Episode 70: Facial Feminization

Episode 70: Facial Feminization

In this episode of Plastic Surgery Untold, our wonderful Doctors and Celebrity Anesthesia talk about Facial Feminization. Facial Feminization is a broad term that many facial procedures fall under. From the upper third to the lower third of the face, the team breaks down the different procedures and options someone has to really make a difference and to finally see themselves as they feel. This episode just barely breaks the surface of all the things to be talked about with Facial Feminization, so stay tuned for much more!

Dr. Adam Weinfeld: Welcome, everybody. We are here on plastic surgery untold to talk about facial Feminization. It’s really a fascinating topic. We have about 30 to 40 minutes. So really, it’s just going to be like an appetizer sampling of it. Before we get to it, why don’t we talk about what’s new? Travis?

Travis Osborne: What’s up you guys. We are back in the studio with another one. What’s up? Well, this week, my wife is out of town. So, she went on a little girl’s trip to Miami, and before she left, they were staying in South Beach, before they left she was “Yeah, we’re gonna go to Miami. I need just like a little bit of time to like, relax and just chill. I was like, “And y’all are going to South Beach?” Like that sounds lucky, right?

Dr. Johnny Franco: I guess…

Dr. Sean Arredondo: Very low-key right.

Travis Osborne: It’s cabin kind of trip.

Dr. Johnny Franco: So, I guess the more question is when’s the boy’s trip to South Beach because this is to relax as well.

Travis Osborne: To rest and relax, to recharge. So, anyway, she’s out there right now having a good time with one of her friends from college. So, she – I’m hoping comes back rested and refreshed.

Dr. Johnny Franco: That’s interesting said, no one – it’s like South Beach in Vegas.

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: I’ve never been so well-rested in my life.

Dr. Adam Weinfeld: So, Dr. Franco, other than enjoying some mini-Coke zeros in glass bottles, what have you been up to?

Dr. Johnny Franco: Ooh, lots of stuff. It’s honestly been super exciting. As you guys know, we recently opened our San Antonio office. We also have a little best of Austin award ceremony coming up. So hopefully we got some good news from you guys shortly. So, that’s been a bunch of our stuff, and super excited. There’s another nugget that we have coming but can’t tell you guys about it quite yet.

Dr. Adam Weinfeld: Speaking of super exciting, we have our two latest additions, our two new partners and we’re going to start with Dr. Arredondo.

Dr. Sean Arredondo: All right. Hey guys, glad to be here. Thanks for having me on the podcast. Life’s been good. We’ve just been getting used to Austin and the 110-degree weather.

Travis Osborne: Oh my gosh, yeah.

Dr. Sean Arredondo: That’s a bit of an adjustment.

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: And because your – your wife’s a physician here in Austin as well.

Dr. Sean Arredondo: She is. She’ll be at the Children’s Hospital doing her neurology thing. And so, we started almost exactly the same time. I started a little bit later, because I’ve got a better boss. So, that worked out well.

Dr. Adam Weinfeld: Cool.

Dr. Chris Micallef: She sees that now.

Dr. Sean Arredondo: Yeah.

Dr. Adam Weinfeld: So, quick – quick, on a scale of one to 10, how did I do with your name?

Dr. Sean Arredondo: Oh, that’s about I’d say nine and a half.

Dr. Johnny Franco: Shut up.

Dr. Chris Micallef: Strong. That’s strong.

Dr. Johnny Franco: Wow.

Dr. Adam Weinfeld: Wow.

Travis Osborne: Wow.

Dr. Sean Arredondo: I can’t say 10 because you know, you still…

Dr. Adam Weinfeld: Yeah. Well, you know what I want to be able to get out? Yeah. Yeah. Okay. Dr. Micallef.

Dr. Chris Micallef: So not much has been going on. My wife is out of town this week. She’s in Chicago selling our wine importing and distribution business. So, that’s exciting.

Dr. Johnny Franco: I think congratulations.

Dr. Chris Micallef: Thank you very much. Appreciate it. So, that’s hopefully going well. We will see tonight when she gets back. But otherwise, super exciting things, we – we recently opened in San Antonio, and it’s been fantastic. We’ve been seeing consults there. Super excited to see where everything goes.

Dr. Adam Weinfeld: Quick tangent. I know you said you had some other endeavors in addition to the wine business. So, what – what are the focus of, let’s say, at least one of them, so we get to know you a little bit better.

Dr. Chris Micallef: So, I also own a real estate company

Dr. Johnny Franco: Oh, awesome.

Dr. Chris Micallef: Yeah.

Dr. Johnny Franco: Which is a little bit of a sensitive subject here in Austin and for anyone who’s been doing some price. So, it’s not Austin…

Dr. Chris Micallef: It’s not Austin.

Dr. Johnny Franco: Okay. Just don’t want people to be upset at you.

Dr. Chris Micallef: That’s alright.

