By Plastic Surgeon Dr Dirk Kremer. 

There are days when it's wonderful to be a plastic surgeon. I always love it, but when I am given the opportunity to help someone become their real self, it is just amazing. That is the case when I help transgender people find their true identity, because they feel stuck with a body that doesn't reflect who they are inside. Cosmetic surgery is all about bringing your inner self and inner beauty outside, and if you are a woman imprisoned in a man's body, or a man trapped in a woman's body, only going under the knife will finalise your transformation into the real "You". It's what happened to Bruce Jenner when he become Caitlyn Jenner; it was a brave choice which I’m sure will make her life so much better. It is encouraging to have celebrities like Caitlyn Jenner, Chaz Bono or Lana Wachowski talk about their experiences and put gender reassignment in the public light, so others, famous or not, can cross that bridge too.

The beginning of the journey: from thought to action

When you feel you've lost the lottery by being born in the wrong body (which we medically call gender dysphoria), it takes courage to decide to do something about it. Education (religious education in particular) and family can sadly be a barrier for some people, since it is hard to overcome what you were taught as a child. Fear of rejection and of other people’s negative reactions does play a part in accepting who you are inside, but I believe knowing your true gender is like a gut feeling: you just need to listen to it, and listen to yourself. Furthermore, as Caitlyn Jenner proved, it is never too late to make the leap!

Baby steps: becoming transgender through non-surgical changes

The path to becoming your true self can start without making any drastic changes to your body, although the final step will be to go under the knife. If you are a trans woman, you can grow your hair, shave your legs and wear dresses (which is called “cross-dressing”) and wear make-up. These outside changes are easier for women who feel like men, as it is not uncommon to see women having short hair and wearing trousers; this change in clothing will generally happen from the time you can dress yourself and decide which clothes to buy. Compared to someone with male attributes who dresses as a woman, far fewer people will look twice at a person with female attributes in men’s clothes and with a short haircut. 

Transgender hormones

If we simplify the matter just a little, what makes a man or a woman is quite simple: some genital attributes, and hormones. Women have a high oestrogen level, and men have testosterone. We all have various levels of these hormones, but basically, men will have more testosterone than women, and women will have more oestrogen than men. This is why once a person has accepted their transgender identity, they may wish to go one step further and start a transgender hormone treatment, to be closer to their true self. In the UK, gender reassignment (also known as gender realignment) can be received through the NHS, so please see your GP if you want to undertake a Hormone Replacement Therapy (HRT).

Effects of Hormone Replacement Therapy

HRT will only achieve so much from a physical point of view, and the results depend on many factors, including the patient’s age, weight, and how their body reacts to the hormones. Patients becoming women through feminisation hormone therapy will see their body hair decrease, their skin become softer, and their breast size increase (to a certain extent, generally to a B size at best). Just like for women by birth, their fat will be redistributed to their hips, thighs and buttocks, giving them larger hips and a smaller waistline. Testes and the prostate will decrease in size, but will not disappear.

Trans men will see their voice become deeper and they will grow facial and body hair; their breasts will shrink and their body fat will be redistributed. Menstruation will cease, and upper body muscles will develop.

HRT may change what makes a man or a woman from a hormonal point of view, but it cannot change the shape of your face or the presence (or lack) of an Adam’s apple, and doesn’t help grow - or get rid of - the body parts that assigned your gender by birth. If you have the will and the financial means to go all the way to become the man or woman you know you are, then the next step is plastic surgery.

Gender reassignment surgery

Gender realignment surgery is not just one procedure, but a multitude of them, depending on what the patient wants to achieve, and how much of their body they want to change.

Genital surgery – genital reconstructive procedures

Hysterectomy (removal of the uterus), oophorectomy (removal of ovaries) and vaginoplasty will be typical sex reassignment procedures for trans men, while penectomy (removal of the penis) and orchiectomy (removal of testicles) will be logical steps for trans women. Penectomy is not a complete removal of the penis in sex reassignment surgery, since cosmetic surgeons generally reshape some of the glans as a clitoris. The removal and/or reshaping of genitalia is just the tip of the iceberg and the first step of gender realignment surgery.

Breast Augmentation or mastectomy

As I said above, when taking hormones, a trans woman will generally see her breast size increase, but this augmentation may not be enough for her. Like any woman who feels her breasts should be bigger, a trans woman can undergo breast augmentation surgery. As always, I would recommend my split-muscle technique, since getting a natural result may be even more important for a trans woman than for a woman by birth.

On the opposite end of the spectrum, trans men may want to reduce the size of their breasts through gynecomastia, or remove them altogether with a mastectomy. A mastectomy does involve some possible scarring, which is why it is paramount to ask a good aesthetic surgeon to perform the procedure, so the scarring is reduced to the very bare minimum; if the healing goes well, you will barely see the scar after a few years.

FFS – Facial Feminisation Surgery

Some people have very male or very female features. This is why some trans women like Bruce/Caitlyn Jenner undergo Facial Feminisation Surgery. This procedure can take between 4 and 10 hours depending on how ‘male’ the original features are. It may involve rhinoplasty, eye lift, brow lift, facelift, neck lift, cheekbone implants, reshaping of the jawbone, and general reshaping of the face to lower the hairline, make lips  fuller and open up eye sockets. It may take a few weeks before your real new face emerges from the scarring and bruising, but I have never seen patients regret it.

Voice surgery

Trans men will get a deeper voice thanks to testosterone, however trans women may find their voice still too low-pitched, and may decide to have voice surgery. This involves adjusting vocal chords to raise the pitch of the patient’s voice.

Tracheal shave

Just like I said in a previous article, the neck is a tell-tale sign when it comes to ageing, and it tends to betray someone’s true age. But that’s not all your neck does: it often gives away your gender. This is why plastic surgeons now offer to perform a tracheal shave for trans women who want to get rid of their Adam’s apple.

Being transgender is often difficult, and it really is a long and perilous journey, both mentally and physically. Thankfully, changes in behaviours and society are starting to make this easier – although not for everyone. This is why I think transgender people are very brave and courageous, and I am proud to say that we, as plastic surgeons, can help them reach their true selves, assisting these caterpillars turn into the beautiful butterflies they are deep inside.