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BackTable / ENT / Podcast / Transcript #27

Podcast Transcript: Facial Feminization

with Dr. Sarah Saxon

We talk with Dr. Sarah Saxon about Facial Feminization Surgery, including the range of procedures, patient selection, and technique. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Defining Facial Feminization

(2) LGBTQ+ Terms to Know

(3) Facial Feminization for Patients of Varying Ages

(4) Workflows for Common Surgeries

(5) Potential Procedure Complications

(6) Incising for Mandible Contouring

(7) Boosting Healing Capacity with Exosomes

(8) Facial Feminization In-Office

(9) Breaking Down the Chondrolaryngoplasty Procedure

(10) Tips for Providing Inclusive Care

Listen While You Read

Facial Feminization with Dr. Sarah Saxon on the BackTable ENT Podcast)
Ep 27 Facial Feminization with Dr. Sarah Saxon
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[Dr. Gopi Shah]
This week on the BackTable podcast.

[Dr. Sarah Saxon]
The process of transitioning is different for everybody. Typically a transgender person feels this way from birth. Even when they were two, they felt like they were the opposite gender. Obviously, they don't have surgery when they're two. [laughs] Now, and actually Children's has a transgender clinic where they'll start seeing kids who start to tell their parents they feel this way. Everyone starts at different points in time, depending on their background and support structure. Some people wait until they're retired from their profession to start transitioning.

I have a 71-year-old that just retired and now is ready to live their best life. [laughs] Usually when they come to me, they've at least done some therapy and hormone therapy. Then typically next steps is facial feminization because they just want to blend in public.

[Dr. Gopi Shah]
Hello everyone and welcome to the Backtable ENT podcast where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you could take something from our show to your practice. My name is Gopi Shah and I'm a pediatric otolaryngologist at UT Southwestern here in Dallas, Texas.

[Dr. Ashley Agan]
My name is Ashley Agan and I'm a general otolaryngologist also practicing in Dallas. We're your hosts. We're excited to be here. How's it going Gopi?

[Dr. Gopi Shah]
It's going good. I'm very excited as always for all of our topics that very excited for this one just because I think that this is an important topic and the surgeries are at the forefront in the field. I'll let you go ahead and introduce our guests and our show.

[Dr. Ashley Agan]
Yes. I'm pretty stoked for this one as well. We have Dr. Sarah Saxon on the podcast today. Sarah is a dear friend. We met back in 2015. She joined the faculty at UT Southwestern. I was a chief resident and really hit it off, have some good memories and good adventures. She has since gone on to open her own practice in Austin. She's a facial plastic surgeon. She also has an office in Dallas. She obtained her medical degree from UT San Antonio. She completed a residency at the University of New Mexico.

Then she completed a fellowship in facial plastic and reconstructive surgery at Boston University under the mentorship of Jeffrey Spiegel. She's here today to talk to us about facial feminization surgery. Welcome to the show, Sarah.

[Dr. Sarah Saxon]
Thank you for having me. Good to see you guys.
[laughter]

[Dr. Ashley Agan]
Good to see you as well. Sarah, just tell us a little bit about your practice and what your setup is like in Austin right now.

[Dr. Sarah Saxon]
Yes. I left UT Southwestern about four years ago and it took me another six months or so to open my practice in Austin. I mainly do about 50% of my practice is facial feminization and the other part is everything else. Since then, I've grown the practice to also have a med spa called Breathe Aesthetics & Wellness. Then we just opened our Dallas office two months ago. That's very exciting.

We've been so busy this last year after COVID that I'm looking for a bigger office space now in Austin, and I'm in the planning stages of starting a fellowship actually as well.

[Dr. Ashley Agan]
Congratulations.

[Dr. Gopi Shah]
I love that. I'm back to school.

[Dr. Ashley Agan]
That's huge. That's wonderful.

[Dr. Gopi Shah]
Good for you.

[Dr. Sarah Saxon]
Yes.

[Dr. Ashley Agan]
Tell us about facial feminization surgery. I'm not that far out of residency, but I may be almost close to 10 years, but we're in counting. I don't recall really having an opportunity to even see any of those or really know that that type of surgery was going on. Just tell us a little bit about it.