Dr. Johnny Franco: What about you?

Dr. Adam Weinfeld: Well, you know, I’ve been spending a little bit of the morning learning about the history of facial Feminization, and I found out some really interesting – some interesting topics, some interesting facts. Does anybody want to take a guess as to when facial Feminization started as a – as a practice, as a – as a field of medicine of surgery?

Dr. Sean Arredondo: 1960s.

Dr. Chris Micallef: 19th Century.

Dr. Johnny Franco: Okay.

Travis Osborne: I would say1970s.

Dr. Johnny Franco: Okay.

Dr. Johnny Franco: Oh, I was gonna say 60s.

Dr. Chris Micallef: I said 19th Century.

Dr. Johnny Franco: Okay.

Dr. Adam Weinfeld: Okay. All right. So, you know, according to Wikipedia, which isn’t always, you know, the end all be all…

Dr. Johnny Franco: Which we’re finding with now, because they took our Austin Plastic Surgeon Wikipedia page down, which – which we’re still protesting. So, anybody listening hasn’t pulled Wikipedia put in a good word for us.

Dr. Adam Weinfeld: Oh yeah.

Travis Osborne: I’ll message them this week.

Dr. Adam Weinfeld: And I donated to them recently. Oh, yeah, alright, maybe it’s because of the donation wasn’t that big. Alright, so, you know, so according to a website that has information, it started in 1982. Now, I’m sure – I’m sure there are – I’m sure there were like little dribs and drabs of procedures before that, but I think what the – what this website was talking about is that one of the most powerful procedures that we do in facial Feminization, that is recontouring the forehead and specifically addressing a large amount of bone, the brow, the frontal bone bossing or the large bone that sticks out beneath the eyebrows, that the first time that that was approached for the purpose of feminizing someone’s face was in 1982, by a doctor Osterhout, who I think was in San Francisco at the time. Someone who did – I think it was probably genital reassignment surgery. I had a patient who was a trans–female transwoman who wanted to have Facial Feminization that really, apparently, is the time that it really began.

Dr. Chris Micallef: Very interesting.

Dr. Johnny Franco: I think is so cool, though, and because I don’t want people to misunderstand is, you know, basically putting these procedures into a structure for this purpose. But a lot of the techniques have evolved from stuff that we’ve done for years and years, whether it’d be from traumas, whether they’d be from other congenital shaping, because there’s lots of stuff where we have to reach a shape the skull, the face stuff, but typically not with this focus and maybe an aesthetic mind.

Dr. Adam Weinfeld: Correct. Yeah. And – and we need to – we need to talk about that real briefly because that – that’s – that’s important but in a minute. I think it’s really important, just so that we do this, right. We got to talk a little bit about nomenclature.

Dr. Johnny Franco: Okay.

Dr. Adam Weinfeld: So, like what we call certain things. And then I think it’s also important to have a little bit of like a disclaimer. So, the language and the concepts that we use to talk about gender-affirming surgery, about people who are transgender, or even nonbinary, that language is always evolving. And so, if we use terminology in a way that is inaccurate or doesn’t reflect how people feel most comfortable, it’s totally unintentional. I think it’s really important disclaimer.

Dr. Johnny Franco: Yes.

Dr. Adam Weinfeld: Because these populations of people, rightfully so, you know, want to have respect. And so, if we make an error, it’s not out of disrespect. So then, under nomenclature. So – you know, and it’s – there’s so much that we could talk about, but let’s – let’s talk about for – for, I’m sorry, about six to eight terms, right? So – so one, when we talk about, you know, what someone’s – what someone, let’s say, looks like coming out of the womb, right?

You know, if they have a – you know, a male body like a penis, things like that, we say that they’re assigned male at birth, right? So assigned male birth, feet, you know, absence of penis and a vagina, and what have you, assigned female at birth, right? Just to say that, but that isn’t necessarily – that’s very specifically not talking about gender, because – because many people who are transgender would say, “Well, my anatomy or who and what I was, at birth doesn’t define who I am in a gender spectrum.” So, that’s important.

So assigned male, assigned female at birth. And I think it’s important that we kind of have that because it’ll make some of our discussion subsequently less cumbersome. So, if you have someone who is assigned male at birth, but always has known internally – always has felt – always as identified as a female, so again, assigned male at birth, but they – they know, truly, they’re a female, we would call that person or they would self-identify as a transwoman or transfemale.

Same as true, if you have someone who is born as a “female,” really, but we’re avoiding using that term, because that’s really a gender-term, but when we’re talking about their anatomy, even potentially, some of their genetics, we’re saying that they were assigned female at birth, if that person, you know, as they’re developing, as they’re growing, as they’re getting to understand who they are, if they feel like they’re a male, we’re going to call or they’re going to call themselves and we should out of respect call them a transmale, or – or a trans man. And – So, then just one other piece of terminology – a couple is that – so if you, let’s say is assigned male at birth, and you identify as male, then the terminology that’s used to address that person is cis male, and that how we come up with that terminology is kind of interesting.

