Overview of Transgender Surgery of the Head and Neck
In the United States, it’s estimated that between 0.4% and 3% of the population, or about 1 million people, identify as transgender. Not everyone who is transgender will want or need medical or surgical treatments, but it’s important for doctors to be aware of the health issues that transgender people often face. According to a 2015 survey of 28,000 Americans who are transgender or don’t conform to typical gender roles, about a third said they had been mistreated when they sought healthcare. Today, more and more medical professionals are learning to meet the needs of transgender patients. One step to make healthcare better for transgender people is to create a welcome environment where everyone uses their preferred pronouns and non-gender-specific bathrooms are available.
Medical treatments that transgender patients often find helpful include mental health services and hormone treatments. Hormone treatments include estrogen and anti-androgen therapy for those transitioning from male to female, and testosterone for those transitioning from female to male. The World Professional Association for Transgender Health recommends that patients consider genital surgery (also known as “bottom surgery”) only after a long period of gender dysphoria and 12 months of hormonal therapy. For chest surgery (or “top surgery”), it recommends a documented history of gender dysphoria and, for those transitioning from male to female, 12 months of feminizing hormone therapy.
The article also discusses surgery to make the face look more typically male or female. Most of these operations are done on transgender women, or those transitioning from male to female. This is mainly because testosterone treatments usually cause enough physical changes in the face that surgery is unnecessary. For those transitioning from male to female, the main focus of surgery is usually the upper third of the face.
Several different techniques may be combined for feminizing the upper third of the face. This includes bringing the hairline forward, hair transplants, lifting the eyebrows, and surgery to reduce a prominent forehead or “frontal cranioplasty”. There are different types of cranioplasty, with the most complex involving removing and reshaping the bone around the forehead and eyebrows.
The list of surgeries that transgender women often request includes eye surgeries, nose reduction, cheek implants or fat transfers, upper lip lifts, jaw angle reduction, chin surgery, facelifts, laser hair removal, and “tracheal shave” or surgery on the voice box to make the voice sound higher. Because there are so many possible procedures, it’s often best if the patient’s care is managed by a team of different specialists including plastic surgeons, oral surgeons, eye surgeons, and ear, nose, and throat doctors. Dermatologists can also provide services like laser treatments and injectable medications. Besides these surgery-focused doctors, ongoing care involving hormone treatments and mental health care is usually handled by endocrinologists or primary care doctors and mental health providers.
Anatomy and Physiology of Transgender Surgery of the Head and Neck
There are several physical differences between men and women in the area of the head and neck. These include:
1. Shape and position of the hairline: Men typically have an M-shaped hairline while women have a rounded one. Men often have a higher hairline than women, especially as they get older.
2. Position and shape of eyebrows: Men’s eyebrows usually sit at the brow bone, while women’s eyebrows are often positioned higher. The shape of a male eyebrow is typically flatter than a female’s, but this can vary based on personal style and trends.
3. Facial structure: Men usually have a more noticeable brow ridge than women. Men also often have less wide faces than women and have fuller cheek fat pads, while women have more chubby cheeks.
4. Features of the nose: Men often have a deeper nose root and a higher, straighter, or rounded nose bridge than women. The tip of the nose for men points less upwards than it does for women.
5. Skin and lips: Men generally have thicker, oilier skin than women, which may require more adjustment during surgical procedures. Men also typically have thinner lips than women.
6. Teeth and facial hair: Men usually show less of their top teeth when their mouth is closed than women. Men’s teeth are more square-shapes, while women’s teeth tend to be rounder. Facial and neck hair are common for men, while women primarily have facial hair if they are older or have a hormonal imbalance.
7. Jaw features: Men often have a sharper jaw angle than women, and men’s jaws are typically taller and wider than women’s. This makes men’s jawlines more prominent.
8. Chin features: Men’s chins are usually wider and stick out more than women’s. Some structures of a man’s throat, like the thyroid and cricoid cartilages, are usually more visible than those of a woman.
As people age, these physical differences between men and women tend to become less noticeable, which might be why older couples who have been together for a long time appear to look similar. For this reason, facial surgery for older adults often includes procedures to emphasize the physical features typical of their gender.
