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BackTable / ENT / Podcast / Transcript #148
Podcast Transcript: Facial Masculinization in Gender Affirming Care
with Dr. P. Daniel Knott and Dr. Rahul Seth
In this episode, Dr. Gopi Shah discusses facial masculinization surgery with facial plastic surgeons Dr. P. Daniel Knott of UCSF and Dr. Rahul Seth of Golden State Plastic Surgery. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Caring for the Whole Patient: Understanding & Using Expansive Gender Terminology
(2) The Importance of Facial Analysis in Gender-Affirming Surgery
(3) How Facial Masculinization Surgery Fits in Gender-Affirming Care
(4) Preparing for Facial Masculinization Surgery
(5) Non-Surgical Options for Facial Masculinization
(6) Surgical Options for Facial Masculinization
(7) Expert Strategies for Augmentation Rhinoplasty
(8) Expert Strategies for Buccal Fat Removal
(9) Expert Strategies for Mandible Augmentation, Brow Implants, & Adam’s Apple Augmentation
(10) The Role of Hair in Gender-Affirming Care
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[Dr. Gopi Shah]
This week on the BackTable podcast.
[Dr. Rahul Seth]
I think the other big pearl is that remembering that these are permanent changes, surgery is permanent. Really having what you're planning and what the patient is planning to line up. These are pretty advanced surgeries that we're talking about, so that individuals have appropriate training and understanding of what they're getting into is really paramount.
[Dr. Gopi Shah]
Hello, everybody and welcome to the BackTable ENT podcast. Our goal is to bring you the best and brightest from our field of otolaryngology. We hope that you can take something from our show and apply it to your practice. My name is Gopi Shah and I'm a pediatric ENT and my guests today are two highly experienced otolaryngologists in gender-affirming care. We have Dr. Daniel Knott and Dr. Rahul Seth.
We have two parts for this podcast. Part one will be focused on facial masculinization for gender-affirming care. Part two will be to discuss the impact ENTs have in gender-affirming care. To introduce my guests, we have Dr. Daniel Knott. He is a professor in the Department of Otolaryngology Head, Neck Surgery at the University of California, San Francisco, UCSF, where he is the Director of Facial Plastic Aesthetic and Reconstructive Surgery.
We also have Dr. Rahul Seth. He is a facial plastic and reconstructive surgeon practicing at Golden State Dermatology and Plastic Surgery in San Francisco. He is also volunteer faculty in otolaryngology at UCSF, where he was an associate professor for nine years before. Welcome to the show, guys. How are you?
[Dr. Rahul Seth]
Great. Thank you so much for having us.
[Dr. Daniel Knott]
Good morning, Gopi. Thank you so much.
[Dr. Gopi Shah]
Good morning. Thank you both for coming on. As you know, I'm a huge fan of your work. I've read they have two articles in ENTtoday, I believe, September 2020 and August 2023 on gender-affirming care. For any of our listeners out there, they're great articles that really push the envelope in terms of advocacy and education in our field. Thank you guys for coming on.
Today we're going to talk about facial masculinization. I have to say, I didn't realize you guys had a recent chapter in operative techniques in otolaryngology specific to this in 2023. Congratulations on that publication. It was super helpful because there isn't a lot out there when it comes to facial masculinization. There is definitely more on facial feminization. Before we get started, can you tell us a little bit about yourself and your practice? Rahul, do you want to go first?
[Dr. Rahul Seth]
Yes. First of all, thank you so much for talking about this topic that there isn't that much out there on. It's certain we can go into more details of that later, I'm sure, but really appreciate the opportunity. I was a full-time faculty member at UCSF for about nine plus years and then made a transition into private practice world and have been performing gender-affirming facial surgery. Actually, Dr. Knott and I started doing that together probably about seven, eight years ago. We both continue to do that as a big part of our practices.
[Dr. Daniel Knott]
Yes. Thank you so much. I want to repeat Dr. Seth's appreciation for inviting us onto your podcast series. I think there is really these areas of conflict in our society right now, in both public and private conflict. It's unfortunate that this has carried off into such a divisive area and has made this topic of facial feminization, masculinization, such a challenging one for people to navigate.
State by state, different countries have different approaches politically, economically, and the way that they structure their healthcare system. This is an area that I think is in tremendous evolution. I think by agitating and advocating for our patients, we will help them recognize their own individual personal journeys. As Dr. Seth said, he and I were partners for nine years at UCSF. We focused in on microvascular surgery, rhinoplasty, aging face surgery, reconstruction of Mohs defects, as well as facial nerve paralysis treatment, so a broad practice covering most aspects of facial plastic surgery. It was our pleasure to work and focus in on a little bit more on gender affirmation topics.
(1) Caring for the Whole Patient: Understanding & Using Expansive Gender Terminology
[Dr. Gopi Shah]
Tell us a little bit about the gender affirming care clinic or practice. Is it multidisciplinary? Who are your partners? Who's part of it?
[Dr. Daniel Knott]
UCSF was one of the leaders in developing a center of excellence for gender affirming care at the university. Dr. Madeline Deutsch is the director of our clinic, UCSF, and she is a transgender female, and as such, really has been a very strong voice to advocate for the patients and establish a clinic and outreach to all of the relevant subspecialties around it, plastics, facial plastics, laryngology, voice swallowing, to try to help her patients access the best care. By advocating, she has been able to gain more funding from the university, hire more navigators, and then a lot of her focus has been on education, try to help the other healthcare providers understand the special needs of this population.
[Dr. Gopi Shah]
The education piece, I think, is such an important piece because it is a specific population, yet it crosses over multiple specialties and subspecialties. Whether you are hyper-focused on that subspecialty, if you're doing gender affirming surgery, for example, for the voice or not, if you're part of the healthcare system, you're going to have these patients come in. I think you're right. The more we learn and understand, the better we're going to be able to help our patients.
Let's just do a quick overview of some terminology. When we say cisgender versus transgender, gender fluid, non-binary, can we just do a quick run through that?
[Dr. Rahul Seth]
Yes. This is a new vocabulary for a lot of individuals in practice. Sex, by definition, is something that a individual is assigned at birth. Gender is how an individual interacts with society and how they present with society. That's typically characterized as man, woman, boy, girl, sex being male, female, or intersex. Somebody who is cisgender has the same sex at birth and presentation to society. Somebody who's transgender has a difference between the sex assigned at birth and the way that they're presenting to society and the way that they feel about themselves.
