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BackTable / ENT / Article
Facial Feminization Surgery Options
Taylor Spurgeon-Hess • Jan 11, 2023 • 96 hits
Facial feminization surgery aims to help provide patients with a more youthful and feminine appearance. These procedures include different types of cranioplasty, chondroplasties, rhinoplasties, mandible contouring, and more. Facial plastic surgeon, Dr. Sarah Saxon, explains her preferred procedures for forehead, hairline, Adam's apple, and eyebrow feminization, surgical techniques, and postoperative care pearls.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Working on forehead feminization creates the largest impact when feminizing the face. Facial feminization surgeries targeting the forehead include type 3 cranioplasty, hairline lowering, and the raising of the eyebrows.
• Chondrolaryngoplasty, or the tracheal shave, effectively removes the Adam’s apple. To avoid complications such as hoarseness, surgeons should locate the anterior commissure during surgery and utilize it as a landmark.
• Postoperative care includes one night in the hospital, oral antibiotics, steroids for 24 hours, and a Medrol dose pack. Performing a nerve block can prevent the prescription of narcotics.
• Exosome injections utilize mRNA technology to accelerate healing and hair growth while simultaneously preventing scarring.
Table of Contents
(1) Forehead Feminization with Cranioplasty
(2) Neck Feminization with Chondrolaryngoplasty
(3) Facial Feminization Surgery Postoperative Care
(4) Accelerating Healing with Exosomes
Forehead Feminization with Cranioplasty
Forehead feminization produces the most dramatic effect when it comes to feminizing the face. The three main procedures targeting forehead feminization include raising the eyebrows, lowering the hairline, and performing a type 3 cranioplasty. There are 3 different types of cranioplasty for facial feminization. In a type 3 cranioplasty, the lateral brow is burred, but the anterior table is also removed after drilling the inner sinus septum and is then set back within the frontal sinus. Other less commonly performed procedures include type 1 and type 2 cranioplasties. Type 1 cranioplasty involves simply burring down the bone, while type 2 cranioplasty is a hybrid which includes the addition of graft material to the upper forehead. The “forehead feminization package” can be completed at the same time as other feminizing procedures; the limiting factor is the surgeon’s preferred length of surgery.
[Dr. Sarah Saxon]
I will start with the upper part of the face. The most common procedure I do is a type three cranioplasty. There are three types of cranioplasty when we're talking about feminizing the forehead. Type one is just burring down the bone. Type two is a hybrid where you burr down the bone but you can add in graft material to the upper forehead, I generally only do type three cranioplasty which means you can actually burr the lateral brow but right in front of the frontal sinus if you burr that area, the anterior table the frontal sinus gets too thin.
You actually have to set it back. Remove the anterior table, set it back within the sinus. I use titanium plates and screws to set it in place. At the same time, I call it my forehead package because I'll lower the hairline and raise the brows at the same time. It's three procedures in one and that had the most dramatic effect on feminizing the face. Something else that's more specific to facial feminization surgery is improving the fullness of the cheeks so I'll do cheek implants or fat grafting in the cheeks oftentimes making the nose have less character.
A feminization rhinoplasty is a lot different than a regular rhinoplasty. I'm significantly de-projecting the nose, increasing rotation, reducing a large dorsal hump. A male nose has a lot more features to it than a feminine nose. In making things so much smaller, they typically have a longer recovery time even in a year. I see changes up to two years. Then moving down, I'll do a lip lift, so shortening upper lip, and then contouring the jawline to making it more narrow, which can be done with osteotomies or just contouring with a drill or powered rasp.
…
[Dr. Ashley Agan]
Would you typically do all of those procedures in the same setting like you you talked about the cranioplasty and rhinoplasty and mandible contouring? Do you, for example, have a limit where you let's only do three or four at a time, or what are your thoughts on that?
[Dr. Sarah Saxon]
They can be done all at once when I was a fellow, we had a fellow, a chief resident, and Dr. Spiegel and we would do it all at once, but it's just me in my practice. My body starts hurting after a while. I like to cut it off at six hours so it's more time based for me anything beyond six or seven hours I really need to start staging it out just because my neck and back cannot handle it.
[Dr. Ashley Agan]
Yes. Nobody wants their surgeon to be tired anyway.
[Dr. Sarah Saxon]
Since I don't have residents with me, I don't take breaks to go to the bathroom or get food or water so that's about as long as I can handle it.
[Dr. Gopi Shah]
Yes, that's understandable. In terms of the forehead, cranioplasty, just so that I have it visualized better for myself, you're literally taking the anterior table of the frontal sinus off, reducing it or recontouring it, and then placing it back and using plates to-- Is that--
[Dr. Sarah Saxon]
Really I'm not doing anything to the anterior table itself. It's all the surrounding bone. I basically start from lateral to medial and contour the bone how I need to. What that does is that ends up blue lining the frontal sinus. Then I'm able to take a saw and remove that anterior table after I've already surrounded it in the level that I needed to be. Then after that, I drilled down the inner sinus septum, and then that allows me to set back the anterior table. At the same time I'm looking inside their sinus so its-
[Dr. Ashley Agan]
Are you in the mucosa then?
