Hi everyone,

I'm about to start looking into consultations with FFS surgeons, but before that, I am trying to get some impartial advice. I just sent some pictures off to the Virtual FFS person, and I'm looking for other opinions. Right now, my top two choices for surgeons are Dr. Zukowski and Dr. Jeffrey Spiegel. If anyone has advice on what procedures I should focus on and who I should be looking into, I would appreciate it. I only have about $20,000 available for surgery at the moment. I don't know yet how far that will get me. If need be, I can try to save some more money.









Thanks!

Any explanation why would Dr. Zukowski and Dr. Spiegel be your top choices? They have very different approach and very different results. I would advise you to take your time, do your research, literally like months... There's no reason to rush into anything, until you know exactly what you want. Asking surgeons for opinions is what lazy patients do. Smart patients figure most if not every detail on their own, and after you research which surgeon is capable of doing what you need to have, and which ones aren't, you will know exactly which one to choose. Maybe you will end up with two or three good options too choose from. Don't limit yourself to only USA surgeons. I personally think the best FFS surgeons are outside of US, but I would include Dr. Spiegel between the best out there. Second thing is price difference, you have much more pleasant prices with foreign surgeons. But don't choose based on money, or location. Choose based on who can give you the best possible result, and predictable result.

procedures I think you should look into:
- forehead reconstruction : the real one, "type3" approach. That would help you cross out some names who are unable to do this
- orbital remodeling : focus on surgeons who give a HUGE importance to this, because it is the most important thing
- hairline : definitely hairline incision, you would benefit from little hairline lowering, and some closing in the corners. You cant have this if you decide for coronal incision, only with additional hairtransplant
- rhinoplastly
- upper liplift
- jaw and chin remodeling, nothing too drastical, just little more V shape
- chin : maybe some height reduction, and definitely improved frontal projection, either with sliding genioplasty or frontal implant

That's my quick observation, don't take me too seriously because I'm not a facial surgeon, I'm just an overeducated patient who spent too much time with research.

I saw both Dr. Zukowski and Dr. Spiegel present at a conference here in Colorado. Zukowski seemed very competent, and he had a good portfolio of results to present. Spiegel seems more reserved and up-front about what he can do, but very qualified. I've read that Spiegel is good at only doing what you need, rather than trying to sell you on everything. Since I mostly just want to have an easier time being accepted as a woman, his approach seemed good.

I should clarify that I actually have more like $30,000 available, but I have been planning on using about $10,000 of that on hair transplants to fill in my temples. My research so far suggests that hairline lowering isn't as important as just getting the right shape, and that transplants are more precise at that than hairline lowering. I plan on doing that part after I'm recovered enough from FFS, because I've read that surgeons will often take advantage of balding temples to make incisions for orbital work, and that doing transplants before that is a waste of time and money.

Also, how do you do research on which surgeons are good at which techniques?

Quote from: ShadowCharms on February 28, 2015, 10:14:30 AM
Also, how do you do research on which surgeons are good at which techniques?

For start, some are able to do certain technique, some aren't as they don't have the knowledge and skill required. Some things are on a level that most plastic aesthetic surgeons can do, some other things only experienced craniofacial surgeons will do. For example Dr. Zukowski and Dr Mayer, and many other, don't know how to do a forehead reconstruction, which is essential for 95% trans patients, for those who need/want to have a good FFS result, bacause the forehead-orbital area is where the difference happens. Overall, observe, compare what you see, focus on a details.. focus on a orbital rim work, look for those who had similar starting point to what you have.. Again, look outside of US, you have surgeons like Dr. Simon and Dr. Capitan from Facial team, Dr. Di Maggio, Dr. Van de Ven, Dr. Van der Dussen, Dr. Suporn, Dr. Cardenas, and more.. And all of those are better and more competent options than what you can have in US (again excluding dr. Spiegel). But it is up to you to compare and research, and make a best decision in the end.

Quote from: mmmmm on February 28, 2015, 10:57:44 AM. . . forehead reconstruction, which is essential for 95% trans patients . . .

