A Surgeon’s Perspective on Facial Feminisation

Facial Feminisation Surgery Special - Part 2 Dr Raul Bellinga
FacialTeam in Marbella is leading the charge in Facial Feminisation Surgery (FFS). In this episode, Dr Raul Bellinga, facial plastic surgery director and rhinoplasty specialist, joins Dr Helen and Marianne. Together they talk about the research and some of the groundbreaking techniques being carried out by the FacialTeam surgeons, as well as how this work is influencing developments in facial feminisation surgery globally. 

As work continues on the updated WPATH Standards of Care, it is anticipated that the transformative role that Facial Feminisation Surgery can play in the lives of trans feminine individuals, will be given more prominence than ever before. This is largely thanks to the groundbreaking work being carried out by experts in the field, including the specialist surgeons at FacialTeam in Malaga, Spain.

In this three-part special, we explore all things FFS; from the theory, with Alexandra Hamer, to the practice with Dr Raul Bellinga and finally the impact, with radio and TV presenter, Stephanie Hirst and her surgeon, Dr Simon.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please visit our Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

We are always happy to accept ideas for future shows, so if there is something in particular you would like us to discuss, or a specific guest you would love to hear from, let us know. Your feedback is really important to us. If you could take a minute or two to leave us a review and rating for the podcast on your favourite podcast app, it will help others to discover us.

 
Links:
http://facialteam.eu/
https://facialteam.eu/blog/ffs-surgery/raul-jimenez-bellinga-md-feboms/
 
The GenderGP Podcast
A Surgeons take on Facial Feminisation: The GenderGP Podcast S5 E5
 
Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.
 

Dr Helen Webberley:

So, welcome everybody to our podcast. I am here with Marianne, as usual. And today, we are really excited to welcome Dr Bellinga from the Facial Team in Marbella. Dr Bellinga, thank you for joining us. I’m going to let you come in and just tell us who you are, what you do, what your lovely and amazing team do. So, I’ll hand it over to you.

Dr Raúl Bellinga:

Alright, good morning to everyone. Thank you so much for your kind words. And let me introduce myself. I am Dr Bellinga, Raúl Bellinga, from Facial Team, Spain. We are placed in Marbella, in the south of Spain, the lovely Costa del Sol. And I am part of a surgical group and whose name is Facial Team. Facial Team is a surgical group which started in 2008, and we are just dedicated to facial feminisation surgery. So, we are pretty experienced about what we are doing now. At Facial Team, we are now six surgeons, and we are all dedicated to one specific feature in the face. In my case, for instance, I am the one who is dedicated one hundred per cent to rhinoplasty, to feminisation rhinoplasty, which is slightly different from cosmetic rhinoplasty.

Dr Helen Webberley:

Okay, wow, brilliant. So, the rhinoplasty being the surgery on the nose, the feminisation surgery on the nose. Just broadly, you've got six surgeons. Do you all do something different? Or how does it work if someone needs a little bit of attention on their nose as well as their forehead? How does it work to get that full kind of picture?

Dr Raúl Bellinga:

Alright, good. As I told you at the beginning, we are experts in one very specific feature in the face. For instance, as I told you, I am the one who does the nose.

Facial Feminisation Surgery Special – Part 2 Dr Raul Bellinga

FacialTeam in Marbella is leading the charge in Facial Feminisation Surgery (FFS). In this episode, Dr Raul Bellinga, facial plastic surgery director and rhinoplasty specialist, joins Dr Helen and Marianne. Together they talk about the research and some of the groundbreaking techniques being carried out by the FacialTeam surgeons, as well as how this work is influencing developments in facial feminisation surgery globally. 

As work continues on the updated WPATH Standards of Care, it is anticipated that the transformative role that Facial Feminisation Surgery can play in the lives of trans feminine individuals, will be given more prominence than ever before. This is largely thanks to the groundbreaking work being carried out by experts in the field, including the specialist surgeons at FacialTeam in Malaga, Spain.

In this three-part special, we explore all things FFS; from the theory, with Alexandra Hamer, to the practice with Dr Raul Bellinga and finally the impact, with radio and TV presenter, Stephanie Hirst and her surgeon, Dr Simon.

If you have been affected by any of the topics discussed in our podcast, and would like to get in touch, please visit our Help Centre. You can also contact us on social media where you will find us at @GenderGP on Twitter, Facebook and Instagram.

