  4. 4. Introduction We feel highly honoured that you are con- sidering Agave Clinic as the place to have your facial feminisation surgery. The following patient guide contains infor- mation on the facial feminisation procedures offered at Agave Clinic. If you decide to pursue surgery, you will find here all the practical information you need.4
  5. 5. About Facial Feminisation SurgeryFacial feminisation surgery (FFS), is the term given to aconstellation of surgical procedures that are designedto alter a masculine face and bring its features closer inshape to those of a woman’s face.Why FFS? Bony and soft tissue workFFS has become increasingly sought after FFS works on both the bone and the Modification of soft tissues of the faceby transgender women. Psychologically overlying soft tissues. Many of its tech- encompasses more standard cosmeticit is often more important than gender niques originate from maxillofacial sur- procedures used for primary anti-agingreassignment because it helps these gery as well as traditional plastic surgery. effect. However, bony work is oftenindividuals integrate socially as women. The few surgeons who perform FFS combined with soft tissue proceduresThe face commonly provides the first usually have a maxillofacial background. to achieve an optimal feminising effect.visual clues and gives an impression of the Douglas Ousterhout was a pioneer in Soft tissue work may be necessary to getphysical gender of an individual. While what is now called FFS during the 1980s the full result of bony work for someother parts of the body can be hidden or and 1990s in the U.S.A. Globally there patients. In general soft tissue work willexaggerated to appear more feminine, it’s is just a small number of surgeons that smooth and tighten areas, making youdifficult to create feminine facial features have specialised in FFS. look younger and by extension morewithout FFS. This is why male to female feminine. The science of changing the skeletal base(MTF) transitioning individuals may of a face is rooted more in the maxillofa- The most feminising procedure is thedesire this surgery in order to transform cial heritage of the procedures. Generally trachea shave. In fact the presence of anthe face and therefore facilitate passing speaking, bony work will have a far more Adam’s apple is the only feature that al-in public as a woman. dramatic effect on the shape of a face, most proves the physical gender is male. which is sometimes necessary to look Besides the trachea shave, the three like a woman. Men and women have most important areas worked on, those basic differences in skull shapes. If the providing the most dramatic change, are shape of a skull is out of the female range, the forehead, nose and jaw. All three of it may impede passing as a woman. The these areas tend to be less pronounced, surgery provides an immediate major smaller and smoother in females. Among improvement, and with aging results the procedures available are: hairline will become more evident as the skin lowering, forehead recontouring, brow becomes thinner and looses elasticity. lift, rhinoplasty, cheek implants, lip lift, lip augmentation, chin recontouring, Facial Feminisation Surgery 5
  6. 6. jaw recontouring, blepharoplasty, face-and necklift, midfacelift, otoplasty andAdam’s apple reduction. But even theteeth can be feminised. The majority ofthese procedures can be performed incombination.The key to a successful FFS outcomeis to plan a combination of facial pro-cedures that can most effectively softenone’s appearance and make a convincingchange.The treatment plan is based upon a com-bination of skeletal and artistic evalu-ations, radiographs (x-rays), anthropo-logical measurements and photographsas well as the patient’s self assessment.So there is no standard set of proceduresthat will work for every patient. Eachpatient usually has one primary zonefor change and two others that couldbe modified. While some patients needjust three or four procedures, others maybenefit from additional ones. Most pa-tients have a good feeling for what willbe effective. A careful discussion with thesurgeon is essential to create an adequateworking list of procedures. As long as themost prominent masculine features areconverted into more classically femininefeatures, a very satisfactory feminisationcan be achieved.6 Patient information guide
  7. 7. Surgical procedures This section will describe all facial feminisa- tion procedures performed by Agave’s team of specialists. 7
  8. 8. Hairline lowering and reshapingThe hairline is an identifying trait for gender, which isaccentuated with age.Gender of the hairline Feminising the hairlineIn males the hairline is often higher than There are two options for reshaping the Hair transplantsin females. The distance between the masculine hairlines. The hairline canbrows and the hairline for women on be moved forward and given a more Hair transplants can also be used to addaverage is 5 cm. For men this is 7 cm. rounded shape either with a procedure volume to hair thinned by male pattern called a “scalp advancement” or with a baldness. This is the definitive treatmentAnother difference is the shape of the for all types of hair loss, and guarantees hair transplantation.hairline. A man usually has receded cor- a natural effect in most cases. In a hairners above the temples that give it an “M” transplant a strip of skin is removed fromshape. Conversely, the female hair pattern the back and sides of the scalp. They are Scalp advancement (hairline lowering)is oval shaped, smoother and full around then transplanted to the target areas tothe facial edge. Scalp advancement involves removing fill in the corners of the male “M” and a section of the skin on the forehead to thicken the areas of hair loss. ThereAn additional difference between male (between the hairline and eyebrows) is a limit to how densely the hair can beand female hairlines comes with the age. and pulling the scalp forward between packed in at one time, so more than oneThere is a typical male pattern of bald- 1.0 cm and 2.5 cm to correct for the procedure may be needed to achieve theness with a recession of the hairline. How receding masculine pattern hairline and desired density.many women have you seen with a re- to approximate, when possible, a moreceding hairline? While biological women feminine ‘oval’ pattern sometimes suffer from hair loss, it isusually an all-over thinning of the hair Scalp advancement is a permanent femi-from the entire scalp and isn’t specifically nising solution for those patients whotargeted to one area. do not suffer from a receding hairline. It acts as a temporary fix for a receding hairline in patients suffering from hair loss, but will not stop the hair loss. We highly recommend that these patients seek out an additional hair loss solution, like hair transplantation, to keep the hairline looking full and healthy.8 Patient information guide
