FFS surgeon DrFensterer to answer questions about transgender surgeries
As a surgeon, what sources of information about trans and nonbinary people do you take in? Are you reading primarily medical literature, or do you also read sociological, psychological, neuroscientific, and philosophical perspectives on trans and nonbinary people? If the latter, how has that informed your clinical practice?
I first learned with the patients because I started very young and I didn't know anything about it. There was no internet like now. I jumped into the community. This means I went to LGBTQIA events. São Paulo is not shy about it. Our parade has 3 millions people each time. Then, when I wanted to learn about the surgeries, I went more technical, not only with medical literature but also connecting with similar providers. I traveled a lot. Now, here in Louisville, we have monthly meetings with all providers and the ones taking care of the policies. I am still learning and I learn from patients but I feel now I can step up my exposure and get involved in public health policies
I’m glad to hear you have been so community and interdisciplinarily focused in your work. How do you conceptualize gender identity? What would you say is the common conception of gender identity among providers you speak with?
Gender identity comes from inside, your essence. Seeing dysphoria made me reflect how much I took my own identity for granted. I can't imagine doing the things I did as a teenager if I couldn't feel comfortable with who I was and if I didn't have help to figure it out. The staff sexualize it a lot. That's the first thing I tell them to separate. They think a trans woman needs to be with a man and they get confused if they come with a woman. I hear a lot, "why then?". I used to teach math to children and it was very hard to explain how 199+1 becomes 200 to a 4 year old. Barely I knew that was my training for my current job. I usually succeed
I’m glad you separate gender identity and sexual orientation. What do you mean by saying gender identity is an inner essence?
I mean it is what you are. You identify
So for you, gender identity is at root a self-identification as a gender?
So being from Brazil, you mentioned that you do body contouring -The Brazilian Way. Now THAT interest me. But what do you think is different about the Brazilian way and the method other surgeons use here in the US?
Oh. I already have my lipo scheduled in Brazil not here. Well, first, in Brazil we listen to what the patient wants and we follow THE PATIENT plan. Second, because of the beaches and exposed bodies, the incisions need to be hidden and minimized. We have dark skin so scars are not welcome. Then, we have the violin body vision with a lots of curves. When we do lipo, we pay attention to the places that the clothes are tight. Under the breasts (so you can use Derby dresses in KY), waist and hips. And of course the Gluteal area as a whole. Lateral and posterior.
I understand that dark skin is more prone to scarring and keloids than white? And younger worse than older. Do you think Brazilian surgeons take more care to avoid scars? If so, how? Because I absolutely hate scars.
Oh yes, the main thing is to hide them and make as small as possible. I always say that the forehead and facelift scars need to be placed in areas that only the hairdresser should find it. I do a lot through inside the hair. Second we can recommend treatments to avoid elevated scars such as micro needling, lasers, scar tattoo, silicone, steroid injections or even resection of the scar.
I am definitely making the trip for a consultation!
Hi. Arnica is very often used to decrease bruising and it is prescribed 3 days before and 5 days after. However, several studies have shown no statistical results. What is knows is that arnica can increase your blood pressure so I don't recommend all the time. Fresh pineapple has bromelain which has been proven to decrease bruising. You also can buy red light therapy at Amazon. Red light increased mitochondria activity and accelerates healing
I used arnica when I surgery in Mexico, but I didn't have any other experience to compare it to. But the studies I've read recently do show that it has benefits, even if only minor.
I still prescribe but I check if patient has High blood or aneurysm history. In that case, I don't
Ok. It is getting late and we will finish for today but if anyone has questions, please post it and I will gladly answer it. I would request to not ask personal questions because I can't do consultations on Reddit. You all have a great night
Thank you!
I must admit I'd not heard of you before you started commenting here 3 weeks ago , but you have a very long history with the trans community. Could you say more about this and what you do these days?
