Treating trans & gender diverse patients

Attitudes to restrictive gender norms are evolving, and aesthetic healthcare practitioners can play an important role in the lives of trans and gender diverse patients.

There is a rising social narrative challenging gender binary and hetero-normative standards. Attitudes to restrictive gender norms and traditional notions of beauty are quickly changing, and the cosmetic clinic is perfectly positioned to help shape the future for a more inclusive and gender-diverse society.

Through increased education and awareness, aesthetic medical practitioners can play a pivotal role in aligning a patient’s appearance with their gender identity – and have a significant impact on their quality of life and self-confidence.

Measuring the gender-diverse population

Earlier this year the New York Times reported that the number of young people who identify as transgender has nearly doubled in recent years, based on findings from a new report by the Williams Institute at the UCLA School of Law – capturing a stark generational shift in the growth of the transgender population.

The analysis, relying on CDC government health surveys conducted from 2017 to 2020, estimated that 1.4 percent of 13- to 17-year-olds and 1.3 percent of 18- to 24-year-olds were transgender. This is roughly double the percentage since the researchers’ previous report in 2017.

Overall, the percentage of US adults who self-identify as lesbian, gay, bisexual, transgender or something other than heterosexual has increased to a new high of nearly 8% of the total adult population, according to the 2020 US Census Bureau (significantly, this was the first time the US government included questions about LGBTQIA+ Americans in its national survey). This figure is almost double the prior estimates for the LGBTQIA+ community. The results also showed more than 1% of people in the US, or two million, identify as transgender, higher than any prior estimates of 1.4 million.

In Australia, there is a critical lack of population-level data to accurately estimate the number of people who identity as trans, gender diverse and intersex. The 2021 National Census, for example, collected information on sex but not gender.

However, based on limited research outlined by Rainbow Health Victoria, part of the Australian Research Centre in Sex, Health and Society at La Trobe University, 3-4% of the population have reported identifying as non-heterosexual. This figure is higher among people younger than 25 in Australia — rising to 4% for male participants and around 7% for female. And some estimates from the Department of Health state that up to 11% of the Australian population identify as lesbian, gay, bisexual, trans and/or intersex.

The role of the aesthetic health practitioner

Despite an increase in the visibility of the gender-diverse population, those who seek gender-affirming health care continue to face barriers and challenges, in part due to a lack of dedicated services and education for healthcare practitioners.

In a 2021 article in the journal Clinical, Cosmetic and Investigational Dermatology¹, ‘Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals’, De Boulle et al state there is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodelling and transformation, regardless of where they are in their transition journey. However, there is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. A review of the existing literature indicated that the most-studied transgender research topic was outcomes of surgeries and hormone treatments.

‘Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process,’ the authors write. ‘When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients’ self- perception and overall quality of life.’

As with all patients, an in-depth- consultation is crucial to listen to the patient’s desired outcomes of treatment and understand the aesthetic concerns and psychological wellbeing unique to the transgender population.

Although transgender patients may seek feminising or masculinising effects, these may not conform to traditional binary standards of beauty, the authors warn. As well, the needs and expectations of patients at each stage of their transition process will be different, and treatment approaches should take into account the significant changes in facial structure, soft tissue distribution and skin quality when hormonal therapy is used.

Maintenance and follow-ups are important, and patients should be aware of the ongoing nature of aesthetic treatment such as injectables.

Minimally invasive cosmetic injectables for transgender patients

Transgender patients may seek minimally invasive cosmetic treatment as an adjunct or alternative to gender-affirming surgeries for a variety of reasons: injectables can achieve significant results with little risk and downtime; unlike surgery, non-surgical intervention is typically reversible or non-permanent, and can provide an idea of what patients could expect from a surgical procedure; there are less barriers to treatment compared with surgery; patients may not be candidates for surgery or may not wish to undergo surgery.

Knowledge of the anatomical differences between masculine and feminine features is key, as is an understanding of the facial aesthetic goals for transmen and transwomen, as noted in the 2019 Aesthetic Surgery Journal article, ‘Nonsurgical Management of Facial Masculinization and Feminization’².

In this article, the authors reviewed the existing literature regarding this topic and provided an overview of non-surgical techniques for facial masculinisation and feminisation.

They noted: ‘Generally accepted feminine facial features include a smooth convex forehead, laterally peaked eyebrows that sit above the superior orbital rim, eyes that are more open, a narrow concave nose, prominent cheeks, flat or slightly convex temples, an obtusely angled jaw, a smaller pointed chin, and fuller lips.

‘The male face is square in shape with a large, angled jaw and equally balanced upper and lower facial proportions, whereas the female face has prominent upper facial characteristics and a gradual taper in facial silhouette from upper to lower thirds.’

