Injectable Fillers & Gender Affirmation

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Welcome to Park Avenue
Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your co-host, Summer Hardy,

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a clinical assistant at Bass
Plastic Surgery in New York City.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator and technology innovator.

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The title of today's episode is
Injectable Fillers and Gender Affirmation.

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We've talked about fillers before. Fill
me in on this filler topic, Dr. Bass.

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What do fillers have to do
with gender affirmation?

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Well, let's start with
the basic definition.

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Gender affirmation or transitioning
when it comes to the face,

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what does that mean?

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So it's taking features that
you were born with that may

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resemble one gender and creating
features that are more identifiable

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to the patient and to the
public as a different gender.

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Okay. So we're going to talk about the
ins and outs of gender affirmation or

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transitioning for the face.
What's the focus of this episode?

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This is a review of what the
standard approach in the facial

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aspects of affirmation are.

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We're going to talk about some
cutting edge things to improve

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customization and
precision in creating the

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right gender look because again,

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it's not literally binary.

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And so we're talking about trends,

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not the specific needs or preferences
of any individual patient.

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That's going to vary from
person to person, of course.

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Everyone's face is unique and
everyone's preferences are different.

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To join me in this discussion,

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I've invited Dr. Jason Plume back to
the podcast and he's been a guest on

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some of the most critical topics
in facial plastic surgery on our

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podcast.

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And he's also been the guest on
a number of the top streaming

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episodes of the podcast.

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Dr. Bloom is a facial
plastic surgeon in Bryn Mawr,

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Pennsylvania. He completed
his residency in ear,

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nose and throat, what medically
we call otorhinolaryngology,

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head and neck surgery at
University of Pennsylvania,

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and his facial plastic surgery
fellowship at New York University

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and Manhattan Eye Ear and Throat Hospital.
And that's also where I completed my

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plastic surgery training so we
share some common academic and

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primatur.

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Dr. Bloom's currently the co-director
of the Facial Plastic and Reconstructive

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Surgery Fellowship Program at
the University of Pennsylvania.

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Dr. Bloom, welcome back.

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Well, thank you for having me.
It's always nice to chat with you.

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I get to see you at some meetings and
some academic things throughout the year.

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So it's certainly nice to be back
and thanks again for having me.

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Welcome, Dr. Bloom.

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Let's kick things off with an overview
of what kinds of surgical procedures are

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done on the face as part
of gender affirmation.

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So some of the surgical
procedures I would say

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more commonly are what's
typically known as

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FFS surgery or facial
feminization surgery.

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These are really kind of
procedures in general that can

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be used to reshape the forehead, brows,

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nose, cheeks and jawline,

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as well as while it's
not a facial surgery,

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something to minimize the
appearance of the Adams Apple in a

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male to female kind of transition.

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These are a lot of the basic kind
of surgeries that are done to

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achieve, for example, a
more feminine appearance.

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It's important to consider things that
the patient may want. For example,

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a typical more masculine brow is

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flatter and less arched,

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but a more feminine look may go for a more

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laterally arched brow. When
we're talking about the nose,

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it could be a more masculine
nose has a straighter,

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more projecting bridge versus
a more feminine delicate

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nose has maybe a soft slope to
it with a little bit more upturn

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and narrowness.
When we talk about forehead,

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male more masculine
foreheads are typically a

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little bit more broad and

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flat,

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whereas a more feminine
forehead tends to have more of a

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slope to the aspect where it reaches the

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supraorbital rim above the brows.

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And then more feminine
cheeks, for example,

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there are cheek implants and
fillers and things that can be done

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such as fat when we're talking
surgically to give more kind of plump

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rounded cheeks

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with more volume out laterally
and less anteriorly in the face.

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And then finally the jaw, and
we can talk about the chin,

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whereas masculine jaws
tend to be more angular,

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wide in the posterior aspect of the jaw.

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And then the chin also has certain
aspects of it which lend to

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a more masculine or feminine chin.

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So a more feminine chin is
more narrow anteriorly with

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we like to keep the volume
within the nasal base and then

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a more masculine jaw or chin
tends to be more square with

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more of the volume centered within
the oral commissures. So all

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these things we look at
and surgeries can go in

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all these different directions
to either masculinize or

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feminize a face depending
on what the patient wants.

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So that's really interesting.

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And I think there's some history
here as well because certain

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things about facial shape,

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the way it's been perceived
by gender historically were

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not as precise as the analysis
that's been made today of gender

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differences.

