A transgender individual is defined as someone who does not identify with the gender assigned to them at birth.1 Growing acceptance of shifting notions of gender fluidity has altered the face of aesthetic medicine. As the LGBTQ+ community has felt safer in the mainstream, their desire for aesthetic alteration – previously pigeon-holed as nontraditional or ‘niche’ – has been given visibility, vision and voice. Overall demand has also leapt; the number of gender-affirming surgeries performed in 2019 was nearly triple that seen just three years prior.2
The tag ‘gender-affirming’ is still mostly attached to the word ‘surgery.’ However, in the quest for gender euphoria the phrase ‘gender- affirming procedure’ has emerged, widening the umbrella. “We are far beyond top and bottom surgery,” stated dermatologist Brian Ginsberg, MD, owner-associate of 
Chelsea Skin & Laser (New York City, N.Y.), whose medical and aesthetic practice sees a significant number of patients seeking gender-affirming procedures. “Virtually the entire aesthetic armamentarium is employable and at the end of the day, none of the techniques are novel. It is just about using these techniques in strategic ways,” he asserted.
“Guided by our understanding of what features are conventionally masculine and feminine, we help the patient understand what we can modify that would help them better express their gender identity,” Dr. Ginsberg continued. “And while many individuals are confident in their identity, others are still exploring their gender and/or how they would like to express it. We are uniquely positioned to help them because almost every procedure that we do is temporary.”
Compassion in Care
Alexander Z. Rivkin, MD, director of Westside Aesthetics (Los Angeles, Calif.) agreed. “Less invasive nonsurgical treatments are critical for the subtle aspects,” he added. “There are so many details that really make the difference. Surgery can be essential, but it is imperfect. The adjunctive therapies take the result to a higher level. There will be maintenance required but the result can be extremely rewarding for everyone involved.” Dr. Rivkin’s investment in the community stemmed from his belief that all people should have access to quality care. “The positive impact on quality of life is extremely satisfying, and the technical challenge is stimulating in profound ways as well.”
Compassion and profound patient satisfaction similarly inspired Dr. Ginsberg. “When I started practicing, I saw the gap of knowledge in caring for the transgender population, and I felt it important to fill that gap in order to make sure that trans people had culturally competent access to care,” Dr. Ginsberg said.
Stigma has been a defining force in the closeted lives and fringe position of many members of the community. Treating the trans population means transcending this stigma, which, due to the lack thereof, led to a significantly higher probability that they would seek substandard care in the past. “Clear communication is absolutely critical but listening is more important,” Dr. Rivkin shared. “If you are treating this population, working to understand exactly what they do and do not want, you must discard all of your assumptions, and respect that everyone is an individual.”
One of the few surgeons in the nation truly specialized in gender-affirming surgeries, trailblazer Dany Hanna, DO, is founder of the Hanna Gender Center (Frisco, Texas). “Practitioners worry about what color the walls are, the artwork they hang, and paperwork issues, but the starting place is respect for the patient, which is true for anybody, but is refreshing for the trans patient. Learn the information, listen to the patient, use the correct pronouns, and whatever mistakes you make, acknowledge them and move on,” he stated.
Combating Misinformation and Misconceptions
According to Dr. Hanna, the misconceptions and misinformation clash with two vital realities. “Gender-affirming genital surgery and upper body procedures – also known as top and bottom surgery – create genitals that are functional, right down to possibilities for intercourse and orgasm,” he shared. “But more importantly, the quality-of-life impact is immense. The outcome of surgery is often curative when it comes to the disconnect between perceived and realized identity. I see this constantly. This is what compelled me to make this a fulltime specialty and travel the world for training.”
While the current climate is more favorable, there is still room for improvement, according to dermatologist Bianca Viscomi, MD (São Paulo, Brazil). Basic misconceptions and myths surrounding the trans community – and the LGBTQ+ community as a whole – are cultural literacy issues for physicians and the cisgender public.
“People generally think of the trans population as wanting to be the opposite sex. This could not be farther from the truth,” Dr. Viscomi explained. “It is about identity, that is why we refer to them as ‘trans identities.’ It is not a choice, it is how they perceive themselves and their identity. Many myths stem from this key misconception, possibly the greatest being the role of sexuality. Sexual identity is a completely separate issue yet contributes to the stigma.”
Thus, what is desired is more of a spectrum of possibilities. “Our first job as clinicians, outside of treating patients with respect and dignity, is to listen to them and help them figure out what they want and how to achieve it safely.”
Dr. Viscomi’s passion for the trans identities community developed as she began digging into the literature on the topic and was left wanting. “I specialize in aesthetic dermatology, but I believe the umbrella of science should cover everybody. We lacked specific science for the trans community, so I decided to contribute myself. To me it should not have to be a specialty, trans people should
be treated just like everyone else.” For example, she authored an article showcasing a variety of ways the minimally invasive toolbox can help achieve facial femininization in male-to-female transitioning patients, using five distinct cases.3
Body surgery is a little more straightforward than facial femininization or masculinization. Expectations management is still vital, but there is more to it, explained Dr. Hanna. “We can pretty much do what patients want; however, we must help them understand that they can only push their body so far from baseline, but oftentimes what we do leads to a spectacular result for them. Be customized in your approach. Do not shy away from possibilities and potential complications, be honest up front, listen to and engage the patient, and do your best. Satisfaction is overwhelmingly high.”
