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Providing Gender-Affirming Care with Facial Feminization Surgery

Author Taylor Spurgeon-Hess covers Providing Gender-Affirming Care with Facial Feminization Surgery on BackTable ENT

Taylor Spurgeon-Hess • Jan 11, 2023 • 39 hits

Facial feminization surgery offers transgender patients another avenue to affirm their gender identity and increase their comfort in their own bodies. A variety of procedures comprise the art of facial feminization and these can be utilized to deliver a more youthful and soft appearance. While people from all backgrounds and identities seek out facial feminization procedures, a large portion of the patient population identifies as part of the LGBTQ+ community. As a provider to this community, additional measures can be taken to ensure that the patient experience remains positive and affirming.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Cisgender people identify with the gender assigned to them at birth, while transgender people identify with a gender that differs from that which was assigned at birth.

• Non-binary people may identify with both genders, no gender, a separate third gender, or have a fluctuating gender. Often, people that identify as non-binary utilize they/them pronouns, however, this is not always the case.

• Facial feminization procedures include a combination of cranioplasties, mandible contouring, rhinoplasties, facelifts, brow lifts, lip lifts, and skin rejuvenation. If light bounces in and toward a person’s eyes, the face will appear more feminine. The upper third of the face plays the largest role in achieving a feminine appearance.

• Asking a patient about their preferred pronouns and name and then making an effort to utilize them correctly can easily create a more inclusive space for LGBTQ+ patients.

• For transgender patients, it is important to understand their medical history as hormone use is common and can impact the plan of care.

A pride flag with a stethoscope promoting gender affirming care

Table of Contents

(1) Defining LGBTQ+ Terms to Know

(2) The Art of Facial Feminization

(3) Providing Inclusive Care to LGBTQ+ Patients

Defining LGBTQ+ Terms to Know

In order to best serve patients who identify as a part of the LGBTQ+ community, providers should make an effort to understand key terminology regarding the labels and identities that can be utilized to describe both gender identity and sexuality. Oftentimes patients seeking out facial feminization surgery identify as either transgender or non-binary. A person’s gender identity can be classified as either transgender or cisgender; they identify with a gender that differs from the one assigned at birth or they identify with the gender assigned to them at birth, respectively. Non-binary people do not identify solely as a male or a female but often feel as though they fall in between or feel that their gender identity changes from day to day. While not a hard and fast rule, non-binary people often prefer to use they/them pronouns. Proper use of these terms and pronouns can positively impact a patient’s comfort in-office and their care experience.

[Dr. Gopi Shah]
I think it's important to go ahead and get into some of the terms. Also just because as a healthcare provider, it is important for us to understand how to take care of our transgender patients for whatever it is that they come in for. For me, with peds, if I have a transgender pediatric patient who's coming in for sinus infections, I just want to make sure I understand the terminology. Can we go into, you use the words cisgender, we say transgender, can we just go into some of what we should know?

[Dr. Sarah Saxon]
Yes, it can be very confusing. I have to look things up to make sure I have things right all the time as well. I do this every day. Just don't put any pressure on yourself to feel like you have to get things perfect all the time. Transgender means that a person identifies as the opposite gender of what they were assigned at birth. If their birth certificate said that they are male, they identify as female now. Cisgender means they identify as the same gender assigned at birth. You go back to chemistry, the cis conformation of a molecule is the same side.

Then now you have a few other terms that are becoming more common, really in the last 5 to 10 years. There's gender fluidity, meaning someone doesn't really-- they can go one day as identifying as female, and the next day, they may identify as male. They go back and forth. A lot of times in surgery, they want to be able to have some feminine features but be able to if they want one day to live as male, then they can. Then gender, a non-binary person means that they don't identify as either, they're somewhere in between. Typically their pronouns would be more like they/them, instead of he or she.

[Dr. Gopi Shah]
That's very helpful. A lot of times, and I feel like with research, with demographics, I always think of, should I be using sex or gender? Even when you're thinking about looking at a chart review, prospective study, and demographics, I wonder, because gender and sex, which you're assigned to at birth is-- I feel like--

[Dr. Sarah Saxon]
It can be confusing with surgery because if someone's of childbearing age and they identify as male, but they still have a uterus, they could still be pregnant. They'd still need a pregnancy test before surgery. They still need pap smears. They still need all the regular medical care, which in primary care, it can be limiting too because there are very few primary care providers that feel comfortable. Even insurance providers say if they identify as male, then they're not going to cover a pap smear.

