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The Role of Facial Masculinization in Gender-Affirming Care

Author Julia Casazza covers The Role of Facial Masculinization in Gender-Affirming Care on BackTable ENT

Julia Casazza • Jun 7, 2024 • 38 hits

While far less common than facial feminization surgery, facial masculinization surgery similarly helps patients achieve an appearance congruent with their gender identity. Recent advances in facial analysis and imaging assist facial plastic surgeons in planning procedures that enlarge and broaden facial features to achieve a more masculine appearance. Dr. Daniel Knott and Dr. Rahul Seth, experts in gender-affirming facial plastic surgery, recently joined the BackTable ENT podcast to explore this salient topic.

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

The BackTable ENT Brief

• Sex is a category assigned at birth based on anatomy. Gender is an abstract concept that describes how an individual relates to ideals of masculinity and femininity. In gender affirming care, gender is best conceptualized as a spectrum rather than a binary.

• Information from intake forms can help determine what pronoun to use with a patient. Otherwise, graciously asking “How would you like to be addressed?” is a good first step.

• The nasofrontal area and glabella are the most influential areas in determining the masculinity or femininity of a face.

• Typically, men have wider noses, square cheeks, wider jaws, and more prominent thyroid cartilage than women. Facial masculinization surgery uses a combination of strategies to reproduce these features.

• Compared to estrogen, testosterone better produces bony changes to the face. Among many patients, testosterone hormone therapy is effective in changing facial appearances if they do not desire surgery.

The Role of Facial Masculinization in Gender-Affirming Care

Table of Contents

(1) Gender Terminology 101

(2) The Role of Facial Analysis in Surgical Planning

(3) Facial Masculinization Surgery: A Key Component of Gender-Affirming Care

Gender Terminology 101

Understanding how to discuss sensitive issues such as gender identity is a useful skill for all clinicians, not just facial plastic surgeons. While sex is assigned at birth based on anatomy, gender is an abstract concept that describes how an individual interacts with the world. Transgender and gender-diverse (TGD) patients conceptualize their gender in ways that defy the traditional male/female binary. When first meeting patients who identify as TGD, facial plastic surgeon Dr. Rahul Seth recommends asking them “How would you like to be called?” or “How would you like me to refer to you?” Importantly, he encourages clinicians to give themselves grace when learning patients’ preferred pronouns. In his experience, patients are patient when they see their clinicians making an honest effort to honor their gender identity.

[Dr. Gopi Shah]
Let's just do a quick overview of some terminology. When we say cisgender versus transgender, gender fluid, non-binary, can we just do a quick run through that?

[Dr. Rahul Seth]
Yes. This is a new vocabulary for a lot of individuals in practice. Sex, by definition, is something that a individual is assigned at birth. Gender is how an individual interacts with society and how they present with society. That's typically characterized as man, woman, boy, girl, sex being male, female, or intersex. Somebody who is cisgender has the same sex at birth and presentation to society. Somebody who's transgender has a difference between the sex assigned at birth and the way that they're presenting to society and the way that they feel about themselves.

For instance, a trans woman is somebody who is sex assigned at birth as male, but has identified in living life and lived life as a woman. There's a few other nomenclatures out there, such as gender diverse, intersex, non-binary. It can get confusing. One of the umbrella terms that we use, especially in our writings, is trans and gender diverse. We abbreviate that as TGD. That seems to be, after talking to numerous experts in the field, one of the most encompassing and appropriate terms to use, although terminology does continue to change.

[Dr. Daniel Knott]
I think it's important, Gopi, to recognize that gender is not necessarily a fixed point on a compass or a spectrum. Myself, when I was early in my career, I believed in a relatively naive way that there was two points, male and female, or perhaps gay, homosexual, somewhere in between or a different direction. Really, there's this broad spectrum of identifications. Really, it's for the individual to decide what he, she, they are most comfortable with and where they want their position on the spectrum to be. As Dr. Seth says, gender expansive terminology, I just think, allows one to identify one's own best position in the spectrum.



[Dr. Rahul Seth]
Clinic medical records have adopted that ability as well, in having a legal name, the name that they wish to be called, the pronouns of preference as well. Part of the intake process takes care of all of that. Nonetheless, it's important, and I find it as a nice opener to the patient when discussing to say, "How would you like to be called?" or, "How would you like me to refer to you?" That ends up opening up the conversation and also just really understanding what may not have gotten transferred through paperwork and medical records, and be able to show up right there for you to continue to utilize. It's really helpful and builds this trust with the patient.

Listen to the Full Podcast

Facial Masculinization in Gender Affirming Care with Dr. P. Daniel Knott and Dr. Rahul Seth on the BackTable ENT Podcast)
Ep 148 Facial Masculinization in Gender Affirming Care with Dr. P. Daniel Knott and Dr. Rahul Seth
00:00 / 01:04

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The Role of Facial Analysis in Surgical Planning

Leveraging advances in facial analysis improves the results of gender-affirming surgery. Drs. Seth and Knott recently collaborated on a statistical analysis of 1573 adult faces to better understand features associated with “feminine” and “masculine” appearances [1]. Their study revealed that male faces are, on average, 7% larger than female ones. The nasofrontal area and glabella are the most influential parts of the face in regard to gender. Other highly relevant areas include the nose (wider in men), the fullness of cheeks (squarer in men), the jaw/chin (wider in men), and the thyroid cartilage (more prominent in men).