Facial feminisation

Facial feminisation can be achieved through fillers for the lip and perioral region, for malar augmentation to achieve a more rounded face and projected cheekbones, and to increase the nasolabial angle to achieve a more feminine look.

Neurotoxin can be used in the brow and frontalis muscle to create a flatter forehead, eyes that are more open, and a more angled eyebrow shape. Injecting the masseter muscle can narrow the look of a masculine jaw.

Transwomen may require higher doses of neurotoxin and fillers in all treatment areas, to counteract greater muscle mass and dimension, as well as thicker skin.

For proper placement of toxins with a genderising approach as the desired outcome, it may be necessary to adjust the distribution and placement of injections outside of standard injection points, De Boulle et al state.

‘For example, being more conservative with injections in the frontalis muscle in men can prevent eyebrow ptosis. In addition, retaining frontalis muscle activity above the lateral one-third of the brow can lift the eyebrow, providing a feminine arched eyebrow. Consideration should also be given to smoothing the skin for males transitioning
to females, such as decreasing pore size and fine lines, as well as improving skin tightness, using lasers, peels and cosmeceuticals.’¹

Brow lifting and shaping

Neurotoxin can be used in the brow and frontalis muscle to create a flatter forehead, eyes that are more open, and a more angled eyebrow shape. Injection in the superolateral orbital portion of the orbicularis oculi muscle allows the lateral brow to be raised; injection into the palpebral portion of the orbicularis oculi can

aid in widening the eye aperture, with injections placed inferior to the lower eyelid and lateral to the mid-pupillary line.2 The central brow can be elevated with injections made in the corrugator and procerus muscles.

Fillers can enhance eyebrow contour and volume and assist with raising the lateral eyebrow arch. The authors of the 2019 study note: ‘This might be necessary in transwomen who may require additional assistance after neurotoxin injection in lifting the eyebrows above the supraorbital rim to achieve a feminine look. Two injections can be made at the lateral-most end of the eyebrow, taking care to avoid the supraorbital rim.’

Forehead filler may also be used to balance the frontal bossing associated with a more masculine appearance.

Jawline and chin shaping

Neurotoxin injections in the masseter muscle can help a masculine-looking jawline to
appear softer and more feminine by reducing the masseter bulk to narrow the jawline. Filler can be used to create a rounder chin within the medial intercanthal distance

as well as soften the angles of a masculine jaw.

Midface volumisation

Midface filler treatment can create more feminine contours, adding volume for more forward- projecting cheeks and more defined cheekbones. Nasolabial folds and grooves can be injected with filler to increase volume in the area and create softer facial contours.

Temple filler

Adding volume to the temple area can create a more rounded, less concaved, feminine appearance, as well as the potential to lift the tail of the eyebrow if so desired.

Non-surgical rhinoplasty

Filler can be used to achieve the look of a more feminine nose, by creating a more obtuse nasofrontal angle, creating a more lifted nasal tip and reducing the appearance of a dorsal hump.

Lip augmentation

Lip filler is used to create shape and add volume. It can shorten the distance between the base of the nose and upper lip and enhance the Cupid’s bow and philtral ridges for a more feminine appearance.

Facial masculinisation

The goals for masculinising the face include: a wide and high forehead, a low flat brow, a strong nose that is straight on lateral view, robust square jaw, powerful projected chin, prominent supraorbital rim and superciliary arches, and facial hair, if desired.¹

Male facial characteristics include an equally balanced upper and lower face.

Facial masculinisation can be achieved with injectables used for chin and jawline augmentation and supraorbital ridge augmentation.

Chin and jawline augmentation

The masculine chin has greater vertical height, more lateral fullness and a more square- looking appearance. Filler can be used to project the chin and help create a wider, larger contour and strengthen the appearance of the jaw. Neurotoxin can be injected into the mentalis muscle to reduce the tightness of the skin envelope prior to filler treatment.

Filler can be used to augment the jawline, or mandibular angle, creating a more square-shaped, well-defined jaw.

Brow modification

A masculine-looking forehead is characterised by frontal bossing and pronounced supraorbital ridge. Neurotoxin can be used in the frontalis muscle above the area of peaked eyebrows to help lower the brow position and flatten the brow contour, and in the lateral brow to depress the brow and provide a more masculine appearance.

Excess neurotoxin in the lateral orbicularis muscle and glabella (procerus and corrugator muscles) may preserve feminine features by raising the brow, which is not desirable.¹ Hence, neurotoxin should be used sparingly to avoid preserving a feminine appearance, unless the patient desires otherwise.

Midface angulation

Judicious use of filler to the midface, rather than lateral cheek, with the cheek apex more inferior than medial, can create a less rounded cheek area with less prominent cheekbones, achieving a more masculine angulation.

Non-surgical rhinoplasty

Masculine-looking noses are proportionately larger and wider. Fillers may be used to enhance the projection and strengthen the profile of the nose. AMP