Here's a link to the article you wrote last year for anyone who's not seen it, M to F, F to M, WTF(Y)-Male to Female, Female to Male, When Titles Fool You by Tathyana Fensterer, Louisville Medicine, page 18-19, Vol. 6, No. 11, April 2020
Yes, my first encounter with trans was 20 years ago when I was gen surgeon in Brazil. Very often, the trans patients would come victims of violence. That affected me. I have a vivid memory of 4 trans who came with severe infection from silicone injections and I took care of them for a full month. when patients are scare, they open their hearts to us and I listened. Nobody should need to go through that. I thought that the health care was not prepared and if I had a trans child, I wanted the best surgeon so I went on my own and learned by myself. I did 4 surgical residencies and I took all the opportunities to improve my skills. When patients come to me, they can enter through the front door any time and I am committed to give the best care from my smile though insurance fighting
Your article is an interesting show of support. Apart from surgery itself, do you do anything else to help the trans community?
And what others surgeries do you do that are of interest to the trans people. I've listed you as an FFS surgeon, but you clearly do a lot more than that.
What are your favorite procedures? I assume surgeon have such things?
Oh yes, I have been the brave surgeon who is very clear about my transgender support here in Kentucky. I have gotten a lot of support and attention. As consequence, I have been invited by the hospitals to do staff training. My approach is to engage the ones who don't have a personal experience but want to provide a good service. I explain how I got involved and the transgender point of view of being scare to be discriminate. I also go to the therapists offices bc I want to see the whole setting and I educate them about the surgeries so they can understand the pain patients go through. We will have a summit in Louisville Nov 13, I am doing a presentation about my job in Brazil next week and I am doing a national training to the nurses, front desk and CEO of outpatient surgery centers in US
I also do other surgeries. I am definitely not your neighborhood plastic surgeon. Lol. I am very strong in breast cancer reconstruction. I also work with paraplegics doing crazy flaps. I will be located between Louisville and Elizabethtown in order to serve Forth Knox. So I am going to take care of soldier, if they are trans or not.
Can you talk about breast fat transfer. I know it's common in reconstruction, but not many of us would need that.
What about its pros and cons vs implants? How much experience do you have with this, and how much volume can you transfer? How much survives long term?
That is a full hour presentation. Lol. Well, fat graft is awesome. I had myself. It avoids capsular contracture, displacement of implants, infection. And we can localize the fat the way we want. It is always placed above muscle so we don't have problems with pain or pec muscle animation deformity. When the nipples are more lateral, I can place the fat more precisely to balance the difference. With implants, we need to get a wider one but sometimes patients don't want a huge breast so there is an a huge gap between breasts. And when patients want under the muscle, the implant might not be at the center of the nipple. Fat graft also has the advantage of giving patient a better contour bc of the lipo itself. It is 2 procedures in one. In cis woman, I do breast reduction with fat graft on the upper pole for prettier breasts. The amount is variable but I can place 500 cc on each breast. Approx 30% gets reabsorbed. The disadvantage is that it can show in the mammogram but a good radiologist should differentiate it from abnormal lesions. I always inform the mammo tech that I had fat graft done. I do that a lot. It is fat everywhere. Face, scars, breast. I always fat graft radiated breasts from cancer. It makes the skin softer
Is it important to go to ta surgeon experienced with trans breast procedures? If so, why? And how many have you done?
Yes because the nipple and infra mammary fold location are different and the surgeon needs to address that. Some will have a more developed pec muscle so the surgeon might want to place above it or make a more extended release. The age is also a factor since we have seen more and more trans women in their 70's. Skin might not tolerate a big implant. Might need mesh. I have done over 100 but I don't know how many
I read that mesh can complicate any further procedures? Any opinion on that, because it does sound appealing.
What happens with implants in old age? Kind of worried about that. Can't see it going well.
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Dr Fensterer is finished for today, but everyone is welcome to post more questions and they will get answered.
Ok. It is getting late and we will finish for today but if anyone has questions, please post it and I will gladly answer it. I would request to not ask personal questions because I can't do consultations on Reddit. You all have a great night
Since you have a lot of experience from Latin America, I was wondering if you had an opinion of taking Arnica or Bromelain to reduce swelling and bruising before and after surgery?