For instance, a trans woman is somebody who is sex assigned at birth as male, but has identified in living life and lived life as a woman. There's a few other nomenclatures out there, such as gender diverse, intersex, non-binary. It can get confusing. One of the umbrella terms that we use, especially in our writings, is trans and gender diverse. We abbreviate that as TGD. That seems to be, after talking to numerous experts in the field, one of the most encompassing and appropriate terms to use, although terminology does continue to change.
[Dr. Daniel Knott]
I think it's important, Gopi, to recognize that gender is not necessarily a fixed point on a compass or a spectrum. Myself, when I was early in my career, I believed in a relatively naive way that there was two points, male and female, or perhaps gay, homosexual, somewhere in between or a different direction. Really, there's this broad spectrum of identifications. Really, it's for the individual to decide what he, she, they are most comfortable with and where they want their position on the spectrum to be. As Dr. Seth says, gender expansive terminology, I just think, allows one to identify one's own best position in the spectrum.
[Dr. Gopi Shah]
When your patients come in, do you usually start it off with, "What pronoun do you prefer?" When they check in to the clinic, that's something that the patient can update or define as they would like?
[Dr. Daniel Knott]
It's fascinating taking care of patients, every age group, because you have a very different set of pronouns and belief systems and language vocabularies, Dr. Seth says, for the older patients than for the younger. Our most important goal is to make our patients feel comfortable when they come in to see us. That means finding out what their preferred terminology is, and then being consistent in using that thereafter. I find that our patients are really forgiving and understanding about that, as long as they realize that you're trying to make them comfortable and value and respect their own identification.
[Dr. Rahul Seth]
Clinic medical records have adopted that ability as well, in having a legal name, the name that they wish to be called, the pronouns of preference as well. Part of the intake process takes care of all of that. Nonetheless, it's important, and I find it as a nice opener to the patient when discussing to say, "How would you like to be called?" or, "How would you like me to refer to you?" That ends up opening up the conversation and also just really understanding what may not have gotten transferred through paperwork and medical records, and be able to show up right there for you to continue to utilize. It's really helpful and builds this trust with the patient.
[Dr. Gopi Shah]
I would imagine that it's pretty routine and important in the clinic that is specific, when it is your gender, the patients that come in for gender affirming care. What about in your other non-- the patient isn't there necessarily for gender affirming care. How often do you find that you clarify pronoun in that setting?
[Dr. Daniel Knott]
That's a great question.
[Dr. Gopi Shah]
Because most of us, that's where we're going to come across the situation. It's not going to happen as common because we may not have a high volume, but I guarantee you we're all going to have a patient that's transgender, gender diverse, whether it's for sore throat, ear pain, a sinus complication, a head, neck cancer, you name it.
[Dr. Daniel Knott]
I think it's a really important topic, Gopi, because if you look at the population of baby boomers, perhaps 1% or 2% were gender expansive, gay, lesbian, and with each successive generation, the number of individuals that do claim that they belong to the gay, lesbian, transgender, intersex categories has expanded now to the current generation that's on the order of 20% even.
I think that being open to one's pronouns, particularly amongst the younger population, because the younger kids, they get this and they're very accepting and open and understanding. It's the older generations, I think, that have a much more difficult time understanding that we don't live in a bipolar world. I completely agree with you that we are all going to be taking care of transgender or gender expansive individuals in our practices and we need to be sensitive to their needs.
[Dr. Rahul Seth]
Just as Dr. Knott was stating, you don't have to be a trans care specialist to see trans and gender diverse patients in your clinic. As you're mentioning, somebody could have an ear infection and be seeing you, and still using the proper terminology is very important. For all practitioners in our field, a great message is to really use the questionnaires appropriately to ask patients how they want to be called and refer to patients by correct pronouns. It helps to really start the care process with them.
I think there was a survey that went around that asked about challenging situations for transgender and diverse patients in medical settings and acceptance. It's a third of patients who have had really challenging scenarios where they haven't been able to fulfill the care that is as needed. That may not be for obtaining care related to their gender. It could be anything. We don't want to turn away a third of our patients just because of these issues. It's really important for general health and for society and an impact on society to adopt these understandings.
(2) The Importance of Facial Analysis in Gender-Affirming Surgery
[Dr. Gopi Shah]
Yes, you're right. The trust, the relationship starts with that right at the door. If we're not able to appreciate how the patient identifies, that's the first thing that's going to go. That's where the patient-physician relationship can start many times. In terms of an intro into facial analysis, can you provide an overview of sex-related facial characteristics that are masculine and feminine just to set the stage for facial analysis?
[Dr. Rahul Seth]
Yes, facial characteristics that are sex-related is a really important topic and facial analysis really sets the tone for everything thereafter when it comes to surgery. If the analysis is not done correctly, then everything thereafter that follows is not going to quite work out. Having that fundamental understanding of facial analysis between what's masculine and feminine is key.
What we did through a research study with the University of Calgary, where there's experts in this, took us about two or three years to put this together, but we looked at 3D facial scans of about 1,600 patients. These scans were really detailed. I'm talking 55,000 points per facial scan. With that and the number of having about 1,600 of them, we compared the, in a very, very high defined mathematical ability, compared feminine faces with masculine faces. We're able to apply statistical analysis in a way that really hadn't been done before to understand these differences.
Our publication, I welcome anybody to look at it. It's on open access and read the main facial plastic surgery journal, which is Facial Plastic Surgery and Aesthetic Medicine. It came out in 2022. Bannister is the first author of our paper. Basically what it showed was the big differences. The most statistically relevant difference is in between the eyes or the area of the glabella. At this area, the brow prominence, the nasofrontal or root of nose prominence, that area is well defined or statistically defined to be the most statistically different when it comes to bony and soft tissue structure or surface analysis.
Dr. Spiegel, who's one of the, really, pioneers of this field, Jeffrey Spiegel in Boston, he did a similar study years ago where he looked at perception-based analysis and also had found the same thing. In our study, we were really able to put data and mathematics behind the statistics to show this and to show that insurance companies and to show that patients should have a change to this area if it fits with the face.
