Safety of Surgery Abroad

Every now and then, a story hits the national news in the United States which describes a surgery gone wrong in Mexico or in some other country. Such was the case when friends started forwarding us a story a few days ago about a patient that died in Texas following surgery at a border hospital in northern Mexico.

This type of tragedy involving a medical tourist is rare but quickly hits the national news in the United States. The fact is that many Americans still believe that the U.S. health care system is superior to the systems of other countries despite a lack of supporting data. Many surgeons in the United States want people to be afraid of surgery elsewhere. Otherwise, how can they justify charging three times as much? The media are are more apt to assign nationwide coverage to medical tourism patients when things go wrong while not paying much attention to those same types of situations when they happen in the United States. The exception to this is often when famous patients are involved.  Joan Rivers, Kayne West’s mom, and Bill Paxton come to mind.  Still, if you look for them, you can find cases online from the U.S. which never hit the national news like this case from Florida. A surgery in Georgia which resulted in serious injury to the patient did make the news, but only because the doctor danced during surgery and uploaded the videos for entertainment purposes!

The truth is that surgery anywhere in the world carries some degree of risk. This applies in the United States, Mexico, Europe, or anywhere. The risk of death is extremely low. But, it is not zero – regardless of where you have the surgery done.  That being said, good surgeons will take certain precautions to reduce the risk as much as possible. We have never lost a patient during surgery or in its aftermath.

So, the long and short of this is that we believe you must seek out a qualified, experienced, and board-certified plastic surgeon no matter where you choose to have surgery. Dr. Lazaro Cardenas is a member of the American Society of Plastic Surgeons (ASPS) and is the current president of the equivalent organization in Mexico. We think that there’s a good case to be made for having surgery with someone who is recognized in the United States by the ASPS while being at the very top of his game in his own country.

Finally, let’s end with a mention of how Dr. Cardenas reduces risk. First, we don’t accept all patients. Patients who are deemed to be high-risk are turned away for their own safety. All of our patients undergo a complete check-up by a cardiologist the day before surgery. If any red flags are indicated which would make the surgery too risky, the surgery is called off or postponed. With regard to anesthesia, we often use local and/or regional anesthesia combined with IV sedation and reserve general anesthesia for the cases that really require it. An Anesthesiologist (a doctor with a speciality in anesthesia) is always assigned to our patients. Lesser-trained specialists are not allowed to administer anesthesia. Finally, most of our patients spend the night after surgery in the hospital for closer monitoring.

So, do your homework and select your surgeon carefully. The location is much less important than this critical factor.

Hair Transplants for Feminization

Any discussion about feminization of the hairline would be incomplete without mentioning hair transplant surgery.  Sure, hairline advancement can help many patients.  But, those with significant areas of hair loss might be faced with limitations.

Hair loss is often concentrated near the temples.  If the hairline is advanced uniformly, then the same areas of recession are still present – albeit lower than before.  For best results, hair transplant surgery can be done either before or after hairline advancement in order to fill in these problematic areas.  As an alternative, some patients might opt to have the hairline advanced primarily near the temples in order to reduce the look of the receding hairline.  However, this means that the hairline won’t be advanced as much in other areas.  It’s for this reason that hairline advancement combined with hair transplant surgery can often be the best solution.

Finally, hair transplant surgery can sometimes represent the only real option for patients with very significant balding.  For those with hairlines that are far back from the front, advancing the hairline could be little or no use.  But, more than one surgery could be required in order to transplant enough hairs to fill in these large areas. specializes in hair transplant surgery done with feminization in mind as main objective.  Up to 2,000 follicular units can be transplanted in a single surgery.  Since each unit has somewhere between 1 and 4 individual hairs, the total number of hairs transplanted is much higher.  If you would like to know if you are a good candidate for this procedure, please send us some photos of your hairline by clicking here.

For a limited-time only, our all-inclusive hair transplant surgery package is only $4,760! This includes up to 2,000 follicular units, all hospital and surgeon’s fees, prescription medications, and five nights of accommodations with meals at our recovery residence.  This offer is valid for hair transplant surgeries reserved between October 10th, 2017 and November 10th, 2017.  To be eligible for this offer, your surgery must be performed before January 31st, 2018. New reservations only. All prices are in U.S. Dollars and all patients are subject to photo evaluation and medical clearance prior to acceptance.


When should you reserve your feminization surgery with Dr. Cardenas?

We often have patients that inquire about reserving the first available surgery date. In the past, we were sometimes able to find an available slot on our calendar within 2-4 weeks. This is no longer the case. If your dates are flexible, there is still a chance that space might be available with as little as 4-5 weeks advance notice. But, we now recommend that patients wishing to book surgery with Dr. Cardenas do so at least 2-3 months in advance.