I’m not gonna go into that because, like a whole chemistry lesson, but essentially, that’s to distinguish a transmale from a female, excuse me – a trans male from a cis male. So, cis male, again, are assigned male at birth and feels like they are who they were assigned at birth. And then the same goes for cis females. And so, it’s important to talk about because I – I’ve learned along the way that you can kind of say things that of course, you don’t intend to say that can, you know, someone can find a little sensitive or offensive, but once you start to understand the terminology, and so the process of – of helping someone feel and look like they know they are, is called gender-affirming surgery, and Facial Feminization is one of the most wonderful aspects that we as plastic surgeons.

As Travis is an anesthesia provider, can be involved with the overall care of these patients to help them – you know, to affirm them and have them feel and pass in the world as to the gender that they know they truly are. So – so I’m exhausted. What questions you guys have.

Dr. Johnny Franco: I think that you brought up so many good points, because one, I think, you know, we all want to help people reach their aesthetic goals and there are lots of things what that means, like you’re stating. And I think sometimes we do miss-speak and I’ve definitely been, you know, guilty of that, but it’s not out of malice. Sometimes, you know, it’s just either lack of understanding or sometimes just a mislip of – of speech…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …more than anything else. I think those are super valid points.

Dr. Adam Weinfeld: Yeah. Yeah. Yeah. Oh, and I know where – I know where we were, you had brought up a really important point. And that is that, almost none of these procedures are actually new. They are all – they are all things that we did in the past, mostly as part of reconstructive surgery and some cosmetic surgery. So, there are things that we did in the past, or they are modifications of things that we did in the past, that are brought together as part of a basket of goods that we can offer to our patients under the umbrella of facial Feminization.

One of the best ways to think about this and help sort out this with patients is to really break the face up into thirds. So you’ve got the upper third, the middle third and the lower third. And I’m going to briefly highlight, like sort of what we’re focused on. And then I think we should have everybody who’s been involved with this, you know, probably talk a little bit about their experience. But if we talk about the upper third, we’re talking about the appearance of the forehead, the brows, even the temples…

Dr. Johnny Franco: Because we know about facial Feminization. This is a broad term that encompasses multiple procedural procedures.

Dr. Adam Weinfeld: Multiple Procedures.

Dr. Johnny Franco: Sometimes people say, “Oh, I want…

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Adam Weinfeld: Dozens of procedures.

Dr. Johnny Franco: …facial Feminization, but then it’s – this is where we have to work with you to be like, “Okay, what does that mean to you…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …what specifically…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …it’s – it’s sort of like, when people use the term mommy makeover, there’s a lot of procedures that can fall inside of that.

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: And it really depends on person to person.

Dr. Adam Weinfeld: Yeah, and I will say that, that, you know, the women, that transwomen who come to see me for these procedures, actually, they kind of make it easy on me most of the time, because a lot of them have – you know, there’s – they’re obviously really passionate about is their identity, right? And – and so, they’ve spent a lot of time researching this, you know.

So, when we start to – they often know what they want on in the upper third, the middle third, the lower third, and I just use this concept of talking – it’s not my concept at all, but you know, breaking things down into thirds to keep us organized. So, we’ve got the – we’ve got the forehead, the eyebrows, the hairline, the temples, and the shape of the orbit as the upper third. Middle third, you’ve got the cheeks, you’ve got the – I’m sorry, the nose, you’ve got the cheek, really the cheekbone, fullness in the cheek, and then the upper lip lane.

Then the lower third, you have essentially the fullness of the lips, the size and the projection of the jaw. And then also the size of – the jaw, meaning the chin and then also the side portions of the jaw called the gonial angles. And then also there’s sort of like the four third, the neck, and there’s some things that we can do in the neck as well. So I know we were talking about this beforehand, you guys have some experience with this. Do you guys want to talk about, like, is there a third that you guys would like to talk about at all? Not to put you on the spot, but are there – or just a particular procedure that you guys have enjoyed doing?

Dr. Sean Arredondo: I’ve enjoyed the – one that I’ve done the most commonly has been addressing frontal bossing, the brow ridge. And I think those are pretty interesting procedures. I would have a question for you, though. We used to get a lot of imaging for these, like CT scans, so we know the thickness of the frontal, the anterior frontal plate, do you tend to get CT scans for your patients if you’re addressing that issue?

Dr. Adam Weinfeld: Yeah absolutely. I do absolutely. And there’s been an evolution in the way that I have – have done things and how I’ve sort of been a part a lot of my practice actually has migrated into this work. And I absolutely get CT scans now. And so – so – and what you’re referring to is that we – there are two different procedures, at least what I believe you’re referring to, there’s two different procedures that we can do in the forehead, in order to decrease one of the things that is perhaps the most masculine component of our facial appearance.

