As soon as one stops working, one feels as though one had never worked.
— Jules Renard

Hello friends. Much of my upper lip and my cheeks are still numb from the surgery, but I’d say that I’ve more or less recovered. This morning was my first stint taking care of our child where I didn’t experience that “Oh no I can’t do this for longer than two hours!” feeling. Normally taking care of her is easy in the extreme: it’s time-consuming and tedious, but doesn’t sap my energy. Was very weird to not have that reserve to fall back on.

I want to write something about the experience of getting this surgery. When you’re looking into surgeons and into the process for surgery, the best forum, bar none, is Reddit. There you’ll find detailed extensive discussions of all the top surgeons. But it’s still nice at times to feel like you’re not taking advice from completely anonymous people on the internet.

When I first came out, I wasn’t that excited about gender-affirming surgeries. I’m tall, broad-shouldered, balding, and I didn’t feel like the knife could affect how I was gendered. But then about a year and a half ago I saw a picture of Elon Musk before his hair transplants, and I was like…I’ve got more hair than that guy had! So then I was like hmm, maybe with hair transplants I could get full coverage!

But I knew that if you’re thinking about getting hair transplants, you should do them after getting facial feminization surgery (which alters any distinctly masculine facial features you might have), so I started looking into FFS.

Choosing a surgeon

When it comes to FFS, there are top surgeons in Antwerp, Madrid, Minnesota, Boston, LA, Texas, and SF. I didn’t want to travel, since I have, you know, a child to take care of. So I limited myself to options in the SF Bay Area. We have two of the most highly-regarded surgeons here: Dr. Jordan Descamps-Braly and Dr. Kyle Keojampa. Both have offices in downtown SF. I also tried to consult with UCSF’s facial plastic surgery team, but they bumped my consultation at the last minute, so I’d have needed to wait six more months to see them, so I ultimately canceled my appointment there.

With DB and KK, I called their offices and asked for a consultation. In each case, I was given a consultation date almost a year in advance. Then DB allowed me to book a tentative surgery date about a year after that. So in April 2022, I was scheduling consultations in Dec 2022 / Jan 2023 and surgeries in Nov 2023. However both surgeons put me on the cancellation list so I could get a sooner appointment if one opened up, and they said since I was local I was likely to come in sooner.

And indeed that was the case. I ended up seeing Dr. Keojampa in July 2022 after he had a COVID cancellation and Dr. Deschamps-Braly in August 2022–about six months ahead of my scheduled consultation time. As I recall, both consultations were $300, and they required that I get high-res CT scans at the same place–the CTs worked well for both so I only needed to get them done once. That was $1000. Insurance didn’t pay for any of this (more on that later).

Both have beautiful offices with nice staff. It’s not uncommon for doctors, and particularly surgeons, who do work with the trans community to be quite transphobic–this is a function of their role as gatekeepers, determining who is worthy to get surgery and who isn’t. But in this case I found both surgeons were great. Never caught an inkling of transphobia from any of them.

The consultations both started the same way–they looked at my face and told me, in their opinion, what I’d need in order to look more feminine. Seeing a plastic surgeon really isn’t designed to improve your self-image. There’s no “You’re beautiful just as God made you” stuff here. Which, honestly, is what you want. Both recommended a forehead setback (they saw off your protruding forehead and shave the edges and staple it back on, but farther back), cheek implants, lip lift, nose job, and jaw reduction. DB has the smoother presentation–he has a strong focus on informing you about the risks of the procedure (not many)–and on making sure you’re very informed, even while he helps to calm you down. Everything just feels very transparent.

Dr. Keojampa was less polished. His focus was that he does 250 of these a year, and he’s been working for thirteen years, and he’s simply the best. He’s very insistent that he’s the best. He also told me that after he was done I was almost definitely going to pass (which is a sales tactic, but I liked the confidence.) I also just liked how he talked about transgenderism and trans women. He was like, “My aim is simple. You have the brain of a woman, and I’m gonna give you the face of a woman to match it.” When you’re doing plastic surgery, you really don’t want someone with an expansive idea of gender. You want someone who knows what a woman looks like and who’s gonna turn you into one!

Ultimately what sold me was simply that Dr. Keojampa has done way more non-white people. He is a PoC himself, and his lookbook had faces of every ethnicity. Dr. Deschamps-Braly has a book on FFS that he gives out, and there’s not a single non-white face in it. When I asked him about non-white people, he said, “Yeah I do think I have some ethnic faces [in the slide-deck]”.

Both seem like good surgeons. Keojampa does have a reputation for being bolder, while DB for a more ‘natural’ look. I wasn’t expecting to come out looking like a beauty queen though.

Less important, since I am capable of paying out of pocket, was the insurance situation. DB doesn’t take any health insurance. He only takes these large tech-company plans that aren’t really health insurance–you just submit an invoice to someone in HR and they pay it.

