FPSAM - Roundtable 2022 - 9

That becomes a very intimidating wound that you
have created, both to close and expect to heal. Dr.
Dr. Alperovich: I think of whether it's covered by
insurance or whether it's out of pocket, I think they are
all essential. I treat these all like any other cosmetic
patient, where I think the threshold for complications
is low. I have just tried to be conservative. I'll do the
rhino first, and then come back and do the lip lift, or do
the lip lift and then come back and do the rhino afterward.
I haven't put them together. I've read your
work and others, in terms of how it can be safely done.
Up to now, I have always staged them.
Dr. Schechter: We are typically seeing people for a
number of procedures above the neck and procedures
below the neck. We have the advantage, or a little bit
of luxury of having various stages where we can
combine some of these procedures. I am personally
reluctant to do the lip lift in association with open
rhinoplasty, and certainly would be concerned adding
the alar base resection.
Dr. Knott: I do it all at the same time. I don't stage it.
I do the alar base production first. I close that intranasally
before I close my lip-lift incision, so that way I can
distribute the skin evenly across that tissue plane. I use
the same incision for my open rhinoplasty that I use for
my lip lift. I don't have double incision and I have been
pleased with that. I think you have to be a little bit
cognizant of the plane you're in so you are not too thin
on the skin when you are raising it. I think that is a wellvascularized
flap and it is quite robust.
Dr.Spiegel:Dr.Rodman,howabout for you in Texas?
Staged, together, alar with rhinoplasty, and lip lift?
Dr. Rodman: Often, together, but some of them I do
stage. My algorithm now depends on how unstable the
rhinoplasty is. If they have a significant caudal-septal
deviation that I need to repair, or they are going to need a
lot of really, anything that is going to be really destabilizing,
like a big septoplasty, I'll usually encourage them
to stage the lip lift. I had one patient where it was a really
difficult rhino. I did a lip lift and then it ended up shifting.
Now she has nostril asymmetry and I am trying to deal
with that. My recency bias is that that's not a good idea.
It probably would be fine. But now in general, if it's a
relatively simple nose-dorsum rhinoplasty, I do it at the
same time, and I'll do the alar base at the same time. If I
think it's at all going to be complicated, I stage. When I
do it at the same time, I do it through one incision. I just
put it down low, at the bottom of the columella. Then if I
do it staged, or if I think it can be complicated, I do it
staged. I just do the lip lift in the office at a later date.
ยช 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
Dr. Spiegel: I do it all at once also, like Dr. Knott
was saying, we will do the alar base with the lip lift
and the rhinoplasty simultaneously, in one large
incision, where the upper part of the incision extends
out onto the alar base as much as I need to.
You do end up with a trifurcate point when you do
that, but I found it heals nicely and has not been
an issue. I will use two incisions and the reason
Idotwo incisionsisbecause what we foundisthat
the blood supply to that lower segment is not
We did write that up, but the main reason I'll do
that is, I have a suspicion, I am never 100% certain
if I am going to need to do anything to the columellar
skin. There are patients for whom I will trim
off some columellar skin if I think that's going to
contribute to a hanging columellar or not contract
up nicely after we have rotated or deprojected.
I don't want to do that trim at the base because the
skin there is very thick and you are pulling down
the medial skin over the medial crow's feet.
Dr. Alperovich: Dr. Spiegel and Dr. Knott, Do you
feel the tension of the inferior pull from the lip lift
if you had rotated the tip, is of concern with your
Dr. Spiegel: That's a great question. I will take that
one. Usually, pulling down the base of the columellar
for me helps my rhinoplasty result. If needed,
you can put a deep stitch to the nasal spine and
then you will not get any rotation or change of
There are many things we can talk about in facial
feminization and gender confirming surgery of the
face because it encompasses almost everything.
Looking younger makes you look more feminine
looking, and more attractive makes you look more
feminine and obviously, the reverse, making you
look more feminine looks more attractive and more
youthful. They all relate together probably from an
evolutionary point of view.
Let us skip ahead to the lower face. The chin and
jaw. Instead of asking about what you expect me to
ask about, I want to know this. What is your pain
point on the chin and jaw? What is the hardest
thing about it? What is the thing you most wish we
had a solution for? Dr. Alperovich can start.
Dr. Alperovich: I don't know if it's just me, but the
gonial angle reduction is, for me, the least favorite
portion of the operation. I have done burring, I have
done saw, I tried lighted Minnesota retractors. I have
tried to use right angle burs and right angle saws. It
would be for me to be able to have something that has
better access and effectiveness.

FPSAM - Roundtable 2022

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FPSAM - Roundtable 2022 - i
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