Rabbi: "Steal?  If one were to take away from your house an ounce of silver, and give you in return a pound of gold, that would not be stealing from you."

Matron:  "But what need was there for secrecy?"

Rabbi: "It was surely better to present Eve to Adam when she was quite presentable, and when no traces of the effects of the operation were visible."

Introduction
As described in the article Male and Female Skeleton, there are several basic differences between male and a female facial skeleton, and also differences in the subcutaneous tissues (depth, type) and skin quality - differences long appreciated by anthropologists studying skulls, and by artists as well.  It is the combination of all these factors that differentiates the appearance of men and women. 

Lisa spent $20,000 on feminisation surgery with Dr Ousterhaut and Dr Watanyusakul - and many girls have spent more.

For the male-to-female transsexual, hormone treatment will slowly help feminise subcutaneous tissue (redistribution, less muscle, more fat), but it will not affect the skeleton of any individual already past puberty when treatment is commenced.  However, in some cases, surgery can help feminise the appearance of the underlying skeleton.

This article looks at such surgery, deliberately excluding sex-reassignment surgery and breast augmentation surgery which act open soft tissues.

Pelvis
Although the greatest male and female skeleton differentiation can be found in the pelvic girdle, unfortunately there is nothing that can be done to directly feminise the pelvis of an adult male to female transsexual woman, however an increase in subcutaneous fat deposits due to hormone use will often feminise the hip contours.  Although not recommended, this can be supplemented by silicone and other implants in the hips and buttocks.
 

Skull and Face

Relating the absolute measures of the male and female face, several surgically correctable differences which will make a dramatic difference in the perceived gender can often be identified to the benefit of a male-to-female transsexual.

[Note: An excellent article by Dr. D.K. Ousterhout on the differences between male and female skulls, and the feminisation of the face of a transsexual woman can be found here.]

Forehead
Forehead recontouring involves rounding the forehead to approximate a female shape, often by shaving bone from the brow of filling in flat areas to round them out.  Reducing brow ridges, if excessive, can considerably improve the feminine appearance.  

Common task include:

Scalp reduction: involves advancing forward the scalp between 1.0 cm and 2.5 cm to correct for the receding masculine pattern hairline and to approximate, when possible, a more feminine 'oval' pattern hairline.

SMAS/platysma (deep plane) rhytidectomy: involves lifting the cheeks, jowls, jawline, and neck and their underlying muscles. 

Forehead contouring: involves shaving the brow bossing and, if necessary, contouring via shaving across the forehead.

Forehead augmentation: involves the use of 2, 3, or 4 implants (Gore-Tex Subcutaneous Augmentation Material).

Nasal Surgery (Rhinoplasty)
[Not strictly skeletal, but worth listing here!]
The nose is the most prominent feature of the face.  Many transwomen find nasal refinement to make one of the most marked improvements in their female facial appearance and it's the most common procedure after breast augmentation.

Nasal surgery or rhinoplasty alters the appearance of the nose by shaping and repositioning the nasal bones and trimming the bone and cartilage as needed to create the desired appearance. As example, rhinoplasty is used to correct a large hump, or a broad or round nasal tip.  Small changes, such as subtly lifting the tip of the nose will often create a more youthful and feminine appearance. 

Commons task include:

Septal Surgery - The strip of cartilage which separates the two sides of the nose is called the septum.  It is sometimes bent and interferes with breathing; if so, it may need to be straightened.  If it is too long, it is often shortened.

Shaping the Profile - Many women complain of a hump on the bridge (dorsum) of the nose. This is usually made of both bone and cartilage.  It is removed with scissors or a saw. When the nose is flat, the profile may be augmented with grafts of bone or cartilage.

Refining the Tip - If the tip of the nose is large or boxy, much of the tip cartilage may be removed or reshaped to refine the shape.

Narrowing the Nasal Bones - If the bridge of the nose is wide, the surgeon will narrow it by fracturing the bone on each side and moving it closer to the centre.

Reducing Nostril Flare - If the nostrils are flared, they may be reduced by removing a small wedge of tissue from the base of the nose.

In 2005, MTV featured 26 year old transsexual Gia on I Want a Famous Face, who wanted lto ook like Pamela Andersen.  She had already had a dozen operations since her teens (inset left), but surgeon Dr Mayer (right) now gave her a new breast implants, la ipo on her abdomen and chin, another nose job, micrografts to her hairline and fat transferred to her smile lines.