[Dr. Sarah Saxon]
Yes, if there are any aero cells that are blocking the outflow tracts, I can remove those.
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Neck Feminization with Chondrolaryngoplasty
Some patients opt to remove their Adam’s apple via a procedure known as a chondrolaryngoplasty or a tracheal shave. In order to prevent damage to the vocal cords, the anterior commissure should be identified in the middle of the surgery. Dr. Saxon achieves this by putting in a laryngeal mask airway instead of an ET tube and places a 22 gauge needle in the exposed cartilage. A laryngoscope can then be utilized to ensure that the needle is in the correct place. The surgeon can then remove any cartilage above this point and the patient should not experience any hoarseness post-procedure.
[Dr. Sarah Saxon]
Then a trach shave, otherwise known as the chondrolaryngoplasty, which means removing the Adam's apple. I'll use fiberoptic scopes and surgery to make sure I identify the anterior commissure so that the vocal cords aren't damaged. Those are the typical things I do. Of course, in addition, like we talked about, I'll oftentimes recommend sometimes a blepharoplasty, sometimes a facelift. If I have to do a lot of those things, I'll stage out the procedures. I'll do all the structural changes first and then six months later come back and do the eight more aging procedures after swelling goes down.
…
[Dr. Ashley Agan]
That's wonderful, though. Can we go back to the chondrolaryngoplasty?
[Dr. Sarah Saxon]
Yes.
[Dr. Ashley Agan]
The Adam's apple or the thyroid notch. Can you go into exactly--
[Dr. Sarah Saxon]
Sure.
[Dr. Ashley Agan]
-how that works? Are you at risk of having voice changes at-- Tell us, go into it.
[Dr. Sarah Saxon]
I use the same technique as Dr. Spiegel. He developed a way that you can identify the anterior commissure while you're in the middle of surgery. What I have the anesthesiologists do is they put in an LMA instead of an ET tube. Then once I have everything exposed, I can use a 22-gauge needle to put it through the cartilage. Then the anesthesiologist puts down a laryngoscope so I can see on the screen if my needle is in the right location and mark it with a booby on the outside.
Any cartilage above that will come off. Sometimes I'm a little low, sometimes I'm a little high. I can precisely identify the anterior commissure with that technique. About 20% of the population, their vocal cords will attach a little bit high. They might still have a little bump, but they don't have any voice changes. I've never had a patient that had hoarseness after surgery beyond just a few days from swelling around the larynx. There are though, however, a lot of surgeons out there that are guessing.
The incidents of hoarseness after that procedure is still pretty high because there are a lot of surgeons doing that surgery that don't know what they're doing. They're not looking at the vocal words since the anterior commissary generally 50% the height of the thyroid cartilage, they're basically saying, "Okay, I can take off all that cartilage above it," but that's not the case every time. I actually got a phone call from a laryngologist in town that he was seeing a patient with hoarseness and their vocal cords just get flaccid because they don't have any tone and it's hard to fix.
There's not a really good way of fixing that. More just going to the right person for that procedure first. It's not difficult. Any otolaryngologist could do it, it's just a matter of using that right technique. That's published, so if anybody looks up Dr. Spiegel's research, it's readily available.
[Dr. Ashley Agan]
I remember doing this case with you, one of the first ones that you did at UC, and I think it's important to also have an anesthesiologist that's comfortable with what's going on because I think the patient kept swallowing or something and we were like--
[laughter]
Yes, it's a very small incision and you can see where you're at with your scope and you just rongeur that cartilage away.
[Dr. Sarah Saxon]
Yes, I don't drill it. I don't drill it. I just use a rongeur just to remove it. You also have to use an LMA that doesn't have a bar across it, because that'll just completely block your view and flip the epiglottis in your way when the anesthesiologist is putting down the scope. It usually takes having someone that has done a lot of fiber optic intubations to be comfortable with it.
[Dr. Ashley Agan]
The patients are completely sedated. It's not like in voice surgery thoracoplasties where sometimes are able to talk to you. They're out.
[Dr. Sarah Saxon]
They're out. Yes.
[Dr. Ashley Agan]
You're not checking for anything. There's no reason because you can see where you are with the scope in. It's quick. It takes me about 30 minutes, so it's not a long anesthesia time, but [laughs] they're out though.
[Dr. Ashley Agan]
There's no concerns for swallowing or anything afterwards because you're not really changing that structure or the [crosstalk].