In fact, there are studies that demonstrate like – like physical anthropology studies that demonstrate that one of the things that’s let’s say, the biggest identifier, as you know, masculine is the – is the bump here that we have, that most men have that is pretty full, that’s either just under or above our eyebrows. And so, what you’re referring to is, you know, how do we address that bump? How do we get rid of that biggest tell if you will? And there’s two ways to go about it.

One way is to burn it down. Well, actually, there’s three ways but one way is to burn it down. One is to camouflage it by placing something in the valley, if you will, above it. And then the other way is to cut the bone that creates that – and set it back. Yeah. And so, imaging can be really helpful for that. And so the way that I found imaging to be helpful is that one, you can use it in combination to your physical exam to know if there’s a significant degree of thickness to that bone that you can merely burn it down without getting into the frontal side which can cause some problems.

So, if you can do that, that’s great. And the reason that that’s great is because then you don’t have to make some cuts into the bone, which – which it’s not hazardous in a way, but it is a little bit more time-consuming. Well, I should say, it’s never safe to say. It’s never right to say. It’s not hazardous in a way what I meant to say is, there’s not a significant amount of hazard to doing that.

Dr. Sean Arredondo: Yeah.

Dr. Adam Weinfeld: But it does – if you can just burn down the bone, that’s a more simple procedure.

Dr. Sean Arredondo: Right. We have a thickness of that bone.

Dr. Adam Weinfeld: Thickness in the imaging is helpful for that. Another thing to know is if they have a fully developed frontal sinus. I mean, some people may have – they may – you may think based on the degree of projection, there’s a patient, I really like to set them back, but you might have one side of their frontal sinus that actually isn’t a sinus at all. It’s just thick – you know, it’s full bone. And that’s a patient that you’re going to have to burn down at least that portion because there’s nothing to cut into to set back. So you may have to split it, cut the one portion, set that back, and just burn the other side, and…

Travis Osborne: We’re sorry to interrupt, but when you say to burn down, for people at home that don’t know exactly what that means. Could you explain that?

Dr. Adam Weinfeld: Oh, yeah, thank you. Yeah, that’s, you know, a rotating instrument that has a round knob at the end of it that has little grooves in it, that chips away the bone in an incremental and controlled fashion, whereas cutting the bone is literally cutting the bone, disconnecting a portion of it, placing it back and using some plates to…

Dr. Chris Micallef: To secure it.

Dr. Adam Weinfeld: Yeah. Yeah. So, you know, to address your question, I – when I talk about evolution, one of the early patients that I did facial Feminization on was someone who had – oh gosh, we could spend the whole session talking, but it was a patient who had a low hairline. So, you know, one of the things that, you know, distinguish a masculine from a feminine face is that with a masculine face, sometimes the hairline is, is receding, either they haven’t lost hair, whereas the height of a feminine face, or feminine forehead is a little bit lower.

So, one of the things that sometimes when we’re talking about the upper third with patients that we do is we advance the forehead – I’m sorry, the hairline, but in patients who don’t actually need that, so a transfemale who actually has, you know, a feminine hairline, there’s no need to make that incision in the – at the hairline to advance the hairline. And that incision is what – or is one of the ways in which you have open access to that – that forehead, that frontal bone bossing to burette, let’s say if it’s a patient that a CT scan demonstrates that you actually don’t need to – to actually cut the bone and push it back.

Another way is to place a cut across the hair, you know, a couple finger breasts couple inches back into the hair and make a cut from side to side, essentially, from ear to ear. Well – well, you know, that’s great, because you don’t have an incision at the hairline. But in some ways, these patients almost always want a brow lift. So then you’re pulling the – then you’re pulling the hairline back a little bit which some patients can tolerate.

Well, this first patient, or first or second patient that I started to think about doing, you know, how do I recontour their forehead, you know, she had a minimal amount of bossing, but enough that she definitely would benefit from removing it. Perfect hairline. So, what I did actually was I addressed it endoscopically.

Dr. Chris Micallef: Oh, yeah. Nice. Okay.

Dr. Adam Weinfeld: I used one of those small joint…

Dr. Chris Micallef: That was fun.

Dr. Adam Weinfeld: … small joint shavers, and I did it as I would do an endoscopic brow lift, but that was actually before I started CT scanning them, and I was just extremely careful about how much I would burr down little by little.

Dr. Chris Micallef: Little by little.

Dr. Adam Weinfeld: …little by little, and you know, and as you guys know, that endoscope does magnify things. So you can kind of get a sense for if you start to see a little bit of, you know, sort of like darkness.

Dr. Chris Micallef: Darker. Yeah.

Dr. Adam Weinfeld: …yeah, you know, that you’re…

Dr. Chris Micallef: You’re getting closer to sinus.

Dr. Adam Weinfeld: … you know to stop.

Dr. Chris Micallef: Yeah.