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And so some of the surgery for
transgender people decades ago

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created a very stylized
look that was recognizable

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not as male or female but as trans.

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And surgery has evolved a
great deal, become much,

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much better to really create
a much more natural look to

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the face with any of these
gender-affirming techniques.

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I think even so much so that as you know,

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in plastic surgery in the
plastic surgery community,

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there are now accredited
fellowships within plastic

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surgery and actually facial
plastic surgery where you can

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do full fellowships just
specializing in the area.

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In the facial plastic surgery fellowships,

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there are to really specialize
in the face and then full body

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gender affirmation fellowships
within the plastic surgery community.

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Yeah, that's a good point.

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And you brought up an issue
about shaping on people's

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faces and you talked about bone surgery
and there's surgery with implants and

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there's also surgery with
fat. You mentioned that.

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And that's going to feed into our
main subject of discussion in this

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podcast episode.

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So how do you think about
implants versus fat in

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terms of what they're
able to do in the face?

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And we'll go from there
and look at injectables,

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which is our main subject today.

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It's very interesting.

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I think there are places where implants do

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very well and they are
by go - to. For example,

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where you have a bony buttress,
for example, the chin,

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some people want a
long-lasting improvement and I

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think a chin implant works
very well in those cases.

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I don't like to put fat or
something in the soft tissue

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that is less shapely and
more amorphous when it's not

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on the bone. So I personally don't use fat

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to augment the chin.

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But when we're talking about
the mid-face and the cheek,

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I can't tell you is probably since my
fellowship was the last time I put in a

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true cheek implant and I
tend to go with either filler

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or fat because you can inject
those at multi-different

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levels,

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both on the bone and in some of the
soft tissue to give volume and it

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works really well in those cases.
So I think it really depends

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on the actual procedure performed

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and the area that they're
looking to get improvement.

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Well, as you said, you
get more durability,

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sort of a permanent change with
bone surgery or with an implant,

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but things like creating a female cheek,

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which is supposed to be
very curvy, very soft,

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not have a highly sculpted look,

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things like fat are probably a better
choice for doing something like

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that because it has that soft round

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appearance that you're trying to create.

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And from there you can think about how

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much precision do you have?
How much longevity do you have?

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How much predictability or control

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over both size, shape,
position and longevity?

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And that's where fat
sometimes lets us stay.

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If I could make one other comment
about just the surgical procedures,

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I think in general,

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the majority of male to female

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gender affirmations like
procedures are reductive in nature.

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You're going from a more kind of
a square chin to a narrow chin.

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You're going from you're trying
to push the forehead back,

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you're trying to give some
more slope to the nose.

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A lot of the procedures are reductive.

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It's much harder to achieve
that kind of result in a

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non-surgical manner.

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And then we think of the
female to male transition or

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gender affirmation is more additive.

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So it's a lot easier to achieve some
of these results when we're adding

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volume or structure or
support rather than...

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And so there is a little
bit easier option.

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We have more options in a
non-surgical and surgical manner

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versus when we're looking at
the male to female transition,

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it's a lot harder to achieve
that without surgical

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procedures.

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This has been a really
interesting discussion.

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There are a lot of small details
I hadn't considered before.

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How much customization is there?

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Are surgeons just producing
cookie cutter faces?

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Yeah. I mean,

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I think now our techniques
are so much better as Dr.

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Bass was saying. Our
techniques are better.

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We're able to not only

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achieve better, more natural results,

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but now we have other things
in our armamentarium to

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perform small tweaks on
the patients to create

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more to help us do these procedures.

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And a lot of the procedures can
be performed without surgery.

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So if we're looking to go from
a more masculine flat brow

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to a more feminized look
and get the brow elevated,

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you can use neuromodulator to do
that and really shape the brow

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and position the brow peak
where you want in our offices

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using neuromodulators
or give more volume to

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someone's lips with fillers.

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There's a lot more things we
have at our fingertips now

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that allow us to produce
these more precise

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changes.

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So I'm going to come back to that,

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but I just hear Summer's
question and want to

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add a comment.

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I think people are trying
to harmonize features,

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look at everyone's individual face
when they do gender affirmation

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surgery. But at the same time,

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there is this standard suite of
techniques working on the brow,

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working on the nose, working on
the cheeks, the jaw, the chin.

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And there are limits to the precision
that that surgery can give you

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the control you have over nuances of

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shape because you're dealing with bone,

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you're working with power tools,

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and you can do a lot
of things predictably.

