FPSAM - Roundtable 2022 - 2

EXPERT PANEL DISCUSSION
distractions, and frontal orbital advancements when I
first got into practice. I operated on the jaw of a
transgender woman. She told her friend, who told her
friends, who told their friends. And that took over my
practice over the past few years. So now I do a lot of
facial feminization. It's predominantly what I do.
Dr. Schechter: Thanks, Jeffrey. Appreciate the opportunity.My
name is Loren Schechter. I ama professor
of surgery and director of gender affirmation surgery at
Rush University Medical Center. I joined the full-time
faculty here back in April. Before that, I was in private
practice. And I have been performing gender affirming
and gender confirming surgeries for 22-23 years in
practice. Now, it is about 90% of what I do. I serve as
treasurer on the executive committee of WPATH. We
started our fellowship in 2017 here in Chicago. It is an
honor and a privilege to be here with you
Dr. Spiegel: Thank you all for being here. I'd like to
start with the ''desert island'' question. To feminize
a face, if you have only one procedure you can do,
what are you going to do? One facial plastics procedure
to help confirm someone's feminine gender
what is your go-to choice?
Michael Alperovich, I see you nodding. Do you
want to jump on that?
Dr. Alperovich: Oh, I like these questions. This was
not what I expected, but this is great. I was just talking
about this with a few people yesterday. I think you can
have a good nose. You can have a bad nose. But I feel
like, especially now with COVID-19, maybe that is not
as much anymore, but I felt like the forehead area and
the glabellar area for me are something that I think
most telling, and certainly for patients when they talk
about being misgendered or having issues in terms of
first-time facial interactions, I find that just this, for
me, has been an extremely powerful one, lowering the
hairline, softening the brow, the frontal sinus setback,
the brow lift, and the soft tissue work.
I think that has made the biggest difference. And I
think, for me, if you had to do one thing and you could
only do one thing, obviously, it depends per patient.
But I find that that, especially in the times of COVID19,
has been the most powerful.
Dr. Spiegel: All right, and the follow-up question is,
what is your second area? Now you get two. It is an
expanded desert island.
Dr. Alperovich: I think in that case, it really does
depend on the patient's anatomy. I think more just
because of the complexity and the artistry associated
with rhinoplasty, I would probably say rhinoplasty.
I think it is something that is much more individualized.
And I think it can frame the face and help be the
2
keystone of how you view a person. In many ways, I
have probably put that as the second.
Dr. Spiegel: OK. Dr. Rodman, please give us some
thoughts on that, too.
Dr. Rodman: Sure, I agree 100%, forehead is most
important. We call it the forehead package, which is
hairline advancement, brow lift, orbital rim reduction,
and brow bossing reduction. I have had a few patients
who did not really need it, but probably less than 5%. I
think even if they do not need a huge setback, the
forehead make big difference.
And this has been supported with some data as well,
both by Dr. Spiegel, and Drs. Knott and Seth just
published an article about facial analysis that showed
that forehead was one of the most important, or one of
the biggest differences in shape and volume between
men and women. Plus, I just love to do it! I love it. It is
my favorite procedure in the whole world because they
look different right away. On the table, you can see
them meld into a more female shape. For #2, I would
say my second is probably cheeks.
I tell patients, it is not going to be a transformative
procedure. But it is like ''icing on the cake''. It does a
really nice job, I think, softening the midface. I use fat
grafting, but whether you use fat grafting or cheek implants,
I do not know that it really matters. But I think it
is just a nice, like I said, icing on the cake or kind of a
nice secondary feature. And part of the reason I think this
is also because, we know injectables in ciswomen are a
billion, with a B, dollar industry. Everybody wants
cheeks! everybody loves to have cheeks, especially in
the submalar, malar fat pad.
Dr. Garcia: I think it is the most powerful. Dr. Spiegel
published a study in 2011 using computer-simulated
changes in a person where the upper third of the face,
midface and lower face were altered and then the simulations
were present to students. From this it was
found that the most powerfully feminizing procedure
was the forehead feminization. The other procedure
that is rather feminizing is the Adam's apple reduction
''trach shave'' as most people call it. However, there
are limitations due to anatomy so a complete flat neck is
not guaranteed. Additionally, if you look at men and
they do not have one, then it is completely fine. If you
look at a woman and they have an actual protuberance,
then that is going to stand out. Men without a protuberance,
don't cause a second look but a woman with a
protuberance will cause a second look. I think the
Adam's apple reduction a very powerful procedure to
reduce a masculine feature.
Dr. Spiegel: I will contribute to this, that I did do
that article about 12 years ago and I think what
everybody said makes sense. Masks have certainly
ยช 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.

FPSAM - Roundtable 2022

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