Episode 35: Facial Feminization Surgery

Dr. Franco: All right, team. Welcome to Plastic Surgery Untold, the greatest podcast in the world as voted by us. I’m Dr. Johnny Franco also known as Austin Plastic Surgeon. We have our celebrity cast back again. Despite our best efforts to replace them, they’re still here. And then we have a special guest, Dr. Sarah Saxon, and we’ll get to her in just a minute. Today, we’re talking about facial feminization by the Saxy Squad. And but before we get into the greatness of this unique surgery, let’s catch up on what everybody’s been doing. G-Berto, anything new on the most beautiful man’s home front?

G-Berto: Not…

Dr. Franco: And you’re looking beautiful for today, for those that are just listening and not actually watching, which they should be on YouTube or Instagram.

G-Berto: Thank you. I’m trying to get into a festive, seasonal mood here. Like, [crosstalk 00:00:47].

Dr. Franco: But you don’t really have green on or anything.

G-Berto: No, it is green.

Dr. Franco: Oh, it is? Oh.

G-Berto: Yeah, it’s green with a little red pocket square.

Dr. Franco: Oh, we’re gonna have to talk to the studio, you look blue. As you can tell, we’re not in the same room.

Dr. Saxon: You do look blue.

Dr. Franco: We’re trying to be COVID-safe here, so we’ve got a little bit of a distance going. So, okay, cool. Well, what else is going on besides your festive season?

G-Berto: Just had a good little visit with the family for the holidays, Thanksgiving. My parents came in to visit and we did a little Thanksgiving, if you may recall. You were an invited guest.

Dr. Franco: I was. I was. I was. My Winston pooped on your rug.

G-Berto: He did. He christened my place.

Dr. Franco: He did. He did. And he…

G-Berto: Better him than John.

Dr. Franco: Celebrity, what about you? What’s going on in your life?

Travis: Oh, man, we have been moving for the past two weeks into the new place. So the new place is finally finished, and it’s been awesome. We crossed the finish line with that, closed on it, and closed on the old house and the sale. And now, we’ve been moving in, which has been a nightmare. Warning to anybody who’s going to move or in the process of moving. Take at least a day or two off work. Just do not do it while you’re working full-time, it’s not very easy.

Dr. Franco: So you’re in. You’re in the new house, you’re living it.

Travis: In the new house, we’ve been there now for, like, four or five days. And it’s been great so far. We really like it.

Dr. Franco: That’s awesome. Congratulations. Is it everything you thought it would be?

Travis: And more.

Dr. Franco: Damn, damn, that’s awesome. Speaking of moving in, we’re down the homestretch to finally move into our new office. I know I’ve been talking about this for two years, but we’ve got two inspections left, Monday and Tuesday. And so, hopefully, fingers crossed, all that goes well. I was actually gluing numbers on the door this morning in the rain. So if anyone saw me, working hard, you know.

Dr. Saxon: That’s so exciting.

Dr. Franco: Sarah, tell us a little bit about you. I appreciate you coming to join us today. But tell the world a little bit about you and your practice and what you do.

Dr. Saxon: Yeah, so, I’m Dr. Sarah Saxon. So I am a double-board certified facial plastic surgeon. I…

Dr. Franco: What does that mean?

Dr. Saxon: That means that, so facial plastic surgery is a sub-specialty of ear, nose, and throat surgery. So I started out in a residency of ENT, so I have a board certification in otolaryngology. And then, my fellowship training is in facial plastic surgery. So we have a separate board for that. So I got to take two tests.

Travis: Double the fun.

Dr. Saxon: Right.

Dr. Franco: And just for people listening, facial plastic surgery typically refers to what type of procedures? I know it’s easy for you and me, but maybe not for everybody listening.

Dr. Saxon: Yeah. Anything from the neck up. So of course it doesn’t include brain or spine, but besides that, I can basically do anything. So typically facelifts, rhinoplasty, cheek augmentation, chin augmentation, craniofacial surgery, also involves reconstructive surgeries. I used to do facial trauma in a former life when I was in Dallas in academia.

Dr. Franco: I feel like rhinoplasty is a big one for facial plastic surgeons who had a full ENT training because it kind of gets you a little bit of the best of both worlds from a functional standpoint, kinda from start to finish. I know in my practice, I don’t do nearly the noses you do, but I don’t really do much of the functional and so a lot of times, I’ll incorporate someone like yourself or an ENT to help if they do the functional portion while I do the aesthetics. And probably one of the unique, cool things about your training is you can really combine all of those things together.

Dr. Saxon: Correct, yeah. And some people still decide to do some ENT in their practice. I chose not to, so I’m full-time, 100% facial cosmetic surgery now. Like I mentioned before, I used to do some reconstructive surgery when I was up in Dallas at UT Southwestern. After about two years, I decided to leave my practice there and start my own…set up my own shop in Austin and be my own boss. So that’s nice. We are actually just getting ready to open our second location back up in Dallas.