(1) Defining Facial Feminization

[Dr. Sarah Saxon]
Yes. Facial feminization is a grouping of procedures that are geared towards feminizing the face. That can be a number of things like bony re-contouring of the face, like cranioplasty or mandible contouring. It also involves everything else that we do regularly, like rhinoplasty, facelift, brow lifts, lip lifts, and also skin rejuvenation because all those things play a part in helping the face look feminine. We want light to bounce off the face in and towards the eyes. Dr. Spiegel, who I trained with in Boston, he did a lot of the pioneering research in what makes a face look feminine.

He found that the upper third of the face has the most impact on looking feminine and also looking young. I incorporate facial feminization into my everyday facial analysis. I consider it basically everything that I do, not just in the transgender community. When I look at someone's face in a console, it's a little bit different than someone who's not trained to do facial feminization. Back when I trained, not many people did those procedures. Really it was only Dr. Spiegel who was training fellows to do his techniques. Now it's become a little bit more mainstream.

A lot of academic centers around the country are learning how to do the surgery. It's becoming more common now.

[Dr. Ashley Agan]
I remember doing a Grand Rounds presentation. My chief here and you were my mentor. It was for facial feminization. I remember you kind of explaining the concepts of how facial feminization is the equivalent of youth. When people want surgery to look younger, it's a lot of the same concepts as looking more feminine. It makes sense when you think about, you look at little kids and if they're not dressed in blue or pink, sometimes you're like, "I don't know because they all look like little girls because youth looks feminine." Can you expand on that a little bit?

[Dr. Sarah Saxon]
Yes. Well, and it's the same concept as someone gets older, they start to look more and more alike too. If you see an older woman who's never taken care of her skin, who her brows have fallen, the skin of her neck has started to sag and it's bringing more emphasis to the lower face and less to the upper face. If you look at an older man and older woman, they tend to look very similar too. Facial feminization as a particular field just gives me more tools in my toolbox to help someone look softer.

If I'm seeing a cisgendered woman, which we'll get into terms a little bit later. If I'm consulting with a cis-gendered woman, I sometimes still will recognize some bony contours that are a little more masculinizing to the face and recommend that for their treatment plan. Now that it's becoming more commonplace and people are googling and looking online at options for them, it's not such a shock when I recommend [chuckles] a cranioplasty for their procedure.

[Dr. Gopi Shah]
I think it's important to go ahead and get into some of the terms. Also just because as a healthcare provider, it is important for us to understand how to take care of our transgender patients for whatever it is that they come in for. For me, with peds, if I have a transgender pediatric patient who's coming in for sinus infections, I just want to make sure I understand the terminology. Can we go into, you use the words cisgender, we say transgender, can we just go into some of what we should know?

(2) LGBTQ+ Terms to Know

[Dr. Sarah Saxon]
Yes, it can be very confusing. I have to look things up to make sure I have things right all the time as well. I do this every day. [laughs] Just don't put any pressure on yourself to feel like you have to get things perfect all the time. Transgender means that a person identifies as the opposite gender of what they were assigned at birth. If their birth certificate said that they are male, they identify as female now. Cisgender means they identify as the same gender assigned at birth. You go back to chemistry, the cis conformation of a molecule is the same side.

Then now you have a few other terms that are becoming more common, really in the last 5 to 10 years. There's gender fluidity, meaning someone doesn't really-- they can go one day as identifying as female, and the next day, they may identify as male. They go back and forth. A lot of times in surgery, they want to be able to have some feminine features but be able to if they want one day to live as male, then they can. Then gender, a non-binary person means that they don't identify as either, they're somewhere in between. Typically their pronouns would be more like they/them, instead of he or she.

[Dr. Gopi Shah]
That's very helpful. A lot of times, and I feel like with research, with demographics, I always think of, should I be using sex or gender? Even when you're thinking about looking at a chart review, prospective study, and demographics, I wonder, because gender and sex, which you're assigned to at birth is-- I feel like--

[Dr. Sarah Saxon]
It can be confusing with surgery because if someone's of childbearing age and they identify as male, but they still have a uterus, they could still be pregnant. They'd still need a pregnancy test before surgery. They still need pap smears. They still need all the regular medical care, which in primary care, it can be limiting too because there are very few primary care providers that feel comfortable. Even insurance providers say if they identify as male, then they're not going to cover a pap smear.

