Experiences With Cosmetic Surgery



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"Feminization of the Transsexual"
Douglas K. Ousterhout,
M.D., D. D. S.



Ignorance used to be bliss...

I thought I had prepared so well for transition. A few months before I started my real-life experience, I underwent facial surgery to eliminate as many masculine features as possible. The surgery on the nose, eyelids, and chin was very helpful, and the tracheal shave completely removed the "Adam's apple" bulge. It was a major improvement and I was very pleased.

In early 1997 I was over two years post-SRS, enjoying life and believing all the surgical procedures were in the past. I had already begun my Web site, and one of my interests was to maintain links to other important sites for information regarding transition. In my searching I came across a site in which a young transsexual woman was describing her facial surgery. I had never heard of her or her surgeon before, but Andrea's writing was very persuasive and I found myself reading her entire story. I had to navigate deep into the site before I found the pictures.

Oh my goodness. This was far above anything I had seen before. Rather than superficial brow lifts, Dr. Doug Ousterhout was doing major craniofacial surgery; he was actually reshaping the skull. I looked at Andrea's forehead in the "before" shots, then I looked in the mirror at a very similar appearance. I had not paid much attention to the bony ridges above my eyebrows until now, but now they stood out like a simian. "I look like a gorilla," I grumbled to Margaux. Then I went back and looked at the "after" pictures. Her skull was smooth and round. The difference was breathtaking. I felt my insecurities rising.

I wrote to Dr. Ousterhout and he responded promptly. I learned that he had both medical and dental degrees, and had studied under Dr. Tessier, one of the greatest experts in craniofacial reconstruction for birth defects. Dr. Ousterhout continued to have a major practice in repairing congenital deformities, but had begun to work with feminization of the male skull for transsexual patients. I was interested enough to make an appointment for an office consultation.

In September 1997 I traveled to San Francisco and met Dr. Ousterhout at his office at Davies Medical Center. Prior to seeing the doctor I had X-rays made of my skull, sinuses, and facial bones. My appointment lasted over an hour as he measured my skull, the length of my forehead, the relationship of the bridge of the nose to the brows. "There's a lot we can do for you," he told me. He recommended the "Forehead-3" procedure, in which he actually removes part of the frontal bone, reshapes it and replaces it. This way he could give more complete removal of the brow bossing as well as protect the frontal sinuses.

When the brows are reshaped, the relationship to the nose is altered, so a rhinoplasty is necessary to restore the proper positioning more posteriorly. Failure to do the rhinoplasty would result in a very prominent appearance of the nose.

We also discussed my chin and jaw. He recommended removal of the chin implant I had received in 1993; I had to agree with him that it did not have the look of a natural female chin. Instead he would do procedures called "jaw tapering" and "sliding genioplasty," in which he actually moves the lower part of the mandible forward slightly, and reduces the lateral bulk of the jaws.

The descriptions all made sense to me, and when he showed me the obligatory series of "before" and "after" shots, I was ready to sign up. You can do that for me? You can make me look like her? Here I was, totally post-transition, in a successful career, and I was approaching more major surgery with the enthusiasm of someone who had never had the first work done.

The physical demands of the procedures were significant, and I knew I would have to take two or three weeks off from work to have them all done. I decided to make plans for the late spring or early summer of 1998, a time when I felt the demands of work would be lower than our busy Arizona wintertime. In retrospect it sounds strange to think I planned to wait that long, but I've not been one to act on the spur of the moment. I didn't know it would be even longer before I was finished.

Dr. Ousterhout - oh heck, I'm going to call him Doug - walked to the door with me, and as I was starting to say goodbye, the door opened and a very attractive blonde woman, wearing jeans and a sweatshirt, entered. "Hello there," she smiled at Doug. He smiled and began a conversation with her as they walked back to the nurses' desk.

Could it be, I thought. She's tall - as tall as I am. But there was no way. This woman had too perfectly natural an appearance. She had to be a non-patient friend. The thought passed and I drove back to my room.

