What is Vertical Maxillary Excess? How can it be Corrected within the Context of Facial Feminization?

When a transgender person is seeking to undertake facial feminization surgery there are several relevant FFS procedures that may be recommended depending on existing facial structure and aesthetic goals. Some FFS procedures fall under the category of plastic surgery (soft tissues), others under craniofacial surgery (the underlying facial skeleton), and others yet under orthognathic surgery (surgery of upper and lower jaws).

One of the lesser utilized FFS procedures is the surgical correction of long face syndrome or vertical maxillary excess. This condition is a facial deformity caused by a disproportionately grown upper or lower jaw making the face appear overly long. Depending on the individual, the vertical maxillary excess may result in a very “gummy” smile and a thin, over-elongated face.

Surgical Correction of Vertical Maxillary Excess within the Context of FFS

Vertical maxillary excess is easily correctable with orthognathic (jaw) surgery and is ideal for transgender individuals who are transitioning into females and have an excessively long face relative to their gender-adjusted soft tissue envelope (the skin, subcutaneous tissue, and deep fascia). The surgery is often used in the setting of a staged procedure. For instance, depending on the individual’s existing features, we usually prefer to complete the maxillary impaction prior to doing a rhinoplasty, unless there is to be a long course of orthodontic treatment involved. This procedure should also be done before an upper lip lift is performed because the lip lift is a finishing touch based on balanced proportions of the facial skeleton. Otherwise, the rest of the surgical procedures follow the same long format surgical session within the cluster of procedures that make up FFS.

Reducing the height of the face significantly adds to the outcome of facial feminization because shortening the face creates a more feminine appearance. Typically men’s faces are longer or taller, more angular, with higher foreheads and hairlines than women. And women’s faces are typically rounder, shorter in height, and less angular particularly around the chin and jaw area — amongst other differences.

Other related procedures that may be recommended regarding the lower half of the face to enhance feminization may include upper lip lift surgery, chin recontouring, “Asian” V-Line surgery, or chin reduction surgery.

How is the Surgery Performed?

The mechanics of surgically reducing the length of the face are essentially identical as those used in the Le Fort Osteotomy – an orthognathic (jaw surgery) procedure. Known as the “workhorse” of jaw surgery, this procedure is typically used in non-FFS patients for the treatment of upper jaw malocclusion and cleft palate.

In FFS patients, the Le Fort Osteotomy I maxillary intrusion involves the cutting of the jaw in the area between the nose and teeth to shorten the maxillary bone. Then reattaching the bone to bring the upper half of the face more harmoniously in balance with the bottom half in order to shorten the length of the face to a more feminine aspect.
Read more about the Le Fort Osteotomy I here.

Chin implants may be a popular choice for chin surgery but removing them is also one of the most popular revision surgeries that we perform.

Chin implants are typically used in chin surgery (genioplasty) to improve a “weak” or nonexistent chin, or within the context of Asian V-Line surgery. The popularity of chin implants has grown over the last few years and has become one of the fastest growing procedures in plastic surgery. Unfortunately, chin revision surgery (revision genioplasty) is also one of the most popular revision surgeries we perform due to the often unsatisfactory results or resultant medical complications of using chin implants.

Chin implants are problematic and often cause complications.

Although chin implants are an option in some cases, and occasionally used, we believe that placing a foreign object (an implant) into your own body is counterintuitive and often problematic when there are much better ways to reshape and augment the chin.

Often chin implants are placed by inexperienced or unskilled surgeons and sold to the patient as an “inexpensive” or simple solution. This, of course, is so often untrue, due to the frequency of need for chin surgery revision procedures! Instead of one operation, the patient needs another one — often at an increased cost because a secondary procedure is always more complex than a primary one — not to mention the suffering, stress and mental anguish over the first, failed procedure.

Chin implants often cause complications, with the most common being:

• The implant shifting from its original location,
• The implant eroding into the roots of the anterior teeth,
• And, most commonly a squaring of the chin which in females, in particular, can have an undesired masculinizing effect that is altogether unsatisfactory.

It is our belief, that a far better option in our experience, is to reshape the underlying skeleton or foundation of the chin by altering or repositioning the bone. In fact, there are several non-implant options for genioplasty surgery: the chin may be moved forward, down, centered, widened, or narrowed — depending on the desired outcome. In these cases, outcomes are improved because there are more “degrees of freedom” for the surgeon to reshape the chin into an aesthetically pleasing shape that is in harmony with other facial features.