The other areas are the nose and the nasal prominence, the eyes and how wide open or what percentage of the face is occupied by the eyes and the orbits, the cheeks and how full they are, the overall shape of the cheek being more square in the masculine face, the jaw being wider and the chin being wider in the masculine face, and the thyroid cartilage being more prominent in the masculine face as well. There's many other sub analysis details that we could go into for a while, but it's a fascinating field that has a distinct application to surgery and analyzing the face.
[Dr. Daniel Knott]
Gopi, we talk about nasal analysis in rhinoplasties and trying to figure out length and rotation and projection and many of these things. Perhaps there's no area that is as detailed, as Dr. Seth points out, as for the entire face to be analyzed and to think about what things you can change and how you would change them, and could you change them in a way that would heal well, will look nice and natural? All of the surgical decision-making really is defined by your analysis that, again, Dr. Seth talked about.
[Dr. Gopi Shah]
On that 3D study with all of those 55,000 points for each image or each picture, were there certain measurements? Was it, had the program measure certain distances, angles? When I think of facial analysis and facial plastic, sorry, I'm coming from a peds world, so there's such a gap in my knowledge about that, but I think of the photos, the front-facing photo, the side, the base, when we look at the nose. Are those some of the similar images that the 3D-- or was it the 3D model? How are those measurements made? What was it looking at?
[Dr. Rahul Seth]
Yes, part of my mission is to try to disrupt the traditional way of looking at the face when it comes to angles and measurements traditionally. That can take us so far, but there's really so much more to it, and we know this through many of our own experiences and through many studies. You can't apply all angles and all measurements to all faces. Race, ethnicity, has a lot to do with it as well.
From an anthropologic, biologic analysis, when we look at faces in real life, they're three-dimensional. The nose relates to the cheeks in a certain way, it relates to the brow in a certain way, everything fits together. If we think about faces in general, there's certain face structures. We typically see an eye shape that goes with a cheek shape and our brains automatically know this.
What the study did was, does look at angles and measurements, but it also goes beyond that and uses a science called geometric morphometrics. I think that is the future of the way we look at faces. Geometric morphometrics basically divides the face or divides a body into size and shape, as these are the two fundamental things. Sizes can differ. I can demonstrate that here by saying that, you have a baseball and a basketball. They're both, in shape, similar, but in size they're very different. Then we can take a football and the basketball. The volume or overall size of those would be roughly the same, but the shape is completely different.
The study takes size and shape, which put together is form, which is the being that we're seeing and performs the analysis in that way. Although we do provide information on millimeters and distances and curvatures and angles, it's really understanding the face in a very different way and approach and one that we can apply some mathematical analysis in a new way. Even the application of artificial intelligence, because many of the programming that we use for the study is AI based. Hopefully that helps to answer.
[Dr. Gopi Shah]
No, it's super helpful. Could this program also take into account race and ethnicity as well in this analysis?
[Dr. Rahul Seth]
Yes. Really interesting question. In the analysis, we only used individuals who identified as Caucasian. The reason for that was deliberate because we wanted to have a population that we didn't have to have that as a confounding variable. We also have subset analysis, not in the paper, but unpublished, and hopefully we'll provide some of that information.
What we found by looking at that is that it doesn't really matter as much. What matters more is how the facial features actually relate to themselves and identified race and ethnicity almost cancels out. If you have a cheek structure, you would expect a certain nose to appear with that. If you have a certain brow structure, it's more that we should have a certain nose structure that appears with it.
That's a really great way of looking at faces and individuals and saying that, "You know what, number one, we're more similar than we think. Number two, it's more about how things come together as a total faces than our backgrounds." Because ultimately, many of us, as we understand with things with 23andMe, we have a lot of mixed background. When we say that we are a certain race, how accurate really is that? In upcoming work, we'll try to also disrupt that application to the face.
(3) How Facial Masculinization Surgery Fits in Gender-Affirming Care
[Dr. Gopi Shah]
Getting more focused into our topic for today, specific to facial masculinization, what exactly does this entail? What are patients looking for? How do they present to you?
[Dr. Daniel Knott]
Most of the time, with our much more commonly performed facial feminization, it's the onset of puberty with the hormones that causes this deviation of the face of the masculine away from what would be commonly thought of as the default, which is the feminine face. As Dr. Seth mentions, with the size and the shape of the face, when we're feminizing a masculine face, it requires both discrete changes to the shape, but also trying to reduce the overall size.
In terms of facial masculinization, we're doing the exact opposite. You're trying to both enlarge the size and to adjust the shape. It requires a very different subset of skills and approaches that you would apply to a female face that you're masculinizing than the opposite.
[Dr. Rahul Seth]
Really, interestingly, we do feminization surgery so much more often than masculinizing surgery. The reasons for that is, I think, a couple. Number one is, I don't think that there's as much knowledge out there that there is potential for that surgery and what it can do in a safe way. As Dr. Knott was talking about, with the onset of puberty and enlargement of the face with testosterone and the onset of masculine features, those are often bone changes. When we want to feminize the face, we have to reduce the bone. Hormone therapy will work a ways for the soft tissues, skin, fat distribution, but it won't really change the bone. However, when masculinizing hormones are given, there are not only skin, hair, fat redistribution, but there's also some bone changes that can occur. Hormones are able to induce more masculinizing changes that may be sufficient for the patient's transgender dysphoria and allowing them to present in line. Therefore, masculinizing surgery is, at this time, sought out less frequently.
[Dr. Gopi Shah]
In terms of hormone therapy, testosterone for masculinization, does it matter when the patient has started? Would a patient, a transgender male, have more masculine features if they started hormone therapy, let's say earlier, let's say at age 18, for example, versus the patient that had started at age 40? Would that give them a better aesthetic outcome for masculinization?
[Dr. Daniel Knott]
I think this is a really critically important and controversial topic because the cumulative exposure to hormones, either feminine or masculine, over decades, do leave their traces and their effects on the face. We see very clearly that the sooner the individual starts hormone therapy, the better the result will be. This then bridges into the idea of starting hormone therapy before the individual has gone through puberty, which would, by its very nature, give the best result and may even obviate any of the needs for surgery, because we're performing surgery because of the fact that the cumulative effect of the hormones have led to these soft tissue and bony changes.
