Media attention given to the open transition of Bruce Jenner to Caitlyn Jenner, and to high-profile transgender celebrities such as Chaz Bono, Laverne Cox, Jenna Talackova, Gigi Gorgeous, and others, has raised national awareness of the challenges faced by transgender individuals.

The medical community has also increased attention to the transgender community to address health disparities and provide multi-disciplinary care during the transition process.  Providers have the important role of facilitating care to transgender patients; medical professionals can reduce patient distress and stigma by creating LGBT-friendly practices, and work to improve health outcomes particularly in the transgender community. For interested health care providers, the American Medical Association (AMA) provides information and an informative list of resources on creating an LGBT-friendly practice, including links to the Fenway Institute and Gay and Lesbian Medical Association.

Gender affirmation surgery

More recently, the surgical community has increased its attention to providing transgender care. This is because transgender patients often seek surgical consultation to undergo gender affirmation surgery as part of the journey to express their gender identity. This may include chest surgery, genital surgery, and also, for the face, facial feminization surgery (FFS) and facial masculinization surgery (FMS). Before embarking on surgery, most will have initiated hormone therapy such as estrogen or testosterone. For the transgender female, estrogen will reduce facial hair, alter fat distribution, and change the appearance and texture of the skin, while suppressing male-pattern hair loss. One other important aspect to consider before seeking surgery is gender affirming surgery should be performed in conjunction with a multi-disciplinary care team including a mental health provider for counseling during the transition and medical health.

So why undergo facial feminization or masculinization surgery? The face is the primary means by which we determine many characteristics of a person including their age, attractiveness, familiarity, emotional state, and…gender! Thus, procedures that change the underlying bone structure or the soft tissue of the face have the unique ability to help transgender individuals to present themselves in the manner most consistent with their sense of self.

Research studies have shown that facial feminization surgery (FFS) improves an individual’s quality of life. For example, Dr. Jeffrey Spiegel published data in 2010 showing that transgender women without surgical intervention show diminished mental health-related quality of life. However, neither FFS nor non-facial gender affirming surgery was equally associated with improved mental health-related quality of life. Those who undergo facial feminization surgery had quality-of-life scores improve to those seen in the general female population.

What facial feature changes have the biggest impact?

Of the many facial features amenable to surgery, what facial features make the biggest impact on transgender female patients? Feminization of the forehead, performed with a procedure called frontal cranioplasty where the “masculine” appearing frontal bossing is set back, was originally described by Douglas Ousterhout after his anthropologic study of the forehead shape of male and female human skulls. Dr. Ousterhout pioneered FFS in the 1980’s and his more recent patient book, “Facial Feminization Surgery: A Guide for the Transgendered Woman.”

More recently, photographs of transgender females who underwent frontal cranioplasty surgery were evaluated by viewers who deemed changes to the forehead as the most feminizing surgical change—more than surgery to the nose/lip or jaw. In a series of 168 patients, only three complications occurred using an older technique that has now been updated.

Other surgical changes to the upper third of the face include lowering and shaping the hairline position and, often simultaneous, eyebrow elevation to create more open appearing eyes. Each of these changes to the eye and upper face helps the transgender female achieve recognition by the casual observer as female.

Transgender females not only undergo gender-affirming changes to the upper third of the face, but also rhinoplasty nasal surgery, cheek shaping, surgical alterations to the shape of the upper lip, chin, and jaw, and reducing the “Adam’s apple”. Where a wide range of procedures exists for the transgender female, facial masculinization is less often performed, often because the effect of testosterone produces masculinizing skin changes.  Augmentation to the bone structure, rhinoplasty, and even creating an Adam’s apple may all be safely performed for the transgender male.

Pre-operative counseling

Before undergoing surgery, the patient and surgeon meet to discuss goals, surgical options, outcome expectations, and also potential risks. Proper pre-operative counseling is imperative for the successful patient experience. In our digital age, photographs can also help convey a reasonable expectation of outcome to the patient. For the patient who may be traveling a distance to a larger city for facial surgery, patients and surgeons should carefully outline the recovery process.

Finally, gender-affirming surgery is not without cost. While insurance providers, private and government, have recently recognized gender affirming procedures as medically necessary, surgery on the face has routinely been considered cosmetic and “not necessary” to a patient’s transition. Patients report facial appearance as a key determinant of a successful transition. The financial barrier to facial feminization surgery without insurance coverage is compounded by other barriers including provider access. There are few facial surgeons, usually in larger cities, available to meet the needs of the transgender population. Media coverage by Forbes magazine on the transition of Caitlyn Jenner noted the cost of facial surgery

“would likely run into the tens of thousands of dollars out-of-pocket with no coverage available.”

Medical organizations including the American Medical Association, surgical societies, and the Gay and Lesbian Medical Association must continue to advocate for coverage of medically necessary surgery to help the transgender patient with gender dysphoria. Many have called upon the World Professional Association for Transgender Health (WPATH) to take a prominent international lead to advocate for FFS and FMS coverage. Medical groups and societies with national voices can serve this vulnerable population not only through member education to provide facial surgery across all corners of the country, but also through advocacy for insurance coverage.

Scott Chaiet, MD, MBA, FACS
Scott Chaiet, MD, MBA, FACS is a practicing physician with dual board certification in Otolaryngology-Head & Neck Surgery and Facial Plastic & Reconstructive Surgery. He is an Assistant Professor at the University of Tennessee Health Science Center in the Department of Otolaryngology, and practices at Regional One Hospital in Memphis, Tennessee and an active member of the American Academy of Facial Plastic and Reconstructive Surgery. Dr. Chaiet also participates in research projects as an Honorary Faculty with the University of Wisconsin School of Medicine & Public Health in the Department of Surgery. He was elected to serve a 2-year position on the LBGT Advisory Committee of the American Medical Association, and recently brought together a panel of experts on transgender health to discuss "Is your practice ready to care for transgender patients?" at the 2016 Annual Meeting of the American Academy of Facial Plastic & Reconstructive Surgery in Nashville, Tennessee.

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