That night several of my on-line TS friends had arranged to meet me and Margaux for dinner at an Indonesian restaurant on Post Street. The proprietors had arranged a table for ten right in the middle of the restaurant; they weren't disturbed by ten tall, husky voiced women of varying degrees of passability.

I was not the last one to arrive. "J" was going to be late, I learned; she had to stop by her apartment to change clothes first. "But you really want to meet her," they assured me. "She's one of Dr. Ousterhout's patients and she recommends him very highly." There were so many people there whom I was meeting for the first time. I was enjoying visiting around the table and sampling our spicy appetizers when someone who could see the door said, "Here she comes."

I turned to see our last guest. "J" was someone I had briefly corresponded with on-line, but I had never seen her picture. I looked up - at the blonde from Doug's office.

We both caught our breath and then laughed in recognition. She took the seat directly across from me, and as I listened to her I knew I was making a good choice in Doug Ousterhout.

"Let me tell you what Dr. Ousterhout did for me," she told me. "He changed my life - literally. He made me look like a woman." She showed me "before" pictures of herself and I was incredulous. How could you have possibly looked like that? Brow bossing, large cheeks and jowls, a bulbous nose - this wasn't the same person! Was it? "I knew I had to do something," she continued, "when I was at a support group and someone asked me when I was going to begin my transition. I had to tell them I had already been living full time for three months. I just didn't appear passable at all! Then someone in the group told me about Dr. Ousterhout. I went to see him and told him, 'I am in your hands. Make me pretty.'"

"J" used her savings to finance the whole suite of procedures. Her recovery took several weeks, but subsequently she found that her whole life had changed. She was now able to go anywhere with complete confidence that she would blend in perfectly as a woman. The job opportunities now multiplied and she had her pick of several excellent positions. "I can never thank him enough for making this possible."

He made you pretty, all right, I told her. He also took fifteen to twenty years off your appearance. "J" and I talked for a long time that night and continued an e-mail correspondence. She and Andrea both had such positive experiences, and I was confident I would be just as pleased. I knew my results might not be as dramatic, but it would be worthwhile to eliminate the ridges on my forehead. As I told Margaux, "Maybe no one else notices, but I do. I look in the mirror sometimes and still see 'him.'"

So I started making my plans and reserved a time in June 1998 for my surgery. In the meantime, however, I had the opportunity to have vision correction surgery at home in Phoenix. I had worn contact lenses ever since high school, and now with the effective, safe LASIK procedure, I was able to throw those little plastic disks away for the last time. I was very happy to have the LASIK surgery, which I chose to have one eye at a time in order to preserve vision for my work demands. But as a result I became concerned about the timing of my forehead surgery. I knew my eyes would be quite swollen afterwards, and I worried about the safety of such swelling so soon after cornea surgery. My opthalmologist admitted that this was a very unusual question, and he couldn't guarantee me it would be safe.

I contacted Mira, Dr. Ousterhout's office manager, and explained the situation. We arrived at a solution whereby I would have the chin and jaw surgery - the sliding genioplasty and jaw tapering - in June 1998 and postpone the forehead and nose surgery until later, when my eyes were fully healed. My circumstances at work don't permit long convalescent periods, and I wanted to be back to full activity in no more than two weeks.

Margaux accompanied me to San Francisco for the duration of my stay. The lower face procedure could be done on an outpatient basis, so I did not have a hospital stay added to my bill. We coordinated our lodging around a timeshare week I had traded from my Phoenix timeshare condo, spending the first few days in our favorite bed and breakfast in Presidio Heights, then transferring to the timeshare on Nob Hill.

I can't really say that I had any doubts or hesitations about having the procedure. Some people have expressed surprise that I would submit to the risks of elective surgery and general anesthesia for a strictly cosmetic procedure. For me it was not a difficult question. I work around hospitals and physicians, and know how many operations are performed safely each day. My chances with a good surgeon and good anesthesiologist are excellent.

