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November 17, 2025
Marianne Waldenfels
Understanding Gender-Affirming Surgery: An Interview with Dr. Dr. Wolfgang Funk on Surgical Methods, Age Groups, Risks, and Why 99% of Patients Are Satisfied
With
Dr. Dr. med. Wolfgang Funk
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How many patients approach you each year wishing to undergo gender reassignment surgery? Has the number increased?
Each year, about 130 patients contact me, of which around 110 undergo surgery. The number has increased significantly in recent years. This is mainly because the social environment today is much more supportive. Many trans people receive more support from family and friends and also experience more legal and social recognition. As a result, significantly more people dare to express their wishes openly and seek medical help.
Are there more men or more women?
In my area, it’s almost balanced. This is because I perform many facial surgical procedures, but also body-contouring operations like breast augmentation, breast reduction, or body contouring.
Do the needs of trans men and trans women differ?
Yes, the priorities are different. For trans women, that is, people transitioning from male to female, facial procedures are more often the focus. For trans men, physical changes are often equally relevant or even dominating.
This is also related to hormone therapy: Testosterone in trans men leads to significant changes in the facial area, such as increased hair growth, hair loss, thinner skin, and a significant reduction in subcutaneous fat—making the face appear more masculine quickly. Estrogens, on the other hand, cause significantly fewer structural changes in the face of trans women, which is why more surgical measures are often needed here.
What is the average age of the patients?
It's hard to give an exact average, but in recent years, more and more younger patients are coming in. Most start around the age of 17, though I generally think it would be beneficial for the process to start even earlier, as hormonal care before puberty could reduce many later surgical interventions.
The largest group is between 20 and 35 years old, with 35 being considered rather late from a surgical perspective – although personal life circumstances often play a decisive role. Beyond that, there are also patients over 60 years old. Many of them have already started families, raised children, and led quite normal social lives, but never lived their true self. They are catching up on that in older age. After the surgery, these patients are generally much more stable, satisfied, and can finally live their identity freely.
What does the male-to-female surgery entail and how long does it usually take?
This surgery is very complex and involves several structural areas of the face:
1. Adam's apple – the prominent thyroid cartilage is reduced, as it is a strong male feature.
2. Jaw and chin – male jaws are more angular and wider; the chin often more pronounced. These areas are harmonized accordingly.
3. Midface – in men, it is often flattened and thus built up or contoured.
4. Upper lip – it is often too long and feminized.
5. Nose – male nasal structures are usually larger and more prominent and are refined accordingly.
6. Orbital (eye socket) - the male orbit is smaller; enlargement may be necessary here.
7. Forehead and orbital complex - particularly important is the modification of the upper eye roof and the frontal bone. This often includes obliteration or repositioning of the frontal sinus and a significant reduction of the frontonasal transition. The entire frontal skull area can also be contoured anew according to preference.
8. Soft tissues of the forehead area - these are individually adjusted to achieve a softer, feminine appearance.
9. Hairline – it is shifted, receding hairlines are reduced or completely closed, creating a round female hairline instead of a male M.
You see: It is a very complex interplay of skeletal, functional, and aesthetic changes that together shape the female appearance.
How do the surgical measures differ between female-to-male and male-to-female transitions, especially in the face and body areas?
In male-to-female transitions, the focus is mainly on facial feminization, as female facial features often need to be reshaped more than male ones. In female-to-male transitions, it is the opposite: Here, the face often requires more extensive structural changes to achieve a clearly male anatomy.
In the face, female-to-male surgery typically builds or enhances more pronounced contours. These include a more pronounced brow region, a stronger cheekbone structure, a flattened midface, a slightly more dominant nose shape, and a stronger chin. These changes are usually made through implants or bone advancement. The approach is fundamentally different from feminization surgery – however, this type of surgery is generally less in demand.
In the body area, however, the situation is reversed. For a woman who wants to become a man, breast reduction is often the priority, combined with the adjustment of the hip and pelvic shape. Contouring of the buttocks is also possible, for example through fat grafting, to achieve a more masculine buttock shape.
