I got FMS (facial masculinization) with Dr. Satterwhite in May 2021. I'd had a Zoom consult with him in January 2021, during which we discussed augmenting my nose, jaw, and chin and removing fat from my lower cheeks. We'd agreed on jaw implants, and for the chin, he gave me two options: a sliding genioplasty, which he recommended because he had a lot of experience with it, or a chin implant. I only did a consult with Dr. Satterwhite because I figured, this was the Bay Area, he runs a trans-specialty surgery practice—surely he's had experience with trans men / trans masc people wanting FMS right? (Spoiler: he had not, and I really should've gone to a surgeon that regularly operates on cis men instead.)

There was no automated appointment system set up, so I had to manually put phone calls or office appointments in my calendar and sometimes take the initiative to reach out to Align to confirm I had an upcoming appointment. When office staff were scheduled to call me, they were often 10+ minutes late or didn't call at all. When I went in for appointments, sometimes Dr. Satterwhite or Debbie (his PA) took 40+ minutes to see me—I'd just be waiting in the room by myself with no update from anyone and no one stopping by to check in on me.

About a week or two before my surgery, I went in for my pre-op appt and was told that the plan for my chin had changed—Dr. Satterwhite wanted to do a "wraparound" Medpor implant, which spans the entire length of the jaw and chin. He seemed excited about it and showed me a digital proof of the implant he'd ordered that was going to be custom-made based on my CT scan. I was pretty pumped from what he told me about the advantages Medpor had over silicone, and I didn't mind having the wraparound since I was going to get jaw implants already. During the same visit, I showed him a slide deck I'd made with images of myself I'd photoshopped to demonstrate exactly what kind of results I was looking for.

When I woke up after the surgery, I found out that Dr. Satterwhite had spent about 3 more hours in the OR than he'd expected, because the wraparound implant had been bigger than expected and he had to hand shave it down with tools in the OR, try placing it in my jaw, take it back out, shape it again, repeat. I proceeded to have months of complications with this implant: from May to July, I couldn't open my mouth more than <1cm, turn my head from side to side without pain, or chew foods that were harder than pasta. I was also constantly (and I do mean constantly) spitting out pus, a yellowy liquid that accumulated in my mouth every few minutes. I had a hard time falling asleep and often woke up multiple times in the middle of the night due to the constant pain. At first, I thought all these symptoms were just post-op effects, but as the symptoms persisted at the same severity levels well into my second month, I got more and more depressed and sought to speed up the healing somehow. My face visually had also taken a turn for the worse—the swelling had been going down until week 3, and then started shifting/accumulating around my chin and lower face until I looked almost gargoyle-like. I did one session of facial acupuncture to see if "improved circulation" could help my state, but a few days after the session, a pus-filled abscess under my chin started filling up and increasing in size. During this May-July period, I'd also been obsessively trawling the Internet for comparable experiences and recovery timelines to try and gauge whether my state was abnormal. I was given very little support or information from Align during this time. When I had seen or communicated with Debbie post-op (because Dr. Satterwhite never contacted or saw me again after the initial post-op visit), her response for every concern I had was pretty much "Give it some more time," even though a lot of my symptoms did not seem like they should've been persisting for as long as they were. When I contacted her about the abscess, however, she immediately scheduled me for an in-office visit and had me come in. During the office visit, they drained as much of the abscess as they could, and what was shocking was that when they injected the lidocaine into the abscess (bulging out from under my chin), I felt some lidocaine squirt into my mouth from somewhere inside my mouth. I concluded that there was at least one passage between the pocket that contained my wraparound implant and my mouth that had never healed fully.