There's a window of time around puberty where that could have a very singularly powerful effect. After puberty, the length of time becomes less important, but still, I would think, a general rule would be the sooner, the better when everything else has been put into place and the patients have been appropriately evaluated, supported, and gone through the appropriate processes to make sure that is a good decision.
[Dr. Gopi Shah]
If a patient had started hormone therapy, let's say, whether it's before their natural puberty or let's say it's at any age, the changes that they may have gained from the hormone therapy, let's say they have to stop it for some reason, maybe it's access, cost, et cetera, loss, would any of the changes that they gained-- whether it's soft tissue, bones, skin fat, will that then also revert if they have to stop their hormone therapy?
[Dr. Daniel Knott]
I think part of this depends upon if they've retained their own hormone-producing organs. If someone has undergone, for example, genital surgery, which is the source of the hormones themselves, and if they were to stop, that would certainly have less of an effect than, say, somebody who has retained genitals and, say, stops blocking therapy or things. Then they would lose and some of those changes would revert.
[Dr. Rahul Seth]
There's a lot of growth and knowledge and research in this area. The specifics are really challenging to understand, and certainly interruptions in therapy when it comes to any process can be detrimental. We're no experts in hormone therapy, but at the same time, we do know that the hormones make changes in the face. My anticipation is that given that estrogen therapy does not lead to too much of a change in the bone structure, my anticipation of somebody who was masculinizing and then stopped hormones, I'm not sure if there would be that much of a change.
I think for the opposite, there would be. For a trans woman who was on testosterone blockers and estrogen therapy, if there was a sudden ability for testosterone to have its effect more strongly, you could potentially have changes. Of course, that depends on what age and what interval, whether there's growth that's happening on the face at that certain time. Many variables that do go into it.
Regardless, having a consolidated approach of therapy from a multidisciplinary team, family support, et cetera., like Dr. Knott was saying, all extremely important in that decision making of this very controversial topic.
[Dr. Gopi Shah]
When you have a patient that does come to you who wants more masculinizing features, are there certain questions that are on your checklist for these patients? Are there any surveys that we have for gender-affirming care specific for transgender men?
[Dr. Rahul Seth]
There are no specific questionnaires for transgender men, nor are there specific validated questionnaires for transgender women. There is a questionnaire survey that is coming out, and I'll let Dr. Knott talk about that because he has some good experience with that particular survey and its application in general terms for research.
What we did was we created a survey that was based off of other validated surveys because we knew that there was an urgent need to understand the quality of life outcomes now, and it takes years and lots of funding to develop validated surveys and testing. As surgeons, we are impatient, and so we, by nature, decided to make our own hodgepodge of validated surveys put together.
We actually used that survey, and it looked at quality of life outcomes, happiness or satisfaction of face, and patients' psychosocial levels of distress after surgery, just basically to understand the overall health-related quality of life after surgery. We administered this to our patients. We recently, this last year, published that in Facial Plastic Surgery and Aesthetic Medicine to show the powerful impact of facial surgery to quality of life outcomes to support the surgery.
I will say that was based very much largely on a feminization surgery as we do about currently 30-to-1 feminization to masculinization based on the patients who present to us. I would assume that with good surgery, good surgery technique, the same is applicable to patients who are going for masculinization surgery as it is feminization surgery.
(4) Preparing for Facial Masculinization Surgery
[Dr. Gopi Shah]
When the patient comes to your clinic specific to get more masculinizing features, what's part of your exam, and how do you use the facial analysis framework that we talked about in the intro and apply it when you're wanting to-- for gender-affirming care?
[Dr. Daniel Knott]
The patients that come to see us usually are well along the pathway and I find that they already have a very firm idea of what they're looking for. My goal is to, more or less, be a steward or an agent of change to enable them to realize their goal and their dreams, not to insert myself as this filter to tell them what they should do or shouldn't do. I really try to enable them to lead that charge. I find that images, which don't capture the whole story but that really is our map for what we want to do in surgery. Without taking a really high quality photos, it's really hard to form a really detailed plan. We take both two-dimensional and then I find 3D photos are also extremely helpful.
Then the software tools that we have at our disposal these days, provided by companies like Canfield and others, allow us then to perform these morphing sessions where we sit down with our patients and then they already have photographs, friends, brothers, fathers that they come in with. Then we try to overlay their goals and their ideas onto these morphing software platforms to create the face that they're looking for. Then I decide if I can actually achieve this goal that they have in mind.
[Dr. Rahul Seth]
It's so important to understand what the patient wants, as Dr. Knott said. Then patients often-- and even surgeons, it's hard to visualize what that will all come together and be. There's a lot of anxiety for the patient to say, "Well, I just don't want to look like my family member or not," and to understand what sort of combination and degree of changes to perform to achieve that result.
The preoperative imaging, like Dr. Knott was saying, especially in a three-dimensional way, really allows them to almost see that self-vision that they've always had of the person that they wanted to see in the mirror come alive through one of our consultation sessions.
3D analysis, and going back to what I was mentioning with the 3D study, we actually were able to take some of the same concepts and created a software package that can take somebody's 3D face and we can take an individual's face on scale of masculinity and femininity while keeping the face appearing natural. If the nose is enlarged, so will the brow in a shape overall for the face that is natural appearing. The brow moves a certain direction and so should the nose. The software based on AI algorithms will do that in an automated way.
This is a project that I've been involved with, and I'm a chief medical officer of the group called Deep Surface AI that we just now started pushing this out in clinics. It's, hopefully, going to be able to really help patients in their decision-making process because ultimately, like Dr. Knott was saying, this is their decision and we're stewards of that, but also surgeons in creating faces that are best suited, most natural.
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(5) Non-Surgical Options for Facial Masculinization
[Dr. Gopi Shah]
That's really cool. Rahul, I have "Deep Surface AI" written down here because we do have an innovations channel. Maybe in a little couple of months or something, we can do another podcast more about your innovations journey as well.
Getting back to the topic at hand, I think it's really cool that people will come in with their family members. They come in with their brothers or fathers and say, "Hey, I want some of these features." I think that's really beautiful. In terms of non-surgical options, I think about, "We're going to need to augment some areas." Are there non-surgical options? Do you ever use fillers anywhere like at the glabella or other parts of the face to augment, to square out the jaw? Is that crazy?