Travis: That’s awesome. Congratulations. That’s awesome.

Dr. Franco: Congratulations.

Dr. Saxon: That’s finally happening. It’s been a long time coming. So I’m actually going tomorrow just to set up the final punch list to see what else we gotta get going.

Dr. Franco: Awesome.

Dr. Saxon: So probably February, I think, is our first clinic.

Dr. Franco: That will be exciting.

Travis: That’s awesome.

G-Berto: That’s fantastic.

Dr. Franco: You know, I don’t wanna get us off tangent, because it’s not the topic for today. But we’ve talked in the past about the importance of having somebody who is properly trained to do your procedure. And I don’t wanna get off tangent, but if G-Berto or Travis to bring in, but I think the thing that’s important from what you do to somebody who isn’t trained in… Because we’ve talked about, we’ve had a lot of plastic surgeons on here, on this show. Correct me if I’m wrong but I think Sarah’s our first facial plastic surgeon.

Travis: She is, yeah.

Dr. Franco: You know, and so the cool thing about this is you went through a AMA accredited surgical residency. And then there’s a formal fellowship towards the facial plastic surgery. So it wasn’t like you did some stuff, and then said, “Hey,” you know, took a weekend course and then decided to do this.

Dr. Saxon: Right, yeah.

Dr. Franco: And I think that’s the point I’m trying to get across to people about the long road that you took to get to this spot.

Dr. Saxon: Yeah, and actually, facial plastic surgery is pretty intense to be board certified. You have to wait at least two years after the end of your fellowship and accrue a certain number of cases, take an oral and a written board. So even I would say it was probably the hardest board I’ve taken, the hardest exam because I think it’s so scrutinized and a lot of people get confused about it. So I think the facial plastic board wants to take that extra step and make sure that they’re limiting the number of people. So you don’t see a lot of facial plastic surgeons depending on what part of the country you’re in.

In Dallas, there are quite a few just because there are a lot of surgeons doing cosmetic surgery in general. In Austin, there’s only a handful of us. There aren’t that many.

Dr. Franco: Well, we’re lucky to have you. And I didn’t wanna belabor the point, but I think it’s super important. Because I think some of the certifications and different board stuff I think sometimes can be very confusing to people. Especially when you’re having something very specialized. And that rolls into my next point, which I do think that Austin’s very lucky in that we have…for the size that Austin is, I feel like the unique and… And Travis, you deal with more of a range of people than I do but correct me if I’m wrong, but Austin has a super unique amount of sub-sub-sub-specialists. Because plastic surgery itself is a sub-specialty. ENT is sub-specialty. Facial plastic is a sub-specialty inside of a sub-specialty. And then you do facial feminization, which I would consider a sub-sub-sub-specialist, even inside of all of that. Which, to me, means that people have had some additional training in some of these things because a lot of these very unique endeavors not everybody does.

And Austin is so unique in not just facial feminization but microsurgery, other things, there’s just a very unique collection and we’re lucky to have you here as someone who specializes in this. And you have people from all over the country that come to see you here in Austin.

Dr. Saxon: Correct, yeah. And I think Austin is a great city for it. We’re a very creative city and tech-savvy city, so I think it attracts a lot of great minds and great thinkers in medicine to sort of rock the bottom and change how we do things and…

Travis: Plus, it’s not a bad place to live.

Dr. Saxon: I know. It is.

Travis: Getting people to come out here and set up shop is not a hard sell.

Dr. Franco: For those people who aren’t familiar, can you give us kind of the broad, Wikipedia version of what facial feminization is? And then we’ll dive into some of the most common procedures that that includes.

Dr. Saxon: Yeah. Well, I think to start, it’s important to know what is the difference between a masculine and a feminine face. So one big difference is in the upper face. So we want to make sure someone has really large eyes that pop. So typically, we want to enlarge the eye sockets basically, lower the hairline, and raise the brows. And even filling in the cheeks bounces light up into the eyes. So a feminine face really emphasizes the upper face rather than the lower face. And for that reason, also thinning out and slimming down the lower face also distinguishes a feminine face from a masculine face. And of course, the same goes for looking young also helps someone look feminine as well.

Dr. Franco: So our listeners don’t get confused when we’re talking about… Because you do a wide range, and you do facelifts on men, women, anybody. You do a lot of rhinoplasties. I know you do revision rhinoplasties. But when we’re talking about facial feminization, does that include just someone who feels like maybe they need to look more feminine? Is this more people who have undergone some type of reassignment surgeries? Or is there kind of a spectrum?

Dr. Saxon: There is a spectrum. And actually, you know, the procedures that I do were popularized by the transgender community, particularly for someone transitioning from male to female. But I do the same procedures in everyone. I have men come to me for brow bone reduction. I have women wanting to look more feminine because they have masculine features. And every woman, as they get older, they sort of develop some masculine features, like, their brows get lower. You know, as the skin starts to sag, it makes their jawline look a little bit wider. So I kind of think of everything I do a little bit as facial feminization.