We are always happy to accept ideas for future shows, so if there is something in particular you would like us to discuss, or a specific guest you would love to hear from, let us know. Your feedback is really important to us. If you could take a minute or two to leave us a review and rating for the podcast on your favourite podcast app, it will help others to discover us.

 

Links:

http://facialteam.eu/

https://facialteam.eu/blog/ffs-surgery/raul-jimenez-bellinga-md-feboms/

 

The GenderGP Podcast
A Surgeons take on Facial Feminisation: The GenderGP Podcast S5 E5

 

Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr Helen Webberley:

So, welcome everybody to our podcast. I am here with Marianne, as usual. And today, we are really excited to welcome Dr Bellinga from the Facial Team in Marbella. Dr Bellinga, thank you for joining us. I’m going to let you come in and just tell us who you are, what you do, what your lovely and amazing team do. So, I’ll hand it over to you.

Dr Raúl Bellinga:

Alright, good morning to everyone. Thank you so much for your kind words. And let me introduce myself. I am Dr Bellinga, Raúl Bellinga, from Facial Team, Spain. We are placed in Marbella, in the south of Spain, the lovely Costa del Sol. And I am part of a surgical group and whose name is Facial Team. Facial Team is a surgical group which started in 2008, and we are just dedicated to facial feminisation surgery. So, we are pretty experienced about what we are doing now. At Facial Team, we are now six surgeons, and we are all dedicated to one specific feature in the face. In my case, for instance, I am the one who is dedicated one hundred per cent to rhinoplasty, to feminisation rhinoplasty, which is slightly different from cosmetic rhinoplasty.

Dr Helen Webberley:

Okay, wow, brilliant. So, the rhinoplasty being the surgery on the nose, the feminisation surgery on the nose. Just broadly, you’ve got six surgeons. Do you all do something different? Or how does it work if someone needs a little bit of attention on their nose as well as their forehead? How does it work to get that full kind of picture?

Dr Raúl Bellinga:

Alright, good. As I told you at the beginning, we are experts in one very specific feature in the face. For instance, as I told you, I am the one who does the nose. Dr Capitán is the one who leads the forehead surgery. Dr Simon is the one who leads the jaw and chin surgery, and so on. Of course, when we are making a surgery, when we are operating, we are not all together. It’s not like a party. So first, we have to do the steps. The first step we start operating in the Adam’s apple. Then we go to the chin surgery. Then we go to the forehead surgery, and I am always the last guy. I am the one who does the rhinoplasty at the end of the procedure. Basically, because the nose is a very important feature, it has to match in regard to the new changes that we have done in the other features, basically the forehead and the chin.

Dr Helen Webberley:

It’s amazing, you know, to think what you can achieve. How did it all start? How come we’ve got six surgeons working in Marbella in the beautiful Costa del Sol?

Dr Raúl Bellinga:

That’s a very interesting question. It’s a lovely story. At the very beginning, the founders are actually Dr Capitán and Dr Simon. They met each other a long, long time ago. And they started to build this group, the Facial Team. Then, a bit later, the one or two years later, he joined the team, Dr Bailón. And then they were only three surgeons, but only for this type of procedure. Only one surgery one case one patient every month, let’s say. A few years later, in 2013, I joined Facial Team. I was working and living in Brussels, Belgium, making a fellowship in Facial Cosmetic Surgery. Then I joined Facial Team just as a kind of rhinoplasty expert on the team. And this just kind of snowballed. So, we were now growing up, growing up, growing up. And because of the amount of procedures, the amount of patients that came to Marbella, we made to include more surgeons in the group, to hold and assist our procedures. Because nowadays we are very busy. In some cases, we perform up to seven or eight surgeries. So, we operate on seven to eight patients every week.

Dr Helen Webberley:

Wow.

Marianne Oakes:

Just as a broad question. How different is it working on facial feminisation surgery as to other facial cosmetic surgeries?