[Dr. Daniel Knott]
No, it's not crazy at all. It's one of the tools we have at our armamentarium to use. Typically in my practice, I would use things like fillers and Botox more as an adjunct after surgery to adjust things, tailor, taper, modify. Certainly you can use fillers. One of the interesting things is that, as women age, their faces become more so-called masculine. With jowling, their faces become more square, their brows drop more in a masculine, straight, flat position, and the fat deposition patterns change also in a more masculine way.
As facial plastic surgeons, we're constantly trying to make our patients look more feminine or more youthful. You can apply all those same ideas in a reverse goal of trying to make patients look more masculine. I think understanding the tools and not just simply applying techniques that you would typically do so for your females trying to look more youthful, you could, inadvertently, have the reverse effect. It had to be very intentional of how you do this to achieve the goal of the patient.
[Dr. Rahul Seth]
I would add that, often, many of our patients would have had fillers done before surgery. That was a pathway that provided a couple of things. One, it led them to a pathway of understanding, "Look, I want this to be a permanent change. My lived experience as a woman or man has been for several years or over a year, and I don't want to continue to have to do this, and I would like surgery." It ends up being a way to create change in a non-permanent way. We see more of that before definitive surgery.
[Dr. Gopi Shah]
Other than fillers and Botox, are there any other non-surgical options and, obviously, hormone therapy, which plays a role?
[Dr. Rahul Seth]
Hair-related procedures. Hair removal, so electrolysis, laser hair removal, and then hair transplantation. Those are major aspects, as well, that we see quite a bit of in patients.
(6) Surgical Options for Facial Masculinization
[Dr. Gopi Shah]
In terms of surgical options, so we can just go through them one by one, tell me, what are the surgical options for these patients?
[Dr. Rahul Seth]
For masculinization surgery, the surgical options are, you can basically take feminization surgery, which there's a lot more out there, and put it all in reverse, as Dr. Knott was saying. The things that we want to do are more augmentative. From top to bottom, projecting the brow out more, dropping the actual hair brows down lower, enlarging the nose, giving it a more prominent profile, making the cheek flatter.
The surgeries, so far, that I've mentioned are a reverse brow lift, and an implant to the brow, an augmentation rhinoplasty, which usually involves a rib cartilage graft, a buccal fat removal to flatten out the cheek more, and a augmentation of the mandible, so putting implants onto the jaw itself to making it greater in height and width. Then an augmentation chondrolaryngoplasty. The opposite of a trach shave, where we're reducing the thyroid cartilage or Adam's apple, take a piece of rib and carve it and assemble it into a prominent-appearing Adam's apple, and putting that into a neck incision onto the thyroid cartilage to give a prominence to the Adam's apple. It's a pretty intensive augmentation surgery.
[Dr. Gopi Shah]
When you do surgery, let's say, for the brow projection and dropping the brow, is this endoscopic? Are you making incisions that would also adjust the hairline at the same time? How does that planning work?
[Dr. Rahul Seth]
When it comes to masculinization surgery, I want to be very careful about creating a significant scar on the head because testosterone, as we know, can elicit male pattern baldness. In years to come, I don't want a large coronal scar to become evident. One thing that we came up with and just recently published, you were mentioning an article that just came out in an issue that we were guest editors of an operative techniques in otolaryngology, a chapter on masculinization surgery was that developed an endoscopic approach to it, where just two smaller incisions are created pretty far back behind the hairline, so in case there is recession, then those are still hidden. Using endoscopic technique, going all the way down the forehead bone, just like an endoscopic brow lift, I can get all the way down to the orbits and place the implant in and actually make small percutaneous incisions that are just tiny at the area of the eyebrow to fixate that implant into position. That's my preferred technique.
[Dr. Gopi Shah]
For the implant, do you have to secure it with screws or does it sit in the pocket? Is the implant created ahead of time? I can't imagine there being like a standard implant for this.
[Dr. Rahul Seth]
There's no standard implant that's out there for a brow. We have to make a patient-specific implant. Using a CT of the patient's face, there's multiple companies out there, but using a company that can do computer modeling of the face and create an implant that's custom to the contours of that patient's bone is the best way. The implants that we use are porous polyethylene and those are secured with screw fixation. You want at least two to three screw fixation points so that it doesn't move around. Porous polyethylene also integrates quite well to periosteum and to bone, and in fact, soft tissues, because what we don't want is that implant to be moving around. Keeping a very sterile environment, preventing it from becoming infected and then really fixating it in a way that's not going to create an artificial capsule around it over time, because it's got- micro movement is key.
[Dr. Gopi Shah]
For the implant, when you're doing surgery, do you irrigate with a bunch of like antibiotic irrigation or anything like that for sterility or just regular saline? Any precautions that you take?
[Dr. Rahul Seth]
Yes. Use antibiotic irrigation. I use a combination of vancomycin, gentamicin, antibiotic irrigation where the implant is soaked and then the whole wound is irrigated copiously. Daniel, I think you had something to say.
[Dr. Daniel Knott]
It's important for the listeners to keep in mind that again, surgical masculinization is perhaps, much less developed and much less applied simply because of the power of the hormone therapy. Really, the hormone therapy has to be the front and center for anybody undergoing masculinization and really surgery is reserved much later in the process, as Dr. Seth mentions. You'd hate to do things that can scar someone's face with the changes that would occur with the hormone therapy and simply because it's so much less frequently performed, the techniques and things that Dr. Seth is pioneering is perhaps a little bit less well-developed than the feminization techniques.
[Dr. Gopi Shah]
I would imagine when a patient comes in, do you find that they might need one or two of the augmentations? Maybe the patient might only need the rhinoplasty to help widen the nose or maybe there's just a little bit of- the patient might just need a little bit of the fat removal at the cheek as opposed to- or do you feel that sometimes these patients do need a lot of these? Because I would imagine, like you said, most patients do well with hormone therapy. That's why we don't have as much surgery for masculinization, but maybe there's some patients that started very late or maybe they didn't tolerate the hormones or for whatever reason or maybe there's just some patients that- there might be that small percentage that don't have the same outcomes.