Dr. Adam Weinfeld: And um, so that’s actually one of the first ways that I – that I addressed the forehead contouring in a transwoman, come to find out I don’t think that’s been actually done before. So we’re – we actually have an IRB to publish, in my experience with it, but I subsequently I started to do imaging to answer your question, I started to set them back. But like I said, we could talk so much about this, because there’s – it’s like a game of chess, just to think about how to dress the upper third.

Dr. Chris Micallef: Where to start. Yeah.

Dr. Johnny Franco: You guys, because – because we could definitely, you know, have an episode over each of these and maybe we need to come back and address some of these in length. But what if we listed the kind of the procedure of from the top down, like hairline…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …bosses up because that way, at least today, people can get a big picture of the overall procedures? Maybe a little highlight and then and then definitely some of these that are super common…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …come back and spend a little bit more time because I don’t…

Dr. Chris Micallef: Yeah.

Dr. Johnny Franco: …I think there’s a lot of people that don’t even understand all the options out there.

Dr. Chris Micallef: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Adam Weinfeld: Well, I could go a mile a minute and like take up the whole podcast. I insist that a lot of people talk about it. So…

Dr. Chris Micallef: I can – I can definitely go over some of these procedures for sure.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: As you said, there are a ton of procedures that fall under facial feminization surgery, but starting at the top, we typically talk about hairline advancement. This is typical for transfemale – transfemale. There’s also potential for a little bit of hair transplant in these patients as well. In particular, if we have to put a scar in order to advance the hairline, we typically will go back and do some hair transplant over that location as well.

Dr. Adam Weinfeld: Yeah, oh, go ahead.

Dr. Chris Micallef: Please.

Dr. Adam Weinfeld: Yeah, keep going.

Dr. Chris Micallef: We can address the frontal bossing that we essentially just talked about in multiple different fashions. In a trans female, we want to change the position of the lateral brow – of the brow and change the shape of the brow. And so, typically, we want to do a brow lift for these – for these – I’m sorry for the trans males, in order to get the lateral brow up and change it. So, it’s more respective of a male’s brow contour.

Dr. Johnny Franco: And sometimes you have to be careful with brows because in general, sometimes people have played with their brows in terms of their shaping.

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …the – you know, aesthetics that people have done in terms of – there’s all sorts of different brow like hair type things, and shaping and tattooing. So, I think sometimes you got to be a little careful, because they’ve they already have artificially changed some of those shapes.

Dr. Chris Micallef: Yeah. Yeah. Absolutely.

Dr. Adam Weinfeld: And to add what you said – to what you said, there are a couple of other subtle things that are really helpful. So typically, if someone has more of a hollow temple, more of a concave temple, that’s more that kind of leans a little bit more masculine on the – on the gender spectrum of facial appearance. So one of the really easy ways to address that is fat grafting to the temples.

Another thing is that what’s considered more of a masculine orbit and perhaps a little bit straight across when you think about the overall shape of it, whereas more of a feminine orbit has a little bit of a tilt up, and sort of out. And so, if we’re doing an open procedure for brow contouring – brow bone or frontal bone contouring, we’ll also burr out a little bit of the upper outer orbit. Yeah. And that – that helps really reconfigure and…

Dr. Chris Micallef: Positive Kendall tilt.

Dr. Adam Weinfeld: Yeah. Yeah. Exactly. Thank you, positive Kendall tilt. Yeah. And so, that can be really helpful as well. You can’t really do that well as a closed procedure. And that’s what – where there’s a lot of like, give and take in discussion with patients, when I meet with these patients, you know, often it’s at least a half an hour discussion where it could – it could really could take, you know, an hour and a half. And I meet with these patients multiple times, because there’s so much to discuss.

So anyway, yeah, so we’ve got the hairline advancement. We’ve got, as you said, for the – the transwoman also elevating the brow. So, you know, brow lift. We’ve got fat grafting to the temples. I also wet, especially if I’m only burring down the bone, I will always before I lift up the skin to burr down the bone, whether it’d be endoscopically or with a full open procedure, actually fat graft in the skin above where the brow bone was going to be.

Because you – you – even if you have a CT scan, you know, you have thick bone, sometimes you’re a little bit sheepish about burring down too much of the bone. But if you do a little bit of fat grafting in the valley above that mountain of bone, then – then you’ve – you know, you’ve…

Dr. Sean Arredondo: You can pause that transition.

Dr. Adam Weinfeld: …you can pause the transition, but not only that, some of the patients that I’ve seen from other really, you know, amazing surgeons tend to have a little bit of a flat appearance. And to do that little bit of fat grafting does help give a little bit more of a rounded, gentle, definitely just a more feminine look to it. So that’s really the – that’s the upper – that’s the upper third in a nutshell, there’s some sort of, you know, one-off things that you do for some procedures. And then when we talked about the middle third, we talked about, you know, the cheek that really – let’s talk about – let’s break up the cheeks sort of into the cheekbone and then the fleshy cheek, and then we have the nose and lip lane. Does anybody want to comment on these?

