My Experience with Facial Surgery

On October 29, 1998, I had the gruesome “Manager’s Special” at Dr. Ousterhout’s famous Muffler, Barbecue and Plastic Surgery Hut in San Francisco.  Later, I’ll tell you all about the recovery and how it’s worked out since.  But first, here is what I had to say about the experience on day 5 following the surgery in a message I posted to the newsgroup:

A Letter from My Hospital Bed

One day after surgery
One day after surgery, and I was already a real babe!

Hello to everyone!

Excerpt from surgeon’s notes: “Patient tolerated the procedure well.  Patient voiced no objections and remained cooperative throughout.  Patient was unconscious.”

There is an often unsaid part of all this that you cannot really lay claim to being transsexual until you have gone under the knife.  It is an initiation ritual that separates the genuine Ts from the mere wannabes.  It is a matter of getting your ticket punched.  But once done, you have earned admission to the sisterhood, I suppose.

Actually, I don’t really believe that in any intellectual way, but there is an emotional aspect that is hard to ignore.  We all struggle to assert our identities and explain who we are in the face of total absence of any possible physical evidence.  So when you can finally point to a scar or describe the pain of surgery or perhaps a hoped-for result, there is an affirmation that this was not just some crazy scheme to ruin the lives of everyone around us.

Douglas Ousterhout, MD, DDS
Douglas K. Ousterhout, MD, DDS.  That’s him, Your Honor!  He did this to me!

In my case, the procedure this time was 9 hours under the knife and saw and chisel and other brutal tools of the trade, remaking the shape of my head and face.  Like most male children, Dr. Ousterhout is clearly fascinated with his toys and my head now bears some evidence he has probably used every one of them on me.  I now carry around a fair number of titanium screws and other hardware that might otherwise have been used to build a small fighter jet.  I believe this was a better purpose.

I am indeed still alive though there have definitely been times when I worried, first, that anyone who felt this bad must surely be dying, but then, on reflection, more concerned that I might not.  This is definitely much more difficult than I ever imagined.  In any event, I did live through it, I had some of my faculties going in and most seem to have survived and I am thankful to be here still.

My hat is definitely off to courageous souls like Andrea (Jokestress) who manage to complete the entire sequence of procedures doing them just one at a time.  I am sure that had I attempted it that way, I would have done one and realized that going on from there was simply impossible.  I would say I learned that by comparison to some people, I am definitely a real baby.

If I had really ever thought clearly about what I was about to do, I fear I would certainly have chickened out entirely.  A good friend demanded with some surprise to know just what the hell I thought was going to happen!  After all, this was 9 hours of surgery!  Five hours is a very long time to be in surgery.  Nine hours is ridiculous.  Of course it was going to hurt!

Well, what can I say?  Obviously, I must not be all that bright to have overlooked this simple matter in my enthusiasm as I counted down the days.  But I suppose that it is good to be stupid about some things.  Perhaps it is a protective mechanism born into us by a mischievous maker, who builds us all wrong and watches to see if we can fix ourselves.  What we all do is obviously on the face of it totally senseless.  You wanna do what?!  The very thought that any of us can do any of this, that we can change our names and our lives and our sex, is completely absurd and impossible.  And yet we do it.  As my friend Margot counseled me privately some months back, sex change is not for wimps.

I am glad to have this behind me and becoming confident that Dr. O may indeed be just the magician to match his reputation.  I can see that my forehead and around my eyes should be much nicer and I think he has probably given me a nicer smile by shortening my upper lip.  It is too early to tell by looking in the mirror just what in the world my nose or chin will look like.  For now, I guess I would say that I have always fancied myself as a somewhat colorful person and today there is no question about that whatsoever.  I am very colorful!  There are pretty purples and greens and yellows and oranges.

I am also getting better, day by day.  Friday, the day after surgery, I got a false wind and felt pretty good but then my body woke up and realized what had happened.  Saturday was the most difficult day I have ever experienced in my life.  I thought I was pretty capable of dealing with pain but that much more than I could handle.  Worse, I was so weak that all I could do was lie there in misery.