The risks, complications and side effects of chin implants.

Apart from the obvious risk of choosing an unskilled or inexperienced surgeon to insert a chin implant – that the aesthetic result will not be a satisfactory one – there are several other serious medical complications and side effects to be aware of:

• Damage to the marginal mandibular nerve — leading to permanent loss of movement in the lower lip
• Damage to the mental nerve (a sensory nerve which provides sensation to the front of the chin and lower lip as well as the buccal gingivae of the mandibular anterior teeth and the premolars)
• Implant is placed in the superficial tissues — not under the periosteum (the dense layer of vascular connective tissue enveloping the bones) leading to implant movement under the skin
• The wrong sized chin implant is used resulting in a chin looks out of sync or inharmonious with other facial features
• Injury or damage to the teeth, gums, or surrounding nerves
• Permanent loss of sensation, and/or scarring.
• Slow healing, infection, or internal bleeding leading to removal of implant
• Inadvertent masculinization of the female chin
• Unsightly deepening of the labiomental crease (the deep groove underneath the lower lip)

It is critical that when you choose a surgeon for your chin surgery, that you choose a U.S. Board Certified surgeon. The risks of choosing an uncertified, unskilled or inexperienced surgeon are too great and must be avoided at all costs.

Feminizing the African American Face

If you are of African American heritage and seeking to have facial feminization surgery (FFS) it’s critical to understand that what constitutes a typically female African American face may be vastly different — aesthetically and structurally — than a typical European, Asian, or even Hawaiian (Polynesian) face.

So before you select a plastic and craniofacial surgeon for your facial feminization surgery, it’s imperative to ensure that they have an in-depth understanding of the differences between the facial structures of people of different ethnic backgrounds, and most importantly proven experience with performing FFS on African Americans.

The forehead is the critical to feminizing the African American face.

The shape and size of the forehead and the brow should be the main focus of facial feminization for those of African American heritage. Typically the forehead will project a little further outwards than that of a person of Asian descent, but not as far as that of a person of European descent.

Forehead feminization typically includes forehead reduction and contouring to create a smoother, rounder, and more feminine forehead. Also, a feminizing brow lift and/or brow shaping procedure is recommended to reduce the distinctly ‘heavy’ African American male brow bossing and to “open up” the eyes to create a more feminine and rejuvenated appearance.

The hairline position on the forehead will also be different because African American women tend to have naturally higher hairlines than European women. Therefore, when we perform feminizing hairline lowering we make allowance for the fact that African American women have slightly higher hairlines to begin with, so we may not lower the hairline as significantly as we might in others. Ultimately, it all depends on your newly feminized facial features to ensure aesthetic balance and a natural looking result.

Feminizing the lower half of the African American face.

Typically, feminization of the nose via feminizing rhinoplasty is recommended for those of African American heritage. Often gender transition patients are seeking a narrower, more streamlined female nose. However, we also want to make sure that your nose will maintain a size and shape that is in harmony with your natural African American facial features, so that you still look like you.

Feminizing jaw surgery is also recommended because often the male African American jawline is quite broad and angular – often wider and squarer than what we see in other ethnicities. The jaw will often need to be narrowed and softened via feminizing jaw contouring or reshaping.

Read more about the cluster of surgical and non-surgical procedures that comprise facial feminization.

Facial Feminization Surgery for Women

Often when we talk about facial feminization we are referring to the surgery within the context of transgender individuals. However, there is another set of circumstances wherein facial feminization surgical procedures may be incredibly useful: for cisgendered women (female assigned female at birth) who are born with “masculine”-looking features and who are want to appear more feminine.

What features make a woman’s face appear “masculine”?

The most common complaint we hear from our female patients who are seeking facial feminization is either the forehead and brow and/or the jawline and chin is too prominent or too “bold”. These two features — more than any others — contribute to a masculine-looking appearance in cisgendered women.