Dr. Franco: And do people typically know exactly what they want when they come to see you? Or do people typically just come in and say, “Hey, I wanna soften my look. I wanna feminize my look a little bit,” and then do you help guide them? How does that process start and roll? Because it seems like such a broad topic and so many things you could do.

Dr. Saxon: Yeah, it really depends on the person coming in. A lot of people have been researching for a long time online, and there are huge collaborations of people, and a lot of my patients have friends that had the same procedures. So a lot of people come in having an idea of what they for sure want, but they usually are open to me making other suggestions as well. There are typically some people that come in and say, “I don’t know what I need, I just wanna look good. I wanna pass as female full-time.”

Dr. Franco: Oh, so you’ve had G-Berto in your office. He just wants to look good, okay, cool. Yeah, that makes sense.

G-Berto: I brought her some wish-pics.

Dr. Saxon: It’s a full range.

Dr. Franco: And Celebrity should be honored that you brought his picture in, you know?

Dr. Saxon: Yeah. And now that morphing software is so mainstream now, a lot of people come in with already a face-tuned photo of themselves saying, like, “This is what I want.”

Dr. Franco: Do you do that type of software imaging in your office?

Dr. Saxon: I don’t, because I usually say, you know, “It’s a different skill to morph a photo versus surgery.” But I do use it as a communication tool. So I have an app called FaceTouchUp on my website, and I’ll have people upload their photos and kind of morph it themselves. And if they wanna bring that into the office and say, “Hey, is this reasonable?” I’ll say, “Yeah, that’s good,” or, “No, that’s impossible to do.”

Dr. Franco: I was interested in your statements about this because even with our body contouring, I think with the…and correct me if I’m wrong. But I feel like, with just pure noses, like our non-revision stuff, I think with breast augs, some of those visualizations are really, really good. When you start looking at other features where you’re needing skin to retract, I think with lipo, stuff like…there’s so many factors into account.

Dr. Saxon: Right, it’s not really realistic to have a…

Dr. Franco: Some of those things are hard to predict for a computer that can’t tell if you’ve got stretch marks if you’ve got loose…you know, the list is endless, you know? Big salivary glands.

Dr. Saxon: Right. So it’s good for rhinoplasty and chin augmentation. But besides that, morphed images a little bit more difficult.

Dr. Franco: But I agree with you at least in the idea of…we do wish pictures for the breast and butt that I do all the time. And it just gives me a general idea of what people are hoping for. Because sometimes, and it sounds like you do it too, where you have to just have a frank talk and say, “I can’t do that,” and kind of then make sure that we’re upfront. And I tell people, “I’d rather they be disappointed at that consultation than, you know, $15,000 later,” and you know, especially your face. That’s not something that you can necessarily hide, and we’ll get into recovery in a little bit. Because there has to be some bruising and swelling that’s involved with most of the stuff you do.

Dr. Saxon: Right, and I think probably the one procedure that is probably most unrealistic with those images is the jawline. Because a lot of times, photoshopping or even Snapchat filters, they’ll give a super sharp jawline, it’s super narrow.

Dr. Franco: I love me some Snapchat filters. I love me some. Yeah, yeah.

Dr. Saxon: Actually, most Snapchat filter feminize the face. So they’ll do some of the same procedures that I do.

Dr. Franco: Really? That’s interesting.

Dr. Saxon: But on an exaggerated scale. So I have to rein people in and be like, “Yeah, that’s not really realistic.”

Travis: We can’t do that.

Dr. Franco: What would be the top four or five procedures in facial feminization? Just to make this real for our listeners who are thinking, like, “Maybe that’s something I’m interested in,” but what are the most common?

Dr. Saxon: Yeah, so the most common is what I call the forehead package. So I trained with Jeffrey Spiegel in Boston, and he did a lot of the research behind what makes a feminine face the most feminine. And he found out that the upper third of the face really makes that determination more so than the other parts of the face. So I…

Dr. Franco: Was this pre or post-mask in COVID?

Dr. Saxon: Pre.

Dr. Franco: I’m just putting this into context. Okay. Because you’re very young. Go ahead.

Dr. Saxon: I’m not as young as you think I am.

Dr. Franco: Just a lot of Botox in the face. A lot of Botox in the face.

Dr. Saxon: I drink the Kool-Aid. I’m always poking myself. So my forehead package involves brow bone reduction. So literally setting back the brow bone, lowering the hairline and raising the brows. So that’s what’s gonna really make the eyes pop the most. The brow bone reduction is not as easy as you would think. On the side, you can shave down the bone.

Dr. Franco: It’s funny, I was thinking, gosh, that brow bone reduction has to be so easy. I was like, damn, I probably could do this in my garage. Fuck.