The extent of physical measures is very individual and depends significantly on hormone therapy. Many trans men have already experienced significant physical changes through testosterone, making only minor corrections necessary in some cases. In other cases, more extensive reshaping is required.
What are the biggest challenges and risks of these surgeries?
The challenges are very multifaceted. Of course, the technical execution plays a big role, but with an experienced surgeon, I assume that the entire spectrum of surgery is mastered safely. The real difficulty lies in precisely capturing the individual wishes of the patient and not only operating technically flawlessly but also achieving the desired feminizing or masculinizing effect.
It often saddens me when I see patients who have already been operated on, done well technically, but still lack the desired gender-typical appearance. This is where the artistic aspect of the surgeon comes into play.
I like to compare it like this: If you give ten excellently trained painters the same canvas, the same colors, and the same brushes, ten different paintings will still be created. Every surgeon has their own idea of aesthetics—and the satisfaction of the patients depends significantly on this. This artistic interpretation is one of the greatest challenges in this field, combined with the willingness for constant self-criticism.
Are patients also accompanied psychologically?
Yes. The transition is based on three main pillars: first is psychological care, followed by hormone therapy, and only in the third step come the surgical measures. Patients are accompanied throughout the entire transition process or can choose to be accompanied. Some consciously decide against it, but a professional therapeutic team is always available in principle.
Is gender reassignment actually reversible?
We hope that reversal surgery will not be necessary. However, there is a small percentage of about 1% where misjudgments become apparent afterward. But this also means that we achieve very high satisfaction among 99% of patients – a rate that is almost unique in medicine.
In principle, almost all surgical steps can be reversed, but the body is never returned to its original, non-operated state. A reconstructed penis remains a reconstructed organ, a re-operated breast remains an operated breast. The best results in reversing changes are usually achievable in the face, both in a male and female direction.
However, our goal is by no means to make reversals necessary. Therefore, diagnostics, indication setting, and psychological support must be as precise as possible. With a satisfaction rate of 99%, we can work very responsibly and successfully overall.
Why did you specialize in gender-affirming surgeries?
This specialization was the result of a long, multifaceted development process. My first contact with transgender individuals was in the 1980s when I cared for one of the first transgender patients in Germany. Her openness, her difficulties in finding competent medical contacts at all, and her years-long struggle for recognition left a lasting impression on me and sparked my interest in this area.
In parallel, I acquired a dual qualification – in oral, maxillofacial, and facial surgery as well as in plastic and aesthetic surgery. This combination is central to gender-affirming surgery as it enables both precise bony changes and sophisticated soft tissue corrections. It’s not just about medical parameters, but always about an artistic understanding of form, proportion, and expression.
My many years of experience in aesthetic facial surgery, particularly facelift surgery, have further deepened these skills. I also had the privilege of being supported by excellent teachers who introduced me comprehensively to the specific medical and psychosocial aspects of transgender medicine.
Over time, the demand grew: Trans people found me through my professional background and dual qualifications – initially sporadically, later continuously. The high satisfaction of my patients was a strong motivation for me to further expand this focus.
My personal concern is to implement the ideas of my patients as precisely as possible. Of course, the anatomical starting situations differ – especially after the completion of puberty – sometimes significantly. Nevertheless, a result can usually be achieved by combining bony and soft tissue-related measures that comes very close to the desired gender.
Today, gender-affirming surgery is a central part of my work. My goal is to meet the needs of my patients at the highest level both medically and personally.”
Since when have you been working in this field?
I have been actively working in this field for about 25 years. During this time, I performed my first transgender surgeries in my own clinic, the Dr. Funk Clinic.
However, passively and in terms of training, I have been dealing with gender-affirming surgery for about 35 years. During this time, I began to engage intensively with the topic, accompany my first patients, and acquire the comprehensive surgical knowledge necessary for this field.