The good news is that a plastic surgeon, such as Dr. Deschamps-Braly, who also has extensive craniofacial and jaw surgery expertise can help to feminize these features while still ensuring that you still look like you. And herein lies the true skill of any form of gender-related facial surgery: along with excellent surgical skills, your surgeon must also possess a deep understanding of gender-related aesthetic differences in terms of male/female facial proportions, and an appreciation for what constitutes “beauty” in the feminine face to ensure an optimum outcome.

Read more about the differences between “beautiful” vs. “feminine” here.

Recommended surgical procedures to create a more feminine appearance:

There are many ways you can make your face appear more feminine. After an in-depth consultation, your surgeon may recommend one or more of the following procedures, depending on your circumstances and desired results:

• Feminizing Forehead Reduction and Contouring: to create a more feminine, softer appearance of the forehead, and reduce the heavy appearance of the male brow.
• Feminizing Brow lift (Browplasty) – raises the eyebrows into a higher, more feminine position on the face. Also helps to reduce common telltale signs of aging such as forehead wrinkles, crow’s feet, horizontal or vertical lines such as frown lines and furrows between the eyebrows.
• Feminizing Rhinoplasty (nasal surgery) – some women may have a very prominent or ‘masculine’ looking nose. In such cases, feminizing rhinoplasty may help.
• Feminizing Cheek Enhancement – gives the cheeks a rounder and smoother feminine appearance. Depending on your existing features and the desired effect, the procedure includes either cheek augmentation or cheek reduction.
• Feminizing Chin Recontouring (Genioplasty) – alters the shape of the male chin by reducing, reshaping, or augmenting (making the chin larger). Most often the male chin is reduced in size and reshaped to be less angular, creating a smoother and more feminine aesthetic.
• “Asian” V-Line surgery – suitable for all ethnicities: this surgery works to contour and slim the lower jaw, creating a more slender jawline while at the same time reducing jaw width and a producing a sharper, better-defined chin profile.
• Jaw Contouring – The male jaw is usually wider and more angular than the female jaw. Men tend also to have a sharp back “corner” to the jaw, which can be made to appear rounder and smoother through jaw contouring resulting in a more feminine look. The bone of the jaw can also be shaved along its lower edge and chewing muscles reduced to make the jaw more slender.

Ultimately, the decision with regards to which surgical procedures will suit your circumstances is one that will be made in consultation with you and your surgeon.

Read our next article on the Key Elements of Facial Feminization for Women with Masculine-Looking Faces.

Feminizing the Asian Face

We often often tell our patients that performing facial feminization surgery on a person of Asian ethnicity is very different than other types of FFS.

If you are of Asian background, either Korean, Japanese or Chinese, and you’re seeking facial feminization surgery (FFS) it’s critical to understand that what constitutes a typically female Asian face may be vastly different — aesthetically and structurally — than a typical European, African American, or Polynesian face. For this reason it’s very important to ensure that your plastic and craniofacial surgeon understands these sometimes very subtle, and sometimes very dramatic differences, and that they have had extensive experience in feminizing Asian faces.

The forehead is the key to feminizing an Asian face.

First and foremost, the shape and size of the forehead and the brow should be the main focus of facial feminization for those of Asian background. Forehead feminization typically includes reduction and contouring to create a smoother, rounder, more feminine forehead. Also, a feminizing brow lift and/or brow shaping procedure works to reduce the distinctly ‘heavy’ Asian male brow bossing and “opens up” the eyes to create a more feminine and rejuvenated appearance.

There are several key differences that we take into consideration when we feminize an Asian forehead. For example, a Chinese female forehead will typically project significantly less than a caucasian female, however, a Japanese forehead may even be different than a Chinese one, wherein sometimes the forehead is even positioned ‘behind’ the eyeball, with no overhang above the eye.

The hairline position on the forehead will also be a little different depending on which Asian background you come from. When undertaking feminizing hairline lowering on Chinese and Koreans we make allowance for the fact that they have slightly higher hairlines to begin with, so we may not lower the hairline as significantly as we might for a person of European background.

Feminizing the Asian nose and jawline.

When it comes to feminizing the lower face the most common procedure we recommend for those of Asian background is “Asian V-line” jaw reduction surgery. This is because Korean, Japanese, and Chinese males (and females) will typically have much heavier and wider-set jaws. Asian V-line surgery is very popular all throughout Asia for both men and women.