[Dr. Rahul Seth]
Yes. For gender affirming facial surgery in general, it's an a la carte menu. A lot of it is based on that 3D facial morphing and facial analysis and pairing that with the patient's own thoughts, desires, dysphoria. If it's just a buccal fat removal or a jaw augmentation, great. That's what we want to be able to help with. I've done just brow implant or just decrease of the enlargement of the jaw. In fact, I have one patient where the bone grew so much for the jaw on testosterone that although they're a trans man, we're actually reducing the jaw, because the jaw just grew and enlarged too much on testosterone. It's very individualized, custom precision medicine, individually tailored medicine for the patient.
(7) Expert Strategies for Augmentation Rhinoplasty
[Dr. Gopi Shah]
In terms of the rhinoplasty, when you do have to do that, you said you normally take rib graft. Is that for the use for the dorsum and then do you have to do adjustments at the tip, at the ala? How do you put it all together when you make it wider?
[Dr. Daniel Knott]
Yes. Typically, you'd like to use their own septal cartilage, because it's like, septal cartilage is like platinum. It's the best thickness, the best suture holding. It's stiff but not too stiff. It's such a great material for the tip of the nose. Frequently, we'll have to use tip grafts to more project and widen the nose, the tip of the nose. It has to be performed in an overall way that the nose will be harmonious, and even so that way the mid vault's not super wide the tip's under projected or vice versa. To do that, you really do need an abundance of material because essentially, you're sculpting the nose. We'll put in these double spreader grafts, thick grafts along the mid vault to widen the middle vault of the nose. You may do osteotomies to like literally push the nasal bones a little bit wider. Then the dorsal onlay grafting techniques have evolved considerably. Those were challenged by warping in years past. I typically like to use these diced cartilage autografts where we take cartilage, we dice it up into about one millimeter or submillimetric size and form more or less a putty of finely diced cartilage that then we can overlay along the whole dorsum. That reliably would project from the radix all the way down towards the tip. Then we pair it with a variety of techniques also to maintain airway. We don't want to neglect the function of the nose as we're also changing the shape considerably.
[Dr. Rahul Seth]
As any rhinoplasty surgeon will tell you, augmentation is often much more challenging than reduction rhinoplasty. It really takes quite a bit of maneuvers to do all the things that Dr. Knott was mentioning. He makes it sound really straightforward, but it is a lot, especially lengthening the nose and down rotating it. You really have to augment the septum and the dorsal onlay to be able to achieve those things.
[Dr. Daniel Knott]
The skin soft tissue envelope is only so large and it will only accept so much enlargement. You have to stay a little bit modest in your goals. Otherwise, you create this tremendous structure, but you can't close the skin over it. You have to make sure that you don't get overly ambitious.
[Dr. Gopi Shah]
Do you have to make wear incisions or incisions at the ala often as well as that standard since everything's getting wider and bigger?
[Dr. Rahul Seth]
Typically, wear incisions are used to reduce the nostril size or do an alar base reduction. It's really hard to enlarge a nostril. That is an area that we just aren't able to really provide a great solution yet when it comes to facial masculinization. Also in non-facial masculinization, having a nostril stenosis, a very challenging thing to fix often will require a composite cutaneous and cartilaginous graft to be able to enlarge. I typically don't put that in my algorithm of masculinization surgery.
[Dr. Daniel Knott]
Every time you make an incision, you have to think about the potential disfigurement of the scar. I don't like to make incisions around the alar base in general, because I think it can look terrific, but at times that scar can be very obvious and telling. That morphology of that beautiful crease is just so beautiful, it's hard for us to recreate it. You can create a Z-plasty where you take the skin outside the alar base, lateralize the ala and put that skin then from the outside into the inside of the nose, and in that way be able to do it. Again, the scarring can be very problematic.
(8) Expert Strategies for Buccal Fat Removal
[Dr. Gopi Shah]
In terms of reducing the buccal fat, thinning out the cheeks, if you will, you do that transoral. Do you have to canalize the parotid duct or do you do anything or just where your incision is placed?
[Dr. Daniel Knott]
Typically, you want to avoid the parotid duct. The incision is almost like the incision to handle a ramus fracture, an angle of mandible fracture. It's a high lateral incision right along the ascending ramus of the mandible. Once you have entered that buccal space, it's got this tremendous pressure on it and that fat will literally just almost just fall into your field and it's quite easy to do a small resection. I think your point is a really good one, Gopi, that if you do try to take out all the fat, then you can potentially injure a branch of the facial nerve or the parotid duct. Yes, it does take some caution and care.
[Dr. Rahul Seth]
Buccal fat bed removal has gotten a lot of press and notoriety with celebrities doing it. One of the big cautions, as Dr. Knott was alluding to, is excess removal. Not only puts the important structures at harm, but also does create a very hollowed, gaunt and aged appearance to the face. It really takes caution and self-control to remove just the amount that you might need to produce the flattening of the cheek and to not overdo it.
[Dr. Gopi Shah]
You would probably lead on being conservative. Take what comes to you, see how they do. If you got to go back and take more another time, maybe that's the better move than trying to get out as much as you can. Because, one, you could injure the parotid duct, and two, you can't go back if it's too hollow.
[Dr. Daniel Knott]
Yes, exactly. You can't go back. You have to always think it's- in general, it's one of the rules in plastic surgeries. It's easier to subtract than to add. You don't want to over resect. The fat is stringy. As you're trying to pull it out, it'll tear and rip. Then you end up digging into this pocket trying to find more. You try to grab things and then you can, as you said, inadvertently damage structures that you really don't want to.
(9) Expert Strategies for Mandible Augmentation, Brow Implants, & Adam’s Apple Augmentation
[Dr. Gopi Shah]
In terms of mandible augmentation, this is different than just a sliding genioplasty, because that's just making the chin bigger or more projective. A mandible augmentation, you're also- it's going to address the angle as well. Talk to me about that.