So here's another one.
I'm sure I'm not the only one who has this issue. When I had my forehead done and hairline lowered it was pulled very tight which thinned out the skin at the top and front of my head. I've always feared that it's the restriction of blood flow under my hair that's made it a lot thinner than it should be. Is there any way to correct this and increase the blood flow?
There is no way to increase blood flow but we can increase the thickness with fat graft or fillers, sculptra, radiesse are biostimulants and produce collagen or even hyluronic acid such as juvederm or restylane. If it is severe, we can do dermal grafts to thicken the skin. The forehead skin becomes thinner by itself just in normal aging. Whenever I have opportunity, I always place some fillers in the forehead.
When you are working for a big hospital, do you put together a surgery team that remains consistent through most of your surgeries? If that is the case, how do you select the right people knowing they might face scrutiny for doing "trans-surgeries"?
Yes, I actually specified in my contract about trans surgeries. It is in my contract that I can't be stopped from operating transgender and nobody can force me to discriminate patients. My current employer understood because I just came from an experience in which I was harassed for operating transgender. Everyone is actually very excited about it. But since this is a new job, I need to train everyone again but now the trans community as well as University of Louisville trans studies are coming to help me. I am very excited. Going to start this new chapter in December of this year. That incident actually is what made me join this community bc I saw a comment I wouldn't offer this surgeries anymore. I will and nobody will stop me.
This comment , for anyone interested.
Can you discuss the cost to the patient of where you in Kentucky vs Brazil vs the bigger cities of the USA?
Well, in Brazil, we have public health care. It is free. The catch is that a resident will be operating on you. It is a teaching place. If you want an experienced surgeon, you will need to go private. I don't know the costs but as far as I know it is similar to US. Here where I am, I can tell the difference between Louisville and Elizabethtown (yes, that movie w Orlando Bloom) 40 min drive but Louisville is urban area and E-town is a small city. I will be seeing patients in both cities but if you had surgery with me in E-town, the surgery will cost an average of $3k less. Same hospital brand, same anesthesia bc they service both hospitals like me and same surgeon.
Hospital dos defeitos da face is part of facial team. This is in Sao Paulo city. Another place that does is the department of Plastic of USP., Also in Sao Paulo. Facial Center Trans is another service in Curitiba. I hope this helps you.
I just noticed your rainbow hair on your official photo. Very subtle, took me a while. Or I'm not very observant, Either way, very nice.
https://www.baptisthealth.com/provider/tathyana-m-fensterer-md-phd-plasticreconstructive-surgery
Thank you. It is my statement. I have had a lot of support and compliments about it!
I bet you did! Maybe I should try it.
Would you mind recommending any Brazilian surgeons, for anything, but especially body contouring and BBL? Its so hard to know who to trust.
Of course. I can recommend Dr Geraldo Scozzafave who was a huge supporter of the trans patients, Dr Jorge Abel who actually started me on forehead feminization, my first one was on a cis woman. Those are in Sao Paulo. I would recommend Vivian de Araújo in Brasilia bc she had the same training and engagement that I had. There are several others but those are the ones I really know.
I tried looking them up. A bit difficult with the language. Are these correct?
Yes, you are good! I am hiring you!
Hey!
I have tougher, slightly darker question for you.
- Do you know of any long term health and mortality research done on invasive cosmetic surgeries or would like to share your thoughts about it?
The only reliable information I've come across that are consistent across different studies are elevated risks for brain cancer and suicide after getting silicone breast implants and that, generally, invasive surgery involves increased risk for a particular heart disease called venous thrombosis, a blood clot, which trans women are much more prone to than the general population.
I'm in the process and obtaining as much information as I can before starting HRT and predicting what makes mortality among trans women so high. Sorry if I'm crossing too far into boundaries.
