FPSAM - Roundtable 2022 - 10

EXPERT PANEL DISCUSSION
Particularly the patients who have less flaring, so
there is less of that 90 angle. I think it's extremely
hard to get low. Then if you break through that fascia,
there is always that venous bleeder there. Once you get
there, I think it's torture. I think it's the hardest to
visualize. In terms of with trainees especially, it's
having to trust them. It's very hard to see down there
and I find that that's the hardest access.
Dr. Spiegel: I agree with all that. Dr. Knott,
thoughts on what is your biggest pain with jaw
surgery?
Dr. Knott: I mean, it's a hassle to always work
around the mental nerve. I think it's a pain for the
patients. That persistent numbness they get afterwards
is a hassle for them. We have begun doing a
soft tissue work at the pogonion to try to narrow the
soft tissue pad over the jaw. No matter how sharp I
make the bone, I can't make a nice tight jaw unless I
do soft tissue work there. That leads to a little bit
spasming of the metallis, which is a hassle also for the
patients, and can be a little bit persistent. I'd say the
vertical height of the jaw for my trans females with a
very tall jaw, I'd like to shorten it a little bit along the
whole length, and I find that to be challenging to do
that transorally.
Dr. Spiegel: Dr. Rodman. Dr. Schechter?
Dr. Rodman: I agree, I hate the back of the jaw.
I probably talk to more patients out of it than into it
now. Mostly because I do many jaw implants in cis
women, they want some definition in the jaw. They
want length, not width. I think many women, trans
women come and they think they are supposed to
have jaw reduction when really they do not have that
much flair or they do not have much width. I do have
some patients that they come in and agree that we
need to do a reduction. It can be difficult. The other
thing I find difficult is if I do the triple osteotomy T
genioplasty there is always a step off. Just burring
down that step off where the bones come in, it's right
under the nerve. I just have not found a great instrument.
I use an electronic rasp, but it takes just not
great. I just feel like it's too much time doing trying to
get it smooth.
Dr. Schechter: I agree with what has been said
and with Dr. Alperovich. Also, treatment of the
masseter I think is helpful whether surgical or with
neuromodulation.
Dr. Spiegel: Absolutely agree. Are people reducing
the masseter by surgically debulking it? Or just using
a neuromodulator afterward? Dr. Schechter,
does your group ever surgically reduce themasseter?
10
Dr. Schechter: I had done it always with the use of
Botox and neuromodulators. My colleague does direct
surgical reduction of the masseter.
Dr. Spiegel: Excellent. I will chime in on all of this.
Shaping the soft tissue at the front is something I
have been doing playing on and off with for 20
years. I'll do it a lot of times, sometimes we'll put a
suture in to medialize the soft tissues. What Dr.
Knott mentioned is indeed the challenge.
If the mental muscle does not connect to the bone
appropriately and meets itself too much, you get a
very narrowed, flaring, rounded chin, which requires
postoperative botulinum toxin for the long
term unless you're going to go back later and release
it. For me, my difficult point with jaw surgery
is prolonged swelling. I find that everything I do
looks good in 2 weeks except the jaw which takes a
month or longer before people really look like
anything beneficial has happened.
It's closer to a year before I'll be happy with how
it looks just because of prolonged edema. We have
been experimenting again with radiofrequency energy
there both in the chin and in wrapping all these
tissues around the jaw. We are finding that helps to
shrink wrap things and reduce edema. That has
been a helpful adjunct for us.
I think what was said about the angle of the
mandible, what's an important thing for us all to
talk about, is that it is the lateral flare that's the
masculine feature. Women really do have a similar
angle. When people cut off the back, they are not
really creating an anatomically feminine shape.
They are getting rid of that lateral flare. It ends
up with sort of an abnormal looking jawline. Dr.
Rodman mentioned that she will add jaw implants
for women because people like this ''snatched''
jawline as people say now with a more defined
mandible. We are taking that away. We are really
eliminating that. It's not so much the angle shape as
it is the lateral projection. Education is an important
part, for all of us. I am sure you are frustrated
by misinformation or patient information, which
might be contrary to what you want people to be
thinking about.
Dr. Garcia: Can I add one thing? One thing that we
never discuss, and this is something that I've been
meaning to discuss: what are the future outcomes in
very aggressively reduced mandibles when the patient
is 60 years old? I treat many facial fractures still and
whenever I see some of the 60- and 70-year-old
mandibles, the bone stock of them is so much more
depleted than that of somebody who is 30 years old.
Even in some transgender patients who are 30 and
edentulous or have poor dentition, the mandible can
look decades older. I recently had a patient who had
ª 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
FPSAM - Roundtable 2022

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