  9. 9. Scalp advancement (Hairline lowering)This procedure is very well com- • The scalp will be mobilized to the Recoverybined with forehead recontouring back of the head and pulled forward • A dressing is placed around theand brow lift, which are often done as much as needed. Normally 1.5 -2 forehead. It will be removed thevia the same incision. cm of advancement is no problem. next day.Procedure • A section of forehead skin at the • The patient may suffer from some• General or local anesthesia is hairline is removed. pain during the first days, which is given. suppressed with medication. Su- • The scalp is fixed to the bone using• An incision is made along the tures will be removed after 7 days. Endotines to prevent it from pulling hairline. The incision is made just back. • A visible scar exists, but it will inside the hairline, in an irregular typically be too faint to be noticed. fashion, to avoid a straight scar. Endotine Straight scars are more conspicu- used to ous than irregularly curved ones. prevent the Complications Also the blade is held in such a scalp from • Swelling will occur around the eyes, direction that about six weeks pulling back. on the forehead and scalp. Forehead postoperatively the hair starts numbness will last several weeks to growing through the scar, making months. it almost invisible. Bianca before and after a hairline lowering (combined with forehead recontouring and eyebrow lift). Facial Feminisation Surgery 9
  10. 10. Forehead recontouring Forehead recontouring Procedure • General anesthesia is given.The forehead is one of the more apparent gender mark- • An incision is made along the hairline.ers. Forehead reconstruction is very powerful and can The incision is made just like in scalptransform a prominent male forehead to fall within the advancement surgery.average female ranges. • The forehead skin is pulled forward to reveal the bone. The boneplate over the frontal sinuses is removed, thinned frontal sinus is hollow, it is more diffi- until the desired thickness is achievedGender of the forehead cult to remove bossing there. It involves and reshaped.The male has more brow bossing (the removing this plate of bone, reshaping • Then the solid orbital rims areridge above the eyes) and a forehead that it, and placing it back in position with shaved.angles more steeply away from the eyes. small titanium screws to hold the bone • Finally the refined boneplate is fixedThe female forehead is typically rounder in place while it heals. in place with titanium all dimensions and almost never has a The heads of the screws are removedprominent brow bone. In profile, female so they cannot be felt or seen throughforeheads are more vertical instead ofbackward sloping. Frontal bossing the skin. • As in scalp advancement, the skin is supra-orbital rims glabella fixed to the bone using Endotines to prevent it from pulling back.Feminising the foreheadForehead recontouring is a procedure Recoverythat involves brow shaving and surgically • Hospital: Most patients will spendaltering the bone. one to two nights in the hospital fol-The outer segments of the bossing that lowing surgery.the eyebrows sit on are called the “su- • Dressing: A dressing is placed aroundpraorbital rims”. These are solid bone the forehead after surgery, and left inand can simply be filed down. place during the first night. It can beThe section of bossing between the removed the day after surgery.eyebrows (the glabella) sits over a anarea called the frontal sinus. Because the10 Patient information guide
  11. 11. • Pain: Pain may occur for a few days, which is controllable with normal painkillers.• Work: Many patients can go back to work within two to four weeks follow- ing surgery.• Sport: Avoid physical activity that causes sweating or a rise blood pres- sure for eight days.• Sutures: Sutures are generally removed within nine days.Complications• Infection: Infections are extremely rare, but antibiotics are used to avoid potential infections.• Swelling: Swelling and bruising may occur around the eyes, but will dis- sipate within ten to twelve days.• Numbness: Forehead numbness may last several months and often doesn’t recover completely. Facial Feminisation Surgery 11
  12. 12. Eyebrow liftHigher eyebrows can offer a younger and more feminine look. In facial feminisationsurgery a brow lift is almost always combined with forehead recontouring and scalpadvancement, procedures using the same incision.Gender of the eyebrow Feminising the eyebrowMale eyebrows are fairly straight and A brow lift is a well-known procedure inthick and sit on or just under the or- plastic surgery, used mostly by older ge-bital rims. Female eyebrows generally sit netic women to restore a more youthful,higher and are more arched. refreshed look to the area above the eyes. A brow lift opens up the face making one look less stern and tired. A brow lift is done by lifting the skin of the entire forehead, therefore raising the eyebrows. This has no effect on the underlying bone, so is not as dramatic as forehead contouring. In FFS, an eyebrow lift is almost always combined with forehead recontouring and scalp advancement. The arch and height of the eyebrows are related to the shape of the frontal bone that lies beneath. This is why, in forehead femi- nisation procedures, it’s very important to correct the position and shape of the eyebrows with a brow lift after remod- eling the frontal bone.12 Patient information guide
  13. 13. The mail eyebrow. The female eyebrow.Before eyebrow lift (and forehead recontouring). After eyebrow lift (and forehead recontouring). Facial Feminisation Surgery 13
  14. 14. Cheek augmentation While the shape of the cheeks is not generally a female or male characteristic, it is true that a lack of cheek prominence is often not appealing. High prominent cheek- bones are frequently associated with feminine beauty. Augmentation is therefore helpful in feminising the face. Gender of the cheek Females often have more forward projec- tion in their cheekbones as well as fuller cheeks overall. Feminising the cheek Cheek augmentations are generally completed utilizing an implant. As we have seen too many problems the pink area indicates the area where implants with are placed capsulation, displacement or infection of silicone implants we only use Medpor® implants that consist of porous poly- ethylene. They allow for surrounding tissue ingrowth because of its open pore structure. This ingrowth of internal tis- sue prevents the implant from shifting out of place. The implants come in all sorts of shapes and sizes and can easily be moulded, depending on the needs of the patient. They are easy to apply and noticable asymmetries after surgery are almost impossible. Bianca before cheek implants. Bianca after cheek implants.14 Patient information guide