Dr. Johnny Franco: I think cheeks is one of these that hits home for a lot of people because that’s something that we do very commonly, and some of those are changed with, you know, a lot of things, and also unfortunately, you still have to take in the natural aging, which changes some of this because for a lot of people, you know, it’s a little while in life before they’re able to make some of these changes and some of it I think is lifestyle, some of it is cost and it’s a discussion for another day of what gets covered what doesn’t…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: And that’s an always evolving…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: …unfortunately a little bit of amazing hardness and I think it’s going to be probably a transition for a little while but a discussion for another day…

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: Because we have been a whole episode on it but – but I think working on the cheeks, the mid-face, because there’s a lot of procedures here but it’s, I think more challenging, especially the older you get, because now you have to take into account not only the – the gender differences and trying to make this facial, but now also dealing with some of the facial agings, the ptosis of the skin, ptosis of these fat pads. And so, I think some of that evolves a little bit, depending on the age at which somebody has some of these procedures in the cheeks more than the forehead, hairline, obviously.

Dr. Adam Weinfeld: Yeah.

Dr. Johnny Franco: That can be an issue.

Dr. Adam Weinfeld: Yeah. Yeah. Yeah. And I thought of sort of a concept that I’m always mindful of, you know, but when we think of a face, sort of a more masculine appearance, again, in a – you know, a masculine-feminine spectrum of facial appearance, you know, a face that we would consider more masculine, also a little bit bottom heavy, whereas a female face, a little bit top-heavy.

So – and when I say top heavy, what I mean is perhaps a little bit more fullness, again, like in the temples, that sort of by temporal distance, and fullness, sort of rounded, but sort of fuller features in the cheeks as well, and then a smaller jaw, whereas in a man, you know, the jaw is a little bit bigger. And so one of the things we can do to shift volume, we talked about a little bit of fat grafting to the – to the temples but adding to the cheek, whether it be fat grafting, or whether it’d be cheek implants.

I’m not a big fan of huge cheek implants because I think they can look really artificial, but even a very small cheek implant can help supplement some of that upper half facial volume, and can tilt that balance a little bit – being a little bit top heavy versus being bottom heavy. And then you add to that, you supplement to that reducing from the lower half of the face, and that’s where we kind of get back to that middle third, buccal fat pad reduction is something that often is helpful in reducing the fullness in the lower half of the face.

Then we do things to the chin and the rest of the jaw to make it less bulky, less, less full, less masculine, more feminine. And that’s where you have your procedures such as genioplasty is, where you can set the chin back, remove a small wedge of bone, setting the chin proper back, placement back together with screws and plates, or even just burring the bone can be helpful as well.

Frankly, when you do set the chin back in a true osteoplastic – genioplasty, you still need the burr of the bone of the chin because the masculine chin, if you will, has two little tubercles. So, two little bumps, whereas a chin that’s considered more feminine is a little bit more rounded. So even if you set the chin back and made it sort of smaller in an anterior-to-posterior projection sense, it still may have the two little tubercles.

So often, if I’m doing a genioplasty, I’ll burr those back as well. But yeah, it’s – it’s one of those – you know, it’s one of those, you know, facial Feminization as an event for a patient and thus, for a surgeon, often is an all-day surgery. So, you know, seven and a half to eight hours. And it is a lot of stuff, you know. We got – so many of these patients, you know, as you can imagine, they’ve been waiting for like years and years and years to look the way they feel, and the way they see themselves, and they want it all done at once. And we do our best to do that for them.

Dr. Chris Micallef: I think one person – one point to mention, we’ve listed, you know, all these different procedures and their stereotypical norms for what appears female, what appears male, that’s not the same for everybody.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: You know, somebody may identify as female, but they see themselves in the squarer jaw. They may see themselves, you know, with a higher hairline. That’s – that’s okay, you know, not everybody is built the same, not every is made the same. And so, it’s kind of our job with all those preoperative consultations is to sort of make sure that we understand each other and are on the same page before it taking on this long arduous – you know, this long list of procedures and making sure that what they see is what we achieve in the end.

Dr. Adam Weinfeld: That’s right. Yeah.

Dr. Johnny Franco: And there’s some other options in terms of facial fillers, other things because, to your point, the recovery is not overnight for this.

Dr. Adam Weinfeld: No.

Dr. Chris Micallef: No.

Dr. Sean Arredondo: No.