[Dr. Sarah Saxon]
Yes, theoretically they could get a hematoma or seroma in the area, which is a bad location to have. I've never seen that happen. I used to keep patients overnight after that procedure, but I don't anymore just because I've never seen any problems after.
Facial Feminization Surgery Postoperative Care
After patients undergo facial feminization surgery, they will likely spend one night in the hospital. Postoperative medications include oral antibiotics, peridex, steroids for the first 24 hours, and a Medrol dose pack after that. The steroids help to prevent the massive swelling after cranioplasty that often causes patients’ eyes to swell shut. Dr. Saxon performs nerve blocks prior to surgery, so postoperative pain is minimal. Therefore, patients do not need narcotics but can instead alternate with Tylenol and ibuprofen.
[Dr. Gopi Shah]
Is it for that care, is it just like peridex rinses and do you do oral antibiotics? Is there diet? How does that work afterwards?
[Dr. Sarah Saxon]
I do oral antibiotics and peridex. I actually started giving everyone steroids after surgery because they have massive swelling for a long time and with cranioplasty their eyes can swell shut. For the first 24 hours since I started using steroids after surgery, just the first 24 hours, I'll put them on a Medrol dose pack at home. While they're overnight in the hospital, I'll have them on scheduled Decadron and that helps a lot.
[Dr. Ashley Agan]
Yes, most of these patients are staying in house overnight.
[Dr. Sarah Saxon]
Overnight.
[Dr. Ashley Agan]
One night or so?
[Dr. Sarah Saxon]
Yes. They don't typically have a lot of pain. I did a lot of research in my residency on regional anesthesia, so I always do nerve blocks before I do surgery in any region of the face. I'll mix lidocaine and bupivacaine so it's more long-acting through the case. Most of my patients are just alternating Tylenol ibuprofen after surgery. They don't have pain, it's just a lot of swelling.
[Dr. Ashley Agan]
Wow. Most of them don't need narcotics?
[Dr. Sarah Saxon]
No.
[Dr. Ashley Agan]
That's amazing. What's your mix of lidocaine and bupivacaine?
[Dr. Sarah Saxon]
It's just a half-and-half mixture.
[Dr. Ashley Agan]
Of 1% lidocaine or?
[Dr. Sarah Saxon]
1% lidocaine with epinephrine and then quarter percent bupivacaine with epinephrine. Recently quarter percent bupivacaine with epi was discontinued. I usually have to get the pharmacy to mix that or I add it in myself if I'm in the office. I have separate epi that I can add in.
Accelerating Healing with Exosomes
In order to speed up healing time and reduce scarring, patients can receive exosome injections. The technology is similar to that of the COVID vaccine; mRNA is injected to boost healing capacity. This allows incisions to heal much faster and hair growth begins much earlier. The incisions only need to be covered with ointment as opposed to Dermabond. Only one injection is required to prevent scarring and the effect is essentially permanent. Additional injections may need to be administered for hair growth but that often requires only one injection as well.
[Dr. Sarah Saxon]
In the hairline incision I've transitioned all my suturing to subcuticular and deep. I'll close the galea with PDS close. I do subcuticular suturing with monocryl and then I add-- I actually started injecting exosomes, which y'all may or may not have heard of. I don't know. It's basically the same technology as the COVID vaccine where they can inject mRNA to boost their healing capacity. That incision heals a lot faster and I see hair growth through it a lot faster. I don't really have them do anything aside from putting ointment on the incision, redressing it with a compressive wrap.
[Dr. Gopi Shah]
It's not like you're putting derma bond or anything on top?
[Dr. Sarah Saxon]
No.
[Dr. Gopi Shah]
The exosome and then that helps it heal. That's awesome.
[Dr. Sarah Saxon]
Right.
[Dr. Gopi Shah]
That's an injection?
[Dr. Sarah Saxon]
That's an injection. I'm using that for scars, using it for skin rejuvenation. I've seen a lot of collagen production, so I've actually stopped doing dermal fillers in the office this last quarter because I use exosomes for everything now.
[Dr. Gopi Shah]
Wow. Do you have to do multiple do you have to do multiple treatments?
[Dr. Sarah Saxon]
No, just one for scars.
[Dr. Ashley Agan]
That's cool.
[Dr. Gopi Shah]
Is this a dumb question? How long does it last for? Or is it once? Do you have to get boosts? With the RNA technology, I just didn't know.
[Dr. Sarah Saxon]
No, it's basically permanent because it's just acting in that acute healing phase of the incision. If I'm injecting for hair growth, sometimes they'll need repeat injections but typically only one.
Podcast Contributors
Dr. Sarah Saxon
Dr. Saxon is a Facial Plastic Surgeon at Saxon MD Facial Plastic Surgery in Austin Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, July 20). Ep. 27 – Facial Feminization [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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