Feminization of the nose is also quite different for those of Asian ethnicity. In our experience, most Asian FFS patients will seek to in fact augment their nose to make it larger. This may seem counterintuitive in terms of feminization because typically we make the male nose smaller to feminize it. However, in some cases a feminizing rhinoplasty will include augmentation to ensure it the nose maintains a natural aesthetic balance with other newly feminized facial features.

Read more about the cluster of surgical and non-surgical procedures that comprise facial feminization.

Authors: Jordan C. Deschamps-Braly, M.D.; Caitlin L. Sacher, M.P.A.S., P.A.-C.; Jennifer Fick, R.N., M.S.N., F.N.P.-C.; Douglas K. Ousterhout, M.D., D.D.S.

As published in the medical journal of the American Society of Plastic Surgeons: Plastic and Reconstructive Surgery, April 2017.

We are excited to announce that our most recent paper has just been published in the medical journal of the American Society of Plastic Surgeons: Plastic and Reconstructive Surgery. We hope you’ll find the article quite interesting. We’ve included the abstract below to give you an overview of the topic:

First Female-to-Male Facial Confirmation Surgery with Description of a New Procedure for Masculinization of the Thyroid Cartilage (Adam’s Apple)

Summary: Although male-to-female transgender patients commonly seek facial feminization surgery, facial masculinization surgery in the female-to-male transgender population is unreported in the literature. This report documents the first known female-to-male facial masculinization surgery, including a new technique for creating an “Adam’s apple” to enhance the facial masculine appearance of a natal female… Read the article in its entirety here.

If Your Plastic Surgery has “Gone Wrong” There are Several Options Available to You

It might seem like an uncomfortable thing to talk about, but sometimes a plastic surgery procedure may not turn out as you expected causing great stress and a lack of confidence. Either your surgeon was not as skilled or qualified as you were led to believe, and/or, as the weeks and months wore on after surgery, the outcome was not as satisfactory as you’d hoped.

The good news is that most – if not all – botched plastic surgery procedures can be remedied by a skilled and US board certified plastic surgeon.

What are your options if you have a botched plastic surgery procedure?

If your previous plastic surgery procedure has gone wrong, there are several things you can do. And indeed, taking immediate action will help you feel better about your situation right away, even if you might need to wait for a few weeks or months for your revision surgery.

First, don’t panic. No matter what your situation, there is a good chance that it can be remedied.

Second, it’s good to know that almost 15% of our patients come to us for revision plastic surgery, with the most commonly requested “do over” procedure being rhinoplasty or “nose job” revision surgery.

Revision Plastic Surgeries

A “revision” or “do over” plastic surgery is its own art and science. Typically, there are several plastic surgery procedures that can be revised with great success. Following are some of our most common. (Note: if you don’t see a particular procedure here please call our office.)

Facelift Revision Surgery

One of the more frequent requests at our office is for a revision, or “corrective” facelift. There are many reasons why you may feel dissatisfied with a previous face and/or neck lift:

• Lack of longevity, early loss of results, or natural ageing: most facelifts have a natural shelf-life of approximately 5-10 years
• Lack of impact: your facelift didn’t effectively “lift” or rejuvenate
• Previous surgeon lacked an “artistic eye” causing lack of aesthetic harmony
• Looking like someone else syndrome: not looking like “you”
• You’re simply unhappy, or unsatisfied with the previous surgeon’s work

The good news however, is that many facelifts that fell short of their original goals can be improved upon via revision or corrective facelift surgery.
Read more about faceflift revision surgery here.

Rhinoplasty “Nose Job” Revision

Revision rhinoplasty is one of the most common of all “revision” plastic surgeries mainly because it is one of the most difficult of all plastic surgery procedures to begin with, so there is a large demand for corrective, or secondary surgeries.

Reasons for revising a previous “nose job” range from a thoroughly “botched” procedure performed by an unqualified or unskilled surgeon, to unexpected healing issues such as difficulty breathing. But most commonly, our rhinoplasty revision patients are simply unhappy with the appearance of their “new” nose; it doesn’t aesthetically “work” in balance with their other features.

Revision rhinoplasty is actually a very common procedure, and the benefits to your sense of self-image and level of confidence are significant enough to make it worthwhile.
Read more about revision rhinoplasty surgery here.