Planning Ahead for Facial Feminization Surgery

If you or someone you love is transitioning, then Facial Feminization Surgery (FFS) is probably near the top of the list of topics on your radar.  Feminization of the Physique and Sex Reassignment Surgery (SRS / GRS) may also competing for your attention.  The purpose of this post is to address some of the common planning questions that we receive on a regular basis.

If you’ve just begun your journey, you may wonder if taking hormones is a pre-requisite for FFS.  Although it is not a requirement, the vast majority of transitioning patients should be on hormones unless a local doctor or endocrinologist recommends against it due to a medical reason.  Even though hormones do not effect the shape of the bones, they do help with the soft tissues of the face and body.  If you have a very masculine forehead, then hormones won’t change that.  If you know that you only need work done on areas like the forehead and nose, then the amount of time that you’ve been on hormones is not really a factor.  That being said, if you’ve been taking hormones for a while, we are likely to get a better picture of which procedures would help you in soft tissue areas like the cheeks and breasts.

Another question that comes up often pertains to clearance letters from mental health care professionals or other doctors.  Doctors who perform SRS typically will require two referral letters from qualified professionals that have been assessing you in your local area.  Dr. Cardenas does not require these letters for FFS or for the procedures that feminize the contours of the body.  There are, however, a couple situations that might require a clearance letter.  HIV+ patients, for example, must submit a letter from their specialist that confirms that they are successfully under treatment with an HIV medication meant to produce a low or undetectable viral load.  Other chronic conditions could also require a clearance letter to ensure that the condition itself won’t subject the patient to an excessive risk during or after surgery.

Finally, we get a lot of inquiries about financing.  Our location in Guadalajara, Mexico permits us to offer superb care at a fraction of the cost in many other countries.  This means that you’ll have a lot less money to raise for Facial Feminization Surgery than you would if you had the surgery in the United States.  Although we don’t offer conventional medical financing due to our international location, we do accept Visa and MasterCard for payment of your surgery and some patients have applied for credit cards and then used the cards to finance surgery.

Good luck with your journey and let us know if we can help!

Feminization of the Forehead – Video

In our last post, we explained how Type III Forehead Bone Reconstruction is done. Today, we’re going to move several steps forward and share a video that we prepared which shows both conventional forehead bone contouring and Type III reconstruction being performed by Dr. Cardenas.



If you would prefer to read a description of how the procedure is done, please refer to our last blog post.

Type III Forehead Bone Reconstruction

Facial Feminization Surgery (FFS) most often includes work on the forehead and we receive frequent questions about it.  In this post, we’ll address how Dr. Cardenas performs Type III Forehead Bone Reconstruction which is one of the available procedures for forehead feminization.

To begin, we must consider what a feminine forehead is and how it differs from a masculine forehead.  A male forehead typically has more outward projection than a female forehead.  This boney projection is comprised of the supraorbital rims just beneath and slightly above the eyebrow as well as the glabella between the two supraorbital rims.  The prominent lower-center part of the forehead is a result of the frontal sinus and the section of bone that covers the frontal sinus.  However, it is important to note that about 5% of patients don’t have a frontal sinus at all and about 10% may only have a frontal sinus on one side.  A typically male forehead also tends to be taller and appears to be larger than the average female forehead.  These, however, are generalities as some cis-females appear quite feminine despite lacking a perfectly flat forehead.  And, some cis-males may appear quite masculine despite lacking a strong projection from the brow bossing.

There are two main procedures that you most often hear about when discussing feminization of the forehead.  Forehead Bone Contouring shapes and reduces the bones of the lower forehead with a shaving technique.  In contrast, Type III Forehead Bone Reconstruction involves temporarily removing a section of bone covering the frontal sinus as well as some bone shaving to adjacent areas.  The thickness of the bone covering the frontal sinus and the size of the sinus itself are the main factors assessed in determining the best approach.  This layer of bone may be thick or thin and the sinus itself may be large, small, or non-existent.  Patients with a thin layer of bone covering a frontal sinus of significant size may have too much outward projection from the center of the lower forehead.  However, these patients would not benefit much from bone shaving due to the limited amount of bone available for contouring.  The solution to this problem is Type III Forehead Bone Reconstruction.

When performing Type III Forehead Bone Reconstruction, Dr. Cardenas begins by making an incision along the patient’s hairline or, in some cases, behind the hairline.  After gaining access to the forehead, a thin layer of tissue called the periosteal flap is pulled back to expose the bone underneath it.  A technique called Transillumination is then used to determine the exact size, shape, and location of the frontal sinus.  The outline of the sinus is marked while the bright surgical beam illuminates it.