  15. 15. Cheek augmentationProcedure Bruises are very infrequent.• Cheek augmentations are usually • Pain: Pain, stiffness and tempo- performed under sedation or gen- rary numbness may occur. eral anesthesia and take about one to two hours. Complications• A small incision is made inside the It is very unlikely for cheek surgery mouth, in the gum above the upper to present any complications. How- teeth, so no scars will be visible on ever, every surgery, no matter how the outside. simple it may be, has certain risks• A pocket behind the muscles of that should be recognized. each cheek is then created and the implant is placed immediately over- • Infection: Because the implant lying the cheek bones. is a foreign material and is be- ing placed through the mouth,• The implants are sculpted at the antibiotics are utilized to prevent time of the surgery for adjustment the possibility of infection. If an to the needs of each patient and infection were to develop in spite then fixated to the bone using mi- of antibiotics, the implants might croscrews to prevent displacement. have to be removed. This has neverRecovery happened in our centre.• Sutures: You will have sutures in your mouth, which are dissolvable. You should use mouthwash 2 to 3 times a day, to keep the area clear of debris. The resulting scars on the gums will be completely concealed inside the mouth.• Swelling: You can expect to have some swelling following this sur- gery. Try to rest and sleep propped up with 2 -3 pillows during the first week after your surgery, to help re- duce any swelling and bruising. The swelling may last one or two weeks. Some illustrations of Medpor® implants. Facial Feminisation Surgery 15
  16. 16. RhinoplastyAside from the trachea shave, nose reshaping is probably the most common facialfeminisation procedure. The nose is the most prominent feature of the face. Manytranswomen find nasal refinement can create marked improvements in their femalefacial appearance. It tends to make the eyes look larger, bring out the cheekbonesand adds delicacy to the overall facial impression.Gender of the nose Feminising the noseMale noses are usually larger than those of Standard rhinoplasty techniques can be If one has thin skin, a significant size ofwomen, with a broader nasal bone. Men used to make the nose smaller and to give reduction can generally be completed.more often have a nasal hump. Usually, it clear feminine outline and proportions, If the skin is quite thick (as is often thebeautiful female noses are smaller than taking into consideration that it should case in males), the contour can still bethose of men, in all aspects. They tend be harmonious with the rest of the face. markedly improved, but there may be ato be narrow and straight, or to have a definite limitation to the size reduction In a reduction rhinoplasty, generally thegentle curvature like a slide. possible. However, contour changing dorsum and tip of the nose need to beThe angle between the male forehead made smaller and the tip lifted. Correc- alone greatly feminises the basic nasaland nose is sharper than in women and tion of the frontal bossing will improve appearance.the angle between the nose and lip is the angle between the nose and thealso smaller (points upwards more). The forehead.angle of the tip of the nose is sharper inwomen than in men. Women´s nostrilsare also usually smaller. 115 120 90 105 Bianca before rhinoplasty. Bianca after rhinoplasty.16 Patient information guide
  17. 17. RhinoplastyProcedure • Narrowing the nasal bone: If the days. The nose is usually very tender at• Rhinoplasties are usually done under bridge of the nose is wide, it can be that point and extra care must be taken general anesthesia. In certain minor narrowed by fracturing the nasal bone to avoid bumping it or sleeping on it. cases, local anesthesia and sedation on each side and moving it closer to • Bleeding: Some sporadic bleeding may be used. The operation generally the centre. could be expected during the first lasts between one and two hours. • Narrowing the nostrils: The volume couple of weeks, which is normal and• For feminising rhinoplasties we prefer of the nostrils can be reduced by alar should not be a cause of concern. the ‘open method’ because it gives the base excision. • Bruising: Most people get bruising surgeon more working room. In the around the eyes and cheeks. The ‘open’ approach one small incision is bruises under the eyes will intensify outside the nose across the columella during two or three days before they (the skin between the nostrils). This begin to vanish. 15 days later, only incision is generally extremely dif- you and your surgeon will be able to ficult to see. notice any traces of the surgery. • Appearance: Your nose will regain • A splint will be put on your nose to its normal appearance very soon, help support the new shape. Packing but the definitive results will be fully is placed inside your nostrils to help appreciated after six months. The stabilize the interior structure of your tip is the area that takes the longest nose. to acquire its new shape. • Small sutures will be used to close the incisions. Complications • Assymetries: The nose is, literally According to your individual needs fol- Recovery speaking, constantly before our eyes, lowing actions may be done: • Breathing: The most difficult part for making any imperfection very notice- most people is being unable to breathe able, no matter how trivial it may be.• Refining the tip: A section of the tip through their nose until the packing Even though the surgeon marks very cartilage is excised to achieve refine- is taken out. Your mouth and lips can carefully the areas he is going to treat, ment or ‘narrowing’ of the nasal tip. dry out very easily and swallowing there may be asymmetries. According can be difficult. Usually the packing• Shaping the profile: The bone-carti- to international statistics, rhinoplast- stays in for three to seven days. lage hump is removed. A surgical file ies are the procedures that have the or rasp is commonly used to smooth • Stiches: The stitches underneath the highest rate of revisions. These revi- the bony hump, in order to achieve nose come out in a week to ten days. sions, if necessary, may be carried out more precise results. after six months. • Cast: The cast comes off after nine Facial Feminisation Surgery 17
  18. 18. Lip surgeryFuller lips can help you pass and give you a younger look. Unfortunately, the lip isfrequently overdone, which can be counterproductive if passing is your goal.Gender of the lips Feminising the lipsThe male face typically has a long upper Lip lift Lip augmentationlip with little or no visibility of the upper In the lip lift procedure, a wave-like If, in spite of this surgery, the lip is stillteeth.The youthful female face is charac- segment of skin (thicker in the middle) too thin, an injectable product can beterized by a shorter distance between the is removed directly under the nose. The applied in the same surgery or at a laterbase of the nose and the upper lip with upper lip becomes shorter, which also date. This can be done with temporarymore visibility of the teeth. It is a typical has the following benefits: injectable fillers or fat transfers (injec-feminine trait that is also characteristic tion of a fat graft taken from the sameof youth, since as years go by the upper • The lip is rolled up, so a larger ver- patient). The effect of injecting mainlylip droops and covers the teeth. million area is visible. on the inner side of the lip, directly underIn regards to the vermillion border, it’s • The resulting curvature increases the the intra-oral mucosa, is an outward roll-considered more feminine when it’s lip projection. ing which shows more of the inner lip.fleshy and has a good projection. This • The upper teeth can be exposed about Part of the fat graft will re-absorb, butis also a typical trait of youth. For this 3 or 4 mm. a significant portion will be permanent.reason lip augmentation remains one of While difficulties remain in the predict-the most frequently sought after cos- ability and longevity of fat transfers,metic procedure performed in aesthetic the aesthetic effect are often impressivemedicine today. because of the resulting appearance. The effect of fat injection is an outward rolling with more show of the inner lip.18 Patient information guide