Dr. Johnny Franco: This is definitely it’s a big change. It’s a big time. It’s a big commitment. So, there’s definitely a lot of patients that we have that do some of this with some facial fillers and definitely can achieve some of the same results. But there are fillers and things in terms of some of the temple hallowing, some of the cheek animation, some of the jaw line stuff that can help, you know, bridge the gap for a little while, maybe just from a resource standpoint, maybe it’s not on your cards, right this second from a time off work or lifestyle, and family stuff. There’s – there’s a lot of factors. And so, I don’t want people to feel like if you can’t undergo this massive surgery, there are no options to get you to a good spot. There’s a spectrum of stuff, maybe like most things won’t be as dramatic, you know, but there are definitely some options for people.

Dr. Adam Weinfeld: Yeah. It certainly allows one to date the process of change and see what it looks like with something that is reversible. And then as you said, it can be less expensive, at least in the short run and the recovery from something like that is a lot easier. You mentioned insurance and I think it’s worth just very briefly touching upon that is that – is that depending on the insurance company and the patient in the contract, some – a lot of these are actually covered by insurance.

Unfortunately, we’re starting to see more pushback with that, but there are certain companies interested like the big tech companies, that tend to support this. So like Apple, Facebook, Google, I’ve seen a number of patients from there. And then Starbucks coffee, actually, they’re really impressive too, with regard to covering this. And we do what we can do to, you know, try to make this a procedure that is – or a set of procedures that’s available for patients when they don’t have insurance. But it’s a lot of work. And so, it’s great when it is covered by insurance. It is great for the patient when it’s covered by insurance.

Dr. Chris Micallef: So, does that makes it more likely to save something for a patient if it is covered by insurance, or is that more dependent on the procedure’s interest in them?

Dr. Adam Weinfeld: That is a good question, and that’s really – I mean, the thing that drives staging things is the intersection of two things, safety, and patient desire. So, I’ve never met a patient who didn’t want to do it all at once.

Dr. Chris Micallef: Right.

Dr. Adam Weinfeld: And – and – and what I’ve told patients is like, “I think this is reasonable, but you have to choose the thing that you care about the least, and I’m going to do that last so long as it fits in the logistics of things. Because if I get to a point where we’re pushing like eight and a half hours, and we’re looking at another hour or two of surgery, we’re going to have to talk about doing that later.” And, you know – and all of these patients I’ve worked with are so wonderful. They’re so understanding.

They’re just grateful to be interacting with someone who respects them, and is trying to, you know, meet them where they are and see them as who they are. They understand that. There – I’ve never had someone who’s had an issue with that. I’ve also never had to do that. But as we start to add more and more to what we can do, I think there are going to be times you’re going to have to pull out that safety card and say, “We’re gonna have to address this later.”

Dr. Johnny Franco: I think just for the sake of time, Stephen, definitely, I think something that we’ve seen here is that, you know, maybe we’ll come back and do like a three-part series where we really address the upper, the middle, the lower third an individual segment because I think there’s a lot more detail that we can go into. And so maybe treat this as a little bit of an overview and some, you know, kind of framework for more stuff to come. And so, you know, for our team would – would be willing to do that.

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Oh, yeah.

Dr. Chris Micallef: Yeah, absolutely.

Dr. Sean Arredondo: Yeah, absolutely.

Dr. Johnny Franco: Any last take homes on the topic that – that you’d like to leave people with, in terms of – of some of these – these treatments, maybe one or two that we haven’t mentioned yet, at least want to give a shout out to? Anything else. Because I would say lip lift is…

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Johnny Franco: …somebody alluded to.

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Johnny Franco: …I think that’s become super popular. That’s another easy one that sometimes can be done in the office, you know, in the right patient.

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Johnny Franco: …sometimes can be in combination with other stuff. And so…

Travis Osborne: With the buccal pad fat pad.

Dr. Johnny Franco: … buccal fat pad is another one that can be done in the office itself. That’s one where a combination of like a lip lift buccal fat pad cheek fillers can make a big difference people from a cost recovery tends to be very reasonable.

Travis Osborne: Yeah.

Dr. Johnny Franco: And one reason I’m bringing it up is that I think that the patients Dr. Wienfeld has done that have had these larger surgeries get dramatic, and they’re super happy. But just from a personal lifestyle, that’s not almost in everybody’s cars and like, “I’m planning this when I need to plan these two years out from now when I’m gonna…

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Johnny Franco: …have people to help take care of X, Y and Z in my life stuff.” So, I don’t want people to feel like if they can’t commit, you know, three or four weeks of recovery and so forth, that there are no options for them.

Dr. Sean Arredondo: Right. And…

Dr. Adam Weinfeld: Right.

Dr. Chris Micallef: Right. … as far as trying things out, too, like you were mentioning Botox can offer some interesting options to with brow shaping or with masseter…

Dr. Johnny Franco: Masseter, that’s a great…

Travis Osborne: Yeah.

Dr. Adam Weinfeld: Yeah.

Dr. Chris Micallef: Yeah.

Dr. Sean Arredondo: Yeah.

Dr. Johnny Franco: …oh, maybe that’s our behind-the-bogey masseter botox. That’s a – that’s a great one. Maybe just for people that don’t know, tell him what botox to the masseters does.