Eyelid Revision Surgery (Blephorasty Correction)

Blepharoplasty correction or eyelid revision surgery is a surgical procedure intended to correct the results of previously performed eyelid surgery or blepharoplasty with unsatisfactory or unwanted results. However, eyelid revision surgery can often be more challenging than the initial procedure.

There are primarily two types of blepharoplasty correction:

1. Revision of “under corrected” eyelid surgery where too much extra skin or fat was left behind and you are unsatisfied with the results. Eyelid revision surgery can also correct ptosis or “drooping” eyelids.
2. Correction of “overdone” eyelid surgery where too much skin and/or fat was removed giving the eyes a misshapen or unnatural appearance, known as ectropion.
   Read more about Blepharoplasty correction or eyelid revision surgery here.

Revision Ear Surgery (Otoplasty Correction)

Otoplasty (ear pinning) is commonly performed on children at a young age to correct prominent or “sticking out” ears, and as they grow into teenagers and young adults, it may be necessary to revise the original surgery.

Also, depending on the skill level of the surgeon who performed the original surgery, patients may find that the ears were “over corrected” giving them an unnatural or “pulled back” look. Other common complaints include unnatural-looking creases where the ear meets the skull. Revision ear surgery can correct these issues.
Read more about Revision Ear Surgery (Otoplasty Correction) here.

Fat Transfer Revision

Fat transfer revision surgery can help address issues that appear after a single fat transfer procedure or a series, such as uneven or unnatural appearance, lumps and bumps, dissolution of implants, and facial asymmetry. Unskilled application of fat transfer may also result in the face appearing too puffy, swollen, or symmetrically uneven and lopsided.
Read more about fat transfer revision surgery here.

Asian “V-Line” Revision Jaw Surgery

Asian V-line revision surgery is most often requested by patients who do not feel that the original procedure addressed all their concerns, leaving them unsatisfied with the results. For example, a square jaw or protruding may not be “softened” or V-shaped enough, or an unwanted “double chin” may still be apparent reducing the contouring effect of the V-line procedure.
Read more about Asian V-line revision surgery here.

Revision Chin Surgery

Chin revision surgery may be necessary if you are unhappy with the results of your initial procedure. In fact, chin revision surgery is one of the most common procedures we perform, often because the previous surgeon has inserted a chin implant, and this approach has not been successful and the chin needs correcting.
Read more about revision chin surgery here.

Corrective Jaw Surgery

The term “jaw surgery” refers to the most common jaw surgeries: lower jaw surgery, double jaw surgery, and bite correction. Revision corrective jaw surgery is any type of orthognathic surgery that is used to correct a previous surgical procedure.

Most typically, patients are unsatisfied because they do not like the look of their “new” jaw. It may be too masculine, or too feminine, or aesthetically not complementing the rest of their facial features. The most common reason for a poor aesthetic or cosmetic outcome is that while the previous surgeon may have had the technical skills to perform the jaw surgery, he may have been lacking the aesthetic appreciation for how the altered jaw would appear with the patient’s other facial features.
Read more about corrective jaw surgery here.

Skull Reshaping Revision

If skull reshaping and augmentation is performed by an inexperienced or unqualified surgeon you may experience an unsatisfactory result. Negative results may also occur due to infection or if the body rejects a skull reshaping implant. In fact, revision or correction of skull reshaping surgery is actually quite common — about 15% of all or our skull reshaping procedures are revision surgeries wherein we are asked to correct a previous surgeon’s work.
Read more about skull reshaping revision surgery here.

Facial Feminization Revision Surgery (FFS)

To capture authentic gender expression, your surgeon needs to be able to surgically integrate the subtle science and intrinsic differences between the male vs. female craniofacial skeleton. One of the most common types of facial feminization procedures we perform is to correct another surgeon’s work. The main reason for this is that while a surgeon may know technically what is required for feminization, they may not have a comprehensive understanding of the subtle aesthetic qualities of what makes a face “feminine” versus what makes a face simply “beautiful”.
Read more about facial feminization revision surgery here.

What is Virtual Surgical Planning?

Virtual Surgical Planning (VSP) is a pre-operative planning method that involves the visualization of a surgical procedure using 3D imaging computer software. The central patient benefit of using VSP is that it assists your surgeon in predefining each step of the surgical procedure including goal planning, bone segment navigation, and ensuring facial symmetry.