Essential for 95%?  I can imagine a good majority would benefit from this surgery, but essential for 95%?  And in what sense essential?  For passing or for beauty?  There's plenty of girls here who are both and who have not had forehead reconstruction.

Quote from: Brenda E on February 28, 2015, 09:34:31 PM
Essential for 95%?  I can imagine a good majority would benefit from this surgery, but essential for 95%?  And in what sense essential?  For passing or for beauty?  There's plenty of girls here who are both and who have not had forehead reconstruction.

Yeah I really think 95% is an exaggeration for how many girls truly need type 3. I would even go out and say probaby not even a majority "need" it.

Quote from: Brenda E on February 28, 2015, 09:34:31 PM
Essential for 95%?  I can imagine a good majority would benefit from this surgery, but essential for 95%?  And in what sense essential?  For passing or for beauty?  There's plenty of girls here who are both and who have not had forehead reconstruction.

It isn't me who came up with this numbers. There is one FFS team (from Europe) which is very organized and extremely professional (maybe even a bit too much...), they did an indepth observation of their patients, and follow the statistics right from the start, and they came up with this numbers. As people who approach FFS very seriously, they are only interested in making the best result for their patients, and there is what a difference is. You can give a patient a little improvement on brow bossing with a little shaving here and there, but there is only just so much you can do, because the sinus wall is VERY thin in 97% (their number!! I generalized it to 95%..) and only 3% of patients who have brow bossing, have a sinus wall thick enough to perform a procedure which will give a satisfying result with just shaving approach and bonepaste filling. For everybody else, removal of the sinus plate, remodeling, and reattaching into the new position is the only option which can give a proper result. Not only in terms of big enough difference, or regarded in terms of beauty, SAFETY is what is essential here, as the bone thickness and structural form in the frontal forehead is more important than any beauty privilege. Think about how many times you hit something or bump with forehead, and how many things can happen in the safe enviroment of our homes, let alone thinking about any possible sport accident, or even car accident. Let say you have a medium prominent brow bossing, with wall thickness of what 97% of patients have, 2.5mm (I could be slightly wrong about this exact number), and you decide for whatever reason, you would only get a procedure with little shaving or burring. From your 2.5mm surgeon will do his best to do what he can do in the terms of result, he shaves of 1.5mm in the front, and you are left with 1mm thick bone wall on the frontal sinus. Lets forget about that you didn't get a real improvement in terms of anything like aesthetics, feminization, etc, because it is not that important compared to what could happen in the future. Imagine playing soccer with sisters kids on a garden lunch party, and you get hit with the ball in the frontal forehead a little too strong. Even though 0.8mm or 1mm of bone seems like a lot, it really isn't. And do you really want to put yourself in a such situation when your sinus wall could collapse just because of an innocent situation like this? Another thing is, if your brow bossing isn't feminized to a level that it could/should be, it is impossible to really efficiently remodel and feminize the orbital rims, which is where the real feminization, eye-expression change, happens. These surgeons who don't know how to do an open forehead reconstruction, do what they can do to somewhat satisy their patients. Because they can't do the real job with forehead and orbital rims feminization they compensate what they can with overdone browlift, which will satisfy some patients in terms of changed look and apperance. But that's not really the way to go if you want achieve the natural results, because overdone browlift really is anything but natural. Where the natural eyebrows should be positioned is determined by your orbital rim shape and height.. so there we go again, because as I said what can be done with orbital rims is very much related to what can be done with brow bossing and forehead shape in general. There is a reason why sugeons are specialized in facial reconstruction, specialized craniofacial surgeons or just maxiliofacial surgeons who acquired enough craniofacial knowledge and skill, only and exclusively perform "type 3" forehead reconstruction surgery on their patients, because there is just not a single good reason why they wouldn't. It just doesn't make any sense. And it also doesn't make any sense to me why would anybody who has brow bossing pay their hard earned money to have an average and dangerous forehead result at best. Its not twice or three times cheaper because of it, they charge the same money for it as those who actually have the education, knowledge and skill to do it properly. It would make sense if dr. Zukowski would charge $6000 for forehead shaving, orbital remodeling, hairline advancement, browlift, with included anesthesiologist and all surgery fees. But that's not the case, isn't it? There is a reason why Dr. Ousterhout was a pioneer of FFS with developing his forehead reconstruction approach, and there is a reason why Dr. Di Maggio has around half year of waiting line for what he can offer to his patients. 

