The History of FTM Facial Masculinization Surgery

The History of FTM Facial Masculinization Surgery
Masculinization techniques. Image credit: Chris Gralapp
Masculinization techniques. Image credit: Chris Gralapp

The World’s First FTM Transgender Facial Masculinization Surgery

Recently, in late 2015 Dr. Deschamps-Braly performed the world’s first full facial masculinization procedure on a female-to-male (FTM) transgender person in his early 20’s. The entire surgical procedure took 8.5 hours of operating time and included the following procedures:

Notably, the surgery included the world’s first Adam’s apple augmentation via natural implant, involving the insertion of an implant made from the patient’s own rib cartilage to increase the size of the Adam’s apple.

Facial masculinization is a relatively new form of gender-related plastic surgery and its history is closely intertwined with facial feminization and also with body-focused gender confirmation surgery.

Facial Masculinization and the Beginnings of Gender Confirmation Surgery

To fully understand facial masculinization and the ground breaking work of Dr. Deschamps-Braly, it is important to see how gender confirmation surgery, and gender-related plastic surgery, evolved into the art and science it is today.

Before Surgery: Dressing to Pass

Before the innovation of gender confirmation surgery, individuals who suffered from gender dysphoria had no viable medical options. They could “dress to pass” as their identified gender, but were still often perceived by the world as their assigned gender of birth. Unfortunately, it was all too common for most transgender individuals to spend their entire lives deeply dissatisfied, feeling uncomfortable in their own skin — physically, emotionally, and psychologically.

The Early, Experimental Years of Gender Confirmation Surgery (1930-1969)

The origin of all transgender surgery can be traced back to the early 20th century when gender confirmation surgery was in its experimental phases. One of the first identifiable recipients of gender confirmation surgery was Lili Elbe, a Danish Transgender woman in 1930The first gender confirmation surgery (removal of the testicles) was made under the supervision of sexologist Magnus Hirschfeld in Berlin. The rest of her surgeries were carried out by Dr. Kurt Warnekros, a doctor at the Dresden Municipal Women’s Clinic.

During the 1950’s, transgender individuals benefited from newly available sex hormones. One of the pioneers in this field was German-born Psychiatrist and Sexologist, Dr. Harry Benjamin, a peer of Dr. Hirschfield in the early 20th century in Germany. After immigrating to the United States, Dr. Benjamin became known internationally for his efforts to advance the field of non-surgical care for transgender people. He published papers and lectured to professional audiences extensively, and his book, The Transsexual Phenomenon, was the first large work describing and explaining the affirmative treatment path he pioneered.

He also established the world’s first clinical psychiatric practice focused on the medical and psychological needs of the transgender individual. For over five decades, Benjamin conducted treatment in collaboration with carefully selected colleagues of various complementary disciplines for hundreds of patients with gender identity issues–and Christine Jorgensen was one of his early patients in the 1950s.

In 1952, Christine Jørgensen an American trans woman, had gender confirmation surgery in Denmark. When her transformation made the front page of the New York Daily News, she became an overnight sensation, and she used the opportunity to become a strong advocate for the rights of all transgender people.

Gender Confirmation Surgery in the United States (1966-present)

The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician in the United States to perform gender confirmation surgery was the late Dr. Elmer Belt, who did so until the late 1960s.

Another notable person to transition was Renée RichardsShe underwent male-to-female gender confirmation surgery in the mid-1970s, and successfully fought to have transgender people recognized officially as their new gender.

Beginning in 1983, facial feminization surgery (FFS) was pioneered by Dr. Douglas K. Ousterhout in San Francisco.

Dr. Douglas Ousterhout - the Pioneer of Transgender Facial Surgery, is mentored by Dr. Paul Tessier, the Father of Modern Craniofacial Surgery

Between December 1972 and June 1973,  Douglas K. Ousterhout, MD, DDS — widely regarded as the world’s pioneer of transgender facial surgery — trained with Dr. Paul Tessier in Paris.

Dr. Paul Tessier is regarded as the father of modern craniofacial surgery and a pioneer of plastic surgery. He understood the superficial muscular and aponeurotic system in-depth, and what made a face appear distinctly male or female; and for this reason, he had the best cosmetic results conceivable in his craniofacial cases, as well as his plastic surgery cases.