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And surgeons have things that work
well in their hands so they do have a

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style or a face to an extent,

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even though they do try to
adjust those techniques for

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the individual facial
features to create harmony in

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the new gender.

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Dr. Bloom and I agreed to do this
episode when we were talking at a meeting

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about the use of injectables
in transgender patients.

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So Dr. Bloom,

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can you tell me a little bit about why
and how you started using injectables

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compared to surgery or fat grafting?

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Yeah, I mean that's a good question.

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As a faculty at the
University of Pennsylvania,

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I get to work with the facial
plastics residents and fellows,

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the ENT residents and fellows,

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as well as the dermatology residents
and plastic surgery residents.

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And one of the former residents
now attendings came to me and

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said, "Man,

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I see a lot of patients
seeking gender affirmation

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procedures." And he was a
dermatologist and he is a

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dermatologist. And he said,

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"It would be so great to
create a multidisciplinary

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clinic for the residents where
you can come in and lecture us and

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teach us about the differences
between the genders and how we can use

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injectables to help these patients
sometimes as almost like a

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trial run in some cases
to see what it would be

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like to have a little bit more volume in
the lips or a little bit more volume in

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the cheeks without having
to undergo surgery. And that

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discussion and

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after multiple meetings
and things like that,

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we decided that this would be such
a great offering to the community.

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And just with our connections through
the different injectables companies,

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we could have them sponsor it and
it's great teaching for the residents.

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And now I've taken this idea and not

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only have the residency clinics,
but we do it in our office.

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I've written multiple publications
about this and I have people coming

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to see me from sometimes all
over for even injectables.

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So that's great.

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And part of the reason I got so excited
when you mentioned you were doing this

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was because it hit a
lot of the same concerns

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and excitement that
I've had in this regard.

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So now that you've gotten a lot of
experience and written articles,

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share a little bit about your view
on what some of the advantages and

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disadvantages of injectables are
compared to surgical techniques

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that are currently available.

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Sure.

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So I think some of the advantages
are certainly it's not a

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surgical procedure.

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We can do this in our office
and allow patients to see

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immediate results of a lot of these
procedures with very little to no

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downtime. And

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a lot of patients just in general,

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whether we're going a true a
gender affirmation procedure or any

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kind of surgical procedure
in general, patients are,

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they're scared of surgery, they're scared
of anesthesia, things like that. And

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it's now injectables,

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whether you're using
neuromodulators or fillers are so

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widely accepted at this
point that patients may

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00:18:27,570 --> 00:18:30,090
not understand or know like, "Hey,

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we're going to do a facial feminization
surgery," but they know what Botox is

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and they know that fillers
give volume and plump tissue.

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So it's a little bit more familiar with
a lot of our patients. Additionally,

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as you mentioned, the
precision is extremely,

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extremely high.
I can almost sometimes pinpoint

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where we want

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the brow height to be or
the brow peak to be using

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neuromodulators. Obviously

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the disadvantages are they go away.

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00:19:06,830 --> 00:19:11,710
So whether you're using a neuromodulator
or a filler, they're very temporary.

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But on the other hand, it
gives sometimes, like I said,

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the patient an option to try it
out before they're really ready to

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00:19:21,110 --> 00:19:25,850
make the next step and undergo a surgical

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00:19:25,890 --> 00:19:28,350
procedure. That being said,

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there are many cases in most

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00:19:33,310 --> 00:19:37,730
cases where a lot of the
facial femininization surgeries

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are covered under insurance
depending on the insurance plans.

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And they'll get a lump sum, the surgeon,

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to use for maybe a bottom
surgery, a top surgery,

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as well as facial feminization cases.

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00:19:55,470 --> 00:20:00,290
And a lot of the fillers and things
like that are not included under that

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00:20:01,190 --> 00:20:02,790
insurance payment.

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00:20:03,870 --> 00:20:08,690
Yeah. So the cost is probably
a disadvantage for sure.

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00:20:09,010 --> 00:20:13,830
And unfortunately beauty is costly over

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00:20:13,910 --> 00:20:14,970
your lifetime,

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completely independent
of any gender issues.

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00:20:19,530 --> 00:20:24,430
But I agree with you in
so much on these points

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00:20:24,510 --> 00:20:29,510
that I think the fillers give a chance
to road test what something looks

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00:20:29,590 --> 00:20:33,650
like. You may look at a feature in
a picture and think that looks nice,

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00:20:33,970 --> 00:20:37,550
but how it looks on your face,
you may feel differently about it.