Everything's still changing, and we have a long way to go.

[Dr. Ashley Agan]
Everyone's trying to figure out how to change things and make it work. Can you talk to us about the process of transitioning, what does that mean, and what steps are involved?

[Dr. Sarah Saxon]
The process of transitioning is different for everybody. Typically, a transgender person feels this way from birth, so even when they were two, they felt like they were the opposite gender. Obviously, they don't have surgery when they're two. Now, and actually, Children's has a transgender clinic where they'll start seeing kids who start to tell their parents they feel this way, and they'll have group therapy sessions or individual therapy sessions at a certain point in time, they start to take hormones. This can be either as a child or in adolescence or as an adult.

Everyone starts at different points in time, depending on their background and support structure. Some people wait until they're retired from their profession to start transitioning, I have a 71-year-old that just retired, and now is ready to live their best life. Usually, when they come to me, they've at least done some therapy and hormone therapy. Then typically next steps is facial feminization because they just want to blend in in public, and then they may or may not choose to do top or bottom surgery, meaning breast augmentation or genitalia reconstruction.

Oftentimes, I'll have patients that just do facial surgery, and that's it.

Listen to the Full Podcast

Facial Feminization with Dr. Sarah Saxon on the BackTable ENT Podcast)
Ep 27 Facial Feminization with Dr. Sarah Saxon
00:00 / 01:04

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The Art of Facial Feminization

Defined generally, facial feminization is the process by which surgeons utilize a number of procedures designed to feminize the face and provide a more youthful appearance. These procedures include cranioplasties, mandible contouring, rhinoplasties, facelifts, brow lifts, lip lifts, and skin rejuvenation. Research has shown that a face appears more feminine if light bounces off the face and then in and toward the eyes. The upper third of the face seems to have the greatest impact on a person’s feminine and youthful appearance.

While both cisgender and transgender patients seek out facial feminization surgery, the procedures can be particularly impactful for trans patients. Oftentimes, the end result allows patients to feel more comfortable in their bodies and reduces gender dysphoria, the psychological distress experienced by people whose gender identity does not align with their biological sex. The extent to which the face is feminized entirely depends on the patient’s preferences. As with anything, everybody is different; some people want to look as feminine as possible and others want only small changes. The wide variety of procedures available allows patients to achieve an end result they are happy with.

[Dr. Sarah Saxon]
Yes. Facial feminization is a grouping of procedures that are geared towards feminizing the face. That can be a number of things like bony re-contouring of the face, like cranioplasty or mandible contouring. It also involves everything else that we do regularly, like rhinoplasty, facelift, brow lifts, lip lifts, and also skin rejuvenation because all those things play a part in helping the face look feminine. We want light to bounce off the face in and towards the eyes. Dr. Spiegel, who I trained with in Boston, he did a lot of the pioneering research in what makes a face look feminine.

He found that the upper third of the face has the most impact on looking feminine and also looking young. I incorporate facial feminization into my everyday facial analysis. I consider it basically everything that I do, not just in the transgender community. When I look at someone's face in a console, it's a little bit different than someone who's not trained to do facial feminization. Back when I trained, not many people did those procedures. Really it was only Dr. Spiegel who was training fellows to do his techniques. Now it's become a little bit more mainstream. A lot of academic centers around the country are learning how to do the surgery. It's becoming more common now.

[Dr. Ashley Agan]
I remember doing a Grand Rounds presentation. My chief here and you were my mentor. It was for facial feminization. I remember you kind of explaining the concepts of how facial feminization is the equivalent of youth. When people want surgery to look younger, it's a lot of the same concepts as looking more feminine. It makes sense when you think about, you look at little kids and if they're not dressed in blue or pink, sometimes you're like, "I don't know because they all look like little girls because youth looks feminine." Can you expand on that a little bit?

[Dr. Sarah Saxon]
Yes. Well, and it's the same concept as someone gets older, they start to look more and more alike too. If you see an older woman who's never taken care of her skin, who her brows have fallen, the skin of her neck has started to sag and it's bringing more emphasis to the lower face and less to the upper face. If you look at an older man and older woman, they tend to look very similar too. Facial feminization as a particular field just gives me more tools in my toolbox to help someone look softer.