Dr Raúl Bellinga:

That is a very interesting question, a bit tricky. And basically, cosmetic surgery is about how to improve your appearance. That’s it. Facial feminisation surgery is just about getting rid of the masculine features. Basically, removing all the features that testosterone caused during your puberty. So that’s completely different. Of course, as a very nice side effect, we can make some degree of beautification or even rejuvenation, no? But that’s not the main goal. The main goal is to look as feminine as possible. I like to say your twin sister’s face, no? The most feminine version of you. And this is very important. Because we must give you core identity. This is not about removing your face and putting a barbie doll’s face. I like to say, okay, if you are looking for that thing, we are not your guys. We don’t like that. That is not our philosophy. I want you to recognise yourself in a mirror, your family, your friends, everyone. So this is about removing those masculine features. And this is very important because I always like to say as well, surgery is not a need. What we do is not a need at all. I mean, surgeries should be taken as a boost of confidence for you. Hairstyle and the way you dress, the way you move, the way you are, the way you talk, you know, that is 99.5 per cent of everything, of all this transitioning process. Hormonal treatment makes a big difference. That’s always good. Surgery is kind of the cherry on the cake, you know, the frosting on the cake. That’s it, it’s just a boost of confidence for you. This is not a need. It sounds weird from my mouth, you know because I am a surgeon. This is my job. Actually, this is my passion. I have to be honest and realistic. And this is the truth, you know.

Marianne Oakes:

That’s so nice to hear, I have to say because I do think some people go into surgery thinking it’s going to make them somebody different.

Dr Raúl Bellinga:

Actually, that is also some kind of mistake. Some patients think we have some kind of magic wand in our hands and this is kind of magic and suddenly you will look like some kind of princess, you know. You must work on that as well. We can give you some little extra. It is the cherry on the cake. But you must first of all be the cake, you know what I mean? It is a big mistake to put too much weight on surgery, in short.

Marianne Oakes:

Yes.

Dr Helen Webberley:

So, what does testosterone do to a face during puberty? What are the key kind of features that happen from testosterone?

Dr Raúl Bellinga:

Okay, basically, the effect of testosterone causes some extra growing in bone and cartilage. So, let’s say, specifically talking about the frontal bone, or we say the forehead, it is very affected by testosterone, because in males, we can see this frontal bossing area and this very strong supraorbital ridge, you know, giving this kind of aggressive look, no? The eyes look slightly deep-set. That’s a very typical masculine feature. And that’s one of the main reasons that the forehead surgery is key, or is one of the star procedures in facial feminisation surgery. Basically, because we are changing as well the frame of the eyes. We are changing the expression of the eyes. And this is crucial. This is very, very important. Talking about the nose, and there is some extra growing of the cartilage. So to elaborate, a masculine nose is slightly bigger, wider, longer, you know. Talking about the jawline, the same. Male jawlines are slightly more squared, wider, bigger, and as well that is what happens with the Adam’s apple. Most of people think the Adam’s apple is a unique structure in males. And this is not true. Everybody, male or female, has an Adam’s apple. But also because of the effect of testosterone, in some masculine patients, we develop a kind of extra growing. It’s kind of the tip of the iceberg, I could say. Everybody, male and female, has an Adam’s apple. This is something very important because you may find a lot of cis women with a prominent Adam’s apple as well with a prominent and a square jaw with a big nose and they look very feminine as well. So we have to keep in mind all those things as well. I like to say my wife, my wife has a slight bossing on the forehead, a big nose, a wide jaw, pretty and very feminine. So this is lovely. This is sometimes as well, it is taste-related as well. For example, you can say I love a squared jaw for a woman. I love it. Angelina Jolie, Sophia Loren, they are even icons of beauty. But following the anthropometric measurements during the western society, we may say okay, it will be great to have a more oval, say a bit more narrower, okay. So this is something we have to put in the balance because sometimes, it is not only about facial feminisation, but it is also about cosmetics and taste. So in short, there is no wrong answer about this.

Dr Helen Webberley:

You talked then, I’m just going to recap what you said, just in case people don’t understand that quite as well as I have. So, basically, you are saying that testosterone makes the bones grow a bit more. So the forehead can be a bit bigger, which means the eyes are more set back. The jaw is maybe more angular and square. And the nose may be wider, longer, that kind of thing.