I am trying to narrow down my FFS surgeon as well, sounds like you might be in Colorado, so am I
Ms. Mmmmm, it seems that you are sell researched, so am I and I am familiar with everything you have said.  The one argument for a non-reconstructive approach and really for Dr. Z which hasn't been addressed here is that a reconstruction method does actually break into the sinus and can lead to sinus complications which are avoided if one just does a burring only method.  Now I'm no excerpt and I can't seem to find good evidence supporting this either way, but dr. Z does provide an article on his website.  Safety is important to me and avoiding sinus complications is definitely something I need to consider.  Likewise, I am very interested in Dr.Z for his use of endoscopic techniques, it sounds like he may be the best out there in use of an endoscope which would minimize the damage done to tissue in the forehead, this is also important to me as he claims that 20% of patients who undergo open techniques do not regain full sensation in the forehead area, I certainly would not want this, Facial Team's coronal incision seems like it would even further increase the risk of loss of sensation as more tissue is exposed.  I would appreciate it if anyone can point me to solid evidence (either way) to address these two safety issues.
After all, I would rather have a tiny amount of a brow prominence than have loss of sensation or sinus complications.  So, this is something I really need to figure out.  I have also seen photos from Dr. Z which have an excellent (flat) side profile of their foreheads, though I admit there are not a lot of these in his public gallery on his website.  Also, I think some of the claims that certain doctors, to include Dr. Z, can't perform a reconstruction is false, I believe that they can and have but do not think it is appropriate and thus do not do it, that's based on conversions I've had with more than one surgeon who uses the burring only technique, I know there is something to be said by taking someone at their word, but I would really need to see some hard evidence that they Can't do a reconstruction.

Ultimately, I know its a big roll of the dice no matter who you go to.  I also know there is big confirmation bias on favoring whoever did one's own FFS if the results were good, and to keep that in mind when reading forum posts.  That and good research would be my advice to others, clearly I still have lingering questions myself.

Forehead reconstruction , as known as "type 3" is an advanced craniofacial surgery technique. Some maxilliofacial surgeons also get special training to learn and safely perform this technique. Cosmetic, plastic surgeons are familiar with this procedure, but are not trained for it. It takes a lot of learning from someone who is doing it for a very long time, in order to do it safely, which includes avoiding complications. Very small number of surgeons in a whole world are trained to do this procedure. Other than resolving post-trauma facial reconstruction, sinus complications, and facial feminization surgery, there aren't that many requests and need for this procedure.
Complications depend on if it is done correctly and safely. I only know numbers for one FFS surgeon... 3 patients had sinus complications out of 700+ patients who had this procedure with him. All three many years after surgery. That being said, even people who never had any kind of sinus involving surgery or anykind of surgery, get sinus complications.

Problems with other not-reconstruction technique are: In most cases, it is not possible to achieve a lot of change to brow bossing. Which leaves two problems, bossing is still there, mostly unchanged, and because of that, it is not possible to efficiently remodel and feminize supraorbital ridge.. how much can a surgeon change orbital rims, is dependent on overall forehead shape. In a case where forehead was not feminized enough, there is only so much a surgeon can do with orbital rims, without making everything look really strange. Orbital area, is the key where achieving feminization happens, because a result of feminizing upper and lateral orbital ridge is change in expression of the eyes, and shift in overall facial expression from masculine to feminine. Plastic and cosmetic surgeons, do the best they can in achieving a feminization effect, and because they in most cases can't efficiently feminize forehead and orbital area, the compensate not achieving "natural" change in eyes expression, with lifting the eyebrows way too high. Which result in a feminizing effect, and happy customer, but also results in unnatural position of eyebrows and unnatural look (natural position of eyebrows is defined by supraorbital ridge).
Another thing is bone strength... bone is usually strongest at the surface area, and underneath that in a much more fragile bone structure. While removing that little bone which can be removed with shaving technique, the strongest part of bone gets shaved away, and from 2.5mm bone thickness, you get left with 1mm thick fragile bone wall. Is it even worth doing anything like this for shaving off 1.5mm of bone, while being left with almost the same amount of brow bossing (although it looks more polished and smooth)? I almost didn't have any brow bossing, just a tiny little on one side. Regardless of that, my forehead shape couldn't be feminized to my liking with this technique, and I really didn't want the risk any accident in the future... like playing with ball with children, and receiving a hit in my forehead, which would result in colapsed forehead wall. Or bumping into open doors of upper cabinet... imagine it yourself. I prefer not to.
If forehead reconstruction is done correctly, when healed, there shouldn't be any risk to forehead wall strength.. With shaving technique this is a very serious risk.