Transillumination to expose the frontal sinus
Transillumination to expose the frontal sinus

After the thickness of the bone covering the frontal sinus has been determined using transillumination, it is reduced and shaped to a safe limit using the bone shaving method.  The bone shavings are set aside for use later in the surgery.  The bone is then cut along the lines marked during the transillumination process and it is removed from its position covering the frontal sinus.

Mucus membranes within the cavity are removed followed by shaping of the upper lid of the sinus.  The inside face of the section of bone that was removed is then contoured as necessary.  Keep in mind that only remodeling the center of the forehead would be insufficient for most patients.  For this reason, the supraorbital rims are also contoured using a shaving technique.

The next step is done to reduce the chance of future problems associated with the frontal sinus.  A small skin graft is removed from the upper forehead and is combined with the patient’s own platelet-rich blood plasma to form a seal which is placed inside the frontal sinus.  This renders the frontal sinus inactive and less likely to cause any future issues for the patient since the connection is closed between the nose and frontal sinus.

As the surgery nears its completion, the section of bone covering the sinus is set farther back and sutured into place.  The bone shavings are then combined with the patients own platelet-rich blood plasma to form a bone paste which is used to seal the bone incision surrounding the frontal sinus.  The periosteal flap that was pulled back at the start of the procedure is sutured back into place.  This flap is important because it irrigates and helps to heal the segment of bone that was cut.  Hairline advancement and the lifting of the eyebrows is often performed prior to suturing the hairline incision and completing the surgery.

Type III Forehead Bone Reconstruction is more invasive than Forehead Bone Contouring.  One of the risks associated with the cutting and temporary removal of the section of bone covering the frontal sinus is osteonecrosis, or the death of bone tissue.  This complication is quite uncommon but can occur when the body fails to reestablish sufficient blood circulation to the bone.  The patient, however, shouldn’t experience any symptoms from this complication due to the plugging of the frontal sinus which was done during the surgery.  The body will slowly grow new bone over time to replace any areas of necrosis.

Type III Forehead Bone Reconstruction can certainly produce some amazing results and should be strongly considered when the patient’s anatomy requires it for the best results.  It is, however, important to note that some patients can achieve equally impressive results with conventional contouring.  This depends on the patient’s anatomy.  An ethical surgeon will always help the patient to select procedures which will produce the desired results with the lowest risk of complications.  In other words, if more than one procedure would produce the desired result, the procedure with the lowest risk should be recommended instead of the procedure with the highest cost.  Facial Feminization Surgery is certainly not a one-size-fits-all set of procedures and must be customized for each patient.



Dr. Lazaro Cardenas voted VP of AMCPER

Dr. Lazaro Cardenas has just been voted VICE PRESIDENT of the Mexican Association of Plastic, Aesthetic, and Reconstructive Surgery (AMCPER).  The vote took place on February 26th at the association’s annual convention in Veracruz.  Dr. Cardenas earned the vote of 63% of his peers!

Dr. Lazaro Cardenas was voted Vice President of the Mexican Association of Plastic, Aesthetic, and Reconstructive Surgery.

The Mexican Association of Plastic, Aesthetic, and Reconstructive Surgery (AMCPER) is the national association of board-certified plastic surgeons in Mexico.  AMCPER’s principal function is to promote the academic growth and continuing medical education of its members through courses, domestic and international meetings & conventions, workshops, and other functions.

Congratulations to Dr. Cardenas!

What type of surgeon should perform Facial Feminization Surgery (FFS)?

If you’ve been considering Facial Feminization Surgery (FFS), you’ve likely searched everything about it on the internet and probably have read many opinions about who should perform your surgery.  Should it be a plastic surgeon?  What about a craniofacial surgeon?  How about an oral & maxillofacial surgeon?  Would a general surgeon suffice or perhaps a dermatologist who took a course in plastic surgery?  The latter may be easy to rule out when it comes to facial feminization surgery.  But, the others require that the patient be more informed in order to avoid being led down the primrose path.

You could probably guess that if a surgeon wants to start performing FFS, he might declare that his specialty is the only one you should consider and that the training that came along with it makes him perfectly suited to perform such a complex set of procedures.  Many of these surgeons are hoping that you won’t ask how long and how often they have been performing FFS.

So, what do all of these various titles refer to?  Let’s review them:

Plastic Surgeons are MD specialists who perform medical procedures designed to alter or restore the body’s shape or form.  Though cosmetic or aesthetic surgery is the most well known kind of plastic surgery, plastic surgeons are also trained in reconstructive surgery, craniofacial surgery, hand surgery, microsurgery, and in the treatment of burns.  In most countries, plastic surgeons must complete medical school followed by a residency in general surgery and finally a residency in plastic surgery.  Due to these two separate residency requirements, a doctor can’t be a board-certified plastic surgeon until several years have passed after medical school.  It’s a long and tedious process.

