The traditional approach is achieved with an incision in the neck the ideal incision is done up high, so it kind of hides under the chin and the jaw. But the higher the incision, the longer it has to be to access the prominence of the laryngeal cartilage.
Whereas our approach that I did with Dr. Seth is an approach that's achieved with an incision inside the mouth. in front of the teeth and behind the lip in that sulcus that you have.
So for our transgender and gender diverse population, for our male to female patients, the male face is usually one of the areas that has both too much size and a shape that's different. So the way that we achieve feminizationis to reduce the size of the mandible or jaw, and then to also change the shape of the jaw to make it look like a more feminine shape.
So it's both reduction in size and alteration in shape. And to do that, we have to get access, and the access is afforded by an incision in the mouth that goes from behind the back tooth on the inside, from the one side, across to behind the tooth on the other side.And it gives us access then to the entire bony, mandible, bony jaw.
And then we use drills to drill down and reduce the width and the projection of the mandible. Sometimes we just narrow, we don't have to de project because the operation allows us to treat a wide variety of different shapes of the mandible. And so every patient gets a operation designed for his or her mandible or their mandible.
Working in front of the nerve, we can use a drill. And so I simply like to use drills because that allows me the most flexibility of how I want to alter the shape of the lower jawbone. And then working behind the nerve, it's more difficult to use a drill because the nerve is there. And so we typically use an ultrasonic saw,
or bone reducing device. It doesn't generate heat. There's no spinning elements. It's a really safe procedure for the nerve. So we recognize doing all this work on the mandible, we can really make it look really feminine, in our male to female cases. Or we can add implants in our female to male patients, with the exact same approach.
Once we've done that, we have really easy access then to continue with the incision around the bottom of the jaw, and then we're in the neck. So it lends itself to this approach.
Why is your clinic at UCSF considered one of the best for Facial Feminization?
Dr seth and I, and our voice colleagues, were the very first in the world to write up this procedure. So we're strong advocates of describing our approaches and detail and our results so that others can also offer these procedures to patients.
So nobody had the idea of doing this in this scarless technique. There's still a scar, but the scar is in the mouth, so nobody sees it. And it uses the same exact incision or scar that we would do to do the mandible work. So essentially, you're getting all the benefit of a pre existing incision and then leveraging or then catapulting over that down to the neck to allow us to achieve a secondary thing like reduction of the prominence of the cartilage without any additional morbidity. Our team here had this idea did research on cadavers, on people that have passed, that had donated their bodies to science for research. Once we had perfected the approach and the exposures and the instruments and all that on cadavers, we then began to then use this on patients that had consented and wanted to do this.
And then we did a series of, I believe it was 10 patients, where we began to try this and perfect this technique in humans. And then once we had done this, we wrote up our experience and published as the first in the world offering this approach.
Who is a good candidate for Scarless Facial Feminization?
A good candidate for the procedure is somebody who is transgender, gender diverse, and suffers misgendering because of the size of that Adam's apple or laryngeal prominence. It's a classically male physiognomy or male feature. And can lead in spite of all this other work that we do in the face to make the face look feminine, this is a source of people being identified as male. So it's ideally in patients that want the mandible work and the larynx work at the same time or voice box work at the same setting. We've been seeing more and more patients come to our clinic who've already had some of the feminization surgeries, may have already had the mandible reduced, already had the scar, but their surgeons didn't offer this approach.
Because they didn't know about it, this is very new we're at the cutting edge of research offering this approach. And the patients want to avoid the potential scarring, visibility of that incision in the neck. You might remove the cartilage, might remove the Adam's apple, but then you have a scar that is saying to people, Hey, I am a trans individual and I've had this incision and it can lead to misgendering. And that can contribute to the dysphoria and the unhappiness people feel that they're not being accepted as their gender of choice.
We see it both in the revision settings and we see it in primary settings where people want both operations at the same time.
Where can people learn more?
I would recommend that some patients look at our paper. It's available online. You can look at a scarless chondrolaryngoplasty by, and you can search my name, Dr. Knott. You can also look up under Dr. Clark Rosen, who was our voice surgeon colleague who did this.
Dr. Vyvy Young, who was also on the paper, and Dr. Rahul Seth. All of our names are on this paper. So if you're interested in the research and want to find out about the technique and the approach, we have lovely pictures and figures about this. You can look at our paper. You can come to our website: facialplastics.ucsf.edu. And you can see our gallery of results. So you can see some of our results and things on there. There's descriptions of the approach on our website. And then, of course, you could call to schedule an appointment. Myself or my colleague, Dr. Park, would be happy to go over the procedure with you in detail, talk about whether or not you're a candidate for the operation, and what the pros and cons are and help you make the right decision.