All FFS surgeons who are able to perform "type3" reconstruction technique, are almost exclusively only using this technique. Only in case of minimal sinus and extremly thick sinus frontal bone wall (3% of patients) would they be able to achieve the same result as with reconstruction. And Facial team said, they would still prefer to remove sinus wall and do a proper reconstruction.

Why dr. Zukowski says what he says on his website is pretty clear. I'm not stupid, I would write exactly the same thing if I was in his position. And like him I wouldn't post side-profile photos of most patients either... Look at the website of dr. Mayer to see what I mean.


Doing the research and observation yourself is the key! In the end it is you making a choice. Reading the forums can help with some information, mostly regarding patients experience... But take everything with a grain of salt.

Thank you for your swift reply!  I hadn't heard of Dr. Mayer, his photos are very helpful, especially since there is a lot of them. I can see varying degrees of the effectiveness of his bony contouring, overall, I think his patients look really good though.
Thanks again, the research continues.

I forgot to answer about sensation loss in forehead area. Some numbness in forehead area will happen in every case, regardless of incision technique, or endoscopic approach. In my case forehead numbeness was only in middle-top forehead area, and after 2 weeks it was only still around hairline. I definitely felt pain while stitches were removed. For first couple weeks top of scalp (behind incision )was very sensationless. At 2 months I noticed more and more sensation slowly comming back, and now little over than 4 months post-op it is mostly all back. It still feels a little strange... Forehead feels completely normal.

I have read about long lasting sensation loss after damaged nerves on the side of jaw. But I never read about permanent sensation loss/numbness in forehead area.

On the side of the jaw- for cheek implants? Can you tell more about that?

For jaw reduction, nothing to do with cheek implants... I had jaw and chin work, and I didn't experience any sensationloss in that area. Maybe some who had can write more about their experience.

Hi ShadowCharms!

I would mostly agree with mmmmm on FFS priorities for you.  I would probably prioritize the following, in order:
1) Forehead / orbital rims.  Hairline goes along with this, but you don't look like you need that to me.
2) Rhinoplasty
3) Lip lift
4) Chin -- if you can get more forward projection, as mmmmm mentioned, then I might put this higher in priority.

I wouldn't do your jaw and, as I said above, I don't see any hairline issues in your pics.

I am trying to figure out the same priority list for myself.  I don't know about you, but I have a lot of angst over which procedures I should do!

Kim

So regarding Dr. Zukowski and forehead brow shaving. I'm actually satisfied with the result. I'm sure there is something considered more attractive out there. But in profile it looks decent. The difference it made is drastic, of course the multitude of procedures I opted for was drastic in of itself.

On the outer edges of the orbital rim (above the outer corner of the eyes) I had I guess notches in the bone. Those aren't an issue any more. I still feel like my eyes are deep set and still wonder if we could have shaved off more. But the result is good! Even in profile (someone said theres a reason Dr. Z doesn't show profile, but I promise you my forehead is round-ish in profile).

I had a forehead that sloped back slightly rather than a 90 degree wall (think like 75 degrees). So that is probably why I look round in profile now. I'm not saying this technique can work for everyone, but this procedure is positively drastic for me.