VSP utilizes medical image data to accurately plan the surgery so that the surgeon can then transfer that plan to the patient using customized 3D printed surgical guides.

VSP is used in several plastic and craniofacial surgical procedures.

Virtual surgical planning is quickly becoming a best practice standard of care for orthognathics and reconstructive craniofacial (maxillofacial) surgeries. Dr. Deschamps-Braly commonly uses Virtual Surgical Planning to plan the following procedures:

• Orthognathic (jaw) surgery
• Chin reduction (osseous genioplasty)
• Pediatric forehead reconstruction (various congenital craniofacial syndromes)
• Gender affirming surgery

VSP ensures that the customized treatment plan we create for our patients is highly accurate, and results in the best possible patient outcome.

The benefits of VSP for patients.

VSP helps the patient by giving them a means to visualize exactly what the surgeon will be doing in the operating room, resulting in clarity of communication and increased peace-of-mind. Our patients are typically quite fascinated by viewing a 3D rendering of their own jaw or skull, and knowing exactly how the procedure will work.

Other patient benefits include:

• Fewer ”surprises” and clearer expectations
• Better outcomes – VSP makes it easier for your surgeon to reconfirm planned operative movements
• Reduced surgery time – VSP can eliminate hours of orthognathic pre-op planning

What to expect at your VSP imaging session.

If you are a candidate for VSP the first step will be to undertake a comprehensive initial workup session. This session will include taking all 3D facial and intraoral images, measurements, plain films, study models, midline notations, occlusion class notation, a bite registration, and a cone beam CT scan. A cephalometric analysis is then performed to show the spatial relationships between dental and skeletal elements.

How we build your treatment plan using VSP.

The data collection is then digitized and virtual 3D models are created to simulate the planned surgical movements and outlined patient goals based on the pre-op analysis. The VSP software shows different colors for different sections of the skull, making it easy to see what goes where and in what order.

Plastic surgical guides are then fabricated using a 3D printer, allowing your surgeon to perform the virtual plan in the operating room to ensure precise repositioning of the jaw and other skeletal features.

Want to know more about Virtual Surgical Planning and how it may affect your surgical procedure? Please ask your surgeon during your session or call our office on +1.415.624.3922.

Image source: https://www.medicalmodeling.com/ 

Long format surgery may take 6-12 hours, is it safe to be “under” for this long?

Sometimes it is recommended to undertake several plastic surgery procedures during one session. This is known as a long format surgery, which may take anywhere from 6-12 hours in duration. Most often we recommend long format plastic surgeries for either Pan Facial Rejuvenation, Facial Masculinization, or Facial Feminization.

These are complex surgeries that involve several procedures that need to be performed together to ensure a successful result. For example, if you need Forehead Feminization, it is ideal to combine this procedure with Hairline Lowering, a Brow Lift, and possibly even a Feminizing Rhinoplasty.

How safe is long format surgery?

One of the great concerns often expressed by our patients is:

How safe is it for me to be under anesthesia for this long?

This is a valid concern, and one we wish to address to dispel any myths or fears around long format plastic and craniofacial surgery.

Two elements are critical to understand:

First, it’s critical that your doctor is board certified, and that the procedure is performed in a hospital or certified ambulatory surgery center setting with a board certified physician anesthesiologist in attendance.

Dr. Deschamps-Braly has a stellar professional reputation and is cross-trained in both general plastic surgery, orthognathic (jaw) surgery, and craniofacial surgery. He works with highly qualified board certified anesthesiologists and has admitting privileges at various hospitals in the Bay Area in the event extended postoperative monitoring is necessary.

Second, the duration of long format surgeries can range from a couple of hours for a single procedure, to 10-12 hours for a multi-procedural surgery. This is why we carefully screen our patient’s health before surgery with lab and other tests to assess their suitability for long surgery. We may require additional input from other healthcare professionals prior to long surgery should anything be irregular on your health screening.

However, while a long format surgery can be safely be done in a single stage, it can also be broken up into parts—typically an ‘upper face’ and ‘lower face’ phase that would encompass a few procedures that closely relate to each other. Phases can be performed as close as two days or as long as several years apart.