  19. 19. Before and after lip lift and lip aug- mentation.Lip lift Lip augmentationProcedure Procedure fat grafting• A lip lift can be performed in • After the injection of local anaes- The trick of the fat transfer is to inject local anaesthesia or in combi- thesia in the donor site, a couple of only a very little amount of fat with nation with other procedures millilitres of fat are aspirated using each pass of the needle. This way the under general anaesthesia. a blunt needle on a syringe. This grafted fat will be in direct contact can be taken from anywhere in with the surrounding tissues and a• After having made the design the body where there is sufficient fast ingrowth of vessels will be pos- for the excision, the local an- subcutaneous fat and used to inject sible, ensuring a higher possibility of aesthetic is injected. into the lips. The donor site is nor- fat survival. Approximately 1/50 to a• The skin is excised and the mally the upper leg, abdomen or maximum of 1/10 ml of fat cells are wound closed in 2 layers. the submental area (below chin). injected with each pass of the needle. • By means of centrifugation theRecovery intact fat cells are separated from Recovery• The non-reabsorbable skin oil, local anesthetic and blood. This • Immediately after the surgery, the lip sutures are removed after 5-7 way, only the intact fat cells are re- will be quite swollen and bruised. In days. Recovery is fast and injected. about 3 weeks time approximately without complications. 80% of the bruising and swelling will • The fat cells are then poured into a tiny syringe on which a blunt have disappeared. After 4 months needle is placed. The lip is injected you can get a good impression of the with a minimal amount of local final result. After 6 to 8 months, if anesthesia after which the fat cells necessary, another fat graft may be are injected along the inner side of performed until the desired effect has the lip, just under the lip mucosa. been obtained. Facial Feminisation Surgery 19
  20. 20. Jaw shave Jaw shaveBesides the forehead and eye area, the most significantcharacteristic of a feminine face is the overall face Procedure • General anesthesia is usually requiredshape. To a large extent, this is determined by the for this surgery.shape of the jaw. A prominent lower jaw gives the face • Incisions are all made intraorally, soa square, masculine look and can be considered unat- no scars will be visible on the outside.tractive for females. • Marked areas of prominent bone are cut with a surgical drill and micro- saw, curving down from back to front, to achieve a well-rounded contour. • The masseter muscle is reduced on itsGender of the jaw Feminising the jaw inner aspect if necessary.The male jawbone is usually heavier built Having a jaw shave can reduce the ap- • The wound is closed with self-dis-and tends to be wider, because the mus- pearance and size of the jaw, making it solving stitches.cles attached to the corners of the jaw- rounder and narrower at the square cor- Recoverybone are much bigger. Female jaw lines ners near the back of the jawbone. • Hospitalisation: Most patients willrun in a gentle curve from the earlobe to spend two nights in the hospital fol- When the masseter muscles are toothe chin. In males, it tends to drop down lowing surgery. thick, they can be reduced by trimmingstraight from the ear and then turn at a them, although long lasting hormone • Swelling: Swelling is expected andsharp angle towards the chin, giving a treatment reduces their mass. varies greatly by individual. A specialsquare appearance. Usually, this surgery is combined with mask will cool the surface of your face chin feminisation surgery to create a and keep bruising, swelling and pain harmonious balance of these two adja- to a minimum. Swelling usually takes cent areas. a significant amount of time with these procedures. Swelling and bruising Patients over 40 may experience loose will peak 2-3 days after surgery. The skin around the jaw or chin after a jaw majority of the swelling will dissipate shave. This can be tightened after the two weeks after surgery; however, original jaw shave procedure with a lower some of the swelling may take several face-lift. more weeks to disappear. It may take20 Patient information guide
  21. 21. 4-6 weeks for the improved contour to become obvious, but the result is worth the wait!• Numbness: Most women experience temporary numbness.• Work and sports: If you don’t mind being seen with the swelling, you may be able to return to your social activities 7 to 10 days after the surgery. You will have to wait until the third or fourth week before doing any hard work or physical exercise. areas where the jaw is shavedComplications• Infection: Infections are possible but rare.• Numbness: Extremely rare is perma- nent numbness of part of the jaw, in areas where the jaw is shaved. Facial Feminisation Surgery 21
  22. 22. Chinplasty Sliding genioplasty Chin shape generally varies widely between males and females, so it can be extremely important in gender Procedure recognition. • General anesthesia is given. • Incisions are all made intraorally, so Gender of chin Feminising the chin no scars will be visible on the outside. Female chins tend to come to one point Luckily, the chin is an area whose fea- • The chin is cut from back to front on in the middle. Men’s tend to have two tures can all be modified: height, width both sides with a saw, separating a points directly below the canine teeth and if necessary even projection. Various horseshoe-shape of bone. and a flat part between the points. This modifications to the chin can be made • A second cut parallel to and a few mil- makes men’s chins look fuller and more depending upon the individual anatomy limetres from the first one can be made, square. Women’s tend to be more ta- of the patient, and the desired result. and a slice of bone removed. pered. The procedure is called a “sliding gen- • The middle part of the horseshoe- Male chins also tend to have more verti- ioplasty”. The chin is cut from front to shaped bone can be removed to make cal height, with a longer space between back, separating a horseshoe-shaped