Are you referring to increase blood clot because of hormones? Yes, there is an increase risk but being a surgeon who operates paraplegic and cancer patients, we address that. There are several risks factors that we take into account such as age, medication, surgical timing, associated diseases that will make us adapt for a safer surgery. It is called Caprini score. We might stage the procedure to decrease operative time, we might give blood thinners, one dose vs a full week and we might keep patient in the hospital for post op. We might not indicate the surgery. Now, hormones have side effects and recently we had a publication at Plastic Surgery Reconstruction journal about it. I added to my presentation and it is a part nobody likes to hear but it can generate breast and pituitary cancer and cardiovascular problems. We don't have statistics of breast cancer in trans woman but I am sure it will be high.
Are you referring to increase blood clot because of hormones?
Ya, I'm assuming those blood clots can be caused by both HRT and surgery.
is a part nobody likes to hear
I do!
Thanks for all that info. I'll be looking into Caprini score a little to help understand some risks involved.
Its not high, at least not for medical reasons.
How long have you been practicing in the US for, out of curiosity? (I think there's a community of surgeons who do trans surgeries in the US, I hope that you're able to connect with them.) Thanks for all you do for my trans femme sisters and siblings!
I started my American PhD in 2008, then I started general surgery residency in 2011 and plastics in 2016. There are more and more plastics and ENT doing facial feminization and I have a feeling nobody will need to travel for those surgeries anymore. Wouldn't that be great?
That would be awesome! Wishing you the best in your career, thanks for all you do :)
Facial hair removal before or after?
It doesn't matter for the surgery itself but I would recommend wait until fully healed from the surgery to resume hair laser or electrolysis.(usually 6 weeks)
Dr. How long should I be on HRT before considering surgery?
Depends on what you want. I personally don't request anyone to be on hormones but if you are taking it and are having surgeries on areas that the hormone can affect such as breasts, belly or hips, I would prefer to wait until you feel the changes are stable. We usually say 1 year but that time is really random. It depends on each one. Now, if you are having bone work, you can have any time bc the hormones won't change it.
Thank you Doctor so breast enhancement is fine without HRT? Great news. What is your opinion about having the work done in Brazil?
Yes. The only thing that will affect is if the implant will be above or below the muscle, if you are too skinny, under the muscle is better if you have some breast tissue (which can be generated by the hormones), above the muscle is a possibility. Brazil is great, I am from there and I started plastics there, you should find a good surgeon who is board certified. I might suggest someone depending on the area. Where in Brazil?
Thank you Doctor you are very kind patient and beautiful. I only just read a short piece mentioning Brazil as a first rate location for surgery, no specific city. I’m sure you have recommendations?
Thank you again. Paulie
Yes, in Sao Paulo, Dr Jorge Abel.
I’m not familiar with bone work, is that the brow? I’m just starting my journey Doctor as I’m sure you’ve gathered 🙏🏻
No problem. Bone work is forehead, the eyes and jaw. The other parts that are not bone but are cartilage and not affected by hormones as well are nose and thyroid cartilage.
What happens with breast implants in old age? Like 70, 80, 90?
Well, patients with old implants will mostly likely need some kind of surgery by then. Not only trans but cis women as well. All implants generate a capsule, it is normal but in some people, this capsule contracts. Those are the ones who will need surgery earlier. Now, about the patients without any contracture or implant rupture, just age. On those patients, the skin becomes saggy, and the heaviest the implant, the saggiest it gets, the capsule also calcifies and becomes harder. Patient has some options here: 1. Remove implant/capsule only and have a poor cosmetic look (it sounds horrible but when you are 90, most people have other priorities in life) 2. remove implant/capsule, lift the breast and have fat graft at the same time or on a second surgery. 3. Remove implant/ capsule, lift the breast and replace with a new implant. In this case I always use absorbable mesh as an internal mesh so the implant is not as heavy on the skin.
Who would you recommend for FFS in Sao Paulo or in brazil?
What techniques to you perform on FtM individuals seeking top surgery?
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