Doug examined me in his office on Monday afternoon, making measurements of the width and depth of my mandible. He made sure Margaux knew about the postoperative care I would need (not much; I'll be in the recovery area for several hours after surgery anyway). I will have two Jackson-Pratt drains, the little squeeze bulbs, overnight, getting rid of any bleeding from the incisions inside the mouth. I can remove them the following morning.

Monday night "J" took me and Margaux out to dinner - Izzy's Steak House. Yum, my last chewy meal for a while. Later I stayed up late, staring out the picture window of my bedroom at the lights on the Golden Gate Bridge. What a beautiful city San Francisco is. Yes, it's ridiculously expensive, and the tectonic plates shift much too much. But what a great place for a visit.

The very early alarm got me moving. No breakfast today! I got into the passenger seat and Margaux drove us back to Davies Medical Center. I arrived at the admissions office by 6:00 A.M. and checked in, getting my plastic identification bracelet and paying my hospital fees. Then we were shown to the preoperative holding area, where I disrobed and donned one of those wonderful hospital gowns. Starting the I.V. was no fun - it never is - but my nurse was skilled and it went smoothly. Doug came in to check me before I went to the operating room, and I met my anesthesiologist who explained what he would be using for anesthetic. I was ready to get on with it! The nurses settled me down and brought a little Valium as a preoperative aid.

Sleepy now, I slid over onto the stretcher and we rolled down the hall to the elevator, down to the ground floor, then through the stainless steel doors labeled "surgery." I scooted my semi-covered butt over onto the operating table. There's my anesthesiologist. "Hi again," he smiled. "Ready for a nap?"

I don't know what I answered, but the next thing I knew I was back in the holding area, listening to Margaux call me name. "Becky? Wake up, it's all over." I opened my eyes and took inventory. This is good. I can move all four extremities and I don't have an endotracheal tube. When I tried to speak, however, I found my mouth was very dry and hoarse.

"Won't talk much right now," I whispered to Margaux. She communicated by asking me "yes" and "no" questions, which I could answer nonverbally. After a couple of hours I was allowed to swallow some water, which helped a great deal. The pain was not severe. I was aware of the Jackson-Pratt drains protruding from both angles of my mouth, taped to an adhesive bandage covering my chin and jaw. This bandage was just for support, since the incisions were all inside my mouth.

Doug stopped in for his postoperative visit. "Everything went just fine," he told me. "I've reduced the bulk of the jaw and chin, but for now there is some swelling. People won't notice much change at first, but as the swelling goes down they will believe you have gradually lost weight." He gave us instructions on antibiotics, pain medicine, and nursing care. The nurses wheeled me out to the curb where Margaux picked me up and drove me back to the B&B. This night I didn't stay up late; exhausted, I slept soundly.

The next morning I surveyed the new me in the mirror. It was as Doug had said, still hard to tell the final result, but even with the swelling I could see my jaw tapered significantly towards the center instead of coming straight forward like before. I was very pleased. The J-P drains were not collecting any more drainage, and so I took a tweezers and gently removed one at a time with hardly any discomfort. I was very fortunate in the rather mild degree of pain.

Several of our friends came by to check on my Tuesday night and asked if I would be able to get a bite to eat. "I don't know about a bite," I laughed. "I can't open my mouth more than a half inch. But I am a bit hungry. Maybe some soft pasta I could slurp?" We found a nearby Italian restaurant and I enjoyed a small portion of fettucine Alfredo, sucking in one noodle at a time.

Wednesday I saw Doug for a followup visit, and he confirmed that I was doing very well. The swelling and brusing were going down quickly. This part of the surgery was very easy for me. The days passed quickly as we moved downtown to the timeshare for the rest of my convalescence. At my final postop visit just before returning to Arizona, we discussed the next operation which I would plan for summer 1999.

These operations are not inexpensive. My first round of surgery was nearly ten thousand dollars, by the time hospital costs were figured in. The forehead and nose surgery would be even more, sixteen to eighteen thousand. If necessary, I would have tapped my savings to pay for the procedures. Many people I know have done just that, reasoning that they can save more money later, but don't want to wait several more years to save up money just for surgery. With a combination of income tax refunds and the creative use of plastic, I was able to avoid depleting my retirement funds.