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00:20:38,030 --> 00:20:42,310
And that ability to try it
out with filler is great.

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The level of nuance that
you can create in detail is

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unparalleled.

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00:20:50,390 --> 00:20:55,330
We can do things with it that there's no
other way to do with the same degree of

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00:20:55,430 --> 00:20:57,050
precision and control.

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00:20:57,770 --> 00:21:02,490
And the longevity issue
is a good thing and a bad

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00:21:02,570 --> 00:21:06,360
thing. I mean, our needs change over time.

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A lot of folks are very focused on gender

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affirmation,

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the event or the process in the short

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term of transitioning,

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but really we maintain our appearance over

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00:21:25,180 --> 00:21:26,960
our entire lifetime.
Again,

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independent of whether there's
been a gender change or not.

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And so

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the needs at different life stages
are going to be somewhat different.

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So after the baseline change in
bone structure or foundation,

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all of the surface support
that's needed over time

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00:21:50,680 --> 00:21:55,420
is something that can be
tailored to what you need at each

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stage going forward.

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00:21:57,540 --> 00:22:02,520
And unfortunately it's
not an event that ever

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really ends.

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I mean, I definitely agree. That
couldn't have been said better.

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It is a continuum and at
different points in a patient's

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life, they may

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consider different aspects of their
appearance more masculine or feminine,

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and we're offering them options to

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00:22:27,200 --> 00:22:31,960
feel better about themselves or
more affirmed in their genders.

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And we have now all these different
tools to help them along their journey.

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Okay, Dr. Bloom, as we
wrap up this episode,

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do you have some takeaways
to share with our listeners?

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00:22:42,740 --> 00:22:43,320
Yeah. I mean,

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00:22:43,320 --> 00:22:48,140
I think that this community
is continuing to grow

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00:22:48,520 --> 00:22:53,240
and it's becoming more and more
commonplace to see patients

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00:22:53,780 --> 00:22:56,340
with these issues,
certainly in my practice.

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00:22:56,920 --> 00:23:01,160
And while I certainly perform things like

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00:23:01,920 --> 00:23:06,680
rhinoplasty and nose surgery to give
a more masculine or feminine look

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00:23:06,740 --> 00:23:07,860
depending on the patients,

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00:23:08,420 --> 00:23:12,820
having the ability to add
additional things like

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00:23:12,880 --> 00:23:17,400
fillers and offer that to
the patients is helping them,

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00:23:17,980 --> 00:23:19,100
again, feel better.

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00:23:19,820 --> 00:23:24,700
I work tightly with other
surgeons in my community who

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00:23:25,460 --> 00:23:30,100
do full body plastic surgery
and the ability to do

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00:23:30,280 --> 00:23:34,760
gender affirmation top and bottom
surgery. And we work together.

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00:23:35,280 --> 00:23:39,720
They have sent me cases to do for the
face and I've sent them body surgery.

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00:23:40,340 --> 00:23:45,020
And it's nice to also
get further training and

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just at least read up if you're a surgeon,

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00:23:49,900 --> 00:23:54,180
read up about this because
the community feels

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00:23:56,000 --> 00:24:00,940
like they feel more accepted when you are

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00:24:01,360 --> 00:24:02,800
using the right terminology and

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00:24:04,460 --> 00:24:08,660
are comfortable seeing these patients.
So it's something that I've kind of

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00:24:08,780 --> 00:24:11,000
learned in the last few years,

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00:24:11,560 --> 00:24:15,660
but I think these cases are really
fulfilling to me as a surgeon.

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00:24:16,400 --> 00:24:18,460
And what are your takeaways, Dr. Bass?

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00:24:19,360 --> 00:24:23,660
Well, I have a whole
mindset about all of this,

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which I'll share. First, there's
no absolute male or female feature.

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00:24:29,200 --> 00:24:33,520
Appearance is a mixture of
how all the metrics harmonize

355
00:24:34,200 --> 00:24:39,160
to create a gender appearance rather
than just saying cheek needs to be shaped

356
00:24:39,280 --> 00:24:41,140
this way to be male or female.

357
00:24:41,940 --> 00:24:45,920
There are standard areas that need
to be assessed and likely address

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00:24:46,660 --> 00:24:47,960
most of the time.