Oral & Maxillofacial Surgeons specialize in treating both the hard and soft tissues of the mouth, jaws, and face.  In the United States and Canada, oral and maxillofacial surgery is considered to be a subspecialty of dentistry.   Oral surgeons are most familiar to Americans as the doctors who surgically remove wisdom teeth and implant certain types of dental hardware. But, they are also trained in other procedures such as treating the misalignment of the jaws & teeth as well as correcting cleft lips & palates.  Doctors who pursue this specialty must first complete dental and/or medical school, depending on the country, followed by an oral & maxillofacial residency program.  In the United States, both dentists and doctors may train to be board-certified oral & maxillofacial surgeons.

Craniofacial Surgeons treat deformities of the jaws, head, neck, face, teeth, and associated areas.  These surgeons are typically plastic surgeons, oral & maxillofacial surgeons, or otolaryngologists (ENT’s).  Once they are board-certified in one of these specialities, they then choose to practice as a “fellow” under another surgeon or surgeons who already specialize in craniofacial surgery.  The length of the fellowship varies and most countries do not have a board that oversees this.

Cosmetic Surgery is a procedure done for aesthetic or cosmetic purposes rather than for a functional or reconstructive reason.  Many of the surgical specialities that we just reviewed deal with cosmetic surgery in some way.  But, what about doctors who call themselves cosmetic surgeons?  The truth is that any licensed doctor can offer procedures meant to improve one’s appearance.  This is not prohibited in most countries, including in the United States.  For this reason, you’ll sometimes find general surgeons, dermatologists, and general practitioners using the cosmetic surgeon title and offering common procedures like liposuction and breast implants.  These types of doctors would be very unlikely to offer specialized surgeries such as FFS.

How do these different medical specialties and titles relate to Facial Feminization Surgery and which type of surgeon should you choose?  First and foremost, you should realize that FFS is a rare specialty performed by a very small percentage of global surgeons.  The vast majority of plastic surgeons and oral/maxillofacial surgeons are not likely to have gained much experience with FFS during their residency programs.  By the same token, most craniofacial surgeons are unlikely to learn FFS during their fellowships.  This is because only a small handful of teaching surgeons from any of these specialities performs Facial Feminization Surgery.  More often than not, experience in FFS is gained by interested surgeons after he or she is in well into private practice and begins exploring more advanced procedures while pulling from everything learned and experienced in the operating room.  The surgeon slowly gains experience and progresses to more advanced and difficult procedures, often consulting with other surgeons and medical literature along the way.  This is how the late Dr. Stanley Biber got his start performing Sex Reassignment Surgery in a small town in Colorado.

So, how does one choose when so may surgeons claim to be the most qualified?  You should begin by verifying that any surgeon you are considering is board-certified as a plastic surgeon or as an oral & maxillofacial surgeon.  If they cannot direct you to an independent website for the appropriate boards, move on.  More importantly, you should find out just how much experience the surgeon has performing Facial Feminization Surgery.  Would you want a surgeon with any of the above specialties who has just a couple of years of FFS experience?

In short, verify experience with FFS as well as training.  One doesn’t mean all that much without the other.

Dr. Cardenas receives ASPS Membership!


Congratulations to Dr. Lazaro Cardenas! He has just been granted membership by the American Society of Plastic Surgeons (ASPS). VERY few international plastic surgeons are granted this honor. Dr. Cardenas has been board-certified in Mexico since 1990 and is now recognized by the ASPS.

From the Chairman of the ASPS Membership Committee:

“Dear Dr. Cardenas-Camarena,

The Board of Directors formally voted you into membership on October 15, 2015 at the board meeting.

On behalf of over 7,000 ASPS members, congratulations and welcome to ASPS.

Membership is granted to only those plastic surgeons who meet the highest standards and who have obtained sponsorship acknowledgment from their national society or their peers. As a vibrant society, ASPS provides its members with many educational, professional and personal benefits to serve you from residency through retirement.

Once again, congratulations and welcome.


Steven H. Williams, MD

Chair, ASPS Membership Committee”

To verify ASPS membership, click here.

X-rays and MRIs prior to FFS

There are many forums and social networks on the internet where anyone with a keyboard and an internet connection can purport to be an expert on just about any subject.  Many people will take what they read with a grain of salt, but others will believe anything.  If it’s on the internet, then it must be true – or not!  Have you received the latest viral Facebook post that swears that Facebook will soon charge to keep your posts private?  Alas, I digress to discuss the subject of this post.

In one recent forum posting, a person stated that an x-ray is a must so that the surgeon knows where to place the incisions required for forehead bone contouring and reconstruction.  She also wrote that the surgeon would need an x-ray of the chin to avoid cutting into the roots of the teeth!

The reality is that 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.