Dr. Saxon: Well, a lot of…that is probably the surgery that needs the most revisions because there are plenty of surgeons out there that think you can just shave it down and be done.

Travis: No, no, no.

Dr. Saxon: No. And so in the middle of your forehead here, you have the frontal sinus which is a pocket of air surrounded by bone. So you can’t just shave that down. You’ll be either left with some eggshell really thin bone or a big hole in your head. So we don’t want you to have those.

Dr. Franco: No, I don’t. No, I don’t.

Dr. Saxon: So I basically take that bone and set it back and use some titanium plates and screws and have it be kind of flat. You want a smooth transition from your forehead to your nose. So, that’s one. I would say the next would be V-line surgery or jaw contouring. You can do that with either just shaping with a special contouring tip that I have or making cuts in the bone. Sometimes you can…

Dr. Franco: I feel like jawline is something that has taken off kind of across the board. Because we’ve talked about it on this show before just from… Obviously, I think your stuff is a little bit more of the bigger changes, you know, filler, other stuff, chin implants, stuff like that.

Dr. Saxon: Yeah, actually V-lines were popularized in Korea, so then it finally made its way over here. So it’s another surgery that I do very often in just the everyday person that comes into my office. Not necessarily just in transgender patients. So that was a third. You wanted four, right?

Dr. Franco: How about tracheal shaving? I’ve heard of this. Is this a thing?

Dr. Saxon: That’s what the next one I was gonna say, yeah.

Dr. Franco: Is that a thing?

Dr. Saxon: I hate the name trach shave, but… Because it’s technically not the trachea, it’s the thyroid cartilage. But somehow that name caught on and that’s what people know it as.

Dr. Franco: I wish we had a whiteboard so we could make G-Berto draw this out for us. Drop a little anatomy on everybody watching YouTube right now, and just show us the difference. But maybe next time, G. Maybe next time.

G-Berto: Yeah, I’ll make sure to invest in one of those for you.

Dr. Saxon: So trach shave, otherwise known as Adam’s apple reduction, I make a tiny, little incision right under the chin here. And we remove that bump, and it’s a little bit easier said than done, because your vocal cords live in that cartilage. So I have to use imaging and a flexible camera in surgery to make sure that the vocal cords don’t get damaged.

Dr. Franco: Does anyone like…?

Travis: I’ve seen this.

Dr. Saxon: I know. Travis has helped me in those cases.

Dr. Franco: But that was gonna be my question. Does Celebrity actually help during this or does he hinder you?

Dr. Saxon: He does, yeah.

Travis: No, no, no.

Dr. Franco: He does. No, he does? Okay?

Dr. Saxon: He drives the camera for me.

Travis: Yeah, yeah.

Dr. Franco: Oh, really? That’s interesting.

Travis: I know. I actually do work sometimes at work. No, I was just gonna say, you know, I’ve done these cases with a couple different people, not just here in Austin but also in Scottsdale. And you definitely take your time, and what’s interesting about it, you go the extra mile when we’re doing these cases. And have me in that flexible, fiber optic scope so I can see between vocal cords and you can see exactly what level you’re at to take off that thyroid cartilage. So we don’t risk damaging or…I mean, there’s still some small risk of damaging vocal cords, but everything we can in our power to limit those risks and reduce that.

Dr. Saxon: Yeah. And if have [inaudible 00:18:06], it’s called the anterior [inaudible 00:18:07] where the vocal cords attach to the cartilage. If you disrupt that attachment, it’s almost impossible to get your voice to be normal again. It takes some pretty extensive surgery. So there…

Dr. Franco: But can you do something to my voice now because I feel like I’d be a little darker. A little more like, “What’s going on, Sarah?”

G-Berto: A little more brooding?

Dr. Franco: Yeah, a little more masculine.

Dr. Saxon: That’s all speech therapy. I’ll send you to somebody good.

Dr. Franco: Can we…? Because I’d like to take people through the process because I think it’s really unique. And I think some people listening to this may have a hard time of figuring out, like, where to go. Because as we talked about in the beginning, it’s very, very sub-specialized, and maybe we can kind of walk through the whole process in kind of a two-minute nutshell here. But if somebody is interested in this, how do they find somebody? Or, how do they know whether this is something that someone does routinely? Because I’ll be honest, the tracheal shaving and most of the stuff you’re talking about is not something I do in my practice. And so how do they find a sub-specialist, someone like you who does these procedures commonly?