Dr. Keojampa does work with insurance, but he’s not in network for any insurance.

After choosing Dr. Keojampa they scheduled me for a June 6th surgery (it was later bumped forward to March 6.) I believe that reserving my surgery date cost $5,000. This is also when I released my tentative date at DB’s office, and they refunded my deposit for that date.

Getting It Covered

I didn’t expect insurance to cover my treatment. Usually trans people have a lot of difficulty with FFS–insurance companies reject it as ‘cosmetic’. They wouldn’t cover a nose job for a cis patient, so why would they for a trans person? However I didn’t know anything about insurance, so I figured it was worth giving it a try.

I’m covered through Rachel, and I have an HMO plan that essentially gives me free coverage so long as I get everything done at UCSF. I didn’t totally understand HMO vs. PPO, or I’d have understood that this is an extremely BAD situation for getting stuff covered. My surgeon, Dr. Keojampa, was not part of the HMO. My plan does not have out of network benefits. It’s pretty open and shut. I probably would not be getting this covered.

Moreover, because the hospital where I was booked didn’t take cash patients, I needed my insurance to at least cover the cost of my anesthesia and hospital stay. Thus, if insurance failed me, I could’ve been very screwed and lost my surgery date.

Keojampa’s office put through my claim in early January, and they started getting back ambiguous messages from insurance–talking about how the claim wasn’t being forwarded to the right number. This is about when I learned what an HMO was and that if they didn’t come through I couldn’t get the procedure. Very nerve-wracking. If I was doing it over, I don’t know if I’d have taken the chance. My sense is that the chance that they would’ve paid for the hospital was always pretty good, since the hospital was in-network, but still, it’s always chancy when you’re trying to get insurance to pay for trans care.

In this case, after several phone calls with the health team that administer’s Rachel’s plan UCSF Blue and Gold HMO, they gave me a preauthorization for my care. Oh, as an aside, this pre-auth requires two letters from mental health professionals attesting that you really have gender dysphoria. One was written by my old therapist. And she connected me to a group called GALAP that connects you to therapists who will write these letters for you for FREEE. From her I got connected to another therapist who wrote me another letter.

After getting pre-authorized, Dr. Keojampa wanted to get a Letter of Agreement in place covering his fees. Both DB and Keojampa made me promise not to share the details of their quotes, but they were both on the order of $80k, with about $10k of that being hospital and anesthesiologist fees. Anyway, he forwarded his quote to my insurance, and after more calls on my part, they signed a letter of agreement with him. I have no idea why they decided not to contest my claim by saying “we have people in our health group” who do this procedure. The details of their decision making are obscure to me. Nonetheless, I know it’s quite rare for insurance to pay up (as they apparently are going to in my case) so easily. Perhaps the reason they paid is the passage of a recent law mandating all insurance cover trans procedures. The law doesn’t cover many plans (it doesn’t cover any large self-insured employer plan, for instance), but it certainly applied to mine. I really have no idea.

If they hadn’t paid, I’d have needed to wire Dr. Keojampa circa 70k no later than a month before the surgery. As you can see, for most people, doing this surgery involves huge gambles. You need to book the surgery long before you can get a yes/no from insurance, and my sense is that sometimes the process of contesting and appealing and denying the surgery takes people down to the wire. In my case, I’d never have advised anyone, knowing what I do now, to rely on their HMO plan paying for an out of network surgeon. If I’d been dead-set on using insurance, I should’ve used UCSF.

However, in the case of UCSF, it felt like facial feminization was a bit of a hobby for their plastic surgeons, who also did lots of other procedures. With my face, I just wanted someone who did this and only this. And, frankly, I wanted one of the best. It’s not an option everyone gets, but there it is.

The surgery

I had a pre-op appointment with my primary care doctor, and he signed off on me getting surgery. I went off estrogen a week before the surgery, which I recommend not doing unless you have risks for blood clots (which I do). I was so depressed the week before the surgery and had terrible headaches. Surgeons are worried about you getting clots because you’re so immobile during and after the surgery, but I think there’s also a harm that comes from putting your body through estrogen withdrawal right before such a big procedure.

The surgery itself is just normal stuff. You show up to the hospital. Mine was a 12 hour surgery, so it was before dawn. Went up, got undressed, waited, met the surgeon again, waited, met the anesthesiologist, waited, met the OR nurse, waited, got wheeled into the OR and put on a table and then put under anesthesia.

Woke up very confused in the recovery room. It was dark and after visiting hours. I was too groggy to use a phone but the OR nurse told my wife about it. However it was too late for her to visit, so I spent a long sleepless night in the hospital. Honestly one of the most miserable parts of the experience. Being hooked up to an IV makes you feel very chained down. The IV monitor goes off constantly, and the nurses take forever to answer it. I was groggy and a bit confused. Had the constant phantom sensation (bc of irritation from the catheter) that I needed to pee, so kept drinking water and trying to pee.