Everything's still changing, and we have a long way to go.

[Dr. Ashley Agan]
Everyone's trying to figure out how to change things and make it work. Can you talk to us about the process of transitioning, what does that mean, and what steps are involved?

[Dr. Sarah Saxon]
The process of transitioning is different for everybody. Typically, a transgender person feels this way from birth, so even when they were two, they felt like they were the opposite gender. Obviously, they don't have surgery when they're two. Now, and actually, Children's has a transgender clinic where they'll start seeing kids who start to tell their parents they feel this way, and they'll have group therapy sessions or individual therapy sessions at a certain point in time, they start to take hormones. This can be either as a child or in adolescence or as an adult.

Everyone starts at different points in time, depending on their background and support structure. Some people wait until they're retired from their profession to start transitioning, I have a 71-year-old that just retired, and now is ready to live their best life. Usually, when they come to me, they've at least done some therapy and hormone therapy. Then typically next steps is facial feminization because they just want to blend in in public, and then they may or may not choose to do top or bottom surgery, meaning breast augmentation or genitalia reconstruction.

Oftentimes, I'll have patients that just do facial surgery, and that's it.

[Dr. Gopi Shah]
Going back to sort of the beginning, where we think of facial feminization, it's youthful. From what you were saying before, you use some of the same principles of facial feminization for cisgender women as well as transgender women. When patients come to you in clinic, does that make a difference in how you with your approach in terms of what kinds of surgeries or augmentations or changes that you're thinking about for them?

[Dr. Sarah Saxon]
It mainly makes a difference to know, I usually ask, do you want to look as feminine as possible? If they're transgender versus gender fluid, or non-binary, I always ask as I never want to assume. Even if they come in identifying as female to me, they may not want to do that every day. If they're cisgender coming in, I still want to know do you want to look more feminine. Oftentimes, they'll come in asking me, "I just want to look good, I can't really put my finger on it, but I need your input because I've seen the work you do on transgender patients. I feel like I look very masculine, and I'm open to whatever procedure you would recommend." For those patients, oftentimes I'll recommend, cranioplasty, or jaw contouring, even rhinoplasty is a very feminizing procedure. In general, I think of everybody kind of the same, as far as structure and soft tissue, whether they're transgender or cisgender, and I'm bringing them to the same point.

[Dr. Gopi Shah]
It's similar in that everyone's a little bit different. Some people want the works and some people just a little bit.

[Dr. Sarah Saxon]
I even have cisgendered men come to me because they have a super-prominent browbone feel like they have that Neanderthal appearance. Even though they're not trans, facial feminization can benefit them because it just gives a more softer appearance and-

[Dr. Gopi Shah]
Youthful.

[Dr. Sarah Saxon]
-youthful, yes, [laughs] but also people tend to think that they look angry all the time when they don't feel that way, so it can just soften other features.

[Dr. Gopi Shah]
Great point.

(3) Facial Feminization for Patients of Varying Ages

[Dr. Ashley Agan]
Can you talk to us about the timeline for surgeries? You mentioned you have patients who are in their 70s. What's the other end of the spectrum? Is there an age that's too young?

[Dr. Sarah Saxon]
I typically don't like to do any big surgeries until after 18 years old, just because, one, is more of a maturity issue, so they're hard to recover from, there's a lot of swelling. If you're too young doing the surgeries, they don't really understand the whole recovery process as much. I want their facial structures to be mature so that they don't change as they grow. There are a few things that I can do younger than 18, which are the same for anybody like if they're over 16. I mean, want to do a rhinoplasty, or I have a 17-year-old that I'm seeing that has a very, very prominent jaw.

He's not transitioning yet, but still, it's more of an over-exaggerated feature on his face. It's something that we can start with, and then once he graduates high school, we can go into other surgeries. A pretty typical time for someone to is between that high school and college transition because they just want to start fresh in college. The younger you start transitioning, the less surgery you need. The brow isn't quite as harsh, they haven't lost a lot of hair with temporal recession and the hairline.