Why do People Need Transgender Surgery of the Head and Neck
The World Professional Association for Transgender Health (WPATH), in its Standards of Care 7 document, didn’t establish clear guidelines for facial surgeries that help match a person’s physical appearance to their gender identity, nor did it say if these surgeries are either medically necessary or for cosmetic reasons. However, these facial surgeries are often a key part of a gender transition. This particularly applies to individuals transitioning from male to female, as hormone therapies don’t always produce significant changes in the face.
While there’s no specific WPATH guidelines on taking hormone therapy or undergoing mental health evaluations before facial surgeries, these steps could be beneficial. Many surgeons suggest that patients who are transitioning from male to female should receive at least a year of hormone therapy before the surgery. This line of thinking is because this treatment can make changes like thinner skin and changes to facial hair that can affect the outcome of the surgery. An evaluation to assess the patient’s mental readiness for surgery might be recommended too. This is because recovering from surgery can be difficult and stressful, leading to risks like depression or even suicidal thoughts.
When patients have taken hormone therapy for the suggested amount of time and are mentally ready for surgery, the specific procedures they will undergo should be decided based on the individual’s preferences and a detailed conversation with the surgeon about their goals and expectations. The exact procedures will differ from person to person. But there are some common surgeries for individuals transitioning from male to female. These are frontal cranioplasty (which reshapes the forehead), brow ridge reduction and hairline advancement, along with mandibular angle reduction (which refines the jawline) and genioplasty (which reshapes the chin). Other frequent options are lip lifting, nose reshaping, and laryngeal chondroplasty (which alters the voice box). Many patients, especially older ones, may also find fat transfer or cheek implants, together with rhytidectomy (a type of face lift), helpful.
Individuals transitioning from female to male often don’t need facial surgery due to the effects of testosterone therapy, but might choose facial augmentations to change the appearance of the buccal fat pads (the rounded areas in the cheeks) or mandible (jawbone). Voice altering surgery might also be useful occasionally, although undertaking speech therapy to learn more feminine speech patterns might be enough. Testosterone therapy is often able to lower the pitch of the voice enough to do away with the need for voice masculinization procedures.
When a Person Should Avoid Transgender Surgery of the Head and Neck
There are some reasons why a person may not be able to undergo facial gender affirmation surgery, also known as facial transition surgery. These factors are similar to the ones that might prevent someone from having other types of major face operations:
If a person has heart or lung disease, they might not be able to handle the stress of surgery. a disease that causes excessive bleeding, malnutrition, a history of wounds not healing well, complications from anesthesia, or other serious health conditions could also make surgery too risky.
If a person has been persistently dissatisfied with past plastic surgery outcomes, has body dysmorphic disorder (an obsession with perceived flaws in one’s appearance), or has had suicidal thoughts, it may be best not to proceed with surgery.
Hormone therapy is another important factor to consider. If a person hasn’t been on hormone therapy long enough for its effects to be noticeable, it may be necessary to delay surgery. Ideally, those taking estrogen should stop taking it two weeks before surgery to lower the risk of blood clots forming in the veins, a condition called venous thromboembolism.
Lastly, smoking can increase the risks of surgery as well. People who smoke are more likely to have problems with wounds healing, and the combination of smoking and estrogen therapy can greatly increase the risk of blood clots.
Equipment used for Transgender Surgery of the Head and Neck
The equipment needed may change based on the different surgical procedures that are being carried out:
For a surgery that involves fixing the forehead bones (Frontal Cranioplasty), lifting the eyebrows, and adjusting the hairline:
* Markers to draw on the skin
* A scalpel for cutting (with a #15 blade)
* Adson-Brown forceps, a type of tool used to hold tissue
* Special clips and a tool to apply them for stopping bleeding (Raney clips)
* A tool that uses electricity to cut tissue or stop bleeding (bipolar electrocautery)
* Different types of surgical tools for lifting and separating tissues (Freer and Cottle elevator)
* A special curved tool for lifting forehead tissue during surgery (1/4 curved Daniel endoscopic forehead elevator)
* Scissors for cutting tendons and similar tissues (Stevens tenotomy scissors)
* Tools for holding skin back during surgery (Joseph skin hooks)
* A high-speed drill with various sizes of cutting bits
* A pair of cutting forceps
* Implants for anchoring tissues in place during surgery (Endotine implants)
* A set of tools for fixing plates to the mid-face area
* Tools for cutting bones (osteotomes) and a hammer-like tool (mallet)
* A suction device to remove fluids from the operation area
* A tool for handling and driving surgical needles (Halsey needle driver)
* Scissors for cutting sutures
* Various types of thread for suturing (stitches)
* An ointment for preventing infections (Bacitracin)
For a surgery that lifts the upper lip:
* Tools for marking skin, cutting, and suturing similar to the ones mentioned above
* Special scissors for eyelid surgeries, which can also be used for lip surgeries (Westcott and Kaye blepharoplasty scissors)
* Tiny forceps (0.5 mm Castroviejo forceps)
* A specific blade used to make precise cuts (#6700 Beaver blade)
For a surgery to reduce the back part of the jaw (Mandibular Angle Reduction):
* A light that you wear on your head to better see the operation area (headlight)
* Tools for cutting, lifting and holding tissues, and suturing as mentioned earlier
* A tool that allows for precise cutting or contouring of bones (reciprocating or oscillating saw)
* A special clamp (Kocher clamp)
For a type of chin surgery (Genioplasty):
* Tools similar to those required for the Mandibular Angle Reduction.