The nursing staff here at the hospital is, shall we say, not the best.  There were times when I simply could not defend myself and did not have the strength to do anything about it.  I’m lactose intolerant, meaning I cannot digest milk products.  Yet they kept bringing me things like yogurt or custard or pudding or cream of mushroom soup which I cannot eat, accompanied by meal orders clearly marked lactose intolerant.  I would try explaining the problem but they didn’t understand me (most of them don’t speak English) and I found myself just having to give up and thank them for the Jello or whatever I could eat.  A couple times, Dr. O came by with a bright smile on his face to tell me the surgery had gone beautifully and ask how I was doing.  I remember one time trying to explain that I’d only had Jello for two days because I couldn’t eat the pudding and so on as I was lactose intolerant.  In a rather amazing lapse, he seemed not to realize what lactose intolerance meant and thought I was complaining I couldn’t eat because my mouth was too sore.  He insisted that of course I could eat the pudding and custard because it was really quite soft.  It was all I could do to insist that lactose intolerance was something quite different.  It seemed to finally sink in and his smile returned.  “Well, have you had enough to eat?” Before I could answer, he had turned and left.  I think he was still smiling.

Later, he told me he’d talked to the kitchen (they don’t really have a dietitian) and been told they thought the pudding was lactose free.  I’m enough of a cook to know this is not bloody likely but I simply was not up to arguing.  I found out later that what they meant was that tiny little dab of ersatz whipped cream on top was fake.  But of course, my determination not to eat that particular dab was merely sensible, not medical.

Friday and Saturday, I was on a morphine pump that, even if it never did deliver on promises to make up for any drug experience I had missed in the 60s, was occasionally effective on managing pain.  It provided a continuous but far too small amount as a drip but had a button I could press every 6 minutes for an extra burst whenever I needed, which was about every 5 minutes.  Unfortunately, the contacts where it plugged into the machine were apparently not very reliable and if it had been jostled (e.g., when I went to the bathroom) it would not work.  Calling for the nurse, I often got a pleasant but frustrating Chinese woman who thought I didn’t understand that I had to wait 6 minutes.  I’d do my best to explain that I had definitely waited long enough but that the machine was simply not working.  She would cluck for a moment over the new information and then announce, “Well, we should do something about that.” Then she would leave.  This happened so many times that after a while, I took to shortening the routine.  Whenever she came in, I would immediately thank her very much for her gracious help.  She would smile and assure me that of course that was what she was there for.  After she left, I’d get out of bed myself and play with the plug ’till it either began to work or I realized I would die right there on the spot if I stood up any longer.  I began to make secret bets with myself as to which was the more likely outcome.

On Saturday, everyone was very upset because I hadn’t already filled a couple prescriptions and quite insistent to know if there wasn’t someone I knew here in SF that could give me a ride to a pharmacy to have them filled.  I thought this was very strange as this was my first experience in a hospital that apparently does not have any medications.  But this was really quite a big deal and I was getting conflicting stories throughout the day about whether the medication would be delivered or if I was really certain I didn’t know someone who could just give me a ride.  I wondered if perhaps secretly they were hoping I would pick up a pizza for them on my way.

One nurse was especially memorable.  She would come often to ask, “How are you, Nicole?” If I answered (as was uniformly the case) that I had a headache and didn’t feel very good, she would ask with genuine surprise, “Why do you think you have a headache? Do you think we should do something?” The invitation to collaborate on my care was of course touching if bizarre.

As I’m writing this, it is now Tuesday, though of course, I have no way of knowing except by asking my computer.  In a hospital room, one’s schedule becomes much more simply oriented around the next meal or the next pain pill.  The packing was removed from my nose yesterday and today most of the stitches, including those across my trademark Ousterhout hairline came out.  I can breathe again, after a fashion, and I’m slowly gaining some energy, though I still am profoundly weak.  When breakfast arrives, lifting each spoonful of cream of wheat is a major accomplishment and the next is one to be planned carefully and attempted only when fully rested.

