Diana Days’ face was swollen. Bruised purplish-blue lines curved along the top of her cheeks beneath her grey eyes and full eyebrows—which she intentionally had not plucked while waiting for surgery—and followed her newly-shrunken brow bone. She had recently undergone a process known as “brow bossing,” in which the brow bone is sawed down by surgeons to give the face a more feminine appearance.
“Women don’t usually have this here,” she said, her hands feeling around her brow ridge, a facial feature which is more pronounced in males because of testosterone.
Her hands maneuvered from the top of her face to her jaw. “As we go down,” she said, almost as if she were the surgeon crafting her newly-swollen feminine face, “they pulverized the bone right here.” Her red-painted nails traced where her prominent jaw used to be.
Days, a 50-year-old Berkeley resident, had just returned from a month-long trip to Spain in February, where she underwent a procedure known as facial feminization surgery, or FFS. Days, whose birth name was Douglas, came out as transgender in January, 2015. Her surgery was performed by a craniofacial surgical team called the FACIALTEAM. Their work spanned from the top of her head down to her neck, where she had her trachea shaved to shrink her Adam’s apple. To give Days a more feminine nose, cartilage was taken out of her right ear to reinforce her septum. The surgical team also gave her a lip lift. “Women in general have at least two to three millimeters less distance between the lower portion of their nose to their upper lip,” Days said.
Even Days’ hairline was changed. She had 1,500 hairs removed from her scalp to be used as transplants, which were inserted along her forehead to give her more feminine hairline. “Your typical male hairline is kind of like a ‘W’ shape,” she said. “The female hairline is more round in the front.”
This was not Days’ first gender confirmation surgery. Last year, she also had a breast augmentation and a Brazilian butt lift, which involves removing fat from different areas of the body, such as the stomach, and placing it in the buttocks make them more shapely. This also creates a smaller waist.
FFS is not universally covered by insurance providers, due to it being seen by some as more of a cosmetic surgery, rather than a gender-confirming procedure necessary for a person’s transition. But for Days, having facial surgery was important because it would allow her to feel more comfortable in her gender identity. “The voice and the face are the biggest giveaways, aside from the breast,” she said.
And she pointed out that it’s a very involved process. “It’s much more than a cosmetic procedure than a woman might get. You know, she might get her lips done or a face lift,” Days said.
After interviewing other top surgeons, Days decided to go with the surgeons from FACIALTEAM. The team includes 42 trained professionals with a background in trans care, and it is led by Dr. Luis Capitán and Dr. Daniel Simon, who are regarded as experts in this procedure. According to their website, FACIALTEAM has completed more than 3,000 feminization procedures.
Still, even though she waited 7 months, paid $45,000 and traveled internationally for the facial surgery, Days said she felt anxious right before her surgery, when she realized she was saying goodbye to her former face. “There is a lot of things that go through your mind at the moment,” Days said, when speaking about the concerns she had about the surgery. “Oh my God, I am never gonna look like that again!”
Days said the FACIALTEAM staff supported her through every step of her surgery. “I felt very comfortable,” Days said.
“It’s five stars,” she continued. “The moment you get off the plane, there is someone waiting for you.” Around her neck she wears a necklace, shaped in the form of a disjointed heart, given to her by the FACIALTEAM, a special souvenir from her trip to Spain.
In the Bay Area, Kaiser Permanente was another medical provider that Days considered. Kaiser provides a variety of medical care for the transgender community both in San Francisco and the East Bay, involving hormone assistance, support groups and surgery, including facial feminization surgery. “I had the option of getting it done through Kaiser,” Days said. But the wait for the surgery drove her to seek other options. “It was about a year and half waiting list,” she said.
Representatives from Kaiser did not return requests for comment.
Days’ situation is not uncommon, and some trans women are leaving the country to receive facial surgery, to avoid significant wait times and in search of experienced doctors. Countries like Argentina, Brazil and Thailand are popular for their FFS services.
Dr. Thomas Satterwhite, a plastic surgeon who specializes in gender confirmation surgery for Brownstein and Crane Surgical Services in Greenbrae, California, performs a number of surgical procedures for transgender women, including facial feminization. He said that at his office, there is usually a wait time of about a year to a year and a half from consultation to operation. He said that this is because of the high demand for the surgery.
At FACIALTEAM, the Spanish team that performed Days’ surgery, the wait can be about 6 to 7 months, depending on the number of procedures, said Lilia Koss, director of marketing and institutional relations for the group.
In Spain, FFS is regarded reconstructive surgery. “FFS in Spain is considered a necessary, functional surgery required for gender transition by trans patients,” Koss said. Despite plastic surgery being involved, the stakes during FFS are much more serious than other forms of facial surgery. “It is categorized under maxillofacial/orthognathic surgery, so in the same area as trauma,” Koss said. (Orthgnatic refers to jaw surgery.)