For Rahul Seth, MD, a facial plastic and reconstructive surgeon at Golden State Plastic Surgery (Walnut Creek, Calif.), and adjunct associate professor for the Division of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology, Head and Neck Surgery at the University of California San Francisco, the common threads between his trans patients quickly unveiled the joys of treating this population. He found the procedures themselves to be both technically challenging and artistic, but it was much more than that. “The truth is that these procedures have more impact on quality of life than any other procedure I perform,” he explained. “Helping patients express their identity has such a profound effect on their core being. It will be life-defining, it could even be lifesaving, and the implications will be lifelong. In fact, many patients are ecstatic just being in my office taking steps toward facial transformation.”
Tools and Resources
In addition to igniting a passion for the community, this energized his interest in facial topography in three dimensions and how it may be presented to everyone. His involvement in the founding of Deep Surface AI (Calgary, Alberta, Canada) evolved from that. Deep Surface AI is leveraging an extensive data pool of facial imagery, AI capabilities, morphing technology and mathematical models to create a HIPAA compliant commercial software platform that can serve the population at large, including the trans community. Dr. Seth co-authored an article4 about the initial work to collect true objective data on facial femininity and masculinity.
“The key was the science of geometric morphometrics (GM), a series of mathematical operations which translates nuanced biometric scanning differences into interpretable, and thus practically representable, information,” he explained. “It boils the information down to size, shape and form which is a combination of size and shape.” The study examined the Caucasian population initially, to prove the concept with a manageable subset, which still included more than 1,500 facial surface scans landmarked by trained experts.
Researchers discovered that while gender differences account for about 6% of facial shape variance, they account for 30% of form variance via objective analysis. “We have had subjective understanding of facial masculinity and femininity for thousands of years, but now we are introducing one based on scientifically validated objective methods. Particular aspects of certain facial features can make the face more masculine or feminine.” Th
e goal is to use this evolving understanding to create tools that can help surgeons and all patients make more informed choices using the visual morphing of their own face as a guide, but it is still only a tool. “It is always up to the surgeon to ask the right questions, listen, and bridge the gap between what the patient envisions and what is surgically achievable.”
Although gaining traction in more recent times, overall professional and scientific investment in the trans community has been ongoing for decades. Established in 1979, the World Professional Association for Transgender Health (WPATH) brought together a multidisciplinary cadre of experts that has since expanded in size and diversity. The latest version of WPATH’s Standards of Care for the Health of Transgender and Gender Diverse People5 was published in 2022. This paved the way for insurance coverage of some procedures, which is an evolving situation. “It also has a gatekeeping effect because guidelines and insurance rules tend to influence patient access to care,” explained Dr. Hanna. “It also provides a pathway for patients to research on their own, and many of my patients come in educated on what they want and how to get it, including thorough documentation which they often bring with them to the initial consultation.”
Pearls and Pitfalls
With body dysmorphic disorder encountered by aesthetic practitioners worldwide, discussion of the psychology issue is warranted. The prevalence of body dysmorphic disorder, according to Dr. Rivkin, is somewhat higher in the trans population, but clinicians should learn the difference and take steps if they are unsure. “It is good to establish relationships with psychologists used to treating body dysmorphia, for their expertise and referrals,” he said. “I do not think it is out of line to consider referring potential patients from any population to make sure any issues with body dysmorphia are part of their overall treatment plan, because first and foremost it is about patient health and safety.”
Dr. Viscomi takes a similar care-centered approach. “It is not insulting to inquire about where trans identities patients are on their journey,” she stated. “Most of them have already built a team to guide and support them. The best overall outcomes – for them personally, not just from procedures – happen when patients have a multidisciplinary team smoothing out the path of transition. We must encourage these patients to seek the best care as they explore themselves, it is very delicate and there is no ‘one size fits all’.”
“Regret rate is another common talking point for mainstream media and political detractors,” Dr. Hanna pointed out. “The reality is that gender-affirming procedures have multi-fold lower rates of regret than cosmetic procedures for cisgendered individuals, and nobody is asking them for letters of affirmation from their mental health providers. As we make progress in our overall understanding, this will only improve.”
“At the end of the day,” Dr. Ginsberg said, “you want every patient who walks into your office to feel as though they are cared for and understood regardless of their identity. Whatever the approach to treating the trans community, the goal is ultimately the same. They just do not want to be made to feel ‘other.’”
“Ultimately we must look at this through the lens of science,” said Dr. Viscomi, “not cultural or religious background. It is just something that happens with human beings, and we must respect and embrace it without judgment. That is half the battle. We perform the same treatments for the trans identities population, using the same armamentarium, just in a slightly different way. As a scientific community we must approach this with curiosity and compassion.”
References:
- Dhingra N, Bonati LM, Wang EB, Chou M, Jagdeo J. Medical and aesthetic procedural dermatology recommendations for transgender patients undergoing transition. J Am Acad Dermatol 2019;80(6):1712–1721.
- Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National estimates of gender-affirming surgery in the US. JAMA Netw Open 2023;6(8):e2330348.
- Viscomi B. From Anatomical Modifications to Skin Quality: Case Series of Botulinum Toxin and Facial Fillers for Facial Feminization in Transgender Women. Clin Cosmet Investig Dermatol. 2022 Jul 14;15:1333-1345.
- Bannister JJ, Juszczak H, Aponte JD, et al. Sex differences in adult facial three-dimensional morphology: application to gender-affirming facial surgery. Facial Plast Surg Aesthet Med 2022;24(5):363–368.
- Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, Version 8. International Journal of Transgender Health 2022. 23:sup1, S1-S259.