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00:24:48,140 --> 00:24:51,880
And Dr. Bloom mentioned
those very clearly,

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00:24:52,940 --> 00:24:57,920
but it's very variable the
amount of change that's needed

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00:24:58,100 --> 00:25:02,460
and the nuances that are needed
to create a certain type of look.

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00:25:03,140 --> 00:25:07,760
So I don't believe this does well when
it's done in a cookie cutter fashion

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00:25:07,860 --> 00:25:08,720
that's simple.

364
00:25:09,500 --> 00:25:14,240
It's great to have a formula because
it's simple and you feel secure,

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00:25:14,660 --> 00:25:18,820
but I don't think that's as natural
and it's certainly not as individual.

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00:25:20,440 --> 00:25:24,820
And that's important because of
a lot of things. Genders aren't

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00:25:25,160 --> 00:25:27,940
absolute and the image is not permanent.

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00:25:28,200 --> 00:25:33,000
Gender appearance not binary just
like feelings about gender are not

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00:25:33,080 --> 00:25:35,360
binary probably in anyone,

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00:25:35,860 --> 00:25:38,360
but certainly not in many individuals.

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00:25:39,100 --> 00:25:44,060
There are a variety of male and
female looks depending on your

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00:25:44,140 --> 00:25:48,500
preference. So even if you
identify as a certain gender,

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00:25:48,920 --> 00:25:52,180
the kind of look you would
like to project still varies.

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00:25:53,580 --> 00:25:56,940
Find a surgeon who's listening
to your wants and needs,

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00:25:57,540 --> 00:26:01,740
not merely someone who's producing
his or her style over and over.

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00:26:02,240 --> 00:26:05,480
It should be your style,
not your doctor's style.

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00:26:06,400 --> 00:26:07,940
And in that regard,

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00:26:08,280 --> 00:26:12,980
injectables are great
because injectables provide a

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00:26:13,040 --> 00:26:16,340
level of precision, testability,

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00:26:16,680 --> 00:26:21,600
changeability and lack of
permanence that's unmatched with

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00:26:21,640 --> 00:26:24,720
any other techniques. And the lack
of permanence, as I mentioned,

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00:26:24,780 --> 00:26:29,580
is both a good and a bad thing
depending on how much you like what you

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00:26:29,640 --> 00:26:34,240
get and how much that stays the
same over time. Your outlook may

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00:26:34,340 --> 00:26:38,280
change and your face is
certainly going to age.

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00:26:38,400 --> 00:26:43,120
Gender affirmation is about
creating and maintaining a

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00:26:43,320 --> 00:26:46,460
look and we maintain
our image with grooming,

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00:26:46,560 --> 00:26:49,980
with a variety of beauty
treatments. In that sense,

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00:26:50,600 --> 00:26:55,500
gender affirmation treatment
doesn't really end much as we

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00:26:55,580 --> 00:26:57,260
might like it to be finite.

390
00:26:57,640 --> 00:27:02,640
It's ongoing with maintenance
just like for people who are not

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00:27:02,860 --> 00:27:07,720
transgender and just like with
taking hormones and other things that

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00:27:07,780 --> 00:27:11,020
are part of gender affirmation.

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00:27:12,620 --> 00:27:17,240
So that summarizes my thoughts
on it and we heard some

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00:27:17,460 --> 00:27:21,920
excellent comments and points
from Dr. Bloom. So Dr. Bloom,

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00:27:22,000 --> 00:27:24,280
thank you again for joining us today.

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00:27:24,440 --> 00:27:28,540
I enjoyed sorting through this
cutting edge topic with you.

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00:27:29,140 --> 00:27:33,540
It's always nice to talk to you
guys and thank you again for the

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00:27:33,720 --> 00:27:36,400
invite. I love discussing
these topics with you guys.

399
00:27:37,120 --> 00:27:40,400
Thank you, Dr. Bloom, for sharing
your insight and expertise with us.

400
00:27:41,620 --> 00:27:45,560
Thank you for listening to the Park
Avenue Plastic Surgery Class Podcast.

401
00:27:45,760 --> 00:27:47,520
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402
00:27:47,680 --> 00:27:49,780
write a review and share
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403
00:27:50,120 --> 00:27:53,560
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404
00:27:53,600 --> 00:27:57,120
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405
00:27:57,180 --> 00:27:58,140
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406
00:27:58,520 --> 00:28:03,060
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407
00:28:03,140 --> 00:28:05,280
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