Dr Raúl Bellinga:

Correct. And that is one of the main reasons when we are talking about facial feminisation surgery, we are talking just about the structure. We are talking just about the bone. Basically, all these procedures are about working or removing the excess of bone, and/or cartilage in these cases like the forehead or nose and the jawline, and also the Adam’s apple, which is typically cartilage. And that’s one of the main differences with cosmetic surgery. When everybody thinks about cosmetic surgery, we are talking about facelifts or eyelid surgery. That is about soft tissue. When we are talking about facial gender confirmation or facial feminisation, you know, hormonal treatment makes a big difference on the soft tissue, we can call the secondary aspects, the fat distribution in the face, the skin quality, also maybe if you are doing some laser or electrolysis you are eliminating the facial hair that will make the skin look thinner, slightly more elegant and that, you know. That’s about the secondary aspects. That’s about the envelope that’s about the soft tissue. But hormones and those procedures do not change the facial structure of the facial bone and the skull itself. The only way to deal with that is by surgery, unfortunately. And that’s what facial feminisation is about, removing, changing the skull. Changing the bone, remodelling the bone.

Dr Helen Webberley:

So can people get an idea about like a before and after idea, before they commit to surgery? So you would have a look at their face. How can you kind of show them what changes you might be able to achieve with surgery?

Dr Raúl Bellinga:

You know, when we evaluate a person, when we evaluate a face, it is very important to follow, as I told you a few seconds ago, the anthropometric measurements. We have to focus on the upper third of their face, the middle third of the face, the lower third of the face. And very important, we must listen very carefully to the patient or to analysis, let’s say. For some patients, they are very worried about the nose, or they are very worried about the Adam’s apple. We, as surgeons, try to give a very objective point of view, a very objective and very realistic—which is very important—evaluation of the facial features. So we try to be very strict and very objective, as I said. And we try to give a very, very realistic evaluation feature by feature, talking about the hairline, talking about the forehead. So, we give our opinion as experts, and then this opinion may differ, may be different from your own expectation, from your own self-analysis, let’s say. And maybe you don’t agree about what we say, our analysis. And I say it’s all in the beginning, there is no wrong answer here. If the nose is the only thing that really bothers you, do the nose. If the chin is the only thing that bothers you, do the chin. If the forehead is the only thing, do the forehead. I mean, there is no wrong answer here. As I said, it’s a boost of confidence, that’s it. of course, when we give our personal opinion, our analysis, you know, we try to be very detailed. And we are experts, so we can detect very easily the masculine features. We explain about that. We talk about that. But then, the final decision, of course, it’s yours. It’s the patients. In case of doubt, I like to say do nothing. That’s my best advice. Because as I said, this is not a need at all.

Marianne Oakes:

I was just going to ask when we spoke about testosterone, and the damage that it causes trans women, you started at the top, and then you kind of work down. When you said about the surgery, I think it doesn’t necessarily work in that direction. Is there a starting point in feminisation, that you would say, you know, rather than commit to something and not be sure, but actually, would just sorting the brow out make a difference?

Dr Raúl Bellinga:

Yeah, you know, when we meet a person for the first time, it’s very instinctive because we can say what we can recognise male or female, how, just looking at the eyes, okay? So in the way we look is basically what we can recognise the gender of that person. So it means if we can modify the way you look, we can modify, as well, the gender perception. And that is one of the main reasons the forehead—when I said the forehead, basically, I am talking about the bridge on top of the eyes, is so important to having facial feminisation. Because it can change completely the way you look. So it changes the perception of your gender. And also, that’s a reason that the nose is so important is because we are modifying the frame along the eyes. So in most cases, it is through that. I would say, in ninety per cent of patients who have a consultation with Facial Team, most of them, we recommend to do the forehead because it is a very predictable procedure. It is an extremely safe procedure, and for sure, it is the one that feminises the most of patients. There is no doubt about that. Now there are many scientific articles proving that. And that is one of the main reasons why we are very, very focused on working on the forehead as well.

Dr Helen Webberley:

You talked about scientific articles there. I know that your team have done a lot of good research, haven’t you? I mean when we were talking the other night, Dr Capitán was telling me that basically when you started this kind of work, there was no rule book. There was no guide. There was no open up the surgical anatomy book, and this is how you do it. You really felt the way and led the way from what I understand in this. And I think we in the medical world we’re still battered every day with people saying there is not enough research, this is not tried and tested, what have you. And I want to congratulate you for the work that you’ve done on the goading research in this area so that other surgical centres can follow your examples. So I just wanted to say, well done on that.

