Feminization Surgery

Creating a Woman…

The laws of physics tell us that the colours of light are made up of red, green and blue. What a sharp division, isn't it? It's hard to grasp. Yet when we look around, we find ourselves in a colourful world: every colour imaginable and every intermediate shade, freed from sharp boundaries.

This is my work: arranging the shades of gender… And creating perhaps the most beautiful of these shades, a woman…

When we think about the physical features that distinguish a woman from a man in the world around us, the genital area of course comes to mind first. So let's start there. Male-to-female (MtF) gender-affirming surgeries worldwide fall into three basic groups. One uses bowel, another turns the penile tissue inside out. Because bowel tissue naturally serves digestion, it constantly releases a secretion with an unpleasant smell, and this secretion forms deposits inside that are difficult to clean; for this reason we never use this method. In the second method, penile inversion, the penis is emptied, turned inside out like a tube and embedded in the vaginal cavity created. But the distance from the base of the penis to the deepest point of the vagina is so long that it is hard to find a penis of that size. That is why it is a method I performed many times in the past but abandoned long ago.

So which technique do I use to create a new vagina? The third method of creating a vagina was popularised in Thailand and then developed further by me. In this method we line the vagina with the skin in the operative field and the remnants of the urethra. Even the clitoris and the small vaginal walls made from the penile skin and glans can be made erogenously sensitive. In addition, by allowing some of the glands to drain into the vagina, visible lubrication occurs in our operated patients when they are aroused. You can find the details of this method in international indexes as follows: Balik O. Construction of Sensitive Labia Minora-Clitoris-Clitoral Hood Complex in Sex Reassignment Surgery in Circumcised Populations: Butterfly Flap. Ann Plast Surg. 2023 Sep 1;91(3):370-375. doi: 10.1097/SAP.0000000000003585. Epub 2023 Jul 5. PMID: 37405858.

In fact, the main subject of this article is the additional operations we perform after the genital area has been corrected so that our patients look more feminine.

First of all, in MtF gender-affirming surgery, the removal of the testes is in itself a giant biophysiological step towards femininity. You are rid of the testes, the main producers of testosterone in your body. And if you also use oestrogen-based medication as support, your fat tissue will increase, your hips will become more oval and your breasts will grow somewhat.

Now let's say that, despite the rising oestrogen level, you find your breast volume insufficient. In that case breast implants come to our aid. Today these silicone implants are the gold standard of breast augmentation. Although breasts can also be enlarged by injecting fat taken from other parts of the body, this is not very suitable after MtF surgery, because the breast tissue, skin and pectoral muscles are firmer than in a cisgender woman and the success rate is low. The fat may not distribute evenly and the result may not be a sufficiently large and oval breast.

As for the buttocks… Again, with the increasing dominance of oestrogen in the body and the removal of the main source of testosterone, the buttocks begin to gain fat and become rounder. And of course the hips fill out too. However, this is usually not enough. At this point there are two options. If there is enough fat elsewhere in the body, we can harvest it and inject it into the buttocks. We call this the Brazilian butt lift, abbreviated BBL. The condition “if there is enough fat” is very important, because if we are not working with a body that has enough fat, the fat tissue we obtain may be insufficient. In that case we can use silicone buttock implants. Sometimes we use both methods at the same time. Why? Because the contribution of the hips to buttock aesthetics is very important, and a small amount of fat that is not enough for the buttocks may be enough for the hips.

What Is Feminization?

Waist narrowing is another feminization topic. As you can appreciate, not every ethnicity is born with anatomical advantages like Thai people. In American and European populations the male skeleton can be very bony and broad. In this case more aggressive work may be needed in body feminization. The procedure known as rib removal comes to our aid exactly here. What is rib removal? In fact, entering through two small incisions at the waist, we cut the ribs and leave them in place. Even though they are not removed, the last two ribs, having lost their resistance in place, flex inwards. This creates a narrowing at the waist that cannot be achieved with any other procedure. Some patients ask for this to be done with aggressive liposuction, but that is generally not possible: although liposuction can remove fat beautifully from almost anywhere in the body, it cannot reach behind the muscle and bone that surround our body.

When we come to the procedures known as facial feminization, rhinoplasty comes first. Noses that may suit a male face even if coarse can be a disaster on a female face. Reduced noses with a slight curve are indispensable in facial feminization. It is usually performed together with rounding of the forehead.

Let me explain forehead rounding and frontal bar shaving like this. The bony protrusion under the eyebrows on a male face is called the frontal bar. Above this frontal bar, right in the middle of the forehead, there is a flattened, hollow area. So in facial feminization this needs to be reversed. Depending on the case, the frontal bar can be shaved, and even the frontal sinus behind it can be set back. Fat can be injected into the flattened area in the middle of the forehead. Why do we do these procedures? Seen in side profile, an oval forehead adds a sexy expression, especially when combined with a slightly curved nose.

Of course, since we have started on the face, lifting the eyebrows and giving the corners of the eyes an almond-shaped upward tilt is another procedure we can perform. This look, popularised on social media as the “fox eye”, corresponds to the procedures known in aesthetic surgery textbooks as temporal lift and canthoplasty.

In the male face, both the lower and upper jaw consist of thick, strong bone. In facial feminization, shaving these bones to obtain a more petite face will of course bring out a more feminine expression.

Hair transplantation is also one of the most important elements of feminization. Male-pattern hair loss is a real and serious problem for our patients undergoing male-to-female surgery, because this pattern of hair loss can directly cause the person to be recognised as male. This problem can be addressed with the FUE method or with methods such as DHI, which can be performed without shaving the hair at all.

Hair removal is indispensable for both body and facial feminization. Even with oestrogen dominance in the body, body hair will not disappear by itself. Laser hair removal solves this at the root. My advice here is that starting before the hair becomes finer, that is, even before gender-affirming surgery, leads to more successful hair removal. I recommend this timing.

Voice feminization surgery is also, without question, an important signature of feminization.

All of these and more can be done. But why? The gender transition process may begin with the genitals, but unless all the other elements are addressed, people may not fully feel their womanhood. Let me give an example. We can reconstruct the breast in patients who have had a mastectomy for breast cancer. In many techniques it is necessary that the nipple and the breast itself are not made at the same time. Yet our patients do not perceive the oval tissue on their chest as a breast until the nipples are made. Only when the nipple is made can they say: “My new breast has arrived.”

Throughout this article we have talked about male-to-female transition and feminization, but by reading the same lines in reverse you can imagine our adventure in female-to-male transition. Perhaps we will discuss masculinization surgery at length in another article.

Thank you for reading, stay with love, and get well soon…

Related page: Gender-Affirming Surgery