They haven't lost a lot of elasticity in their skin so they don't need as many skin treatments or facelifts or blepharoplasty, or anything like that. It's usually just bone contouring and restructuring depending on when they started hormones. If someone starts hormones at puberty, they really don't need that much surgery, because they haven't developed those secondary sex characteristics of the face.

[Dr. Gopi Shah]
Can we go into some of the surgeries now, we keep talking about these surgeries let's go into some of them.

(4) Workflows for Common Surgeries

[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 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.

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.

Sometimes I don't need to go as far as a facelift because you can get some loose skin around the jawline if you're making it that much smaller. I have a device called FaceTite which is radiofrequency skin tightening, so I can come back and do that in the office six months later and just tighten the skin around the jawline. In between that time I have them do hair removal and skin resurfacing and IPL and good skin products, tweezing their eyebrows a little bit, that's all. [chuckles]

[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.

[Dr. Gopi Shah]
Is there a risk of like mucoceles in the future or what kinds of what's the complication of chronic sinusitis or frontal outflow tract problems?

(5) Potential Procedure Complications

[Dr. Sarah Saxon]
Yes, theoretically you would think that there would be a risk of mucocele, but Dr. Spiegel, having done this for decades, has never really seen that. I'm sure if there are surgeons who don't have a background in ENT, maybe they don't know to identify problematic air cells that might be blocking or, I'm making sure that if there is a problem with flow through the nasal frontal duct, that I have everything open and so I can make those changes at the time. If someone doesn't have a background in sinus surgery, they may not be able to identify that.

I make sure that there's no mucosa that's caught in any crevices of the bone. I've never had any issues. It actually gets better, more than worse for most of my patients.

[Dr. Gopi Shah]
Do you ever have to get preoperative imaging for the forehead recontouring or the mandibular contour? Is there a need for any CT or any x-rays or anything like that?

[Dr. Sarah Saxon]
That's a pretty controversial topic because there are some surgeons that absolutely think that, you need CT scans, but they're also not using the same technique that Dr. Spiegel uses. Like I said, blue lining the frontal sinus, I'm not doing image guidance so there's not really much need. If the supraorbital nerves are in the way, I can actually see them. If they're in a foramen instead of a notch, I can just remove the bone underneath the nerve and get them out of the way.

In revision cases, I do require a CT scan because I don't really know what other surgeon did. If it's a revision case, they often will have just burred down the bone and it's super thin and I may need to do bone grafts and things like that. I use that for planning. Same for jaw contouring. I'm not like making big osteotomies, but if they have had surgery in the past, I'll get a CT scan. Or if I do need to do osteotomies, say they just have a really overgrown chin and jawline and you do a sliding genioplasty, I make those measurements first beforehand.

I don't like to just, my aesthetic is more natural instead of overly aggressive jaw surgery. There are some surgeons that will remove the angle of the mandible. I don't think that that often looks good and it makes the upper face flow into the neck without a defined jawline. I think that aesthetic is going out of style honestly, I like to keep it looking natural but more narrow and just a more slim physique to the jaw structure. To do that I don't need to do CT scans.

(6) Incising for Mandible Contouring

[Dr. Ashley Agan]
Where's your incision for your mandible contouring? Is it transoral?

[Dr. Sarah Saxon]
Yes, transoral. Just the same as you would do a mandible fracture. I usually leave a cuff of tissue around the mental nerves though because we are retracting so much and using powered instruments and so that just leaves extra bit of cushion so that I don't avulse the mental nerves. I'll make an incision in the gingival labial focus in the midline and then separate incisions posteriorly and leave a cuff of tissue in between.

[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.

[Dr. Gopi Shah]
Got you. Then this might be a ignorant question, but is there then a wrap that you're doing?

(7) Boosting Healing Capacity with Exosomes

[Dr. Sarah Saxon]
Yes, I tell them they're, they're going to look like a Q-tip when they come out.

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.

[Dr. Ashley Agan]
On the topic of the exosomes, we wanted to talk about what you like the non-O.R. procedures as well. I think this is a good segue, what kinds of things are you doing in the office?

(8) Facial Feminization In-Office

[Dr. Sarah Saxon]
Just about everything.