Dr. Saxon: Yeah, it’s a little bit different than most other procedures, because there are so few people that do them in the world really that you can Google it and really, in the first two to three pages of Google, you’ll find everybody that’s busy doing it. So it’s not something that you have to keep scrolling and keep scrolling. However, there are a lot of people now that it’s become more mainstream that are trying to sort of dabble in it. So that’s what is more difficult. So you have to really see that they have a lot of before and after photos, make sure that they have other resources. Usually, the people that do this a lot will have resources to endocrinologists to get hormone therapy or a therapist in the area. Some surgeons have patients fly in from all over the world, so that won’t necessarily be a localized thing. But also resources if and what insurance plans are taken for transgender surgery and facial feminization, that’s more typical in California. Texas is more difficult. It changes from month to month, it seems like, the insurance world. But the people that…

Dr. Franco: You’re talking about whether this would be a covered procedure by insurance?

Dr. Saxon: Right. It used to be never, and now sometimes. But…

Dr. Franco: Okay. Unfortunately, that’s what I tell breast reduction patients too. “Maybe.” And sometimes it varies from insurance plan to insurance plan. So you know, just because G-Berto got covered for something doesn’t that mean that Celebrity would. You know, especially if they’re covered by different insurance companies.

G-Berto: I needed those calf implants, John.

Travis: I was just gonna say, I need my calves to be bigger too.

Dr. Saxon: It usually depends on who the person works for. So, like, companies like Starbucks or Amazon or Google, sometimes their specific insurance plans will cover it. But if a surgeon really does a lot of this surgery, they’ll be more knowledgeable about all the ins and outs of all of these little details. And when to come off hormones, and how… They’ll have a specific post-op care plan, which I know we’re gonna talk about in a little bit. It’s not just something that they may do once or twice a year. It’s something you do on a weekly basis.

G-Berto: I’m sorry. Dr. Saxon, are these procedures that are done in stages? Or is it all done, like, at one time when you’re doing these feminization-type procedures?

Dr. Saxon: It really depends. It depends on how much downtime a person has. If someone’s doing a lot of surgery, sometimes these can be up to eight-hour surgeries. I mean, you really need to take a month off of work, and mostly, for swelling, you don’t really feel bad. The times that I say absolutely, you have to stage it is if it’s an older person. So they not only need all the bony restructuring, rhinoplasty, lip lift, all those types of procedures. They also need procedures that help them look young, like facelifts, and blepharoplasty. And those things, if you account in the one-stage procedure, it just doesn’t look as good. When you’re doing a facelift on someone who’s already had eight hours of surgery, they’re so swollen that once they heal, that skin is just gonna recoil back a little bit. I just don’t think that the results are as good. So I stage those patients out about six months, at least if not longer.

Dr. Franco: And we also worry about standard stuff too. Once the surgeries get long, I mean, people start to get tired. Two, we worry about DVT blood clots. It’s one thing if it’s a big tumor in the face and you have to do all these stages at once, that’s much different than the stuff that we can electively do that’s not gonna harm somebody.

Dr. Saxon: Yeah. And it’s different for me because, you know, back in my former life, I had residents, and fellows and a whole team of people to help me. And now it’s just me. So I actually like…

Dr. Franco: Well, what about Celebrity? He’s part of your team?

Dr. Saxon: Yeah. I mean, scrubbed in helping with surgery.

Travis: Not just there for moral support and keep the patient still.

Dr. Saxon: It’s really physically taxing on the body. I actually inject my neck with disport because I get knots in my neck from these long cases. So I cut it off at six hours, and if it’s longer than that, I’ll stage it out.

Travis: I think that’s just a pretty good general rule of thumb as far as the… I like that six-hour time. Because then, at least you could have the conversation, like, “Hey, okay, at six hours, are risks gonna outweigh the benefits? Are the benefits gonna outweigh the risk? How do we make decisions?” I like that six-hour time.

Dr. Saxon: It might go over a little bit, but if I’m anticipating longer than six hours, I’ll say, “Hey…” And some of these procedures can be done in the office too. So I do lip lifts in the office all the time. So I’ll say, “Hey, you know, we can do these procedures in the OR. Why don’t you come back a few months later and do lip lift and blepharoplasty in the office?” And that cuts down on some of the time too.

Dr. Franco: And I think that’s super important is where you have somebody with some experience that can help guide the order to do stuff. Because I think sometimes if you’re changing jawline, bony structures, and then trying to do a facelift or something, sometimes the order doesn’t matter depending on the specific situation. But sometimes it does and you want someone to help you guide you a little bit to make sure you don’t kind of mess up the order and then having to revise things.

Dr. Saxon: Right. And for the most part, people stage things just for a financial reason. So I can give them kind of a stage criteria, like, “This is really what’s most important for you to look the most feminine. So do this first. And then here is a second surgery, we can do this second and here’s the third.”

Dr. Franco: It’s funny because we talk about that all the time. You know, this is the biggest bang for your buck, you know? This is where you should start.

Travis: Well, helping the patients prioritize some of that stuff because you guys see the finished product and y’all have done cases where patients have had four or five things done, right? So y’all know, “Hey, if you have this much money right now and you’ve got this much time off that you can devote to this, this one thing is gonna give you the…this facelift is gonna help the most with rejuvenating your look.” And you guys can help guide them through that.

