Transgender feminization should not only be focused on full breast fullness, but also on alternations of waist/hip ratio. Although the cross-sex hormone therapy will gradually shift the abdomen fat into the buttocks and inner thighs, there is still some distances between the innate male skeleton and female body contouring. We wish both the transgender body contouring surgery and fat transposition could achieve the ideal goal.

The relative ratio of waist to hip reflects the distribution of fat, the content of subcutaneous fat, and the innate skeleton. The ratio of young females and males is approximately 0.67-0.8 (the best ideal value is about 0.7) and 0.85-0.95, respectively. With age growing and subsequently endogenous hormone decreasing, the female waist/hip ratio is gradually shifted into that of male. In other words, the body contouring is changed from a pear-like female body to an apple-shaped male appearance.

	Android	Gynoid
Appearance	Apple-shape	Pear-like
Skeleton	Sharp subpubic angles	Obtuse subpubic angles, wider pelvic brims
Gluteal area	Flat or even a distinct concavity	Distinct transition from the lower back Fuller, rounder shape

• To create a defined or lower waistline
  • Less fat over the waist: Endoscopic rib resection of bilateral 11th and 12th ribs is performed to achieve a lower and obvious waistline.
  • More fat over the waist: Subcutaneous liposuction is preferred rather than ribs removal.
• Improve the shape and waist/hip ratio
  • The previously harvested fat could be transferred to buttock shape improvement. Because of the limited amount of fat, it is not possible to fill all the areas at once.
    The priority will be to fill the depressions of the buttocks, followed by the achievements of pear-like buttocks.

Chest CT, BMI control, abdominal bandage preparation, hormone therapy suspended for 2 weeks.

• Use an abdominal garment.
• Try not to apply weight over the fat refilling area for 2 weeks.

• Surface unevenness or pigmentation over the liposuction area.
• Asymmetry, fat necrosis, hematoma, infection, subcutaneous seroma, postoperative bruising, deep vein thrombosis, fat embolism, etc. over the fat refilling area.