Today, because of the increase in visibility of the transgender community, she said, “there are much more FFS providers today than 10 years ago, with greater expertise.”
FACIALTEAM is not alone in considering facial surgery to be an important procedure of a person’s transition. Satterwhite sees FFS as a reconstructive surgery. “In terms of facial feminization being cosmetic or reconstructive, it is completely reconstructive. I think everyone needs to get it out of their head that it’s not cosmetic,” he said. A patient who identifies as transgender non-binary which “is basically living in a body that does not match their particular gender identity,” he said.
The process of FFS is complex, because a surgeon must make sure that they take into account the subjective perspective of the person seeking the surgery. When it comes to making a face more feminine, Satterwhite first checks in with the patient to see what they would like changed. “I always ask the patient up front, you know, what their goals and wishes are,” he said.
And while subjectivity is important to consultation, Satterwhite notes that when it comes to sculpting a more feminine face, certain characteristics typically make the face more feminine. For the hairline, females have a more rounded shape and the hairline is higher on the head. The brow bones, which are sawed down during the brow bossing stage of FFS, tend to be more arched and higher up the face. This differs from the male brow bone, which tends to be lower and protruding. When it comes to crafting a jaw, Satterwhite mentioned Jay Leno’s chin as exaggeratedly masculine jaw. A jaw is made more feminine by making shorter, by taking out a sliver of bone and decreasing the angle of projection.
Despite the year-long recovery time it takes for the swelling to completely go away, Satterwhite said many transgender women are able to be more productive in society because of how their new face makes them feel. “They’re so happy. … A lot of those feelings of depression and anxiety and suicidality go away. Patients start to take care of themselves. Patients start to move forward,” Satterwhite said.
For Days, she has already noticed a difference in how she is treated in public. “First things first, I am getting a lot more ‘Ma’am-ed’ than I was before,” Days said. “So it’s definitely a gender-confirming surgery.”
Days was not alone on her trip to Spain. She was accompanied by her friend Ruby Frischer, a 29-year-old trans woman from San Francisco whom she met at her support group for trans women at the Pacific Center for Human Growth. The center connects Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) people to wellness groups and mental health services.
Frischer, who had her own FFS surgery a year and half prior in Argentina, met Days in Spain to help her recover. “The process of transitioning takes over our life, almost,” Frischer said speaking from Spain via Skype in February as she assisted with her friend’s recovery. “I don’t think people really appreciate the process.”
Frischer’s surgery was done by a surgeon in Buenos Aires, and while she was concerned about the reputation of the surgeons in Argentina who would be performing her surgery, her biggest obstacle was the cost. While the cost of the procedure averages around $40,000, it can sometimes be as high as $60,000.
Frischer worked three jobs to fund her surgery, working at In N Out, at a restaurant as a cook, and teaching at San Francisco State University in the English department. “I saved all my money, literally cleared out my bank account,” Frischer said. She spent a total of $13,000 on her surgery, and was supported by her partner at the time, who was in turn transitioning from female to male. (Frischer’s former partner uses the pronoun “they.”)
“I can’t afford $40,000. Even $13,000 is expensive for me,” she said. “I have to save up on my 14, 15-dollar-an-hour job, and take an airplane to another country,” she said.
Frischer recalled the night before both she and her partner were going to leave for her surgery in Argentina. They both lay in bed next to one another, talking about the change to come. “I remember they were just touching my face,” Frischer said, “but they were just running their fingers over my brow ridges and they were like, ‘This is gonna be gone. I can’t believe it. I can’t believe that it’s going to be gone forever.’”
Frischer agrees that facial feminization should not be considered a cosmetic procedure. “It is not cosmetic for us,” she said. “Facial feminization is just as important as bottom surgery.” Bottom surgery refers to the process of altering one’s genitals to affirm what their gender is.
While a majority of Satterwhite’s patients are under some form of health plan; such as the San Francisco Health Plan, which is targeted to low- and middle-income users, FFS is not as universally covered, as are other gender-affirming surgeries such as vaginoplasty and breast augmentation. “Unfortunately, I think the biggest issue is that most patients don’t have insurance which will cover facial feminization surgery,” he said.
Diana Days will be having more procedures in the upcoming months including voice surgery, and will end the year with bottom surgery in December. And although she says she wishes she had transitioned earlier, Days has no anger towards her former life as Doug and is happy with the results of her facial surgery—“despite me having a hard time smiling now,” she said, because the surgery had disconnected some of the muscles in her jaw.
“All in all, I am in a very good place,” she said.