[laughter]

[Dr. Ashley Agan]
How much time do you have?

[Dr. Sarah Saxon]
I started out just with a micro-needling pin and chemical peels and then as I had patients reach their limit in what I could do with those devices, I added in an IPL, it's Texas so everybody has a lot of sun damage to their skin. After that, I added in EmbraceRF, which is a combination of Morpheus8, so a radiofrequency micro-needling, and a FaceTite. That radiofrequency skin-tightening device that I talked about. I do a lot of that. I don't have actual lasers in the office because I use so much radio frequency in the office.

After I started using those technologies enough, then I had patients that wanted some body contouring and they didn't really want to go to another location. We developed trust over time. I had no intention of doing BodyTite, which is a body handpiece for FaceTite. I invested in some non-invasive body contouring treatments through BTL Aesthetics. That's all using radio frequency, it works really well. Then EMSCULPT, which sculpts muscle. In our IPL platform, it also has laser hair removal. A lot of my trans patients will get laser hair removal through our office too.

If their hair's too light, they'll go-- There are a few electrolysis in town that do a really good job. There's not a whole lot that I can't do in the office. I do a lot of nerve modulators too, but like I said, I've just gone away from dermal fillers because I just do so much fat grafting and exosomes and skin regeneration that I don't really need it anymore. That's just something that's happened this year that I realized we don't do enough anymore because we don't need to. [laughs] Might as well not even do a syringe here or there because it's not really worth the cost of buying the product.

It's something really exciting. Myself and my PAs getting a lifestyle medicine certification. Along with the body treatments will be counseling them on lifestyle modifications and diet and alcohol consumption exercise and all that good stuff. Their results are boosted even more.

[Dr. Gopi Shah]
That's great.

[Dr. Sarah Saxon]
I just don't sleep.

[laughter]

To make sure everybody else does. I feel like I don't work a day in my life because I really love what I do.

(9) Breaking Down the Chondrolaryngoplasty Procedure

[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.

(10) Tips for Providing Inclusive Care

[Dr. Gopi Shah]
Well, as a provider treating any transgender patient in our ENT clinic for any otolaryngology problem, what do you think is the most important thing that we can incorporate or think about as providers and in our practice of how to really be a good provider for these patients?

[Dr. Sarah Saxon]
I think just being aware of and being open to using the right pronouns. If you feel nervous that you're not doing the right thing, you can just ask because they don't mind, you can say, "What pronouns do you prefer to use?" They'll say he/she or they/them. Not to put so much pressure on yourself about it, but to have the right intentions. It can be on a subconscious level, you might mess up sometimes [chuckles] and that's okay. As long as you're well-intentioned, I think EMRs have a long way to go in having the infrastructure to put what their legal name is versus what they go by.

What gender they go by versus their medical history. Knowing if someone is on hormones, and this is something I didn't touch on before, I do have everyone, especially for longer cases go off of hormones two weeks before surgery. There's no data to say that there's increased DVT risk, but no one's ever going to do that study because it's too risky. Some people can be on pretty high levels of hormones. As these patients get older, they may need cancer surgeries, things that are hours long, and their DVT risk, theoretically, is pretty high.

They have all the same medical issues that everyone else could have too. Getting pre-op clearance and whatever you need, but just being aware of the specific issues they may have with hormone therapy or the past surgeries they've had. If they've had bottom surgery, getting a foley in may be a problem if they have strictures. A lot of things can come up even for me that I don't think about. [laughs] It's a learning process through our whole lifetime. I'm sure other things will come up as more and more people get all these surgeries more commonly.

[Dr. Ashley Agan]
Well, thank you so much for taking the time today. You're such a inspiration. I'm so proud of you and excited for you. Congratulations on the new Dallas office. I couldn't be happier for you.

[Dr. Gopi Shah]
I would love to do another one on lifestyle medicine, it compliments your practice. I'm super curious. Could you just give us maybe just a quick little peek into what that means and then I would love to have another podcast on that.