A good friend of mine calls every day to ask how I am doing and to ask if been out walking at all.  I know he would like to hear I’ve seen Fisherman’s Wharf and the Golden Gate Bridge and it seems somehow inadequate when I answer that I’ve made it all the way to the bathroom twice today without soiling myself.  He asks if I know where the fire escape is and I have to confess that if there is a fire, I think they will just have to save me.

It is funny how the simple pleasures can mean so much.  I am talking about that extravagantly wonderful sensation of having completely filled the bowl in one long, continuous, unbroken, smooth and uniform movement.  This is but one of the important things you miss so much when you wake from surgery to discover that while you were under, they have secretly smuggled a small load of bricks into your abdomen.  You begin to wonder if perhaps you are the one patient who will never again have a bowel movement.

And of course it is frightening at times like that to know that you are in a surgeon’s care, for we all know a surgeon’s attitude that if it can’t be fixed with a knife, it will probably get better on its own.  And if it doesn’t, and gets worse, then it probably can be fixed with a knife.

So you can imagine the relief one feels when that first rocky little stone plonks into the water.  I think it was for me an unexpectedly transcendental moment.

4 Days Post-op with Karen’s Teddy Bear
Four days post-op with my teddy bear.  Thank you, Karen.

I feel deeply indebted to my many friends who’ve called or visited or sent flowers and wished me well.  When my stealth friend Karen learned I didn’t have a stuffed animal of my own, she sent a teddy bear.  I have never ever before received flowers and haven’t had a teddy bear since childhood and found these acts of kindness to be powerfully touching.

Whether we like to admit it or not, there is a ritual admission to the sisterhood.  For me, this was but one step, the next big one scheduled a few months from now in faraway Wisconsin.  I think it is appropriate that at each step, we should know that we do none of this alone, that our pain is shared along with our successes.  We can do this, we can lay claim to our lives and to our rightful sex and we can be happy.

Looking back to its miserable beginnings last November and the horror of losing my home and my family in February, this has become a most wonderful year for me.  I am so grateful for the help I’ve had along the way from my wonderful friends.  I don’t believe I could have made it without you.  And I hope that if there is someone else lurking out there right now, wondering if she will ever have the courage to do what she must, that she may be encouraged to know that life can be very good.

Thank you all so very much.

Nicole Hamilton


Surgical Intake Photo 7 days post-op 12 days post-op
One day before surgery.  I have a very prominent, pointed chin, a large nose and my hairline is too high.  It’s hard to say exactly why this makes me look so masculine, but obviously, it does. Seven days post-op.  Even I was surprised at the improvement.  The corners of the jaw are very swollen.  Raising the eyebrows has the temporary effect of pulling the eyes open.  The bruise on my neck is obviously a bootprint. Twelve days post-op.  Already, the bruising and swelling have diminished significantly and I’m definitely looking more feminine.  (It took about four weeks for the bruising under the eyes to disappear completely.)

In these pictures, you can see how Dr. Ousterhout has reshaped my forehead, rounding it out with a plastic material applied to the bone; brought my hairline down and lifted my eyebrows; filed down some brow bossing at the corners of my eyes; completely reshaped my nose; shortened my upper lip with an incision just under the nose; working from inside the mouth, sawed a roughly 1 cm thick slice of bone out of my jaw, shortening it considerably; sliced off more bone at the back corners of my jaw and thinned the muscle there; and shaved the cartilage on my Adam’s apple.  The effect was to shorten my face, making it rounder, and to soften and feminize my features.

Days 2 and 3 post-op did turn out to be the worst and from there, I experienced a steady improvement.  Through day 7, I was on an absolutely marvelous diet.  I lost about 12 pounds.  It was water and, ... well, water.  Some days they did flavor it a little.  Wednesday was the best:  that’s beef broth night.  And they do have the best jello in the world, especially the red kind.