[Dr. Rahul Seth]
Facial characteristics that are sex-related is a really important topic and facial analysis really sets the tone for everything thereafter when it comes to surgery. If the analysis is not done correctly, then everything thereafter that follows is not going to quite work out. Having that fundamental understanding of facial analysis between what's masculine and feminine is key.

What we did through a research study with the University of Calgary, where there's experts in this, took us about two or three years to put this together, but we looked at 3D facial scans of about 1,600 patients. These scans were really detailed. I'm talking 55,000 points per facial scan. With that and the number of having about 1,600 of them, we compared the, in a very, very high defined mathematical ability, compared feminine faces with masculine faces. We're able to apply statistical analysis in a way that really hadn't been done before to understand these differences.

Our publication, I welcome anybody to look at it. It's on open access and read the main facial plastic surgery journal, which is Facial Plastic Surgery and Aesthetic Medicine. It came out in 2022. Bannister is the first author of our paper. Basically what it showed was the big differences. The most statistically relevant difference is in between the eyes or the area of the glabella. At this area, the brow prominence, the nasofrontal or root of nose prominence, that area is well defined or statistically defined to be the most statistically different when it comes to bony and soft tissue structure or surface analysis.

Dr. Spiegel, who's one of the, really, pioneers of this field, Jeffrey Spiegel in Boston, he did a similar study years ago where he looked at perception-based analysis and also had found the same thing. In our study, we were really able to put data and mathematics behind the statistics to show this and to show that insurance companies and to show that patients should have a change to this area if it fits with the face.

The other areas are the nose and the nasal prominence, the eyes and how wide open or what percentage of the face is occupied by the eyes and the orbits, the cheeks and how full they are, the overall shape of the cheek being more square in the masculine face, the jaw being wider and the chin being wider in the masculine face, and the thyroid cartilage being more prominent in the masculine face as well. There's many other sub analysis details that we could go into for a while, but it's a fascinating field that has a distinct application to surgery and analyzing the face.

Facial Masculinization Surgery: A Key Component of Gender-Affirming Care

Facial masculinization surgery aims to produce an appearance consistent with the patient’s male gender identity. To this end, surgery focuses on enlarging the face and producing a more angular shape. Oftentimes, facial masculinization surgery is sought out when testosterone treatment is insufficient to produce desired facial changes. Testosterone therapy triggers bony changes in the face but estrogen therapy does not, so facial masculinization surgery is less common than facial feminization surgery. Dr. Seth estimates that for every facial masculinization case he completes, he performs another thirty facial feminization cases.

[Dr. Gopi Shah]
Getting more focused into our topic for today, specific to facial masculinization, what exactly does this entail? What are patients looking for? How do they present to you?

[Dr. Daniel Knott]
Most of the time, with our much more commonly performed facial feminization, it's the onset of puberty with the hormones that causes this deviation of the face of the masculine away from what would be commonly thought of as the default, which is the feminine face. As Dr. Seth mentions, with the size and the shape of the face, when we're feminizing a masculine face, it requires both discrete changes to the shape, but also trying to reduce the overall size.

In terms of facial masculinization, we're doing the exact opposite. You're trying to both enlarge the size and to adjust the shape. It requires a very different subset of skills and approaches that you would apply to a female face that you're masculinizing than the opposite.

[Dr. Rahul Seth]
Really, interestingly, we do feminization surgery so much more often than masculinizing surgery. The reasons for that is, I think, a couple. Number one is, I don't think that there's as much knowledge out there that there is potential for that surgery and what it can do in a safe way. As Dr. Knott was talking about, with the onset of puberty and enlargement of the face with testosterone and the onset of masculine features, those are often bone changes. When we want to feminize the face, we have to reduce the bone. Hormone therapy will work a ways for the soft tissues, skin, fat distribution, but it won't really change the bone. However, when masculinizing hormones are given, there are not only skin, hair, fat redistribution, but there's also some bone changes that can occur. Hormones are able to induce more masculinizing changes that may be sufficient for the patient's transgender dysphoria and allowing them to present in line. Therefore, masculinizing surgery is, at this time, sought out less frequently.

Podcast Contributors

Dr. P. Daniel Knott discusses Facial Masculinization in Gender Affirming Care on the BackTable 148 Podcast

Dr. P. Daniel Knott

Dr. P. Daniel Knott is a professor in the Facial Plastic, Aesthetic and Reconstructive Surgery Division and the director of Facial Plastic and Aesthetic Surgery with UCSF in San Francisco, California.

Dr. Rahul Seth discusses Facial Masculinization in Gender Affirming Care on the BackTable 148 Podcast

Dr. Rahul Seth

Dr. Rahul Seth is a facial plastic and reconstructive surgeon with Golden State Plastic Surgery and Golden State Dermatology in San Fracisco, California.

Dr. Gopi Shah discusses Facial Masculinization in Gender Affirming Care on the BackTable 148 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2023, December 14). Ep. 148 – Facial Masculinization in Gender Affirming Care [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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Facial Masculinization in Gender Affirming Care with Dr. P. Daniel Knott and Dr. Rahul Seth on the BackTable ENT Podcast)

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Navigating Facial Masculinization Surgery

Navigating Facial Masculinization Surgery

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