Dr Raúl Bellinga:

This morning, I have received a message because once again, the Reconstructive Surgery Journal has accepted a new article, one by the Facial Team. So that’s great. And this is very important, because most of surgeons that perform facial feminisation surgery, they still think, okay, this is kind of artistic work. It’s sort of taken like that. This is pure science. We are doctors, and this is surgery. We are surgeons. So this should be taken as pure science, you know? Everything should be completely protocolised. And we strongly believe in these protocols. So we try evolve in this field, so we try to publish all these protocols. And the way we think it should be done. Because at the very beginning, the father of facial feminisation was Douglas Ousterhout, published the first scientific paper in 1987. And for almost twenty years, there was a long, long gap in the medical literature with no mention to facial feminisation surgery. For twenty years. So, of course, we started gradually. Nowadays we have published quite a lot, no, not quite a lot, but a nice number of scientific articles about facial feminisation, in which we improve this growing field.

Dr Helen Webberley:

I know that people listening, there’s going to be a very few burning questions, and I am just going to throw them at you. I want to know, we want to know, does it hurt? How long does it take to get better? How much does it cost? Will I have scars? Is it obvious? Just take us through this kind of very basic questions.

Dr Raúl Bellinga:

The technical things, okay. That’s good. That’s fair. So, one of the main goals of FFS, of course, the first one is to look as feminine as possible. Second one, in an extremely safe way. And of course, in this kind of threefold because we must use invisible approaches. Because it has no sense to change a feature into a visible scar.

Dr Helen Webberley:

No.

Dr Raúl Bellinga:

It’s nonsense, you know, so everybody can point and say oh she has that scar, that means she’s trans. That’s not the goal. The goal is to balance society to become visible, okay? So for example, when we work in the jawline to make some recontouring in the jaw or in the chin itself, we always use what is called intra-oral approach. So all the small incisions that we perform are inside the mouth. So it’s not visible. When we operate on the Adam’s apple and the tracheal shave, it has no sense, and we still see that in many, many cases. In patients who have operated somewhere else, you know, they place the incision on both, just on top of the Adam’s apple. It has no sense, then, because we are changing that feature into a very visible scar. It should be done just below the chin, in the mandibular plane. So that when you are facing that person, no one can see that scar. When we work in the forehead, and this is very controversial because it’s a kind of a hot topic in conferences and so, nowadays, most of surgeons perform what is called a hairline approach. The hairline approach means that they make an incision just in the hairline itself to work in the forehead, and simultaneously try to advance it, to pull down the scalp to lower them, to lower the gap between the eyebrows and the nose to the hairline. We do not agree with that. It may leave you quite a visible scar here, so you won’t be able to pull your hair back. And also by doing that, it sounds good, but it doesn’t work because it cannot close the temples to create a natural and round hairline. The way we do that is by using a coronal approach. It means we do the incision just on top of the head, completely hidden by your own hair. So it’s not visible. And the best way to correct the temples is by hair transplant, for better and for good. For good because it is extremely predictable, long-lasting, natural with no visible scars, which is very important as I told you. But on the other hand, I do understand it may be expensive. When I perform the rhinoplasty in every single case, I perform what is called the open approach rhinoplasty. Rhinoplasty, there are let’s say, there are two main ways to do that. Closed approach, open approach. The one I use, or we use at Facial Team, is the open approach rhinoplasty. It means we have to make a very short and small incision between both nostrils, okay? That scar, in few weeks it becomes almost invisible. In one year’s time nobody will be able to see anything at all. So it’s not a concern for any patient about that. So, invisible, or non-visible approaches are crucial in facial feminisation. Nowadays, some surgeons still perform external approaches, external incisions to perform jaw surgery. It has no sense, it’s nonsense.

Dr Helen Webberley:

That’s amazing. I mean, you’ve taught me so much there. And I’m just going to recap again in my kind of language. So basically what you’re saying is that anyone who needs some jaw reshaping, don’t cut under the jaw where you’re going to see a big scar.

Dr Raúl Bellinga:

Yes.

Dr Helen Webberley:

So in through the mouth, and inside the mouth to get to the jaw. And for the Adam’s apple, instead of making a cut on the Adam’s apple, go higher up like under the palate, under the tongue.

Dr Raúl Bellinga:

That’s it. Correct.

Dr Helen Webberley:

And so the forehead, instead of making an incision at the top of the forehead where the hair starts, go further up into the hairline so you can get down to the forehead from there.