[Dr. Rahul Seth]
Yes, it depends on how much jawbone the patient has and where the goals are. If the patient just wants a chin enlargement or just needs a chin enlargement, then the implant can just be done of a chin area. More often, it's the entire jaw that we want to enlarge. Again, custom implants using CT scan and creating a 3D implant through computer modeling, medical modeling, and then creation of a porous polyethylene, custom implants, all the way from ascending ramus to ascending ramus is the way. The challenging part is to get such a large implant into a gingivobuccal incision. That, a square peg in a round hole sort of a situation. There's also the mental nerve that should not be disrupted. What we do is we actually create the implant into three pieces, posterior on both sides and then an anterior one divided at the area of the mental nerve so we can safely work around it and then secure it into position.
[Dr. Gopi Shah]
Are you also doing the vein jet soaked irrigation, soaking the implant, irrigating the area as well as you do with the brow implants?
[Dr. Rahul Seth]
Yes. Another important concept, like Dr. Knott was mentioning with the nose and not being able to have the skin close over it, although we typically think of the mucosa as more distensible. I will say if you get overambitious with implant size, the mucosa will break down and be at risk for breaking down. You have to think ahead of time to not get carried away and set expectations so that you have a successful surgery.
[Dr. Daniel Knott]
Oftentimes, we place implants in the chin through a submental incision. Those typically are silicone, these really soft, squishy implants. The angle of mandibles you would place, of course, transorally. What Dr. Seth is talking about really is placing these large implants transorally into the chin. That is challenging. Again, that mucosa can easily break down. Then you're also- the patients have to be eating. How are you going to manage their diet and oral hygiene afterwards? It's quite challenging.
[Dr. Gopi Shah]
Do you routinely do Peridex or any oral mouth rinses? I think of mandible fractures and clinda and Peridex and hoping that it all heals up. If there's a little rent, then the mucosa should mucosalize over, because it's still- some periosteum or bone underneath that- over an implant. I don't know if that rent is going to heal up.
[Dr. Daniel Knott]
That's why really meticulous attention to the mucosa, a double-layer closure, Peridex after surgery, soft diet. You take every precaution in the book, because the impact of a rent and exposure is you have to remove the implant. That's just devastating for your patient.
[Dr. Gopi Shah]
In terms of whether it's the brow implant or the mandible implant, do you have any tips for drills or screws? Are these all monocortical usually? That's tricky. Everything's small, you're in a pocket. Any tips?
[Dr. Rahul Seth]
Yes. For the brow, a percutaneous screw placement is pretty much the only option. Making a small stab incision with an 11 blade hidden within the hair of the brow is what we've published about. Then for the mandible, it's just really hard. If you think about like putting in ramus fracture plates, it just gets really hard and you have to sometimes use a percutaneous hole to end up with a trocar to be able to access the area. If one is trying to completely avoid scars, one trick that I've used, but I got to say it's just so challenging, is they have drills that are actually 90 degree or angulable and narrow to get into a narrow space. I'll use the 90 degree drill to get that posterior implant secured into place. Again, really challenging. What I think matters the most and what makes it a lot easier is the patient specific implants become contoured to the bone shape and can almost fix there while you are fixating it securely. I used to use silicone for the jaw and I just don't do that anymore, because it's just too slippery and I can't see down the hole of the mouth and the transoral gingivobuccal approach and really know that the implant is sitting right where I want it to and symmetrically to the other side.
[Dr. Gopi Shah]
Do you usually routinely use antibiotics post-op for the brow augmentation and I assume the mandible augmentation, yes?
[Dr. Rahul Seth]
Yes, absolutely. Post-operative antibiotics.
[Dr. Gopi Shah]
Yes, for the implants. What's the standard if they have no allergies? What do you like to send them home with?
[Dr. Rahul Seth]
Keflex 500 TID for about 10 days, 7 to 10 days, is what I'll do. Then if they have allergies.
[Dr. Gopi Shah]
For the brow?
[Dr. Rahul Seth]
Yes. Then if we're doing anything in the mouth intraoperatively, it becomes Unasyn. Then Augmentin for post-op if there's any oral exposure for the surgeries.
[Dr. Gopi Shah]
Usually about 7 days, 10 days. Do you have a preference on how long?
[Dr. Rahul Seth]
7 to 10. I don't have a preference necessarily. Dr. Knott, do you?
[Dr. Daniel Knott]
No, I like to use BID antibiotics, if possible. I like Dox for the forehead area, and typically I do a week. I'm not sure there's any really good data about 5 days versus 2 weeks versus a week. Then I carefully monitor them for any redness, any early signs of infection. Because once it really gets infected, it's almost impossible to salvage an infected implant. If you can get to it early, I think then you have a chance of actually being able to salvage the implant.
[Dr. Gopi Shah]
Meaning you can go back, wash it out, and—
[Dr. Daniel Knott]
I even tried not to go back. If they have redness or any early signs, a little bit of swelling, a little bit of redness, something asymmetric, some telltale sign of something, then I'll give them a good course of oral antibiotics and see if I can delay the surgical treatment.
[Dr. Rahul Seth]
We get a lot of this data from the more commonly performed malar implants or cheek implants which go through a transoral incision and for transorally placed chin implantation. Just like Dr. Knott was saying, giving things a little bit of time to settle in and hopefully not have to remove. Sometimes it's not terribly uncommon that if there is a perioperative infection, there's a biofilm that arises. Then three months later, a patient's calling with a similar process and then you know that, okay, we have to probably do something here.
[Dr. Gopi Shah]
One more question about the brow implant. I assume you have to do it-- When you make the screws, do you ever get into the sinuses? Is that possible? Is a lot lower? How do you know? Does it matter? Maybe you do and it just doesn't matter.
[Dr. Rahul Seth]
Yes, you're exactly right there, Gopi. It doesn't matter. Just like with trauma of the frontal sinus, you can go right through the anterior table, no problem. Of course, if you go through the posterior table, different story. That's why it's important to get CT imaging and know where you are and putting your screws.
[Dr. Gopi Shah]
In terms of thyroid cartilage augmentation, so you're basically- my understanding is you're getting a rib graft and you're putting it on top of the thyroid cartilage and securing it to create the quote "Adam's Apple." Talk me through that.
[Dr. Rahul Seth]
Yes. First of all, it takes a large amount of cartilage. A lot more than one would think. I like autologous cartilage better than cadaveric cartilage for this, and I have no data to support that necessarily. It becomes a little bit like woodworking class and you're trying to create a pretty three-dimensional piece of tissue that looks like the thyroid, in the sense that it's like a pyramid with a greater projection at its anterior aspect. Typically, I'll suture together about four pieces of cartilage to get that shape just right and I use proline. Then we'll suture it to the native thyroid cartilage via transoral incision, making sure not to go anti-laryngeally with the suture fixation.