[Dr. Sarah Saxon]
Sure. I ran across lifestyle medicine from a friend of mine who's an endocrinologist who now does concierge medicine in San Antonio. She and I both don't really like the idea of just pushing supplements, which is a lot of what other integrative medicine programs are in like. Or there's a lot of hormone therapy and "lifestyle treatments" out there, but it's really just giving people supplements. Lifestyle medicine is more based on diet and food as a way to cure disease instead of just throwing in medications and supplements and pills.

It also incorporates getting enough sleep and what's the data behind all of that. There's a whole curriculum online developed to train physicians and allied health professionals to educate people on that. Really most of our medical schools don't teach us that in our regular training. I think it's becoming-- more physicians want to treat patients in a different way rather than just putting a band-aid on it with a pill.

[Dr. Gopi Shah]
Yes. Right.

[Dr. Ashley Agan]
Yes. it takes time to talk to people about changing daily habits and things like that.

[Dr. Gopi Shah]
Sounds difficult.

[Dr. Ashley Agan]
And not always reimbursed. Believe the healthcare system will change so that those incentives line up.

[Dr. Sarah Saxon]
Yes, it's a little bit easier for me because I'm outside the insurance world now. I know a lot of colleagues now that did the same in primary care and they just have a model they can spend more time with patients. It's really rewarding to be able to celebrate victories with them in a way that's not something that we typically would've done in the same way before.

[Dr. Ashley Agan]
Yes. Absolutely.

[Dr. Sarah Saxon]
I'd say a lot of patients coming in for body contouring don't really qualify because their BMI's too high, but at least I can offer them something else, and then we can set goals for them.

[Dr. Ashley Agan]
Yes. Well, thank you so much, Sarah. I learned a ton. Thank you for being here with us.

[Dr. Sarah Saxon]
Yes, it was a tough fun. I can't wait to be back in Dallas again. We'll all have to meet up. [chuckles]

[Dr. Ashley Agan]
For sure.

[Dr. Sarah Saxon]
I just go about every other week, so next time I'm in town I'll let you know.

[Dr. Ashley Agan]
Sounds great. I'll hear you more often then.

[Dr. Sarah Saxon]
Yes, I know.

[Dr. Ashley Agan]
I know you're on social media. Can you tell our listeners where they can connect with you or learn more about what you're doing?

[Dr. Sarah Saxon]
Yes, my Instagram handle is Saxon MD and then I have two Med Spa accounts, breathe_atx and breathe_dallas and my website is saxonmd.com. If you have any questions for me personally, you can e-mail me at drsaxon@saxonmd.com. Be happy to answer anything.

[Dr. Gopi Shah]
Thank you so much for sharing.

[Dr. Ashley Agan]
I just had a memory about operating with you and I don't remember who coined it but it might have been Lincoln but when we were operating with you that it's sexy time.

[Dr. Sarah Saxon]
I still use that and actually I tell that story to everybody because we have the sexy squad now and surgery is sexy time and we have sexy abs and sexy lips, this and that. I'll tell people because they'll like, "Oh, that's catchy," and I'll tell that story of how I found out that you guys made that up. [chuckles] I think you even gave me a glass mug that has it etched in. This is dancy time. I still got that.

[Dr. Ashley Agan]
I think you're at it.

That's awesome. Well, thank you again, and let's see. Lots of thanks. Thanks to Ann Dong for our social media, Varun Sagi, and Wasik Nadeem for blog posts. Big thank you to all of our listeners. Thanks for checking out the show today. Please subscribe, rate, and share the podcast. You can follow us on social media. We're on Instagram and Twitter @_backtableENT. What do you think, Gopi?

[Dr. Gopi Shah]
Yes, find us on SoundCloud, Spotify, iTunes, Apple, and [unintelligible 00:42:41]. I got that down now.

[Dr. Ashley Agan]
Thank you. It's a wrap. Bye, everybody.

[Dr. Gopi Shah]
Bye-bye.

Podcast Contributors

Dr. Sarah Saxon discusses Facial Feminization on the BackTable 27 Podcast

Dr. Sarah Saxon

Dr. Saxon is a Facial Plastic Surgeon at Saxon MD Facial Plastic Surgery in Austin Texas.

Dr. Gopi Shah discusses Facial Feminization on the BackTable 27 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Facial Feminization on the BackTable 27 Podcast

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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