Day 7 was my first day back on solid food and that afternoon, Mira, Dr. Ousterhout’s assistant, took out the last of the stitches and all the staples that had been used to close the scalp incision.  Both Mira and Dr. Ousterhout clucked over me for quite some time, insisting everything had come out beautifully! My response, given one look in the mirror, was to insist they both had quite a future selling suits!

That evening, my last there in San Francisco, I got to take my first shower in a week.  It was also my first experience with the numbness in the top of the head that all Ousterhout patients end up with as a result of the hairline incision:  It feels just like you’re shampooing a cardboard box with hair growing out of it!  My hair is so naturally curly that after being caked with blood for a week, it took me almost two hours to get it clean.  Standing that long was really more than I was up to and though I had friends waiting to take me to dinner, I first had to just sit and collect my strength for a while before I could attempt getting dressed.  I did manage to eat an entire rack of lamb dinner that night, but even the least little exertion, e.g., walking down the stairs at the restaurant, caused me to quickly overheat.

I went home at day 8 following surgery.  I did request wheelchair assistance at both San Francisco and Boston and was glad I had done that.  I could not easily have walked all the way to the gate on foot.  Pain was pretty well managed with Vicodin (a powerful combination of Tylenol and synthetic codeine) but I admit, I did look like I’d just beamed down from the mother ship.  Small children were terrified I might vaporize them at any moment and adults asked gently, not how much it cost, but whether it could be fixed.

The good news is that however horrible one looks immediately after surgery, it’s all just swelling and bruising that does go away quickly.  Photos taken on day 7, just after the stitches and staples had been removed, but before I’d been allowed to shower, are definitely scary!  But just 5 days after that, I already looked fairly normal.

Mira, Dr. Ousterhout’s assistant.
Mira, Dr. Ousterhout’s assistant.  An expert with staples.

The flight itself was mostly uneventful save only my discovery when I tried to rest my head against the window that Mira had left one staple still in my scalp.  Actually, I’d suspected she’d missed one but she’d insisted at the time I was probably just feeling a scab.  Well, I do hope I have a pretty good iron level in my blood, but this felt somewhat more metallic that it should have.

Fortunately, I did have my little Swiss Army Knife with me and I set to work, prying the staple out of my head.  The guy next to me was doing his best to ignore me.  (I think he didn’t want to risk showing interest in anyone so frightfully unattractive, lest he somehow be misunderstood and get stuck with me!) But I could see him watching out of the corner of his eye, in horror and fascination, as I sat there stabbing that little knife into my skull.  I resolved that if he couldn’t say anything to me even though his curiousity was killing him, I’d be damned if I was going to say anything to him either!  Neither of us said a word to each other the entire flight.

The next two days were a weekend and my kids came to stay with me.  Though I was tired, I found that shopping, cooking meals, etc., were all entirely doable.  The next week, I continued to feel tired and tended to loaf, but felt pretty good.  By day 14, I was completely off the Vicodin and using only ordinary Tylenol for pain.  By day 21, I no longer needed even the Tylenol.  Gradually, the numbness in my upper lip, over my right eye, my chin and the tip of my nose have begun returning to normal.  Some vision disturbance and difficulty fully closing my right eye (which made it difficult to keep soap out of my eye in the shower) have also self-corrected.  Today, at a little over 8 weeks post-op, I really feel quite normal and while there is still some residual swelling in my jaw, it’s really quite minimal.

In February, I go back for a facelift.  At my age, I was already starting to be a candidate anyway, but reducing the bone in my jaw but leaving the same amount of skin draped over it has left the skin rather loose.  If I smile, I look okay, but if I relax my face, it makes me look much older.  In that same surgery, Ousterhout will correct anything that didn’t come out quite perfect in the first surgery.

Overall, I would recommend this surgery enthusiastically for anyone who can afford it.  While there are two days in recovery that are truly hell on earth, they do pass and after that, recovery is not bad otherwise.  (And in fairness, part of the difficulty I had in recovery was my fault.  If I had remembered to bring my meds and simply been able to sleep through that Saturday while still on the morphine pump, I think my overall experience might have been much easier.)