In Dr. Tessier’s experience, many craniofacial cases involving reconstructive surgery were also plastic surgeries; therefore, understanding the aesthetics of what differentiated the male and female face was critical. During his fellowship, Dr. Ousterhout assisted with numerous rhinoplasties and observed many facial surgeries–learning key techniques and best practices for aesthetic contouring in craniofacial surgery.

Dr. Ousterhout’s practice as a pioneering transgender plastic and craniofacial surgeon was directly influenced by his early training with Dr. Tessier.

After training with Dr. Paul Tessier, Dr. Ousterhout returned to San Francisco where he helped launch the Center for Craniofacial Anomalies at the University of California, San Francisco, Medical and Dental Centers.

His work at the Center for Craniofacial Anomalies at UCSF paved the way for his future focus–pioneering work and expertise in facial feminization.

Dr. Ousterhout conducted extensive research to identify which features were considered “female vs. male”. He derived measurements defining those features from a series of cephalograms taken in the 1970s, and then worked with a set of several hundred skulls to determine if he could consistently differentiate females and males using those measurements only.

Dr. Ousterhout then began adapting surgical techniques and materials he already used to transform and enhance gender-specific facial features. For over two decades, he added more procedures and developed more aggressive techniques, with the goal of producing better outcomes and more attractive faces for transgender patients.

Dr. Ousterhout began his private practice in San Francisco in 1973, making the practice one of the oldest continuing plastic surgery practices on the west coast. His specialty became gender-related plastic surgery for both trans men and women, and he was widely considered the foremost transgender facial surgeon in the United States.

In addition to publishing well over a hundred scientific publications, Dr. Ousterhout published his medical textbook Aesthetic Contouring of the Craniofacial Skeleton in 1991. In 2009, he published Facial Feminization Surgery, a guide for the prospective patient, which was based on having completed nearly seven thousand various procedures on eleven hundred patients.

FTM Facial Masculinization: A New Concept for the 21st Century

By 2010, Dr. Ousterhout had completed six full facial masculinization procedures on cis-gendered males, as well as many more individual procedures: a total of 10 forehead masculinizations; and 42 individual chin masculinizations; and mandibular (jaw) augmentations, including four with bone and others with implants.

He published his article “Dr. Paul Tessier and Facial Masculinization” in the Annals of Plastic Surgery, Vol 67, No. 6, December Supplement 2011 — outlining his techniques, findings, and recommendations for facial masculinization.

Dr. Ousterhout discovered that to really affect a major change in masculinizing facial appearance, augmenting and recontouring the underlying bony structures was necessary. His surgical results were uniformly satistfying with a very low incidence of postoperative complications.

Facial masculinization is still less common than feminization procedures, but demand for it is increasing. Generally, the areas addressed surgically in masculinization involve augmentation of the forehead, the chin, possibly the cheeks, nose, and the angle of the mandible (jaw).The ideal scenario is a long format surgery that addresses the set of individual features requiring masculinization — which reduces the incidence of postoperative complications and allows for a smoother recovery period.

In the course of more than 30 years, Dr. Ousterhout has performed thousands of successful gender-related facial surgeries–seeing each patient as an individual who deserved to have their desired physical appearance and enhanced self-esteem. His contributions to patients and the medical community are unparalleled and he is known by the medical community as the pioneer of both facial feminization and facial masculinization surgery.

2015-Present Day: The World’s First Transgender Facial Masculinization

Dr. Deschamps-Braly is the only surgeon that Dr. Ousterhout has trained and mentored in the art and practice of gender-related plastic surgery. His groundbreaking full facial masculinization procedure in 2015 on a female-to-male (FTM) transgender person is a world’s first.

Dr. Ousterhout has now retired and Dr. Deschamps-Braly now continues his practice and legacy of innovative plastic surgery, making the practice one of the oldest continuing plastic surgery practices on the west coast.

Deschamps-Braly’s article on his ground-breaking masculinization procedure on the first transgender individual was recently accepted for publication in the Plastic Reconstructive Surgery Journal – due out in 2017.

Read more about facial masculinization surgery here.