Dr. Franco: And then, you know, so now people have found surgeons. In the facial feminization world because it is such a sub-specialty, do you tend to do virtual appointments at least as a first screening to see if people are even a candidate, get an idea of a pricing? I know at some point, you see them in the office to kind of go over some of the fine stuff. But is that an option? Because it seems like if you’re out in West Texas, it may be really hard to find somebody who does this without coming to Austin or Dallas or Houston.

Dr. Saxon: Yeah, that was actually one of the easiest things that I went through during COVID is we already had that infrastructure for virtual visits in place because I do get people from all over the world really. I did a consult the other day from someone in Singapore. But so that’s something I typically do. I have blocked time in my clinic schedule for virtual visits, so it’s something I do every week even now that we are back in the office.

Dr. Franco: Which I think has been really nice for people especially for some sub-specialists, because while it may be a 30, 45-minute visit for us in the office, if they’re coming from something like, you know, West Texas, Odessa, Midland… I picked that because my aunt just drove here because she had a heart procedure done recently. It took them seven hours because of road construction, each way. So, you know, that’s not nothing. So and to at least get an idea, get the ball rolling, and make sure this is a good fit.

Dr. Saxon: Yeah, the hard part is I still have to see people for post-op visits. So you can still have wound issues, these are huge surgeries. So you still have to know if you’re traveling somewhere to have these big surgeries that you have to be willing to go back if there’s an issue with healing. And that’s probably the hardest thing that people have to grasp. But if you find someone that does facial feminization in your area, they still may not be a right fit from a personality standpoint, and from an aesthetic standpoint. Because everybody has their own style.

Dr. Franco: Style, yeah. G-Berto and I talk about that all the time because we feel like our style is very similar, you know? I don’t know. We’ll see what happens.

G-Berto: I couldn’t agree more, Dr. Franco.

Dr. Franco: And from a surgery standpoint, if you had a couple tips, words of advice for preparing the surgery, going through the surgery, what would you tell people in terms of these procedures?

Dr. Saxon: Yeah, well, typically, if I have someone who’s trans, they’re on hormones. And the hardest part of preparing for surgery is going off those hormones. And that’s from a safety standpoint because you run the risk of DVT or deep vein thrombosis during surgery if you’re on high doses of estrogen and sitting paralyzed while you’re asleep during surgery. So I always have everyone come off of hormones for two weeks beforehand. And then as soon as they’re up and walking around after surgery, which most of the time it’s the day after surgery, then they can go back on them. But it’s almost like experiencing menopause a little bit, so some mood swings, some night sweats, all the good stuff. So that can typically be the hardest part.

Dr. Franco: So something they should make sure that they’re clear with their physician before the surgery if it’s coming up, just to make sure they’re…

Dr. Saxon: Yeah. And then maintaining good nutrition, because I have seen some wound issues just from not getting enough protein or vitamins in their diet. Being optimized medically, that’s very important because you wanna heal well. I don’t have as many wound healing issues as what I think about in body surgery, you might say otherwise, but the face has a really strong blood supply. So I don’t usually see infections or things like that, but it does happen from time to time.

Dr. Franco: And this is something we’ve talked about in terms of pre-op clearance stuff, you know, and getting labs, other things done ahead of time, especially if they’re coming from out of town. I tell people, “Do it sooner rather than later so there’s time if you need to adjust, do something. You don’t need to do them the day before, because you come all the way to Austin and you get canceled for your surgery,” that’s heartbreak for everybody.”

Dr. Saxon: Yeah, yeah. And everything that I do is very visible, so any incision that I make, especially in the hairline or lip lifts, you want those to heal really well. I actually now started putting everyone on Mend, which is a powder supplement you can put into smoothies. So after jaw surgery too, you’re all swollen, so you’re using smoothies and milkshakes and everything too, so it’s just really easy to put in some powder and get your vitamins in. So yeah.

Dr. Franco: Just like that. Just like that. And then, what about recovery? What are some recovery tips that you have for people?

Dr. Saxon: Yeah. The hardest part about recovery is the lower face, because gravity brings all swelling, and you have lots of huge muscles that attach to the mandible. So that’s the hardest part, and I’ll have people on steroids for that. It’s hard to chew, hard to talk. The other part of the procedure after forehead surgery, your eyes can sometimes swell shut, they get so swollen. Another reason I have you on steroids. But those first 24 hours are the worst. And after that, it’s really not bad other than dealing with boredom and swelling. But I don’t typically see a lot of pain.

Dr. Franco: Just do a little Netflix and chill. Netflix and chill if you will.

Dr. Saxon: I do hear stories from other places where patients will be in pain, but I use a lot of regional anesthesia during the procedure.

Travis: I can attest to this. I love it. I love it.