the chin more pointed. the lower lip and the base of the chin. segment of bone. A slice of this segment • The final position of the piece ofskull Female bone In some cases, male chins have a verti- can be removed. This will reduce the is chosen. At this point the chin can be cal crease in the middle, usually known height of the chin. The middle part of moved forwards or backwards. as cleft chin, which is very unusual in the horseshoe-shaped bone can be re- women. moved to narrow the chin. Also the chin • The bone parts are fixed using titanium can be moved forwards or backwards to miniplates and screws, which will never correct a receding or protruding chin (if be removed. necessary). • Liposuction is done when necessary. Sometimes liposuction to remove some • The wound is closed with self- of the fat that some people have below dissolving stitches. the chin is needed to add definition to the chin shape. Recovery • Hospitalisation: Most patients will spend two nights in the hospital fol- lowing surgery.Horsehoe shapeof bone(dark blueindicates wherebone is removed). Female skull 22 Patient information guide
  23. 23. • Compression Bandage: A bandage will be left over the chin to reduce hematoma. It can be removed on the next day.• Swelling: Swelling is comparable to that after jaw surgery.• Numbness: Most women experience temporary numbness.• Work and sports: If you don’t mind being seen with the swelling, you may be able to return to your social activities 7 to 10 days after the surgery. You will have to wait until the third or fourth Male skull (blue indicates where Female skull week before doing any hard work or bone is removed). physical exercise.• Scars: If a complementary liposuc- tion is needed to add definition to the chin shape, a couple of very little punctures (2mm) will remain for sev- eral months and then vanish.Complications• Infection: Possible but rare.• Numbness: Extremely rare is per- manent numbness of one half of the lower lip and chin due to damage to the mental nerve. Before chinplasty. After chinplasty. Facial Feminisation Surgery 23
  24. 24. Classical rejuvenation proceduresClassical beautification and rejuvenation procedures are often performed in conjunc-tion with a facial feminisation. After a facial feminisation surgery, a face-lift willadjust the soft tissues of your face to your new bone structure and the female outlineof your face will be more clearly defined.Blepharoplasty FaceliftSimultaneously with a facial feminisa- Face-lift surgery will make you look and the effects of swelling can leave ation surgery it is common for eye bags many years younger than you really are. previously non existing sagging skin.and sagging eyelids to be corrected with The difference between your real age and Face Lift Surgery (rhytidectomy) liftsa procedure called “blepharoplasty”. your looks will last for decades; that is, as the areas that gravity has pulled down, you grow older you will still look much especially the cheeks. The Submusclar younger than you really are. Aponeurotic System (SMAS) is a layerNasio-labial folds Moreover, if you have already had a beneath the skin which includes the fa- facial feminisation surgery, a face-lift cial muscles. By tightening the SMAS,It’s very hard to get rid of the deep cheek will adjust the soft areas of your face to the jowls are lifted, the neck is tightened,folds that extend from the corner of the your new bone structure and the female and the cheeks are elevated. This “deep”nose to the corners of the mouth (na- outline of your face will be more clearly or “2-layer” facelift is an improvementsolabial folds). This area seems to make a defined. over earlier skin-only techniques.difference in passing. After jaw or chin surgery it is often A facelift enhances the cheeks defini-A facelift can help reduce this, but the necessary for older patients to have a tion and volume because the surplusbest results are acheived withfat grafts. face-lift because the reduction in bone skin is cut out to allow the tightening of what is left, but the surplus muscles (worked at the SMAS level) are not cut out: they are instead folded up over the cheekbones. This means that the loose muscles that currently sag below the cheekbones are raised and repositioned as a pleat in front of them to make them look fuller beneath the tensed skin. This lifting manoeuvre also decreases the flabby tissues over the jowls area, which in turn reduces the nasolabial folds. Facelifts will not improve the foreheadBefore fat injection in nasio-labial folds After fat injection in nasio-labial folds nor eyebrow areas. For this, forehead or(and lips). (and lips). brow lift surgery is necessary (which is usually standard in facial feminisation surgery.)24 Patient information guide
  25. 25. Necklift FaceliftTo remove any pronounced neck cordsa necklift is commonly needed. Thisinvolves a small incision under the chin. Procedure head that will be removed about • A facelift is usually done under 24 hours later. general anesthesion. The operation • Stitches: Between one and twoSubmental liposuction generally lasts between two and weeks after the surgery the stitches three hours.Fat in the submental region is usually will be removed.related to obesity. However, fat may be • The surgeon makes an incision very • Bruising: Bruises may develop,present even in individuals of normal close to your ear, following its natu- especially below the eyes. Theyweight. As aging progresses, many ral outline. will be at their worst during thepeople develop submental fat deposits • He separates the muscles and the first week but, at time goes by, theyindependent of their weight. skin of the middle area of your will slowly disappear. The swell-Liposuction is the treatment of choice face. ing lasts about a month. The coldfor fat removal in the youthful neck. facemask helps you recover faster. During the first few days, you willLiposuction is done by inserting a have to sleep with your head andsmall cannula with a vacuum attached, torso elevated to encourage properthrough a tiny incision made in the skin. drainage.The cannula is pushed and then pulledthrough the fat layer, breaking up the fat • Work: Most patients are able tocells and suctioning them out. return to work in two to three weeks. You should allow four to • The surplus skin is cut out to allow eight weeks before major social the tightening of what is left. engagements.Breast augmentation and • The surplus muscles (belonging to • Scars: The scars frombody sculpting the SMAS level) are not cut out: facelift surgery usually fadeBreast augmentation with implants helps they are instead folded up over the and are barely enhance the results already achieved hormonal treatment. • The incisions are closed using ComplicationsTo enhance of overall feminisation ef- very fine stitches. • Infections: Infections rarely de-fect, additional body contouring can be velop, and are prevented by takingvery effective. Abdominoplasty (tummy the appropriate antibiotics. Recoverytuck), and/or suction assisted lipectomy • Hospitalisation: You will need to • Seromas: Seromas, or fluid ac-(Liposuction, Liposculpturing) will stay hospitalized half a day. cumulation beneath the skin, maygreatly change the body contour. develop. In some cases, they have • Compression bandage: You willBy narrowing of the abdominal muscles to be drained with a syringe. leave the operating room with atowards the midline (muscle plication) compression bandage around yourduring an abdominoplasty, the abdomi-nal shape can be significantly improvedtowards a more feminine contour; alsothe waist line can be reduced. Facial Feminisation Surgery 25