Just really miserable and frustrating and depressing. I’d never spent the night in the hospital before. I really don’t recommend it. The doctor wrote my discharge papers early the next day though and I was out by 9 AM. Rachel drove me home–they won’t let you leave unless someone is with you. If you’re traveling and are alone, then you need to arrange transport with some sort of service, which I imagine is annoying and stressful.

The recovery

Every surgeon tells you the same stuff about FFS: it’s an easy surgery, it’s not that invasive, you won’t feel much pain. And they’re right in a way: if you had a twelve hour open-heart surgery, god knows what the recovery would be like. And it’s true that there’s surprisingly little pain. It’s mostly just quite uncomfortable. First, my nose was blocked up with blood clots. I also had to sleep on my back and to sleep on an elevated pillow, so it was difficult to sleep. I was quite anhedonic. Reading and watching TV brought me no pleasure for the first few days. I was totally useless, was sleeping most of the day–couldn’t help with Leni at all.

After about four days, I could enjoy watching TV, but I was still uncomfortable. My mouth was completely ringed with interior stitches, which I could feel whenever the painkillers wore off. I felt like a mummy or a science experiment. My head was held together by metal staples that were crusty and itchy and protruded from my scalp. I was dead-tired all weekend, and it was only on Sunday, about six days after my surgery, that I could take any kind of responsibility for our daughter.

She was great by the way. We bought her several “mummy is ill / on bed rest / going to the hospital books” and she got the idea. When I came home, she kept saying, “We are going to make mummy beddah!” And if I needed peace or quiet, I could get it by telling her I needed to rest to get better.

During this whole time I also didn’t poop. Rachel finally forced me to take a walk, and that got it going.

On the Tuesday after the surgery (eight days later), I got out my head staples and my non-oral stitches. I still felt pretty beaten up all week, and my mouth stitches irritated me, causing canker sores. And I’ve been fairly tired until today. But all in all not terrible

The Face

Very TBD. I didn’t have the world’s highest expectations. It’d be nice to pass, but I also never expected it. When you first come out of surgery your whole face is swollen, and it gets even more swollen over time–you look comical, very chipmunky. The swelling takes about a year to fully come down, and underneath it, the face is doing a lot of shifting and healing. Much of the FFS process involves slimming down parts of the face (the nose, the jawline, the brow) in ways that are obscured by the bulkiness from swelling.

Which is to say, most trans women don’t love the way they look after the surgery. Usually it’s about one to three months before they feel like something good happened, and at around six months they’re ecstatic.

One common reaction women have is, “He didn’t really do anything”. I didn’t have this reaction. My face looks very different. My forehead has a totally different shape.

But at the same time, the overall look was pretty lumpy and not particularly female. However, as the days have passed, and the swelling has receded, I have started to see more of its final shape. And I like it! Overall I always had faith that whatever could be done, would be done.

On an emotional level, the only strange thing is I’ve been waiting for this for so long that I’m like, wow, life is empty, there’s nothing to come next.

I haven’t really looked into them, but after I’ve had this face for about a year, I plan to get hair transplants done. My hormone regimen has recently changed, and my estrogen numbers have gone up, and the result has been a huge increase in the amount of head hair. It’s sort of astonishing what HRT can do. I have so much hair. I am still visibly balding, but much less so than before. In the meantime, I wear a wig for most of my appearances in public. But with my new face, it feels like I can just toss on the wig and not have to put on foundation to even out the shape of my face and present as more feminine.

Who knows? It’s too soon to say.

Takeaways

Getting your whole face operated on is a huge deal. The experience left me with so much compassion for everyone who’s ever had plastic surgery, for any reason. It’s real medical procedure, but it can feel very frivolous and self-indulgent. I felt so guilty over the burden this put on my wife (even though she was really good about supporting me and never made me feel bad). I can’t imagine how lonely it is for women who have to recover alone in recovery houses or hotels after traveling for this surgery.

I also think that because of the money and the time involved, this surgery carries the weight of peoples’ hopes and fears. People look at their face, and they wonder, will I be able to date? Will I be able to find love? To walk down the street safely? To get a job? Everything depends on this surgery, and all that emotional turmoil inevitably complicates the recovery.

A lot of people in the world have a lot of problems that could be solved by $80,000. Part of me can’t believe insurance paid for this. When you measure up the difference it’ll make to me over the course of my life, it’s probably a much better return on that $80,000 than would be the return on many forms of medical treatment (for example, late-stage cancer treatment that has a low survival rate), but it still strikes me as a large amount of money. It also strikes me that I couldn’t even have taken the chance of trying to get it paid for if I hadn’t already had the ability to pay out of pocket–yet another example of how the richer you are, the more things you get for free.

That’s my experience. I put it here not for the regular readers of my newsletter, but for the benefit of anyone out there who is googling trans FFS insurance HMO keojampa, deschamps-braly, etc. Hope you find this useful.

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