Because long format surgery involves general anesthesia for an extended period of time, certain precautions must be taken. While undergoing 6-12 hours of surgery is typically safe, it is best to minimize the amount of anesthesia that is required–to also minimize postoperative sequelae.

Although delirium and confusion are rare after long format surgery, we require admission to the hospital for observation for any cases lasting longer than 5-6 hours. We work with anesthesiologists to tailor your anesthesia in such a way as to minimize any post operative confusion.

What type of anesthesia is needed for long format surgery?

Long format surgery is performed under a very light general anesthesia. We typically limit the amount of narcotics and other agents that circulate in the body for extended periods which also improves the recovery process.

Although staging surgeries into two smaller surgeries is possible, it rarely is necessary to do this way, and often increases costs by creating two separate trips to San Francisco.

Your surgeon will explain to you how much and what level of anesthesia is required for your specific series of surgical procedures.

During preoperative testing and evaluation, Dr. Deschamps-Braly will determine how safe general anesthesia will be for your particular situation, particularly if you have any other medical problems or conditions to consider. Local anesthesia is always combined with general to decrease the amount of general anesthesia medications that are necessary.

Your general health and lifestyle habits are also important predictors of outcome:

• You should also have clearance from your family doctor to make sure you are healthy enough for a long surgery.
• You should be put under anesthesia only by a board certified anesthesiologist and plan to spend the night of your surgery in the hospital.
• You will be observed in the hospital overnight to make sure that you recover as planned.
• Additionally, you should make sure that your surgeon does everything to ensure you have good circulation throughout long format surgery and during initial recovery time.

Have any major studies been undertaken in terms of long format surgery and patient safety?

Several studies validate that long hours for surgeries are not a higher risk to patient safety. In fact, one study noted considerable improvements in patient safety.

A 1999 study on the complications of long operations determined that reconstructive surgical procedures often take a long time to perform and duration of surgery is frequently cited as a major risk factor for postoperative complications. Yet, the study suggests that duration of surgery alone is not a major determinant of postoperative complications, and that the type of surgery performed and the patient’s general health are more important predictors of outcome.

A new national study published in the New England Journal of Medicine and presented at the Academic Surgical Congress in February of 2016 showed that allowing surgical residents the flexibility to work longer hours did not pose a greater risk to patients. The highly anticipated seminal study was led by Northwestern Medicine.

In addition, we have performed over 1,700 long format cases without a single serious health related complication. We maintain a successful track record through very thoughtful patient selection and screening.

What precautions do you take to ensure patient safety?

Dr. Deschamps-Braly and his team are highly regarded for their surgical expertise and exemplary patient care. Your pre-op planning consultation with Dr. Deschamps-Braly is an ideal time to discuss all the practical and important ways you can prepare yourself for a safe surgery and an optimized recovery, both initially and in the long term.

There are preliminary protections to take well in advance of surgery, the day of, and post-operation which include:

• Follow all recommended pre-operative recommendations for optimal emotional, psychological, and physical well-being prior to surgery.
• Specifically, your surgeon will discuss what level of sedation is needed, and will aim to keep the anesthesia as light as possible.
• Per your surgeon’s instructions, discontinue any medications before and after surgery that could further alter brain activity.
• Be well hydrated and nourished before surgery, to improve blood flow to the brain. Ensure you drink plenty of water and even electrolytes if you feel dehydrated.

Your safety is always our highest priority and primary concern.

Dr. Deschamps-Braly and his team take every step to ensure your utmost safety so that your entire patient experience is a positive one–that yields you the desired aesthetic outcomes as well as the best postoperative recovery experience possible. If you have any further questions, please don’t hesitate to ask Dr. Deschamps-Braly during your initial consultation.

Beauty is often mistaken for femininity with regards to facial features – especially within the context of gender-related plastic surgery such as facial feminization (FFS).

Therefore, it is critical to note that there is a world of difference between aesthetic beauty and a truly feminine face.

A common type of operation we perform is surgery to correct a previous surgeon’s work for an unsatisfied or unhappy patient. Often, attempts to make the face more beautiful may not have achieved the primary goal of making the face more feminine.

In nearly all cases, revision surgeries are necessary because what constitutes masculinity or femininity in the patient’s facial features has not been successfully captured or represented. The patient may appear more beautiful, but not “feminine” or “masculine” – as is their desired gender representation.