  26. 26. Trachea shave A prominent Adam’s apple is often a constant embarrassment to transwomen, which can be improved by the trachea shave procedure. The sex of the trachea Feminising the trachea The Adam’s apple is a characteristic fea- A trachea shave is an effective solution to ture of adult men. The name says it all: this problem. it’s one of Adam’s, the Man´s, attributes. The surgeon reduces the cartilage in the This feature is actually a lump of cartilage throat to make the shape more femi- located in front of the larynx. The larynx nine. is the voice-box where the vocal cords Trachea shave is one of the simplest and are located. During puberty, the larynx swiftest feminisation surgeries, but it grows much more in boys than in girls. must be done by an expert surgeon since This creates a resonance, deepening the a too aggressive shave could weaken the voice, whereas girls voices don’t change larynx structure or voicebox and perma- so much. nently alter the vocal quality. It is not always possible to make a large Adam’s apple invisible with this proce- dure, rather the intent is to change it from the masculine 90 degree angle to the feminine 120 degree angle. areas where trachea is shaved vocal cords26 Patient information guide
  27. 27. Before and after trachea shave.Trachea shaveProcedure Recovery Complications• This can be done as an outpatient • A piece of gauze will cover the incision • Voice change: Your voice may change procedure with local anasthetic in for the first 2 or 3 days. in case of over-dissection. about 1-2 hours. Many women • For about 7 to 10 days you will prob- combine this operation with other ably have a burning sensation and procedures under general anas- some difficulties when swallowing or thaesia in the hospital. talking. Patients report it as being very• An incision of about 2 cm is placed similar to a simple sore throat. under the chin, if possible, inside • Mild voice weakness may occur in a crease. the first few days after surgery, but is• From there a tunnel under the skin normally temporary. is made to the thyroid cartilage. • Swelling will peak during the first With a bur it’s prominence and 24-48 hours, which will com- upper rim are trimmed. pletely subside after about 6 weeks.• The muscles that run along and over the cartilage are united in the middle to cover the remaining prominence Facial Feminisation Surgery 27
  28. 28. Practical information In this section you can find here all the infor- mation you need before and after the opera- tion.28
  29. 29. Patient coordination Our patient coordinator, Lilia Koss, looks after patients that have to stay in Marbella a bit longer after their surgery. She assists with accommodations and organizes your taxis and appointments. Our patient coordinators are here to support you.Flying to Malaga Hotels in MarbellaOur patient coordinators will suggest We will help you find your preferred with a companion; patients who travelairlines from your country to Spain. Ma- accommodations nearby and assist with alone may be recommended an extendedlaga international airport is only a 25 - 60 reservations. Room service, internet and hospital stay or nursing care in the hotelminutes taxi drive to Agave Clinic. More other amenities are available upon request. (additional fees involved).than 60 airlines fly to Malaga. Prices vary according to the season.The airport transfer is provided to you Consultations and check-for free. About 40% of the population Aftercare in Marbella ups abroadof Marbella is of non-Spanish originso you’ll find English-speaking people Our personal care and attention contin- Each month we have a day of consulta-everywhere. ues long after your procedure. During the tions and check-ups in the U.K. (London) first week post-op, you will have daily re- and in the Netherlands (Dordrecht).You visions in Agave Clinic. Once you return can make an appointment by contact- home, we hope to arrange for 3-month, ing Agave Clinic in Marbella. If you’re 6-month and 1-year evaluations with the interested in dental implants and have a surgeons. However, it is highly recom- panoramic x-ray it would be very useful to mended to our surgical patients to come bring it with you. Facial Feminisation Surgery 29
  30. 30. Typical Schedule of a FFS patient• Day 1: Arrival—The taxi driver will • Days 3-4: Release from the hospi- • Day 9: Final Revision and Depar- wait for you in the airport, holding tal—If alone, you will be escorted to ture—You will have an exit interview a sign with your name. The trip to your hotel by taxi. Our patient coor- with the surgeons. The nurse will Marbella takes about 1 hour. dinators will make sure you have eve- remove any sutures or dressings re- rything you need for the night. maining.• Depending on your flight, you may come directly to Agave Clinic for the • Our patient coordinators will provide pre-operative consultations and tests, • Days 4 - 8: Daily revisions— You you with the medical authorizations which will take most of the day. In will come to the clinic to change you need and arrange for a taxi to the meeting with the surgeons, you wound dressings and have cool- take you to the airport. will confirm the treatment plan and ing mask sessions as necessary. discuss the procedures in detail. The You are only a phone call away patient coordinator will orient you at all times, as we will provide on the schedule for the week. you with a spanish mobile phone.• You should plan to do a bit of shop- ping for essentials the day before surgery. This way you may get the rest you will need post-op.• You will not be able to eat or drink dur- ing the 8 hours before the scheduled operation. Nervousness may impede a good nights sleep, but try to rest.• Day 2: Surgery—You will see the surgeons before surgery for any necessary facial drawing. One hour before surgery you will go to hospital admissions with our patient coordi- nator.• The cooling facial mask will be placed immediately after surgery and kept on for the entire first night. You will stay 1 - 3 nights in the hospital, depending on the extent of the sur- gery and if you are unaccompanied. The surgeons, nurses, anasthesi- ologist and coordinators will see you frequently during your hospital stay.30 Patient information guide