Dr Raúl Bellinga:

I understand, technically talking, doing that approach much higher, it’s a bit more tricky for most of surgeons, but as I said after we do it seven or eight times every week, so it’s our day by day, actually.

Marianne Oakes:

You started talking by saying that that’s controversial. Well, what’s controversial about that? Why do other surgeons not use that?

Dr Raúl Bellinga:

Because most of the surgeons they still think or believe that hairline approach is the best way to correct the hairline. And as I said, in most of conferences, they don’t even show the scar. They put the frames like this, and a nice hairstyle, hiding the incision, hiding the scar. Actually, it doesn’t work so well. As I said, the best and only way to correct properly the hairline is by hair transplant. Unfortunately, because doing that technique is much more easy, that’s the thing most of surgeons still prefer the hairline approach because technically talking it is much easier. You don’t need to be a brilliant expert about that. So expertise is crucial. It’s key here.

Dr Helen Webberley:

And the other two things I know people are going to ask is how much does it cost –I know it’s going to be individual—but a rough kind of feeling? And also, how long does it take to get better? How long does the bruising and the bandages stay and everything like that?

Dr Raúl Bellinga:

I will start talking about that. You know, this is big surgery, actually. Thank god it’s a very safe and a very predictable, the way we do it. But of course it’s certainly not like going to the hairdresser. So it needs some recovery time. Of course, the more procedures we do, the longer that recovery. That is common sense. But let’s say the patient performs, let’s say basically all of these procedures from top to bottom, like the forehead and the nose and jawline, etcetra, they only have to stay at the hospital for two nights. After those two nights, they can leave the hospital, but of course, they have to stay around the hospital, in the city, and eight days after, we remove the sutures, we check everything is fine, and then you are ready to take a flight back to your place. You know, 99 per cent of our patients come from abroad. So let’s say, in short, since the patient arrives in Marbella until the patient, she takes a flight back to her place, she has to stay with us about 12 days. Two weeks, in short. In two weeks’ time, that patient can do let’s say normal social life. Of course, that is not a final result. There is still some swelling, maybe still some bruises. Very easily if they cover with some makeup, that patient can go for a walk with some friends, take a coffee with the family. Nobody will look at her twice in the street. She knows she is swollen, I know she is swollen. We know that is not the result. But for the rest of people, nobody will take care about that. Nobody will know what the hell happened there. So they don’t look like a monster, not even in two week’s time, right?

Marianne Oakes:

Wow.

Dr Raúl Bellinga:

So to start, normal activities, it depends on the job, but in 3 weeks time, the patient can start doing let’s say regular, normal things, like working at a computer, going out with friends, family, working properly. If the patient likes to workout, to do some exercise, we have to wait a bit longer, up to six weeks. In six weeks, let’s say, in six weeks time, the bones are completely healed. Even you can do boxing. Maybe not. If you do boxing, something may happen. I mean, there is no need to wear a helmet for the rest of your life. In six weeks time, everything is healed. But of course, that is not the final result. We like to say you have to wait long time to see final result. Even a bit more, with longer than one year, it doesn’t mean that during that first year you will look swollen and bruised, it’s not like that. But to see the final detail, the final millimetre, we have to wait a bit longer, a bit more than one year, I would say. But in short, in two weeks’ time, you look fine. It means once you are at home, you look okay, you look fine, okay? In one more week, you can do normal activities. In three more weeks, you can do a sport. And that’s it. Is it painful? Is the surgery painful? You know, it’s not painful itself. You will feel at the very beginning a discomfort, because of the swelling, because of the pressure of that swelling. It’s very important to know as well the first days or even the first weeks after the surgery, that patient will experience a very strong numbness sensation in the forehead or in the jawline. Basically, of the compression of some nerves that gives the sensation to those areas, okay? But day after day, and week after week, you will recover the sensation. But on the other hand, that helps to diminish that pain. Of course, we always provide a lot of painkillers, anti-inflammatory, to a main antibiotic. But it’s not painful itself. Talking about money, because it’s a very let’s say a hot topic here, yeah, honestly talking I cannot tell you very, very precisely. It depends, of course, on the amount of procedures you do. But it can be in the range from, let’s say, six thousand euros up to, let’s say, twenty-five or thirty thousand euros. It depends. Of course, if you include hair transplant, hair transplant is expensive, you know? But that’s basically the range. If you’re doing just the rhinoplasty, it’s very cheap. Cheap, you know, it’s not cheap, but this is surgery. Unfortunately, you know most of governments still do not cover these procedures. I don’t know how it works there in the UK, but here in Spain, the sex reassignment is completely covered. It is good of course, hormonal treatment is covered by the national health system, like in the UK. And also, the Adam’s apple surgery. And that’s one of the main things. Because when we see patients who have an operation done in the health system, we see those horrible scars here, and that’s one of the main things that we don’t like. See the scar here. I guess in France, and also in Denmark, I think, it’s partially covered by the health system, I mean the forehead, the rhinoplasty, the jawline, you know, and also in The Netherlands. But this is something we have to evolve as a society. Nowadays, facial feminisation surgery is not covered, unfortunately, by the governments.