If I'm seeing a cisgendered woman, which we'll get into terms a little bit later. If I'm consulting with a cis-gendered woman, I sometimes still will recognize some bony contours that are a little more masculinizing to the face and recommend that for their treatment plan. Now that it's becoming more commonplace and people are googling and looking online at options for them, it's not such a shock when I recommend [chuckles] a cranioplasty for their procedure.



[Dr. Gopi Shah]
Going back to sort of the beginning, where we think of facial feminization, it's youthful. From what you were saying before, you use some of the same principles of facial feminization for cisgender women as well as transgender women. When patients come to you in clinic, does that make a difference in how you with your approach in terms of what kinds of surgeries or augmentations or changes that you're thinking about for them?

[Dr. Sarah Saxon]
It mainly makes a difference to know, I usually ask, do you want to look as feminine as possible? If they're transgender versus gender fluid, or non-binary, I always ask as I never want to assume. Even if they come in identifying as female to me, they may not want to do that every day. If they're cisgender coming in, I still want to know do you want to look more feminine. Oftentimes, they'll come in asking me, "I just want to look good, I can't really put my finger on it, but I need your input because I've seen the work you do on transgender patients. I feel like I look very masculine, and I'm open to whatever procedure you would recommend." For those patients, oftentimes I'll recommend, cranioplasty, or jaw contouring, even rhinoplasty is a very feminizing procedure. In general, I think of everybody kind of the same, as far as structure and soft tissue, whether they're transgender or cisgender, and I'm bringing them to the same point.

[Dr. Gopi Shah]
It's similar in that everyone's a little bit different. Some people want the works and some people just a little bit.

[Dr. Sarah Saxon]
I even have cisgendered men come to me because they have a super-prominent browbone feel like they have that Neanderthal appearance. Even though they're not trans, facial feminization can benefit them because it just gives a softer appearance.

Providing Inclusive Care to LGBTQ+ Patients

When working with LGBTQ+ patients, increasing awareness of LGBTQ+-specific issues and implementing small changes can create a huge impact on the quality of care for these patients. Asking what pronouns a patient prefers (e.g. he/him, she/him, they/them) and making a true effort to use them can validate patients tremendously. The intention is key; if a provider makes a mistake and catches it in time they can restate the question or statement with the correct pronouns. Additionally, some patients may go by a different name than their legal name in the system, so asking what they prefer to be called and marking it in their chart can also better the patient experience. Understanding a transgender patient's medical history is especially important as they may be on hormones or may be at risk for certain conditions based on their biological sex, which likely differs from their gender identity.

[Dr. Gopi Shah]
Well, as a provider treating any transgender patient in our ENT clinic for any otolaryngology problem, what do you think is the most important thing that we can incorporate or think about as providers and in our practice of how to really be a good provider for these patients?

[Dr. Sarah Saxon]
I think just being aware of and being open to using the right pronouns. If you feel nervous that you're not doing the right thing, you can just ask because they don't mind, you can say, "What pronouns do you prefer to use?" They'll say he/she or they/them. Not to put so much pressure on yourself about it, but to have the right intentions. It can be on a subconscious level, you might mess up sometimes [chuckles] and that's okay. As long as you're well-intentioned, I think EMRs have a long way to go in having the infrastructure to put what their legal name is versus what they go by.

What gender they go by versus their medical history. Knowing if someone is on hormones, and this is something I didn't touch on before, I do have everyone, especially for longer cases go off of hormones two weeks before surgery. There's no data to say that there's increased DVT risk, but no one's ever going to do that study because it's too risky. Some people can be on pretty high levels of hormones. As these patients get older, they may need cancer surgeries, things that are hours long, and their DVT risk, theoretically, is pretty high.

They have all the same medical issues that everyone else could have too. Getting pre-op clearance and whatever you need, but just being aware of the specific issues they may have with hormone therapy or the past surgeries they've had. If they've had bottom surgery, getting a foley in may be a problem if they have strictures. A lot of things can come up even for me that I don't think about. [laughs] It's a learning process through our whole lifetime. I'm sure other things will come up as more and more people get all these surgeries more commonly.

Podcast Contributors

Dr. Sarah Saxon discusses Facial Feminization on the BackTable 27 Podcast

Dr. Sarah Saxon

Dr. Saxon is a Facial Plastic Surgeon at Saxon MD Facial Plastic Surgery in Austin Texas.

Dr. Gopi Shah discusses Facial Feminization on the BackTable 27 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Facial Feminization on the BackTable 27 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, July 20). Ep. 27 – Facial Feminization [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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