  31. 31. Preparation• Medical history: Once you have • Accomodations & Airport transfer: • Eating: You will be on a bland liq- chosen Agave Clinic, we will ask for If you wish, we can help you choose uid or pureed diet for a few days af- your written medical history as soon a hotel near the clinic. We will also ter surgery. You may find it difficult as possible, so we have sufficient time arrange for you to be collected from to chew or swallow normal foods to take the necessary measures. the airport on arrival. Transporta- or open your mouth wide enough tion to the clinic will be by taxi; each for normal-sized utensils. Plan to• Anticoagulant medication: Any an- way will cost around 5 Euros. purchase wide straws and baby-size ticoagulant medication you are tak- utensils. Even a large syringe is useful ing must be stopped in good time. • Weather and Clothes: Marbella is for consuming pureed foods. We will Please contact the physician that very hot and humid in the summer provide you with an electric blender gave you the prescription, ask what and mild year-round. In the autumn and a flexible baby bottle. High Cal- measures should be taken, and report and spring you will need a coat. orie shakes and powder mix, which this to us. Winter nights are cold. Although contain all the nutrition you need it rarely rains, it is possible between until you are able to eat normally,• Hormones: On the day of surgery October and April. You will need to can also be purchased in pharmacies. you’ll receive some antithrombotic wear a hat, head scarf, or bandana to Once you are ready to go out, restau- medication. Therefore it’s not neces- protect your face and incisions from rant food in Marbella is varied. sary to stop taking hormones. foreign bodies and the suns rays. Bring button-down blouses or shirts • Caring for yourself: You will have• Smoking: We strongly advise you to with a wide opening to make it easy daily visits in the clinic for after-care stop smoking three weeks before sur- to dress. if necessary. Medications will be pro- gery, as smoking counteracts wound vided upon release from the hospital. healing. • Entertainment: Don´t forget personal However, it may be helpful to have a entertainment items such as a laptop stroll around the neighbourhood the• Travelling companion: A travel- (with appropriate electrical adapt- day before surgery to locate the near- ling companion would be ideal. If ers), music, journals, crosswords, etc. est pharmacy and supermarket. It is patients come alone, during the first We have a selection of English novels a good idea to purchase beforehand day in the hotel we may require a for your use. The first few days after any toiletries, food, drink, moist tow- nursing companion to provide 24hr. surgery you will probably spend most elettes or antiseptics to care for your care, at an additional cost. It is highly of the time in your room. However, incision points while at the hotel. recommended to come with someone you may like to get out towards the The first 48 hours post-op you may you trust to help you with daily activ- end of your visit. For this, we provide not feel up to shopping for necessi- ites like shopping, cooking, washing you with a list of low-impact activity ties. your hair and getting dressed. ideas in the area. • Eating and drinking before sur-• Stay: Prepare to be in Marbella for • Adaptor: If you want to use any elec- gery—You should refrain from eat- four to nine days, depending on the trical equipment from abroad you ing and drinking during the 8 hours extent of the procedure: one day be- will need an appropriate adapter. before surgery, unless otherwise in- fore, and two to seven days after the structed by the doctor. day of surgery. Facial Feminisation Surgery 31
  32. 32. Recovery of your facial feminisation• Cooling: During the first postop- • Aftercare: Normally, you will be dis- • Leaving: Before you leave Marbella erative hours a mask with a constant charged from hospital by your sur- you will be seen at Agave Clinic. If temperature of 15 degrees Celsius will geon one or two days after surgery. If necessary sutures and stapples will be cool the skin of your face and keep alone, one of our nurses will accom- removed 5 to 7 days after your sur- bruising and swelling to a minimum. pany you to your hotel. You will have gery. This will add to your comfort and as- daily revisions in Agave Clinic dur- sist you to more rapidly recover from ing your stay in Marbella. • Working: About two to three weeks surgery. Nevertheless you should be prepared to be seriously bruised and • Our team is permanently at the pa- after surgery you can start working again. The swelling will disappear tient’s disposal. Contact with our swollen for about one week. completely in about one year. specialist during office hours can be made by telephoning our direct line. After hours this contact is avail- • Sports: Refrain from contact sports for 6 weeks. able through the 24-hour emergency services of the USP hospital. • Check-up: We need to see you again • Oral hygiene: If you had any intra- after three months for a check up and after one year to evaluate the final re- oral incisions, we will provide you sult. These check ups can take place in with a post-surgical antiseptic mouth- the U.K., Holland or Marbella. wash, with which you should rinse as directed. However, you should clean with a toothbrush, toothpaste and dental floss as soon as possible. We will also do intra-oral cleanings in the clinic as necessary, to keep wound areas antiseptic. • Depression: During the first week some patients tend to suffer from depression. You may find it difficult to come to terms with your new look and you may even feel that having a surgery was a big mistake. This is a normal and necessary phase. Our patient coordinators are happy talk with you or your companion when-• Pain: Postoperative pain normally ever needed, even in the early morn- is surprisingly mild. We will provide ing hours! you with some painkillers for the first few days.32 Patient information guide
  33. 33. Frequently asked questionsWhen can I wash my hair? How long will I have swelling? Will I have numbness?Almost immediately. Don’t be alarmed About 90% of swelling will have disap- The treatment areas will feel numb in theif the wound bleeds a little bit while peared after 2 to 3 weeks. For a final result beginning. It will take 3-6 months to re-washing your hair. For wound healing it’s you’ll have to wait up to 1 year. cover feeling, and you may not regain thevery good to remove all excessive blood same level of feeling as before.cloths and crusts, even better when youuse shampoo. Just remember to blow- Where will the swelling be?dry thoroughly and dab with a drying Immediately after surgery the swelling What kind of pain can I expect?antiseptic, like alchohol, afterwards to will be mostly in areas of loose connective Pain is surprisingly mild, considering theeliminate any remaining moisture. tissue (cheeks, lips, around eyes). During extensiveness of the surgery performed. the first few days, the swelling will move Many patients don’t speak of pain at all downwards towards the lower jaw and but more of discomfort. With normal painShould I sunbathe? neck due to gravity. Swelling and bruising suppressants and anti-inflammatories, anyThe young scar