Cardenas FFS Results at ~2 months

[ArielAce]

Hi everyone. I had surgery with Dr. Cardenas two months ago. I had a semi-blog about it here: https://www.susans.org/forums/index.php/topic,186912.0.html

Now that I am a bit recovered I wanted to show some of the results so far. I would say it is a very large improvement. I had lip fat injection, type 3 forehead, chin, and rhinoplasty. I'm mostly pretty happy. It's still early on and there is quite a bit of remaining swelling, so final results still pending. I'll be back with updates again closer to the six month mark.

And just as a preemptive strike, yes, I should probably get bangs to cover my scar, but one of the perks of having FFS is being broke. :| I think I look quite a bit better with bangs, so it's on my list of things to do.

Here is a collage I made. The top is before and the bottom is after. Most of these were taken between the one and two month mark.



This is a picture collage I made. The left row is the original, the middle is a virtual FFS result done by Alexandria, and on the right is me about 1.5 months after surgery. In the virtual FFS picture, the results of a hair transplant were added and the lips are unaltered. Otherwise, they are the same procedures. Forehead, rhinoplasty, chin.



Here is a picture Dr. C sent me comparing my forehead. Left is right before surgery, right is 2 months afterward.



Here is a picture of me and my companion right before our plane trip to Guadalajara.



Here is a picture of my best friend and I approximately two months after surgery. I think it makes a good comparison picture because I'm smiling.



Here is a picture of my amazing makeup skills. Okay, not really an expert, but one of the added benefits of this surgery is that I no longer have hooded eyes. Winged eyeliner is a breeze to pull off, whereas before it was very difficult. I never had good results with winged liner before.

[Ⓥ]

You look really wonderful, and pass easily

[Wednesday]

Your results look *really* great (have to say you had a nice start point to begin with).

Mind if I pm you to ask questions? Thanks!

[ArielAce]

Your results look *really* great (have to say you had a nice start point to begin with).

Mind if I pm you to ask questions? Thanks!

Sure. Or you can ask me here. I don't mind answering questions publicly.

[Wednesday]

Ooook! Here I go!

- How many hours did the operation take?

- Was her wife in the preop consultation to assess you about the rhinoplasty?

- Did you ask them to be conservative/aggresive in any procedure? Which ones?

- Did he include the upper forehead shaping and the orbital bone burring in the Type III procedure?

- Did he reshape your orbital rims? Did he use any bone cement/paste or fat graft to reshape your forehead?

- Did he perform X-Rays or CT Scan on your skull?

Thank you!

[ArielAce]

Ooook! Here I go!

- How many hours did the operation take?

- Was her wife in the preop consultation to assess you about the rhinoplasty?

- Did you ask them to be conservative/aggresive in any procedure? Which ones?

- Did he include the upper forehead shaping and the orbital bone burring in the Type III procedure?

- Did he reshape your orbital rims? Did he use any bone cement/paste or fat graft to reshape your forehead?

- Did he perform X-Rays or CT Scan on your skull?

Thank you!

- I don't know how many hours the operation took.

- No.

- I did not make any special requests in particular.

- Yes, that's generally included.

- Not sure.

- No.

[myfairlady49]

- Did he perform X-Rays or CT Scan on your skull?

Answer:  "No" 

                                         *********************

I am not a doctor and I didn't stay in a H I  express last night.

However,  if that is true,  it is one of the several compelling reasons to not get surgery in places that do not adhere to universally recognized standards of care. 

I am pretty sure that most well trained craniofacial surgeons would point out that doing a type III forehead surgery without a prior x-ray and / or CT of the forehead area - - would be surgical care that is inconsistent with the universally recognized standard of care for that type of surgery.

Worse,  it is unlikely the surgeon  could determine with certainty whether the patient needed a type I or a type III - - without the x-rays!

Does it save money?  Yes.  It is a way to cut corners?  Yes.  But if they are willing to cut corners in that critical area - -  what about other areas ?

A surgeon cannot have any idea what kinds of surgical surprises and complications they may encounter if they do not have the x-rays to study as part of the pre-op planning.   The surgeon could not even possibly provide legitimate informed consent to the patient.    What if the area behind the frontal sinus is inflamed and infected before they start surgery ?   OOPS  !!!   What a disaster that would be.

