I think that imagination is very important," says Dr Sanguan Kunaporn, reflecting on his life's work. For some, the imagination is exercised through pen or paintbrush. Dr Sanguan's creativity flows through the scalpel.

His meticulous surgical methods, finely honed over years of practice, have elevated Dr Sanguan, in less than 20 years, from a general practitioner in rural Thailand to a world-renowned plastic surgeon.

The Bangkok-born doctor arrived on Phuket 13 years ago to work at the government-run Vachira Hospital, where he performed countless re-constructive and cosmetic procedures. He now runs a clinic (phuket-plasticsurgery.com), is a consulting surgeon to the island's three private hospitals and performs operations at Phuket International Hospital.

Dr Sanguan's career as a plastic surgeon began when, after serving as a rural doctor on Koh Samui, he applied for a residency in plastic surgery at Bangkok's Chulalongkorn University Hospital. His teachers asked him to draw a face on a board. "I drew the human face — the eyebrows, the eyes, the nose, the cheeks," he recalls. "Maybe the teachers thought that I had some idea about beauty, about the form, so they accepted me as a resident." He was one of only four chosen for the programme that year.

Today, Dr Sanguan forms a key part of the island's current drive to become a "health tourism hub", where people visit Phuket for quality medical procedures at reasonable costs, then spend their recovery time relaxing in paradise. Indeed, such is the demand for Dr Sanguan's work that Phuket International Hospital does not need to market his services.

Many of his patients are Westerners, some of whom are willing to endure the seven- to nine-month wait for Dr Sanguan's highly sought-after, male-to-female sexual reassignment (SRS). Just one part of Sanguan's extensive plastic surgery work, SRS is surely the most fascinating. Even Sanguan, who has performed some 500 SRS operations, remains slightly in awe of it. "It's very amazing, very amazing," he says. "I have given many lectures and presentations about SRS to groups of people, the community and other surgeons. I can see on everyone's face that they think it's unbelievable."

Many professions allow practi-tioners to claim a clear impact on other individuals. There are few, however, where seven or eight hours of your hands-on work will forever change the course of a person's life. As Dr Sanguan says, "Every case is interesting."

While he can describe in graphic detail, with no inhibition, the two-phase procedure for creating a woman's sexual organs from a man's, Dr Sanguan holds a certain reverence for SRS. He never forgets that his patients are real people, not merely subjects upon which to refine medical techniques.

"I call it the life-altering surgery," he explains. "After surgery, the patients begin to chart a new life, in another sex role." Dr Sanguan sees his SRS work not as a way to trick nature, but as a means of releasing individuals from traps — from a wrong body or wrong sex in which they have been caged all their lives. "Some patients say they recall that they have wanted to be a different sex since they were two or three years old," he says. "Ever since childhood, they wanted to play with girls, to wear their mother's clothes, to wear lipstick, paint their eyes. This really surprised me."

While Dr Sanguan is modest about his abilities, Internet websites and chat rooms dedicated to transsexual issues are full of testimonials from former patients, who rave in particular about his special skill in creating the female sexual organ. "There are only a handful of doctors with his reputation for SRS — maybe 12 doctors in the world," says American plastic surgeon Dr Harold M. Reed, who recently visited Phuket to observe Dr Sanguan's work. "For most transsexual patients, the important thing is the depth of their [vaginal] wall, and his dissection of that space is very meticulous, very careful."

Dr Sanguan is also renowned for ensuring that a key bundle of nerves in the male organ find their way, intact and functional, to the newly formed female organ. His mastery, many claim, is apparent in the fact that it not only looks the part, but that it feels the part as well.

While a functional organ is imor-tant, another crucial factor in the success of an SRS operation, according to Dr Sanguan, is the support of family and friends. Among most of his patients, that level of support is high. Amazingly high. "Some patients come to Phuket with their mother," he says. "Others come with their ex-wife. Some bring their present wife. Some patients come with the whole family, present wife and three kids. One patient of mine came with her son. At that time [before the operation], her son called her 'mum' already."

For Dr Sanguan, the greatest reward of his work comes from patient feedback. Weeks, even months after the operation, he'll get a fax or an e-mail from patients telling him that he has changed their life for the better. "It makes me feel proud that I have played such an important role in their lives," he says.

Like most doctors, Dr Sanguan understands his role as that of helping people. He cares about the outcome of his surgical procedures. He keeps in regular contact with many of his patients following their recovery and their new life after their return home. Mild-mannered and soft-spoken, he nevertheless exudes a quiet confidence that would reassure anyone about to undergo a major life change.

He's certainly no pushover. Unlike some plastic surgeons — the most famous examples being those who, in stages, largely removed the face of pop-star Michael Jackson — Dr Sanguan refuses to accept patients who seem to harbour "unreasonable expectations" about what surgery can do for them. His SRS patients must satisfy certain criteria indicating that they are ready for the procedure. They must have undergone extensive psycho-logical evaluation, had hormone treat-ments for at least one year, and ex-perienced a "real-life test" — lived as a woman twenty-four hours a day for at least six months — before undergoing the operation.

His criteria for accepting cosmetic surgery candidates are less stringent, but he won't consider anyone who is merely toying with the idea of a change. "For example, a patient will come up to my office and say, 'Please look at me. What improvements should I have done?' I refuse to answer." About half of those seeking nose jobs are turned away. "There's nothing wrong with your nose," he tells them. "Leave it alone." Or he'll study their face and advise them that it's the protruding chin, not the nose, that needs adjustment to bring balance to the face.

Though the fortysomething doctor, an avid cyclist and beacon of calm, looks like a model of health and vitality, one wonders whether, like the painter who experiments with self-portraits, he's ever considered cosmetic surgery for himself.

Dr Sanguan laughs and says "never", though he does concede that some colleagues have suggested it might be time to consider hair transplants. "I tell them maybe in a few years, but not right now. I'm okay with this."