is very sensitive to differ strongly from one person to another pain and swelling can be well managed.the sun´s rays as it contains very few and can be anywhere. Preferential placesmelanocytes. Therefore during the first are around the eyes and in the lips, but6 months after surgery we recommend can also involve the lower jaw and neck. How do I clean the extra-oral incision ar-protecting the scar with a sunblock or to Bruising may not appear immediately eas? What should I do and for how long?stay out of the sun. During the first week and will gradually fade over the course of If there are steri-strips covering theafter surgery it’s better to keep out of the several weeks. wound or you have a bandage you shouldsun completely as the risk for infection not touch it and keep it dry. If there aremight be higher if your face and body get no strips or bandages, extra-oral incisiontoo warm. What will the hairline scar be like? area’s should be cleaned carefully on a The hairline scar will be irregularly curved daily basis by bathing the area as advised for a natural effect. In the beginning it will and patting it dry carefully. After about 2What about smoking? be red and quite visible, but after about weeks the wounds will be healed enoughAs smoking counteracts wound heal- 6 weeks it will become less conspicuous to begin applying a special ointment toing we strongly advise against smoking and the hair will start to grow through the improve the scars. For this we recom-during the 3 weeks before surgery until fine scar. Maturation of the scar will take mend Dermatix gel, which you can buy3 weeks after surgery. Smoking dramati- approximately one year. at any pharmacy. Use this ointment withcally increases the risk for skin necrosis gentle massage for 12 months until theand should be avoided at all times. scar has matured Will I lose hair? As the incision is just inside the hairline and the mobilisationWhen should I expect to return to of the scalp is in a layer deep under the Will I be able to eat?work? Normally our patients return to roots of the hair, you shouldn’t lose much If you haven’t had any treatment involvingNormally our patients return to work hair. Any hair loss is usually minor and your teeth or orthognathic surgery, you’llafter 2 to 6 weeks, according to the extent temporary. be able to eat normally quite soon. Dueof surgery. Facial Feminisation Surgery 33
  34. 34. to the effects of general anesthesia, youshould only feel nausea for the first fewhours. You may prefer to eat softer orpureed foods initially if you have intra-oral sutures. Patients should prepare ac-cordingly in advance and purchase juices,yoghurt and soups to have during for thefirst few days after surgery.Will I be able to get up and walkaround?In the hospital, once the catheter hasbeen disconnected, you should gentlywork up to getting out of the bed andwalking around a bit, unless your doctoradvises differently. Listen to your bodycarefully and get plenty of rest, but don’tstay in bed all day. After a few days you’lllike to go outside, which you should do.What happens if I need to see a doc-tor when I return to my home country?First, contact Agave Clinic during officehours or after office hours through theUSP Hospital. We have contacts withseveral doctors in various countries thatcan see you. If there isn’t a doctor weknow in your neighbourhood, we wouldadvise you to see your GP or the doctorthat is on call. We would then discussthe problem with this doctor once you’vebeen seen, and recommend the appropri-ate treatment. In extremely rare cases itmight be necessary for you to come toMarbella.34 Patient information guide
  35. 35. Agave Clinic Agave Clinic is an international pioneering centre dedicated to complete oral and facial reconstruction. Our goal is to achieve natural looking beauty by creating facial harmony. 35
  36. 36. To create facial harmony you need to be Agave Clinic is only a 40 -60 minute taxi Surgeries requiring general anaesthesiaable to manage not only the facial skin, drive to Malaga International Airport. take place in the adjacent USP Hospi-but also the facial bone and teeth. Each month we also have consultations tal. Agave Clinic not only cooperates in London and Dordrecht (the Nether- closely with the USP Hospital, but alsoIn our centre we perform: lands). serves as its maxillofacial and dentistry• dentistry and implants, department. This hospital houses a team In Agave Clinic´s state-of-the-art facility, of more than 150 medical specialists,• orthodontics, you are sure to receive first-rate service in with six operating theatres, an intensive a modern atmosphere. Our experienced• maxillofacial surgery, care unit as well as an Emergency Serv- team of professionals utilise the latest• facial plastic surgery ices department. Agave Clinic can be technologies for a detailed examination contacted 7 days a week, 24 hours a day,• and body plastic surgery. and radiological assessment. through the USP Emergency Services.Because we have this complete teamof experts for dentistry, facial and plas-tic surgery under one roof you can besure that all possible options will betaken into consideration and you willget the most comprehensive treatmentplan options to solve your problems.It is the wide variety of treatments of-fered in combination with this closecollaboration between professionalsthat makes Agave Clinic really unique.Agave Clinic is truly international be-cause of its multilingual staff and theproximity to an international airport.Our staff are fully conversant in English,German, Spanish, Dutch, Portuguese,French and Arabic. For all other lan-guages we can provide an interpreter.36 Patient information guide
  37. 37. Founding of Agave ClinicAgave Clinic was foundedby Dr. Bart van de Ven (theNetherlands) and Dr DanielSimon (Brazil). They got toknow and appreciate eachother’s expertise during two mis-sions in Vietnam and Kenya forCaras Felices, the Cleft SurgeryOrganization (CSO). CSO isanother initiative of Dr Bart vande Ven. Its mission is to providefree cleft surgery for affectedchildren from poor families( Bart van de Ven and DrDaniel Simon not only sharedtheir passion for Caras Felices,but also shared the dream ofstarting an all-round clinic forfacial surgery and dentistry inEurope, where patients couldaccess quick and superior treat-ment options. Facial Feminisation Surgery 37
  38. 38. Contact information Address: Av. Severo Ochoa, 24. Marbella, Spain (next to USP hospital) Website: Email: Tel Agave clinic: +34-952.864.191 Tel USP Hospital: +34-952.774.200 Each month, we also have a day of consultations and check-ups in the United Kingdom (London) and in the Netherlands (Dordrecht). You can make an appointment by contacting Agave Clinic in Marbella.38 Patient information guide
  39. 39. If you have any questions,please don’t hesitate to contact us.
  40. 40. Address: Av. Severo Ochoa, 24. Marbella, Spain Website: Email: info@agaveclinic.comTel Agave clinic: +34-952.864.191Tel USP Hospital: +34-952.774.200 General conditions You can find the general conditions of Agave clinic on