FPSAM - Roundtable 2022 - 11

those characteristics and as soon I started shaving
down the bone came off too easily so I did less. I think
in general we are over reducing to get excellent aesthetic
results and I have seen it in some outside of the
Some surgeons outside of the country are removing
a centimeter, centimeter and a half inferior ramus/
angle or body of the mandible-what are the outcomes
in 10, 20 or 40 years? We don't have those outcomes
(fractures, loss of dentition) to know how overaggressive
reduction can affect our patients in the future.
It always makes me think, when do we know if
we are doing too much?
Dr. Spiegel: That is an excellent point.
Dr. Rodman: It will be like the rhinoplasties of the
80s. In 20 years, we will know, oh, that was too much.
Dr. Garcia: Yes. Unfortunately.
Dr. Spiegel: We are getting close to the end. Let's go
around and talk about two things. One is, what are
the other procedures you recommend? What have
we not discussed that you think everybody needs to
be doing? What do you not do together? What
would you not do together? Let's go reverse alphabetical
order this time. Dr. Schechter?
Dr. Schechter: I think we did talk about lip augmentation,
fillers, and again, the nonsurgical treatment.
Whether it's autologous fat, whether it's HAs,
whether it's what have you. Other face fillers. Then the
nonmedical interventions. Hair, makeup, teeth, and so
forth, which I think can be very important. We did not
discuss speech. Speech and mannerisms are other
features for individuals who are very much interested
in the social transition. I think those also can be very
important. Lastly, the most provocative issue I think
that we have now, and likely impacts the role of facial
surgery, especially being in Boston is the use of pubertal
suppression and gender analogs. Ultimately,
what are we going to see down the road. Will there be
less surgery? Will the GNRH analogs be used more
Dr. Spiegel: Excellent. Dr. Rodman?
Dr. Rodman: I second the idea of some of the nonsurgical
things that patients can do, although I find I
have a hard time convincing people of this. I've had a
lot of patients say, ''I want to look like you.'' I put a lot
of money into this this look! (laughs). There is a lot of
Botox, fillers, hair, brows, and lashes. I mean, I get all
that done. Nails and skin care. I mean, there's a lot of
money that goes into looking female. I have a lot of
patients say, ''well, I don't want to have to do that for
ยช 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
the rest of my life.'' Or I don't want to get lip filler for
the rest of my life. Well, neither do I. But I do. I think
all that stuff really matters, but I find it a hard sell.
The only other thing I would add is that I have
sometimes done surgically ear reduction or earlobe
reduction. I have some patients whojust have these big
floppy earlobes or floppy floppy ears.
The thing that I will not do together, if I have an
older patient, I try to stage the surgery. I will do, for
instance, forehead, nose, chin, and, if they need it,
Adam's apple in one. Maybe fat grafting, then if they
need a facelift, I will usually do facelift. Arthroplasty
and then lip lift in a second surgery, but any of those
things that could be done together. Except not the facelift.
Especially if we are doing anything in the lower
base, it just swells so much. I feel like it is countering
the lift and the tightness I am trying to get.
Dr. Spiegel: Dr. Knott?
Dr. Knott: Thank you, Jeff. I completely agree with
Regina's comments. For my patients over age 45 or so,
I'll stage the facelift and the blepharoplasty. What
Laura said as well, I completely agree with. I think one
topic that we have not really discussed, which is going
to be really what we touched on, is revisions for patients
who want revision surgery. I find those can be
quite challenging because you just do not know what
you are going to find until you open it up, so to speak,
and particularly noses. Doing a revision rhinoplasty on
a patient with perhaps a rib graft to harvest cartilage, I
find that requires a whole degree of focus. Very discrete
surgery, and I have a hard time doing that in
addition to everything else in one setting with adequate
focus attention to detail, and so I tend to do that
separately as well.
Dr. Spiegel: Excellent. Dr. Garcia, what won't you
do together, and what else do you think needs to be
Dr. Garcia: I agree with Regina, that any soft tissue
tightening I separate from most of the bony work depending
on their age and their own tissue laxity. I still
do voice feminization separately and will only pair it
with the trach shave at the same time. I do advice that
the voice feminization be performed last mostly due to
the risk of releasing the web inadvertently during intubation.
Lastly, the other thing I would like mention is
skin rejuvenation.
Again, it is very costly to maintain. So even many cis
women, we get treatments on the skin like three times a
year. Again, the expectation for many transwomen is to
wake up and look completely natural. I heard this many
sentiment many times. I do tell my patients that I use
thick creams and retinols at night, wear sunscreen daily.
I always wear mascara on however sometimes I'll

FPSAM - Roundtable 2022

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