So, planning ahead for 1999, I reserved another timeshare, this one in the Fisherman's Wharf neighborhood. I scheduled my surgery for a Tuesday before moving to the timeshare on Saturday. This would give me several days in the hospital and its guest rooms to recuperate. Margaux timed her flight to coincide with my moving to the timeshare. "There's no need for you while I am still in the hospital," I had told her. "You can be here if you wish, but you may be bored for a few days." She decided to stay and get some work done the first part of the week.

One of my long time friends had a wonderful surprise for me. She was also having surgery with Doug, the day before mine! Margaux and I had seen Sally about a year prior to this, and always enjoyed spending time with her. How nice to know we would go through the experience together.

The date in June arrived and I flew back to San Francisco, taking the airport shuttle directly to the hospital this time. With the change of ownership, it's now California Pacific Medical Center, Davies campus. I checked in at the admissions office - been here before, know the drill - and brought my luggage up to my room. It was so good to see Mira again! She's become a personal friend. We enjoyed our visit while waiting on Doug to arrive. Then I went to his exam room and he did the appropriate set of measurements for this surgery. By mutual agreement, we decided that he would also take a few millimeters off the point of the chin at no extra charge. As pleased as I had been with my jaw surgery, I agreed that it might be a little less prominent. I asked for one more relatively minor procedure called "lip shortening," in which he makes a small incision at the base of the nostrils and removes a short segment of upper lip, to make my lip turn up a bit more.

"I have complete confidence in you," I told Doug. "I wouldn't be here if I did not. I know you will do your very best to make me as attractive as you can."

"I think you'll be very pleased," he replied. "Your features will be very suitable for a very good result from this operation."

I got my blood tests drawn and the preoperative visit with the "patient care coordinator," an R.N. who explained the procedure and made sure my questions were answered. Then I went upstairs to the acute care wing to check on Sally. For a moment I was sorry I had seen her: eyes swollen near shut, the top of her head bandaged like a mummy. I'm going to look just like that tomorrow. I tried not to picture myself in that position. I caught up with Sally's S.O. and the two of us went to dinner together to help distract our thoughts.

Tuesday morning came very soon, and the nurses woke me for my preop medicine. Then came the same familiar trip down the elevator as before. I would be relocating from the guest rooms to the acute care unit, and my belongings were carried to the appropriate room.

I woke with considerably more discomfort that I had with my first operation. My eyes opened only a small slit, but I could see well enough. Postponing after the LASIK surgery seemed to be a good decision. The nurses were in and out frequently, showing me the button to click for the patient-conrolled analgesia. I'm pretty fortunate in my pain tolerance, but I'll admit pushing that button a few times the two days I had it available. Speaking was easier this time compared to the first operation. I was able to take Margaux's call and tell her I was okay. I did not get out of bed the first day.

On Wednesday I had a visit from Sally, already up, moving about, looking considerably better. This gave me great hope for my quick recovery. Indeed, Doug came in and removed the "mummy" bandage. Now I could wash my hair if I avoided getting the nasal dressing wet. This proved to be easier than I had feared. The scalp incision was closed with steel staples; I had never had staples before and it was a strange feeling and sight. I stood in the shower, head back, letting the warm water relax me and clean my scalp.

The most discomfort of all was nasal, just as it had been in 1993 with my first rhinoplasty. There's no way to say this except that being unable to breathe through your nose really SUCKS. I was so uncomfortable having to breathe through my mouth all the time. I counted the hours until Saturday morning, when the packing would come out. On Thursday I was released from the acute care wing and returned to the guest room area. I arranged to continue to get a meal tray from the kitchen so I wouldn't have to go outside the hospital for my meals just yet. Thursday and Friday passed quietly as I spent time with Sally and went up to visit yet another friend, Donna, whose surgery was on Thursday. Indeed this week Doug did four of the forehead-3 procedures, which were more than his usual.