Dr. Sean Arredondo: So, what Botox in the masseters does certain doses? It actually decreases the size of the muscle because it paralyzes it. And so, it just doesn’t get that same use it does. So, it actually shapes the face a little bit differently because a little bit narrower of a gonial – not gonial but just narrower sort of cheek with – their jawline.

Dr. Johnny Franco: So, celebrity doesn’t act right, we can botox his calf muscles and make his…

Dr. Sean Arredondo: That’s right.

Dr. Johnny Franco: …legs just fade away.

Dr. Sean Arredondo: Chicken legs are coming up.

Travis Osborne: Unbelievable.

Dr. Johnny Franco: Would you like to take us home with a quote of the day?

Travis Osborne: I will, but just right before that, I want to touch on a couple of key anesthetics…

Dr. Johnny Franco: Oh, yeah.

Dr. Sean Arredondo: Oh, yes.

Travis Osborne: …thoughts from these cases. These are airway cases, generally or it’s in and around the airway. So these patients, and I’ve worked with Dr. Weinfeld doing a ton of these, and you know, they’re longer cases. So they are intubated. I mean, these cases can run anywhere from 4, 5, 6, 7, and even up to eight hours sometimes. And, you know, that is where he and I will have this conversation or there’s this conversation between the anesthesia and the surgeon about “Hey, how long is too long? Where – did one part of the procedure go a little bit longer than what we were planning for? And then we kind of make some – some game time decisions while we’re back there, and like you said, “What’s your least important thing?”

Sometimes that that gets punted to another procedure day because it’s not safe to continue doing anesthesia that long in an outpatient setting. And the real reason that we’re worried about that is because of airway edema and swelling in the airway that can happen during a long period of intubation, and – and I can just set the patients up for risk of having an adverse, you know – adverse airway swelling after the procedure and after that breathing tube is removed.

The other thing that we can have is, you know, a lot of time under anesthesia, those anesthesia drugs just build up in your system. So it just takes longer for those – those drugs to exit your system and for you to recover fully from that anesthetic. So just a couple of things to think about, it is not an immediate recovery. This is not like the one-hour breast aug where you go in, and you’re ready to go really within 45 minutes of being done with your case. These are typically just a little bit longer recovery cases.

Dr. Johnny Franco: I think that was a great point,

Travis Osborne: Yeah.

Dr. Johnny Franco: …that we didn’t even get to stuff in the neck like tracheal shaving and other stuff that…

Travis Osborne: Yeah.

Dr. Johnny Franco: …that even have other rest of maybe something for us to talk about in the future.

Dr. Sean Arredondo: The forgotten third.

Travis Osborne: The forgotten third. I do think – I mean, this is a very hot topic in, in not only, you know, media, but plastic surgery, and just all around like – and people need to raise awareness, they need to be mindful of these things, and I do appreciate the fact that you took a few minutes, in the beginning, to address nomenclature in the way that we – we talk about these – these surgeries in these patients. So definitely think this would be a good one to run back again.

Dr. Sean Arredondo: Yeah.

Travis Osborne: I do have a quote of the day and I wanted to share it with you. It’s from Dwayne “The Rock” Johnson.

Dr. Johnny Franco: Oh

Dr. Adam Weinfeld: Oh.

Dr. Chris Micallef: Oh.

Dr. Sean Arredondo: Oh.

Travis Osborne: I don’t know if anybody saw me give the people’s eyebrows, but our viewer base, I’m guessing, did not get that joke, but it’s from Dwayne Johnson. Success isn’t always about greatness. It’s about consistency. Consistent hard work leads to success. Greatness will come.

Dr. Johnny Franco: No, I agree. Love it. I want to thank Dr. Weinfeld for leading today. This is – I think, a super complex, evolving, and hot topic, and I think it’s something that definitely needs more updates. Hopefully, he’ll lead a few more discussions.

Dr. Adam Weinfeld: Oh, yeah, yeah. We’ll break it up into thirds.

Dr. Johnny Franco: We only scratched the surface of literary works.

Dr. Chris Micallef: Of course, yeah.

Dr. Johnny Franco: Would you like to take us home?

Dr. Adam Weinfeld: Yeah. Well, thanks for joining us on plastic surgery untold. What does we got coming up in the next four sessions, or should we leave that as a cliffhanger?

Dr. Johnny Franco: We – we actually are breaking down a segment. We’ve highlighted this before, but a little Med Spa minute if you will. We’ve never done a little rapid fire, you know, so that’s coming up next. So I think super exciting, and another special guest. You guys won’t have to deal with celebrities, so you’re welcome.

Travis Osborne: I’m out of here y’all.

Dr. Sean Arredondo: Alright.

Dr. Chris Micallef: See you. Bye, bye.

Dr. Adam Weinfeld: Bye.

Travis Osborne: See you.

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