[RubyAliza]

Hi Ariel, you looked pretty before surgery and now you look even better. I think the biggest improvement is actually your nose! Much smaller

myfairlady49: Even without x-rays, it's pretty obvious she needed a type 3 contouring. However you are correct that an x-ray is an absolute must. In fact, surgeons can't even do a type 3 without x-rays; they need the x-rays so they can drill tiny holes tracing the sinus cavity from within like perforated dotted lines so they can take it off. The front x-ray allows them to see the exact the shape and size of the sinus. Without an x-ray, the doctor could drill into a part of the skull that does not enter the sinus cavity, extremely dangerous!

Only an craniofacial or maxillofacial surgeon should attempt type-3 forehead contouring. It is a very specialized procedure with a higher risk of complications. That's why even the best plastic surgeons like Dr. Zukowski and Dr. Mayer don't do it, instead only offering type I. A doctor performing type 3 should be both a craniofacial and plastic surgeon.

Furthermore, an x-ray is needed for chin work too, so the surgeon can see how far down the roots of the teeth are. Otherwise, they may risk damaging the roots. Even for a simple procedure, like a dentist filling a cavity, might require an x-ray. They are inexpensive as well. Why not do one?

I don't know how the doctor did this surgery without an x-ray. But that's just me. Personally I think the results are perfectly fine if you are happy with them. The most important thing is that you are happy Ariel Indeed you are amazing with make-up!

Hope your healing continue to progress.

- Ruby

[ArielAce]

Well, as I said, mostly happy with the results. I think my forehead could have been slightly better -- there is a slight curve to it, although admittedly it is much improved. I don't really regret my choice. It was affordable and I look objectively more attractive now.

Just sharing my results. Hopefully it will help someone make an informed decision. 

[radialan]

Even without x-rays, it's pretty obvious she needed a type 3 contouring. However you are correct that an x-ray is an absolute must. In fact, surgeons can't even do a type 3 without x-rays; they need the x-rays so they can drill tiny holes tracing the sinus cavity from within like perforated dotted lines so they can take it off. The front x-ray allows them to see the exact the shape and size of the sinus. Without an x-ray, the doctor could drill into a part of the skull that does not enter the sinus cavity, extremely dangerous!

Only an craniofacial or maxillofacial surgeon should attempt type-3 forehead contouring. It is a very specialized procedure with a higher risk of complications. That's why even the best plastic surgeons like Dr. Zukowski and Dr. Mayer don't do it, instead only offering type I. A doctor performing type 3 should be both a craniofacial and plastic surgeon.

Furthermore, an x-ray is needed for chin work too, so the surgeon can see how far down the roots of the teeth are. Otherwise, they may risk damaging the roots. Even for a simple procedure, like a dentist filling a cavity, might require an x-ray. They are inexpensive as well. Why not do one?

I don't know how the doctor did this surgery without an x-ray. But that's just me. Personally I think the results are perfectly fine if you are happy with them. The most important thing is that you are happy Ariel Indeed you are amazing with make-up!

Hope your healing continue to progress.

- Ruby

An x-ray in only useful in determining with relative certainty in advance as to whether a patient needs the Type III forehead procedure rather than conventional bone contouring.  It serves no useful purpose beyond this.  An x-ray does not show the surgeon where to place the incisions or how to perform the surgery.  It merely helps to determine in advance which surgical approach is necessary. In any case, if a patient needs to know with absolute certainty whether or not Type III is required, then Dr. Cardenas actually prefers an MRI.

In most cases, Dr. Cardenas reviews the patient's photos and makes a provisional recommendation based on his experience.  He subsequently examines the patient in his office prior to the surgery.  He still won't know with complete certainty if the patient needs Type III or conventional contouring without viewing an MRI or x-ray.  In cases where the patient must know before reserving her surgery, we will request an MRI.

So, how does Dr. Cardenas know for sure about Type I vs. Type III without an MRI or x-ray?  How does he determine the size of the sinus and precisely where to cut?  The answer lies in a process called transillumination.  Once the skin and tissue covering the bone are pulled back, the lights in the operating room are turned off and a bright surgical lamp is placed on top of the bone.  The frontal sinus then illuminates and Dr. Cardenas can see the its exact size and form.  The Type I vs. Type III question is then answered with certainty and the frontal sinus can be marked for surgery.  With transillumination, Dr. Cardenas learns exactly where to cut.  An x-ray won't provide any assistance in this area.  An MRI would tell us this but Dr. Cardenas would still use transillumination to mark the incision points.  We understand that most of our patients prefer not to spend as much as $1,000 or more on an MRI when transillumination provides us with the answers that we need.  If a patient is going to trust Dr. Cardenas enough to allow him to operate, surely she will trust him to make the Type I vs Type III judgement in surgery.  If not, then we will request an MRI in advance.   