Saturday morning I looked forward to getting the packing removed and was so relieved when I was able to breathe again. Doug left a small crosspiece visible externally, and thin plastic splints internally which would stay in place until the next Thursday. These were no major bother. I was still a bit swollen, but could already see the difference, especially in my forehead. The disappearance of the brow bossing was such a wonderful sight.

Early Saturday afternoon I checked out of the guest room and waited in the lobby for Margaux to arrive. I was so glad to see her getting off the airport shuttle. We called a taxi and let the driver haul our heavy luggage into the trunk as we set off for the timeshare suite at Fisherman's Wharf.

San Francisco is not an easy place to keep an automobile, and I recalled the difficulty we had had in 1998 keeping the rental car in a garage several blocks from the timeshare. We decided not to rent a car on this visit. There were several times during the week I regretted this decision, as it was not at all easy to get back to Doug's office. Taxis were expensive. Public transit was cheap, but slow. Although the cable car stop was just outside our door, the cars were crowded, often full. When we finally got to Market Street we had to take the MUNI to the Castro Street station and walk the four blocks to the hospital. That would have been easy enough, if I had been smart enough to know the difference between the MUNI and the BART. Instead we rode the BART to the barrio, a couple of miles away from Davies Medical Center, and had to call Mira to come pick us up. Next time I'll shell out the bucks for a taxi.

Transportation difficulties aside, the week in the timeshare was very pleasant. We enjoyed visits again from several friends. One took us to a wonderful vegetarian restaurant on Sunday; another brought us over to her East Bay home and entertained us on her grand piano before preparing a delicious dinner. We even got to spend a wonderful evening with Mira at her favorite sushi restaurant on Fillmore Street. Ghirardelli Square was two blocks away with its shops and dining. A highlight of the week was the afternoon at the San Francisco Museum of Modern Art, which had major exhibits of both Tibor Kallman and Bill Viola.

On the day before we went back home I saw Doug one more time. He removed the splints and bandages, then handed me a mirror. I could tell he was very pleased for me; I have come to consider him a personal friend also. "Turn this way and look at your profile," he smiled.

The result was everything I had hoped for. My forehead looked so normal. The eyebrows were in the right position and there were no more brow ridges. The lip shortening had made a very nice effect, and the slightly shorter chin was a very good idea. The nose was still a bit swollen, but I could see the shape enough to know that it was, well, cute. I have a cute nose. I could never say that before.

In the months that followed, the swelling continued to resolve. I get comments frequently from my patients and colleagues on how nice I'm looking, but hardly anyone asks if I've had surgery. That's the best possible combination, in my opinion. I trusted Doug to "make me pretty," and he didn't disappoint.

Am I finished with the cosmetic surgery? Well, no. There's always more. I'm looking at some cosmetic dentistry to be done locally; and in a year or so, once my credit cards have recovered, I will probably be back in Doug's operating room for a face lift which will take off those extra years. I spent far too many years hating to look at my image in the mirror. I hope to enjoy that mirror more and more from now on.

Face Lift Surgery, October 24, 2000

This was the easiest of all the procedures! I spent one night in the hospital, then transferred to the hospital guest rooms for the rest of my stay. There was very little pain, and less swelling than I expected.

These pictures were taken very early in my recovery: the ones in the yellow top were taken on the fourth day postoperative, and the one in the green top was taken on the fifth day.

A very slight swelling is noticeable under the chin, where sutures were removed on the fifth day.

Since I didn't have as much "down time" after this operation, I used my extra days in San Francisco to test my stamina and my navigational skills. My most memorable achievement was walking all the way from Ghirardelli Square, at Fisherman's Wharf, back to the hospital at Duboce and Castro. I don't know how many miles that covers, but I can tell you it's a darn long way!

I walked to Van Ness, then down to Union Street, wishing I had the time and resources to browse all the shops. I paused for dinner at Pasta Pomodoro on Union and then tackled the Webster Street steps up the hill to Broadway. Turning around at the top, I looked out at the entire Bay vista and said to myself, "I climbed that hill? I really must be getting younger instead of older."

And I think that's true. Life is still good.