Dr. Ousterhout's Preliminary Consultation

(Note: Dr. Ousterhout's letter has been edited to remove all pricing information.
-Jess)


Dear Jessica:

Thank you for your extensive letter, photographs and to a degree your desires. I should begin by telling you two things. First of all I think that what we can deliver best of all is femininity. I cannot tell you, that you will be beautiful but I think we can make you look female. I would want it to be obvious at 8:00 in the morning when you are lying in bed and someone rings the doorbell and when you answer it without putting on any of your feminine appearing robes, etc., that the person when you answer the door states “I am sorry to bother you Ma’am….” I want you to be that female. I do not want you to depend on having to wear your cosmetics, jewelry and dresses. The other situation is that we do not use computer imaging. It has not been completely successful. It turns out that we actually do better than the computers. If you were to come to our office we could show you tons of pictures but unfortunately, for privacy acts, I cannot mail you any of these. You will however, find a number that have been put on the Internet by patients themselves.

I will do my best to give you an estimate of what I feel will be important to you in feminization of your face. You must understand that this is an estimate based on photographs alone and will remain so until such time that I have had the opportunity to see you in person, can make measurements directly on your face and have reviewed the appropriate radiographs. I would want you to obtain these radiographs in San Francisco for I know they will be completed appropriately for our purposes. I have had considerable experience at this and I am usually quite accurate. If there is a question in my mind I will tend to over estimate rather than the reverse so that if I am wrong it will become less expensive rather the more expensive. No promises. I will work from the top down and then summarize this at the end.

SCALP/FOREHEAD: You have a long forehead with a moderate degree of temporal hair loss. I would begin by changing your Finestride to Avodart. Avodart will be at least 30% more effective than Finestride. You will take 0.5 mgm per day. Even if you did not get some hair back, I think we probably can give you a fairly normal if not a completely normal female hair pattern. It will however, take more than one operation. I can only stretch the scalp in one direction at a time and while the temporal area will be reduced it will not be completely eliminated and it will require at least one secondary procedure no less than four months after the primary procedure.

You have what I call a type III forehead. A type III is not better nor worse than a I or II, it is just for different anatomical situation. A type III however does take longer in the operating room than a I or II. The approach, healing time, black and blueness, pain are all basically the same with any of the four procedures.

NOSE: You have a nice nose but it seems to be deviated somewhat with the tip going over to the right and seemingly the left alar rim is larger than the right. It appears that you will need at least some part of a rhinoplasty and maybe you will need an rhinoplasty to be determined after I examine you. I am going to say that you need an entire rhinoplasty but if you do not then obviously it would be less involved and less expensive.

CHEEKS: Your cheeks are very nice and I do not see any problems with them.

UPPER LIP: Your upper lip is long. When you open your mouth and without smiling, I only see something like a millimeter or less of upper tooth. In a female of your height I would expect to see at least 4 mm of upper tooth when you open your mouth and before you smile. An upper lip reduction will be necessary.

CHIN: Your chin is vertically high, it is particularly broad, and you have a fairly deep sulcus between the lip and the chin. That will need to be filled in at the same time I complete a feminizing sliding genioplasty. We fill that in with a material called hydroxyapatite. I will discuss this more with you when I see you.

JAW: You have quite a rectangular lower face and the angles of your mandible are broad. You have bowing of your jaw. You will definitely need a jaw tapering angle reduction procedure.

THYROID: The thyroid cartilage is prominent and you will need a thyroid cartilage reduction.

Therefore it is my feeling that your first operation would be a scalp advancement, forehead III, open rhinoplasty, upper lip reduction, chin feminization, jaw tapering and a thyroid cartilage reduction. These can all be completed at one time under one general anesthesia. It will take approximately 10.5 hours. You will be in the hospital two nights following the surgery. We will want you to stay in San Francisco for an additional eight days before returning to the UK. Depending upon your line of work you will want at least another week and a half to two weeks before returning to work especially if you work in front of other people. By then most of the black and blueness and the majority of the swelling will have disappeared.

If you wanted to combine your final evaluation with your scheduled surgery you could do this by arriving in San Francisco at least two days before your planned surgery. On the first day you would obtain the appropriate radiographs, we would meet, measurements would be completed on your face, the radiographs would be reviewed, we would discuss the issues in detail, and surgery would be finalized. The next day, the day prior to surgery you and I would have appropriate amount of time to talk about all aspects of your surgery, answering all of your questions and hopefully more.

The majority of our out of town patients will spend those two days before and the eight days after hospitalization at the Cocoon guesthouse. This has worked out very nicely for our patients. If you are not familiar with this you may want to look at lynnconway.com.

Mira, my Business Manager, whom I assume you have already been in touch with, will enclose with this letter an estimate of the costs of the surgery. This will include my fees, the anesthesiologist’s charges, the hospital operating room expenses and the cost of the guesthouse. It obviously does not include the cost of getting to and from San Francisco, the cost of getting to and from our office while in San Francisco, the cost of your out of hospital medications nor the cost of the radiographs.

I hope the above is helpful. Obviously if you have any further questions we will be very happy to answer them. You will find Mira to be extremely knowledgeable and helpful about the things that we do.

My very best.

Sincerely yours,
Douglas K. Ousterhout, MD