When chin contouring or reconstruction is performed, an x-ray is not used to determine where the roots of the teeth are located.  Should any surgeon cut into any part of the teeth or roots, then he or she is placing the incisions way too high due to a lack of basic understanding about the anatomy of the area and/or insufficient training and experience.  An x-ray of the chin can help the surgeon see the size and shape of the chin.  However, he or she can also see the size and shape of the chin simply by examining it.  On the other hand, an MRI could help surgeons who don't often work on the chin avoid damaging the mental nerve.  Dr. Cardenas rarely requests an MRI of the chin because he has many years of experience working on all of the bones and tissues of the face.  This experience has long taught him where to place the incisions and how to avoid damaging the mental nerve.  There are surgeries unrelated to feminization where an MRI would be indispensable.  Orthognathic surgery, for example, involves the surgical correction of the misalignment of the jaws and teeth and would generally require an MRI.

To address the remaining point, it is not fact-based to suggest that a board-certified plastic surgeon is not qualified to perform bone reconstruction.  Plastic surgeons are not merely trained in cosmetic procedures.  They are also extensively trained in areas such as reconstructive surgery, craniofacial surgery, microsurgery, and burn treatment. 

[Blairdlena]

I can't help but jump in here. Just because something proves to be common practice in the U.S. It can't be said it's a necessity to perform certain procedures. We've grown accustomed to hearing x-rays are required. In the U.S. X-rays are completed for everything. Does it mean a surgeon knows exactly what-is-what before cutting? From experience with many surgical procedures in the U.S., the answer is 'no'. Call it a litigation-aversion procedure.

We've also been led to believe only a cranio-facial surgeon should perform certain procedures. Who says this? Cranio-facial surgeons. I've been to Guadalajara twice to see Dr. Cardenas. I've also had friends who have made the journey to GDL. I've also had friends go to other surgeons (Boston and Spain specifically). Complications for these friends proved to be severe. The gals that went to Dr. Cardenas had no complications... at all! Dr. Cardenas' approach is careful and methodical. Further evidence of this is shorter maximum duration of surgery in a single day.

Pre-surgery cranial x-rays for type-III forehead reconstruction and jaw reconstruction may be commonplace, but not a necessity. Likewise, a title does not make a competent surgeon. Paying $50,000 for FFS does not imply a better end result over $20,000 paid.

At the skilled and unbelievably deft hands if Dr. Cardenas, I've  had both type-III forehead reconstruction AND a sliding genioplasy/osteotomy of the chin (along with a few other procedures). No... there were no x-rays taken. An incredibly skilled surgeon with 'soft hands' can feel and sense how much is just enough. As with me, Dr. Cardenas, when cutting away the flesh from the chin/jaw, could see where the mental framem nerve was. My 'down time was nonexistent. Sorry to say, one of my friends who went to Boston is still down, months later. My friend who went to Spain had to have her jaw wired shut.

So... don't make a judgment about the pre-surgery stuff, the cost (more=better), or a title be your guiding light when deciding on an FFS surgeon. I'm glad I didn't get scared away by those who really don't know, but assume. Dr. Cardenas, his staff, and his facility is world class!

[RubyAliza]

Interesting to see that a staff member of Transop responded to my post. I wasn't putting Dr. Cardenas down obviously and your post was enlightening! I've never heard of transillumination. Different surgeons use different techniques and it sounds like this one works well for him (personally I got to keep my x-rays and I can clearly see the outlines of my sinus from the front - so x-rays can be used for that purpose). I was just curious how Dr. Cardenas did it and you explained it well so thanks. Still, I'd rather have an X-ray or MRI then. My question still stands: why not do one when they are relatively inexpensive? I'm pretty sure getting at least an x-ray is something most surgeons do.

Ariel seems happy and this is her thread. And it's nice that Blairdlena was happy with her surgery also. I don't think it's fair however to say that some people are intentionally "scaring" others away. Personally, I was going to go to Cardenas but changed my mind because I liked the before/after photos from another surgeon better. I'm extremely happy, my forehead is pretty much completely flat without any bone cement being added to the top of my forehead (I've seen some surgeons use that which works for some patients but I'm not fond of it). I don't believe that any person should make a decision based off any anonymous person's post, especially if there is no photographic evidence. That's why I put all my photos up and answer all PMs that people send me. Thank you Ariel for doing the same! Before/after photos are the most important to me. Words after all are only words. The proof is in the non-edited photographs in my opinion. On my doctor's website, all the before/afters are without makeup or photo editing and are of the same position/size.