When it’s over, no one will mistake you for a guy ever again.

How it’s Worked Out

Me, before surgery Me, 9 weeks post-op
April, 1998, a few months before surgery.  You can’t tell from the picture, but this was actually quite a flattering angle; what you don’t see here is my profile, which always used to give me away. January, 1999, nine weeks post-op.  The changes to my forehead, chin and nose are surprisingly subtle but have a powerful effect.  I’m not wearing any makeup in this picture, nor has the photo been retouched in any way.

As I’m writing this, it’s been a little over 8 weeks since surgery.  In a word, it has changed my life.

The curious thing is that when I look in the mirror, I still look like me.  It’s a little hard even for me to say quite what’s different.  Yet, it is. It’s very different.

I thought I was passing “okay” before surgery.  So far as I could tell, I was rarely read and if it never got any better, I could have been happy all my life.  (Actually, a year ago, when I started this, I expected I would never pass, that I’d always be read, but that I had to do this anyway.) I went to Ousterhout because I’m the sort of person who’s never satisfied unless I’ve done the best I can.  I had the money, I have several friends who’ve been worked on by him, and I was anxious to see what would happen.

What happened has far exceeded any hopes or expectations I might ever have had.  It’s not even an issue of getting read anymore.  I can go anywhere, do anything, dressed any way I like and no ever sees anything but a woman.  It’s fully automatic from everyone I meet.  It doesn’t even seem to occur to them that I could be anything else.

Sometimes, it creeps up on me when I’m not expecting it. A couple weeks ago I was in Dallas.  Coming out of the airport to catch the rental car courtesy van, the driver jumped right out to grab my bag.  As we drove on to other stops, I saw that if there were guys there, they could be struggling with the bags the size of refrigerators, but that was their problem.  But when he saw a woman even carrying some itty bitty bag, he was right out to grab it.  I realized that even from a distance, in just jeans and a tee shirt, I was a woman and I was going to be treated as one.

Then there are all the simple day-to-day pleasures of just “fitting in.” A couple days ago I was in a store buying shoes.  A woman trying on shoes near me wanted my opinion on whether the ones she’d picked out were going to go with her jeans.  Another woman, seeing the boots I’d picked out, decided she had to have a pair also.  I was just yet another woman there.

But the best part, I think, was what it did for my relationship with my mother.  She came out to visit for Christmas, having warned, before she came, that she really needed to see if I actually “looked” like a Nicole before she could really accept all this.  The whole visit was wonderful, punctuated by some really cute mother/daughter exchanges.  On the struggle I’m having, trying to decide whether to do top and bottom (sex reassignment and breast augmentation) together:  “Oh, yes, you’re too small.  You need to be a C.” In response to my wearing jeans one day:  “Oh, that’s terrible!  You look much better in slacks or a dress.” In answer to my question whether, if I got romantically involved with anyone ever again, she’d want it to be with a man or a woman:  “Oh, you’re a woman now.  It should be a man.” And so on.

We went to visit my cousin’s widow, Mary, and her friend, John, the night before Mom left.  Just for Mom, I wore a real nice black dress and red jacket.  I’d met John, a retired priest, a couple times before, but that night he was unusually interested to make small talk.  I overheard Mom tell Mary, “John’s quite fascinated with Nicki.” And in the car, later, she told me John was obviously enjoying a conversation with “a pretty young girl.”

The morning before I took her back to the airport, Mom told me she wanted to give me her diamond as she no longer can wear it (arthritis) and thought I could have it reset or matched for studs.

I just don’t believe I’d have this same chance for a life as an ordinary woman without everything Dr. Ousterhout has done for me. The surgery was expensive and it was painful but this was the best money I’ve ever spent and the pain has been inconsequential compared to the benefits.

Dr. Ousterhout, if you ever read this, please know that I will always be grateful.

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Copyright © 1999-2013 by Nicole Ashley Hamilton.  All rights reserved.
This page was last modified April 8, 2013.