Bringing the Misunderstood Gender Out in the Open with Facial Feminization

I, Dr. Toby Mayer, have spent 40 years mastering the art of facial feminization for transgender patients. Many of the procedures which I developed have given transgender patients the possibility of being the person that they feel they are on the inside. My job has been to make the outside match the inside feelings of femininity that the male-to-female transgender patient has.

Recently, there has been a great deal of attention paid to this issue because of the curiosity of the media with Bruce Jenner. If indeed he is a transgender patient, the process that he is going through is feeling like a woman on the inside, yet having the facial features of a man.

Many people are aware of minor procedures, like shaving the Adam’s apple, which is a secondary male sex characteristic, but are not familiar with the multitude of procedures that are necessary to create the total appearance of the female, in the transgender patient.

So, what are the procedures that we developed for this change?

First, we developed the hairline lowering procedure to lower the hairline. Rather than using grafts, which often look unnatural, we lower the hairline and make the hair grow through the incision, so it is not seen. At the same time, I shave the bone below the eyebrows, so it does not protrude and is essentially flat. Also, at the same time, I am able to raise the eyebrows to a feminine position without looking strange. If the patient has a hairline that is highly receded, we can do a Fleming Mayer Flap, which brings an entire section of hair-bearing scalp from the side of the head to the front, to give a feminine hairline. This does not look unnatural since it is as dense as the hair on the side of the head. But, hair does not fall out or change texture.

Some patients will need cheek implants to give them the high cheekbones many desire as seen in many models. Some males already have these high cheekbones and do not require this procedure.

Rhinoplasty gives the transitioning patient a feminine, natural nose without creating a “pig-like” nose, or a nose that is too small, which does not fit the rest of the proportions of the face, as described by da Vinci. This should result in a natural balance to fit the rest of the skull.

Very often males have thin lips. The lips can be made much fuller without looking over-done, as has been seen with many celebrities. This is performed by using the patient’s own concentrated fat and placed in the red portion of the lip. A lip lift can be performed to shorten the distance between the lips and the base of the nose at the same time.

Often, males have a very square chin, which can be reduced both in size and shape. Sometimes a chin implant is also used to balance features, if the chin is also receded.

Very often I see patients who have had the angle of their lower jawbone shaved and I do not think this gives a good result. It creates an unbalanced look and makes the upper two-thirds of the skull look larger in comparison to the small jaw. We never want to trade one problem for another problem.

I explain to patients that I make money by operating on them and when I tell them they should not have a procedure done, they should listen closely.

Patients like Bruce Jenner may also need aging surgery such as a facelift or lower eyelid surgery, etc. After all of the above surgery is done, the transgender patient faces one very important problem in passing for a female. The male voice dominates the female appearance and prevents the patient from being totally female.

Forty years ago, I developed a voice procedure which has since been perfected. This procedure raises the pitch of the voice into the female range and makes the patient sound female. The purpose of this procedure is so people say, “thank you, ma’am” on the phone instead of “thank you, sir.” When transgender patients meet other people, they now appear and sound female.

Non-transgender patients are always very curious about transgender patients that they meet in the office. They do not understand often that for a patient to undergo this type of surgery, which is both time-consuming and expensive, that the psychology involved is something the patient is born with. They don’t choose it, it chooses them!

After thousands of surgeries on transgender patients, they have taught me a great deal about acceptance, humility, compassion, and caring, and remind me of the reasons that I chose plastic surgery in the first place. It has been extremely satisfying to be able to help these patients who only want to make the outside match the inside.

Toby G. Mayer, M.D., F.A.C.S.
Co-Medical Director
The Beverly Hills Institute