A few days later, I returned to the hospital for a cleaning of the implant and possible removal. Dr. Satterwhite told me the morning of the second surgery that there was a 50-50 chance he could take it out, clean it, and put it back in. Leading up to the surgery, though, I'd read a lot of academic papers about implant infection and had learned about the biofilm that can form on Medpor implants prior to placement, and I didn't have high hopes for salvaging the implant. Once the biofilm is on the implant, there is no cleaning that can get it off. After I woke up from the second surgery, with the implant taken out, I could immediately open my mouth and turn my head side to side without pain again. Dr. Satterwhite came to visit me in my recovery room and we discussed how him repeatedly shaving down the implant, placing it in my jaw, taking it back out, etc. during the first surgery was probably when the biofilm formed on it. From a paper I read: "The greatest risk for infection of facial implants is from inoculation of bacteria at the time of the initial surgery, and the subsequent formation of biofilm." We concluded I'd probably had a low grade infection from May - July that was so low grade that it never induced fever or skin redness and thus went unnoticed by Debbie and me. I also personally concluded that, because it was Dr. Satterwhite's first implant he'd ever placed (as Debbie let slip during my post-op appt) and because my range of movement had never improved during May - July, I probably would've never been able to chew, open my mouth fully, or move my head without pain had the implant stayed in, no matter how long post-op time had passed—so I guess I'm thankful the abscess happened and caused me to get it removed. A year later now, I have tingling and only about 50% nerve sensitivity back on the right side of my lower lip and the skin between my mouth and my chin on the right side—basically the area directly above the abscess. I don't expect nerve sensitivity in that area to ever go back to 100%. (It was slowly coming back after surgery 1, but surgery 2 was the nail in the coffin I think.) The functional consequences are not terrible, but whenever I have food or something on my chin or lip in that area, I can never feel it and am frequently told by people to wipe it off. To place (and remove) the implant, I was also cut open between my lower teeth and lower lip from side to side, and that area between my teeth and lip still has a stiff scar that I can feel 24/7 and impairs movement and sensation.

You may also remember I got a rhinoplasty during surgery 1 in the middle of all the mayhem lol. In the immediate months after surgery 1, my nostrils were quite crooked, but whenever I pointed it out to Debbie, she said she didn't see it. Dr. Satterwhite had not told me he was going to use a homologous graft (rib tissue from a cadaver) prior to surgery—I only found out because my insurance denied the prior authorization request from Align for the CPT code for rhinoplasty using homologous tissue and I had to ask Dr. Satterwhite about it. I was not informed about the tradeoffs of using autologous vs. homologous grafts, and I was also only told at the pre-op appt 1-2 weeks before surgery 1 that he would harvest some fascia from the side of my head for the rhinoplasty. I was not told that my hair wouldn't grow back in that area, which is probably not a problem for FFS patients since most of them probably have long hair, but I have short hair!! And I've had to change my hair style permanently since the hair has not shown any sign of growing back. The worst part is, I've consulted with a revision rhinoplasty specialist since then, and he told me that Asian patients like me don't even need fascia for rhinoplasties 😭 Just kidding, the actual worst part was that my rhino grafts got resorbed and my nose looks almost the same as it did before rhinoplasty, because homologous grafts have a higher rate of resorption than autologous ones. I really wish I'd gone to a nose specialist for a rhinoplasty the first time around, because it sounds all nice and efficient to have 4 procedures in 1 session for a FFS or FMS until you have a revision surgeon tell you, "Sounds like he didn't spend too much time on the nose since you had so many other procedures in the same day."

So what am I left with after all that turmoil and enduring the 2 worst months of my whole life in terms of mental and physical health? A wide bank of knowledge and completed research about facial plastic surgery, for one! I kid; I also got lower cheek liposuction and buccal fat removal out of it and there haven't been any complications with those. (I haven't really seen significant change in the roundness of my face after those procedures, though.) After surgery 2, my chin also became a little more square, which was more "masculine" (albeit uglier than my chin pre-surgery).

The main takeaway that has kept me sane through all of this is the idea that our bodies, especially as trans people, are always going to become in a generatively transformative way. Although we may cut, shape, and remove, getting scarred and losing nerve sensation in the process, the body (and self) that comes out afterwards is spiritually more than the one that went in. And that is a rich slice of the human condition that many people never get to experience.

The more practical takeaways are that I should've gone to a nose specialist that used autologous grafts from the jump, done chin filler instead of an implant, left the jaw entirely alone, and saved to pay out of pocket for a Beverly Hills surgeon that operates on cis men instead of giving into my urge to support a trans clinic, sadly.