Dr. Saxon: Yeah. And then after surgery, I alternate Tylenol and Ibuprofen every two hours, and so most of my patients aren’t even on narcotics. They’re just taking those, some icing to help with swelling and that’s about it.

Dr. Franco: Let’s jump into that, a little bit of anesthesia for this. And maybe you and Celebrity can talk a little bit about any special stuff. You do some blocks, it sounds like, during these procedures. And maybe anything special that Celebrity does for some of these facial procedures.

Travis: Yeah, I mean, most of the cases that I’ve done with Dr. Saxon have been general anesthetics, and with those cases, the patients are completely asleep, completely unconscious with a breathing tube. Especially when we’re doing rhinoplasties and things where I have to protect the airway, we have to have a breathing tube down into the trachea to completely seal it off. So none of the stuff that we’re rinsing out in the nasal passage, any blood, or anything that may drip down, none of that is gonna get through their trachea into their lungs, because that could set them up for post-operative pneumonia.

But other than that, pretty straightforward cases. They’re incredibly challenging on her end. Lucky for me, once they’re intubated and everything is set up, they’re pretty smooth cases, and they’re even smoother because, like, she alluded to earlier, she uses a lot of regional anesthesia. So once she goes in and the patient’s already asleep, she’s able to localize certain nerves in the face or in the trachea in wherever she is taking care of, and she’s able to completely anesthetize them. So, the patient is not transmitting any of that pain to their spinal cord and to their brain. So that’s not even being sensed. It makes my job a lot easier.

Dr. Franco: But you make everything look easy, Celebrity. I mean, that’s just a given. That is a just given with you, yeah. Yeah, even those jogger scrub pants, you just look so good.

Dr. Saxon: Yeah, so I…

Dr. Franco: You have jogger scrub pants too?

Dr. Saxon: I do. I do.

Travis: That a girl.

Dr. Franco: That’s interesting. Yeah, if I only had the ankles for it.

Travis: I know what you’re getting for Christmas now.

Dr. Franco: What other take-homes would you like us to know or would you like the world to know about facial feminization surgery?

Dr. Saxon: I would say it’s a really rewarding surgery. I think there are a lot of nuances to the face that a lot of people don’t really get with your typical facelift, rhinoplasty. There are a lot of other options out there than what you’re normally searching for online. So if you don’t really understand exactly why you don’t like something about your face and the things that you’re researching aren’t really…you don’t think that’s it gonna help you, there’s probably another option out there. And usually, that involves a bigger surgery like bone work, but I think it’s gonna make a big difference. And it’s not as obvious as people think.

Usually, you look really, really natural. It’s not like you’re kind of a caricature of yourself. It’s just making tiny millimeter changes that end up making a big difference overall.

Dr. Franco: Because even with a lot of the bony structure you’re talking about, just so people don’t get confused, most of these incisions just like we do with the facelift, either are right at the part of the ear, the hairline level, up in the top of the hair and some fancy zigzags. There’s lots of ways that you’re hiding this, there’s very few actual facial cuts. Or in through the mouth and through the inside eye like we do like a bleph. So you’re still using all of those aesthetics tricks for all this bony work, and that’s what makes some of these big challenges. It’s not like you have a big cut across your forehead.

Dr. Saxon: Right, correct, yeah.

Dr. Franco: I just don’t want people who are listening to get confused that all this fancy stuff you’re doing is coming straight through.

Travis: Yeah, she’s being modest. She’s very, very, very good at what she does.

Dr. Saxon: It’s actually, I feel like facial feminization, especially doing bone contouring, is so much more like sculpture than anything else. It’s not something that you can…you know, some people talk about virtual surgical planning, and I think that’s useful. But you can’t discount your eye when you’re drilling and contouring the bone to know when to stop, because that’s just gonna look good. And it takes more of an artistic eye than just a left-brain surgeon that can look at a CT scan and say, “This many millimeters.” A lot of it takes some finesse at the time of the procedure to know when to stop and what’s gonna look natural.

Dr. Franco: And I feel like that’s hard because it’s kind of a moving target a little bit. It’s not like our breast augs where we can just sit them up, you know, the sizers [SP], and say, “Damn, that looks good.”

Dr. Saxon: Yeah. I think especially with jaw surgery, I’ve seen it overdone before. So some surgeons will cut off the ankle of the mandible, which is fine in some people. But for others, you’re kind of left with no jaw back there, and you don’t have anything for the skin to sit on. So no matter how much you wanna create a jawline, you’re just never going to without adding implants or fillers back in because they’ve over-resected the bone. So maybe on a CT scan, it looks great, but when you look at a person after they’ve healed, it still doesn’t look awesome.

Dr. Franco: So measure twice, cut once, is that what you’re saying?

Dr. Saxon: Yeah.

Dr. Franco: And so we like to do a little segment on the podcast called Behind the [inaudible 00:35:28]. And so this is something either in surgery or behind the scenes that you think is really cool that most people wouldn’t think about in the surgery. What’s a cool little nugget you can share with the world?