[Dr. Gopi Shah]
As we start to round out the episode, any general pearls or tips for your post-op, follow-up care, anything that's like, this is really important, make sure, I always think about this, anything in your practice that you do for any of your- whether it's these patients in particular or any of your facial plastics patients?
[Dr. Daniel Knott]
Gopi, I think it's important just to go back one step. What Dr. Seth just said, I think he glossed over something that was remarkably difficult. Creating a new Adam's Apple and then suturing it in place transorally is—
[Dr. Gopi Shah]
See, I heard him say that and I was like, well, maybe- I keep thinking maybe it was a mistake, and I assumed it was transcervical in my head.
[Dr. Rahul Seth]
I meant transcervical. I apologize. Yes, it is transcervical.
[Dr. Gopi Shah]
Yes.
[Dr. Rahul Seth]
Okay. Yes. I'm no magician. It's definitely a transcervical.
[Dr. Daniel Knott]
Sometimes we do sutures transorally. A mixture of both transcervical and then transoral passing. This is a- it's a very mobile structure, the thyroid cartilage, and so it's hard to fixate it and be accurate in where you're placing your sutures.
[Dr. Rahul Seth]
We've been doing transoral chondroringoplasty, scarless, for a reduction of Adam's apple. I'm just so used to saying transorally. To do augmentation thyroid grafting, it's really requires a transcervical incision. It's very- the view required and the amount of fixation sutures required is pretty extensive, because you do not want that graft to move around.
[Dr. Gopi Shah]
Do you do direct laryngoscopy either at the time of surgery or after to check your sutures, to check the airway? Is there any ever a need for that?
[Dr. Rahul Seth]
I have done that just to make sure that no sutures- I'm not seeing proline intralaryngeally.
[Dr. Gopi Shah]
I just imagine, is it ever-- I just imagined airway cartilage or a mass on my thyroid cartilage. Is it ever heavy? Do patients ever say, God, this is feels a little heavy on my neck or anything like that? Is that a silly—
[Dr. Rahul Seth]
Surprisingly, no. It's important to- speaking of the postoperative time period, important to put a drain in, because you will have fluid accumulation in the area. Interestingly enough, typically patients will feel some heaviness there, of course, because there's a change. But the body is so miraculous and heals so well and patients get used to a new shape and the fact that it's- extralaryngeally, we don't disrupt any of the musculature, the strap muscles all go back together overall, and rib cartilage doesn't really weigh that much. Overall, you don't really have that much disruption.
[Dr. Gopi Shah]
Any tips or tricks for when you make your transcervical incision for the scar not to scar down to the cartilage or the rib so that it's not moving when they swallow? Have you found anything that works well?
[Dr. Rahul Seth]
Yes. This is just really challenging, and the- I would say re-approximating the strap muscles over the implant so you don't get cartilage to dermal or dermal fat approximation. You want to make sure you create a barrier there and you keep your strap muscles intact. Again, it's the same concept of you can augment only so far, but if you can't get your muscles or your skin to close on top effectively and create that barrier, that's a great point that you mentioned, Gopi, is that you don't want that scar- the incision to scar down to the graft material.
(10) The Role of Hair in Gender-Affirming Care
[Dr. Gopi Shah]
Then any other final thoughts or pearls, whether it's specific overall to facial masculinization or in your postoperative care as we start to round this episode?
[Dr. Daniel Knott]
I would just say that the management of the hair is such an important part of that. Having an expert- on your team who's an expert in managing the hair, I think is something that can really help your results look much more natural. Both with the beard augmentation if needed and management of the frontal hairline. As it is for our feminization patients. Management of the hair is something that I think is underappreciated and under stress, but is critical to a natural appearance.
[Dr. Rahul Seth]
I think the other big pearl is that remembering that these are permanent changes. Surgery is permanent. Really having what you're planning and what the patient is planning to line up. These are pretty advanced surgeries that we're talking about, and so that individuals have appropriate training and understanding of what they're getting into is really paramount.
[Dr. Gopi Shah]
Then just one last question. Dr. Knott, when said having a good partner that knows how to manage the hair, are we talking about like an aesthetician or somebody that is specialized in like hair transplants?
[Dr. Daniel Knott]
Having an aesthetician, I think, is always a really nice part of your team, but it's both having someone- either someone you can refer to, someone in your team, a colleague, or even contacts across the country and people that are both number one expert in electrolysis for hair removal as well as hair transplant technology. Oh, yes, that is super important.
[Dr. Gopi Shah]
Thank you guys so much for your time and your knowledge and your pearls. In the show notes, we will include links to your chapter on facial masculinization surgery and operative techniques in otolaryngology 2023. We'll try to just include like a PubMed link given the articles, Dr. Seth, you had mentioned, in facial plastics and aesthetic medicine. Also we'll include the links to the ENT Today articles on gender-affirming care. They're both excellent. For our listeners, please check out the Otolaryngologic Clinics of North America, the August 2022 issue on gender affirmation surgery in otolaryngology. That's where Dr. Knott and Dr. Seth's chapter is on sex-related characteristics of the face. The entire issue is thorough, I thought it was well-written. Kudos to you guys. Kudos for the team of authors and the editors. They did an amazing job. For those interested on more gender-affirming care on Backtable, check out episode 125, gender-affirming voice care with Dr. Mark Corey and speech and language pathologist Sarah Schneider, and episode 27, facial feminization with Dr. Sarah Saxon, and I think it's a wrap.
Podcast Contributors
Dr. P. Daniel Knott
Dr. P. Daniel Knott is a professor in the Facial Plastic, Aesthetic and Reconstructive Surgery Division and the director of Facial Plastic and Aesthetic Surgery with UCSF in San Francisco, California.
Dr. Rahul Seth
Dr. Rahul Seth is a facial plastic and reconstructive surgeon with Golden State Plastic Surgery and Golden State Dermatology in San Fracisco, California.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 14). Ep. 148 – Facial Masculinization in Gender Affirming Care [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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