Dr Helen Webberley:

Do you do any payment plans or anything like that? Any staged payments? Because, you know, this is the kind of thing—I mean, of course, any type of surgery isn’t needed to validate somebody’s gender, you know? Someone is the gender that they are, whatever—

Dr Raúl Bellinga:

A need, this is a need.

Dr Helen Webberley:

Actually, the other things that challenge women, the femininity of a trans woman is about so much more than just that facial appearance. Like you said it’s the icing on the cake. But obviously, it comes at an expense. So are there any other ways of softening that blow, in terms of payment plans or anything like that. So is there something that you’ve got to say about it?

Dr Raúl Bellinga:

I don’t know exactly the way we do it, because it’s a different department, you know, in Facial Team. But I know there is some kind of possibilities to make everything a bit softer for the patients. And also we are working, we are trying to make any kind of, how do you say that in English? It’s, you know, kind of social work or community. And this is something we are developing. We are working on it. In some specific cases, we can offer something for free, in some specific cases. Some kind of social work for patients, let’s say, for patients who have no possibilities at all. It’s a foundation.

Marianne Oakes:

Excellent. Can I just ask, is there any psychological assessments before people can access surgery?

Dr Raúl Bellinga:

Actually, there is no need. We also have a psychologist at the Facial Team unit. But just if the patient demands or asks something, we can offer that, it’s a possibility. But there is no need to bring, let’s say, any kind of paper document to prove anything. I mean, that’s it. Of course, before any surgery, we have a meeting, an appointment, a proper consultation, where we can talk it out and answer any questions. You can also meet the psychologist. Well, actually, any way you will meet the psychologist because we work all as a group. We offer all this, not treatment, I mean but all these possibilities to the patient just to make you feel more comfortable and more confident with their choice, with what you’re doing here.

Dr Helen Webberley:

I remember quite a few years ago, we had a patient who wanted to have some nose surgery in the UK, and they were being admitted the next day to have their surgery. And they hadn’t told their surgeon they were trans. And then as soon as the surgeon found out they were trans, they were like, no, we can’t do this. You need to go back and get two letters of referral and go and have a psychological assessment. I can’t do anything for you until you’ve had all this done. It was someone who wanted their nose to look prettier. And you talked about it. You talked about rejuvenation. You talked about beautification; making yourself look younger, making yourself look prettier, making yourself look more feminine. You know, why does it matter whether you’re cisgender or transgender when you want your nose to make you more confident.

Marianne Oakes:

You can have your face tattooed without having a psychological assessment, you know? If you’re eighteen and over—

Dr Raúl Bellinga:

Don’t try to find some sense, because there is nothing about it.

Marianne Oakes:

Is there an age limit?

Dr Raúl Bellinga:

No. Well, I mean, of course, we don’t like to perform surgery in patients under 16 years old. For growing. Basically, for growing, and how do you say that in English—

Dr Helen Webberley:

Their whole structure still hasn’t—

Dr Raúl Bellinga:

Because there are still structures that haven’t grown up in the face. So that’s the main reason we prefer to wait after the patient is 16 or 17 years old. And this is something we are seeing now much more frequently in Scandinavian countries. Now, when we have some consultation over there, like Stockholm or Copenhagen or Oslo, we see a lot of very, very young patients coming with their family, and they have started hormonal treatment when they were ten or eleven years old. And that’s amazing. Because hormones make a very strong effect, a very powerful effect (unclear 34:08). So they develop and grow up as a girl. And there are just—you have to focus very much and maybe just a slight detail here and there. That’s amazing, that’s great. On the other hand, you see a lot of patients, sixty years old, you know, with no hormonal therapy at all. A lot of beard shadow and baldness. And that’s much more tricky, much more difficult to deal with. Because if they didn’t start with the hormonal treatment before, you know, this is not magic, we grow very close to our patients. So we are kind of like a growing family here. It’s fine because, at the very beginning of my medical career, I was very focused on oncological patients. I just wanted to operate on oncological patients.

