SHARE ANTHONY PLASCENCIA/THE STAR Dr. Gil Kryger of Thousand Oaks discusses gender surgery with Farnaz Sabet of Reseda. ANTHONY PLASCENCIA/THE STAR Dr. Gil Kryger discusses an upcoming gender procedure with Farnaz Sabet during a consultation. ANTHONY PLASCENCIA/THE STAR Drs. Zol and Gil Kryger conduct a breast removal surgery with the help of assistant Kendell Klepic. ANTHONY PLASCENCIA/THE STAR Dr. Gil Kryger removes bandages from the chest of Farnaz Sabet four days after performing a breast removal surgery.

By Tom Kisken of the Ventura County Star

Farnaz Sabet swiveled his bare chest in front of a mirror, slowly rotating as he examined blue-sutured terrain that once carried breasts.

This was life changing.

For the surgeon in scrubs studying the incision he made four days earlier, it was just Tuesday.

Dr. Gil Kryger and his older brother, Zol, perform about 150 operations a year in which they remove the breasts of patients who were born female but think of themselves as male. Once labeled gender reassignment, doctors and advocates now tag it as gender confirmation.

Patients call it top surgery.

In surging numbers pushed in part by changed insurance coverage, people convinced they were born with the wrong body parts come to Thousand Oaks and the Krygers' two-story clinic with the massive chandelier.

From either side of an operating table, the brother plastic surgeons perform an outpatient procedure that takes two hours, leaving a flattened chest, lifelong implications that will always spark debate and, for many, a clearer sense of identity.

"You know you're a man but you don't have the body," said Sabet, who grew up in Tehran and lives in Reseda. "You do this surgery to know who you are."

The Krygers entered the picture five years ago.

A person in his mid-20s from the San Fernando Valley came to the Thousand Oaks doctors. Identifying himself as male but born female, he said he felt trapped in the wrong body. He felt male in every way except for biology.

He had little money. But he asked for help.

Debilitating Distress

The Krygers are Orthodox Jews, members of a Hasidic movement that preaches taking care of others. One side of the family comes from Poland, the other from Russia. Both were decimated in the Holocaust.

The family ended up in Canada, then California, finally Israel. Gil and Zol grew up in Haifa, both serving in a special forces division of the Israel Army.

They returned to California in their early 20s, surfers who enrolled at UC Santa Barbara.

After a decade of medical training, they built a practice that ranges from reshaping noses to reconnecting hands severed in traffic pileups.

They listened to the man's story. They said yes.

"The distress he had having breasts, it was so psychologically debilitating for him," said Zol. "It was amazing to me how powerful it was."

Using some of the same skills employed in building breasts after a mastectomy, they rebuilt the patient's chest. They removed, then regrafted the nipples.

After surgery, the patient referred a transgender friend to the Krygers. The friend told another friend.

A trickle became a stream and then, over the last 18 months, a river.

Few docs do it

About 1.4 million Americans including 218,400 Californians — 0.8 percent of the state's population — identify as transgender, according to a June report from the Williams Institute at the UCLA School of Law.

Edicts from the California Department of Managed Health Care and a provision of the federal Affordable Care Act pushed insurance companies to offer more coverage of transgender care.

Cultural awareness grew when transgender actress Laverne Cox became a star in the television series, "Orange is the New Black." It grew again when Bruce Jenner went through top surgery and became Caitlyn.

Bottom surgeries involving penile implants or vaginoplasty require a urologist. The Kryger refer those cases, which are few, to a Bay Area practice that performs 100 gender procedures a month.

The brothers are not the only plastic surgeons in Southern California or even Ventura County that perform top surgery. But the number is limited with one doctor citing the small size of the transgender community and another pointing to the behavioral health component of gender procedures.

"They're one of a very few who do this," said Ward Carpenter, director of the transgender health program at the Los Angeles LGBT Center.

Many of the Krygers' patients are in their 20s, though a few have been teens, as young as 14. Parents have to sign off on their procedures. All patients see a therapist before going to surgery as an insurance requirement.

Most people plan their transition for years. They research every detail of the procedure.

"The classic statement is I've been waiting for this since I was 7," said Gil Kryger.

Hurdling fears

When Sabet was 7, she was part of the Bahai Faith and living with her family in Islam-dominated Iran.

Even then, she felt different. She wouldn't wear the scarf-like hijab required for females. Standing in front of the mirror at age 8, she stuffed toys into her pants to make herself look the way she felt.

"I wanted to be a boy," Sabet said, "I didn't know it was a possibility."

Sabet started calling himself a man three years ago. Testosterone treatment made his voice change. He grew a full beard. He wore a binder to hide his breasts.

He's 35, a burly ceramist with slim fingers, an easy smile and a favorite word: Awesome.

Friends described him as selfless and open. They support his transition. So does his mother, still in Iran.

He began looking for doctors. He considered a Florida surgeon before a transgender friend suggested the Krygers.

Sabet makes $2,100 a month working in a ceramics lab at USC. He opened an account on Kickstarter, offering handmade mugs to donors. He raised more than the $2,500 needed to cover his share of a procedure that starts at $6,000.

On the last Tuesday in June, Sabet stood awkwardly in a paper gown. Gil Kryger examined his breasts and explained the shape of the scar that would replace them.

Afterward, Sabet revealed the internal conversation that pushed him to surgery.

"You're not happy," he said. "You know what you want. You want to live as a guy."

Surgery is easy

Top surgery remains a charged topic. Therapists and some surgeons worry about people envisioning changed body parts as an answer to all their problems.

"The whole person is not being considered. I always tell clients that the easy part is surgery," said Max Fuhrmann, a Conejo Valley psychologist. "The hard part is all the social stuff."

Opponents of surgery contend already high suicide rates rise after surgery. They said the surge in procedures is driven by media fixation of celebrities like Caitlyn Jenner and doctors looking for revenue.

"It's a money game," said Walt Heyer, who underwent gender surgery, then a reversal and now operates a website called sexchangeregret.com.

The claim made Gil Kryger laugh.

"We don't make any money from this," he said. "We make money from cosmetic surgery."

The brothers said they understand the complexity of the transition. They said their patients have met with therapists. They've taken testosterone.

They already consider themselves men.

"We're not changing gender, we're dealing with people who have breasts that they don't want," said Zol Kryger.

Observers worry about people changing their minds after surgery. That can happen but after five years of surgery involving hundreds of people, the Krygers said they have not seen it.

"Never," said Gil Kryger. "By the time they walk into our office, they know what they want."

'A real boy'

After a last conversation with his mother, frozen yogurt and a mostly sleepless night, Sabet was driven by a friend to a Thousand Oaks surgery center at 7 a.m.

In the first of three top surgeries that day, doctors used scalpels and an electrically heated instrument to remove the breasts. They reconstructed Sabet's chest. They grafted nipples in place.

Afterward, Sabet lay in the recovery room, still groggy and sore, a flesh-colored binder wrapped around his torso.

"Like Pinocchio says, 'I'm a real boy,'" he said.

Four days later, Gil Kryger unwrapped the binder, giving Sabet the first look at his new body. Staring at his reflection, the patient smiled, took a step to change his profile and smiled again. A friend clapped.

"I feel free," Sabet said.

Gil Kryger thought of being an Orthodox Jew, part of a belief system often linked to conservative views on social issues. He said his faith focuses on making a difference. In his mind, top surgery is in sync.

"I'm trying to make the world a better place," he said.