Cheeks
Cheek implants, also called submalar implants, can make the face look less flat, which can enhance its feminine appearance.  Like any implant, there is a danger of rejection.

Common tasks include:

Cheekbone reduction: involves an intra-oral incision which requires an extended recovery period (with severe facial swelling/bruising for about 10 days).

Cheekbone augmentation: involves an intra-oral incision to augmenting the bone with a hard silicone implant.

Lip contouring: involves lifting the upper lip via a shallow 'v' incision below the nose or by an incision inside the lip. If necessary, the lower lip can be made fuller via an incision inside the lip.

Chin and Jaw
The chin is an extremely important area in gender recognition.  Although the potential benefits can be great, the difficulties involved in re-shaping a "robust" lower jaw sufficiently to make a significant improvement in overall facial feminization prevents this being a very common surgery.

Sara Randall, apparently a young transgirl, show's off her feminine mouth and jaw.  She offers advice on the dental work and FFS needed to achieve this on her website.

Possible tasks include: 

Jaw reduction: involves a 1.0cm extra-oral incision under the jaw line to cut the bone (on average, by 1.0cm depth) and thus reduce the sharp angle of the back corner of the jaw where it rises up to the ear.  

Alternatively, an intra-oral incision can shave (but not cut) the bone.  Although this technique prevents external scaring, it is less effective, has more risk of infections, and requires an extended recovery period due to severe facial swelling/bruising. 

Chin reduction: involves an intra-oral incision to shorten and narrow the chin (if necessary, including contouring with a hard silicone implant). The technique involves: (1) shaving the bone; (2) cutting the bone; or (3) sectioning out the mid-section of chin and joining the upper and lower sections via steel screws.

Sliding genioplasty: involves an intra-oral incision and sliding forward or backward the lower section of chin (if necessary, including contouring with a hard silicone implant).

Chin augmentation: involves an intra-oral incision to advance a short or/and receding chin with a hard silicone implant.

Neck
A trachea shave is a common procedure undertaken in order to reduce the woman's "Adams's Apple".  

Examples of FFS

A search for 'Facial Feminization Surgery' using Google or AltaVista will produce dozens of often inspiring instances - here's just a few samples that I came across:

 

It's hard to find any feminisation surgery that Amanda Lepore has not had - beginning with rhinoplasty at 15 and SRS at 19.

Other Surgical Procedures

Rib Removal or Adjustment
These are an uncommon procedures which are undertaken to improve the figure. 

In the first technique, one or two of the floating ribs at the bottom of the rib cage are taken out to have a smaller waist, typically by 1 - 2 inches unclothed.  Corsets also become far more effective as they can act upon a greater area of soft tissue rather than rigid bone - although a reduction of more than 4" reduction is likely to soon cause damage to internal organs.  The resulting back scars, the vulnerability of exposed internal organs to damage from bangs and bumps, and the possibility of unsightly rib re-growth makes this a very problematic procedure which is rarely performed by reputable surgeons.

An only slightly less dramatic and dangerous procedure is to break the lower ribs, bend them inwards to reduce the waist line, and force them to mend in the new position by the continuous wearing of a tight and rigid corset for a month or more.

Long Bone Shortening
It is possible to shorten the bones of the legs (most commonly the femur) and arms by resection in order to reduce physical size and height.  This procedure is considered dangerous and is very rarely performed on transsexual women.  Excessive reduction of limb length will destroy the proportions of the body.

Cost of Surgery

It's worth ending this article by noting the very high cost of feminisation surgery. 

Basic procedures such as a "nose job" are widely available, and good quality surgery can be economically obtained from clinics that don't otherwise deal with transsexual women.

But more extensive feminisation surgery is a specialist field in which there are only a few reputable surgeons practicing.  Facial femisation surgery from a top surgeon such as Dr. Ousterhout will start at about $10,000 and soar upwards from there.  There are cheaper options emerging,  particularly in Thailand, but carefully check out the surgeons references and make enquires about them on the Internet.  Poor quality surgery is far worse than none.

Transsexual Maxine had undergone 35 operations and procedures in 10 body areas by age 21, costing about €26,000 ($32,000).	Kelly-Anne spent $50,000 feminising her body.	Barbie spent $80,000 on plastic surgery to look like ... Barbie!

Weblinks

For more information on facial feminisation surgery I highly recommended Sally's Resource Morsal at http://tsresource.info/

For more links, check out the Transsexual Women's Resources website at http://www.annelawrence.com/facialindex.html