Dr Helen Webberley:

On cancer patients, yeah.

Dr Raúl Bellinga:

Because I just wanted to help people. Now, of course, I changed my mind. The last oncological patient was my mum. She’s still alive, okay. I moved more towards working on facial deformities, so children, stuff like that, you know. And then I keep on switching. And now, in this state for several years now, I am operating on trans patients. I really feel—it’s difficult to explain that in English, I’m sorry. It’s a great pleasure, basically. Because I really feel like a doctor, I really feel like a medical professional, you know, because I feel I am really helping people. Some of our colleagues they say, yeah you are operating just noses on trans patients, you are not a real doctor. But now, honestly talking, I really feel like I am helping people to make, to improve your quality of life. Make you happier, you know. So I really feel like a doctor anyway.

Marianne Oakes:

I say this all the time, and I don’t think people always get it, but it isn’t always about saving lives. It’s about making lives. And when you give a trans person the confidence to be themselves and help them to get out into the world and integrate into society with confidence, that’s creating a life.

Dr Raúl Bellinga:

You made my day, come on.

Marianne Oakes:

Obviously, I feel it. So, that’s the truth.

Dr Raúl Bellinga:

Beautiful words, thank you so much.

Dr Helen Webberley:

I wanted to pick up on what you were saying there, Dr Ballinga. I hadn’t really considered it before, but what we are talking about is we haven’t got somebody who is ill. We haven’t got somebody who has got a disease or a disorder or a—we’re not kind of saving their lives in a traditional way that a doctor might heal a patient. But actually, what we’re doing by medicines and surgery is helping that life be much better.

Dr Raúl Bellinga:

Of course.

Dr Helen Webberley:

And I think we still have got to know that the medicines have their—all medicines have a certain element of risk. All surgical procedures have a certain element of risk. And we balance that with the fact that this patient is not ill in any way, but we’re making that patient’s life happier, more content, easier to live. And the doctor, as a doctor, what a privilege. What a privilege to be able to help someone in that way.

Dr Raúl Bellinga:

You know, this is not vanity. This is the most important to know here. This is about your life, about the patient’s life. Quality of life to improve the confidence. And that helps quite a lot. So this is not aesthetic surgery, which is purely vanity. This is life-changing, basically.

Dr Helen Webberley:

And a two week holiday in Marbella. What could be better?

Dr Raúl Bellinga:

With no bruises and swelling, that would be better.

Dr Helen Webberley:

I know we could talk for ages. There are lots and lots of questions that are going to come in about this. And I think the best thing to do might be if we could get some questions in and write the answers and we could put them on our website so people can—

Dr Raúl Bellinga:

Great. Feel free to do that.

Dr Helen Webberley:

Yeah, I think that would be wonderful. It’s been really lovely talking to you today, really lovely. And, you know, facial feminisation surgery isn’t really a big thing over here. Everyone talks about top surgery for transmasculine people, or gender confirmation surgery down below, so it’s really interesting to look at something which actually everyone looks at every day, which is your face.

Dr Raúl Bellinga:

Yeah, the way you present in society.

Dr Helen Webberley:

Really interesting. So if anyone in the UK has any questions to throw at the Marbella team, we will get them answered and put them on our website.

Dr Raúl Bellinga:

It would be a great pleasure to do that, for sure.

Dr Helen Webberley:

Good. And it’s been lovely, lovely talking to you today.

Dr Raúl Bellinga:

Same here. Have a lovely day. Ciao, cheers, bye-bye.

Marianne Oakes:

It’s been an absolutely fantastic speaking with you Raúl. Thank you for giving us the time today.

Dr Raúl Bellinga:

Real pleasure. Whatever you may need, you ask, and here I am.

Marianne Oakes:

Cheers. Bye.

 

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