So just to clarify, much respect to all surgeons who do FFS including Cardenas, and the "doctors from Boston and Spain" you mention, who I could only guess are Dr. Spiegel and Facial Team. One hoping to get FFS must understand that there may be significant downtime which is different from patient to patient. This is a major surgery. These doctors work compassionately to make the lives of transpeople better and this forum should remain a positive place for others to hear diverse opinions
- Ruby

[myfairlady49]

I can't help but jump in here . . .

Pre-surgery cranial x-rays for type-III forehead reconstruction and jaw reconstruction may be commonplace, but not a necessity. Likewise, a title does not make a competent surgeon.

"Pre-surgery cranial x-rays for type-III forehead reconstruction and jaw reconstruction may be commonplace, but not a necessity." 

Really ?   Really ?

Of course,  pre-surgery blood work to hunt for problems like elevated WBC or lack of clotting are "commonplace" - -  but not a necessity, either ?  Right ?

Here is a modest thought to consider:  Anybody that reads those claims and what appears to be an orchestrated effort to defend deliberate deviations from world wide accepted standards of medical care - - will end up being even still more reluctant to EVER consider going to countries whose surgeons who do not follow those routine standard of care precautions (like taking simple x-rays) before subjecting their trusting patients to anesthesia and highly invasive frontal sinus surgery.

There is a reason that competent surgeons have  well recognized "titles"  like  "board certified"  and  "Plastic Surgeon"  and "Craniofacial Surgeon".   

The reason they have those titles is because they demonstrated to their surgical peers that they are highly competent and always follow the highest standards of medical care.

Without the guarantee of quality training and experience that only comes with the "title" which you so casually disparage  - -  the typical patient is simply just guessing at what kind of care they may or may not receive.

Caveat Emptor !

[RubyAliza]

myfairlady49- Well said! X-rays are not standard/commonplace for no reason. And yes, I agree, titles DO matter. But I think it's best to just let forum goers make their decision. Do you want x-ray or MRI taken before your ffs? Do you want a certified craniofacial AND plastic surgeon to do this complex surgery? It's best not to argue and assume that each person should be allowed to make their own well-informed choice.

I don't see any other people who actually work for the surgeons posting here. Radialan I appreciate that you're willing to take your time to post here. We mean no disrespect in any way. We mean only to give our own perspectives and are not putting anyone down whatsoever, especially not Dr. Cardenas who has done some very good work.
- Ruby

[Miril]

Well, I just realized that I know so little about this topic.   Time for me to hit the books as well as dig into the forum.    If anyone has any recommendations on good resources, I would be appreciative.

Ariel, regardless of procedure or protocol, you look great!

[radialan]

myfairlady49- Well said! X-rays are not standard/commonplace for no reason. And yes, I agree, titles DO matter. But I think it's best to just let forum goers make their decision. Do you want x-ray or MRI taken before your ffs? Do you want a certified craniofacial AND plastic surgeon to do this complex surgery? It's best not to argue and assume that each person should be allowed to make their own well-informed choice.

I don't see any other people who actually work for the surgeons posting here. Radialan I appreciate that you're willing to take your time to post here. We mean no disrespect in any way. We mean only to give our own perspectives and are not putting anyone down whatsoever, especially not Dr. Cardenas who has done some very good work.
- Ruby

Thank you, Ruby.  I didn't view anything in this thread as disrespectful in any way.  I just felt that I should explain the process that Dr. Cardenas follows and why MRIs or x-rays aren't usually necessary.  That being said, we do sometimes have patients who have MRIs done in their communities.  A patient who wants an x-ray or MRI can certainly send it to us in advance. 

Dr. Cardenas has been board-certified as a plastic surgeon since 1990 and has been performing FFS since the mid 90's. When seeking out a surgeon, a long track record with many years of experience performing FFS should be a key factor.

[Paula1]

Unfortunately all surgery has it's risks ...  no matter how good the surgeon is.

I have had my fair share of complications down the years but I am still willing to have more surgery to correct surgery that is still not right.

What angers me though is when you pay a lot of money and the surgery was done badly in the first place.

What us girls need to go thru is mind boggling and we have to be some of the strongest people alive.

Life sure is a lottery.

Sorry to say, one of my friends who went to Boston is still down, months later. My friend who went to Spain had to have her jaw wired shut.