Dr. Saxon: A cool little nugget? So, about the surgery itself? Or…?

Dr. Franco: Anything in the world of facial feminization.

Dr. Saxon: So some people don’t know this. About 5% of people do not have a frontal sinus. It’s just solid bone in your forehead.

Travis: I didn’t know that.

Dr. Franco: I feel like that’s G-Berto. I feel like that’s G-Berto.

G-Berto: Are you saying I’m hardheaded?

Dr. Franco: Yes, I am.

Dr. Saxon: So for the most part, I have to use titanium plates and screws for forehead surgery, but there are those 5% of people that it’s just solid bone and I can shave it down because they never developed a sinus.

Dr. Franco: Damn, okay.

Travis: Very cool.

Dr. Franco: Cool. Can we do a quote of the day?

Travis: You got a little quote of the day ready? All right, all right.

Dr. Franco: Who’s taking this, Celebrity, G?

Travis: I’m taking this one. I’m taking this one.

Dr. Franco: Okay.

Travis: This is Maya Angelou, and it says, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” I thought that was good for the facial feminization thing, because I mean, small changes make a huge impact on these patients’ lives.

Dr. Franco: I like it. G, any comments? You seem speechless?

G-Berto: I feel like Travis just did a mic drop here.

Dr. Franco: Oh, really? Like footprints on the moon? Okay. Well, cool. Well, before we wrap up today, I do want to…because as some people may or may not know, not exactly today, but this puts us basically at our one-year anniversary. Because this will…we film a couple of episodes in one day. This will be our last filming for the end of the year. So, one year. So I got all of my colleagues… I can’t hand it to them because of COVID screening and obviously why I couldn’t tell that G-Berto’s got a green coat on. I did get us… And I don’t know if they can zoom in on this. But I got us some Plastic Surgery Untold Yeti mugs, extra-large here.

Travis: Oh, yeah, money, that’s what I’m talking about.

Dr. Franco: So I got one for each of my colleagues here. And as a new tradition, one for our guests. Our guests get a Yeti mug, they’re gonna carry around our podcast, so boom, boom, boom.

Dr. Saxon: That is so awesome.

Travis: Very cool.

Dr. Franco: Yeah, a little something-something. Producer Donald, who is sitting behind me, may or may not get one. It depends on whether he carries some weight today. I don’t know if they can zoom in. He’s back here, you know, just kind of hanging out. Not sure what’s going on back there. He was supposed to be fact-checking G-Berto, but G-Berto didn’t say anything today. So, team, any last words, anything before we wrap this up?

G-Berto: This was a really great cast. Thank you, Dr. Saxon, for enlightening us about facial feminization.

Dr. Saxon: Thanks for having me.

Dr. Franco: I truly appreciate you coming and nice to have someone who’s such a sub-sub-specialist take the time out of your busy schedule to come enlighten us. Because this is something I don’t do in my practice, and so truly, truly appreciate it. And I think there’s a lot of people out there that would love this. And tell me just again one more time, your website and how they can get a hold of you if they have questions.

Dr. Saxon: So, my website is saxonmd.com. You can also follow us on SaxonMD on Instagram. We’re on Facebook. We’re everywhere, on YouTube.

Dr. Franco: And you’ve even got the Saxy Squad. What is that?

Dr. Saxon: We have the Saxy Squad. There’s kind of a long story behind that, but since my last name is Saxon…

Dr. Franco: So we’re gonna get the PG version.

Dr. Saxon: So actually, when I was at UT Southwestern in Dallas, I found out, when I was about to leave from there, that the residents, before I would staff a case at Parkland, they would say to themselves, “It’s Saxy time.” And so it just kind of caught on, so a lot of my marketing is, “We have Saxy lips, and Saxy cheeks, and Saxy lift,” and everything is Saxy.

Dr. Franco: But I like the Saxy Squad.

Dr. Saxon: Saxy Squad is just everybody that is associated with our office who can be in our little special club.

Dr. Franco: Awesome.

Travis: I dig it. I dig it.

Dr. Franco: Well, we appreciate you letting us be part of your club today, so…

Dr. Saxon: Yeah, you’re totally a Saxy Squad.

Travis: Saxy Squad, I love it.

G-Berto: It’s nice to have some female energy on this show again.

Dr. Saxon: I know.

Dr. Franco: Well, I’d like to thank everybody for listening. Plastic Surgery Untold, download us on iTunes, iHeart, and now Pandora, wherever you get your favorite podcasts. So the greatest podcast in the world as voted by us, Plastic Surgery Untold. Thanks, guys. Bye. See you.

Travis: See you.

About The Author

Dr. Johnny Franco
Episode 34: Is Zoom Neck a Thing?Episode 36: Building an Empire – The Synergy Way


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