* A set of tools used to fix plates to the lower jaw area (mandible plating set)
For a surgery that reshapes the voice box (Laryngeal Chondroplasty):
* Tools for cutting, retracting, and suturing as mentioned earlier
* DeBakey forceps: a forcep used to hold or manipulate delicate tissues
* Petit-point Crile forceps: a forcep used to hold or enclose tissues or vessels
For other procedures like nose reshaping (rhinoplasty), recycling a patient’s own fat for cosmetic or reconstructive procedures (autologous fat transfer), and face lift operations, please refer to the related articles.[19][20][21]
Who is needed to perform Transgender Surgery of the Head and Neck?
For the best outcome from your surgery, several medical professionals work together as a team to take care of you. This team typically includes:
A surgeon, who might be a specialist in plastic surgery, facial plastic surgery, eye-related (oculoplastic) surgery, or mouth-related (oral) surgery. This is the doctor who will actually perform your operation.
A surgical first assist: this might be a second surgeon, someone who is learning to be a surgeon, a physician assistant, or a nurse who has been specially trained to assist in operations. They help the main surgeon during your operation.
Anesthesia provider: This medical professional is responsible for making sure you don’t feel any pain during your surgery. They might put you completely to sleep (general anesthesia), or they might just numb a certain area of your body (local anesthesia).
Circulating nurse: This nurse helps during surgery by doing things like getting needed instruments and supplies, helping the surgeon put on his or her gloves and gown, and checking in with the anesthesia provider.
Surgical technologist: This is someone who has been specially trained to help during operations. They might do things like preparing the operating room before surgery, helping the surgeon during the operation, and cleaning up the operating room after the surgery.
Endocrinologist: This is a doctor who specializes in glands and the hormones they produce. They might be involved in your care if your surgery involves a gland.
Behavioral health provider: This member of your team helps address any emotional or psychological issues you might be having. They could be a psychiatrist (a doctor who specializes in mental health), a psychologist (a professional who studies the mind and behavior), or another type of counselor.
Preparing for Transgender Surgery of the Head and Neck
Before undergoing any surgery, it’s important for doctors and patients to have an open conversation about what the patient hopes to achieve, what changes their body can support, and what they should expect during and after the surgery. Surgeons will take a detailed medical history to make sure the patient is suitable for surgery and that any risks related to the use of general anesthesia are minimized. Special attention is given to the patient’s risk of blood clots.
This is particularly important in facial surgeries for gender affirmation, as most of the patients undergoing these procedures are on estrogen therapy which can elevate the risk of deep vein thrombosis and pulmonary embolism – types of serious blood clots.
Since gender affirmation surgery may be only available in urban areas with specific medical facilities, patients may need to travel long distances for their care. This can increase the risk of blood clotting. Therefore, many surgeons recommend stopping hormone therapy two weeks before surgery. Hormone therapy is key for both transgender men and women. Interestingly, for transgender men, taking testosterone for one to two years may even help them to avoid facial surgery due to the development of male features.
In preparation for surgery, doctors often use images to plan the procedure. These can include standard photographs, similar to those used before face-lifting or nose surgery, taken using a professional camera from various angles to guide the surgeon during the procedure and allow for comparison after the operation.
CT (Computed Tomography) scans, which provide detailed pictures of areas inside the body, can also be beneficial. They allow the surgeons to determine the best surgical technique and plan operations that involve re-shaping the bone structure without damaging key nerves. The images can be further manipulated three-dimensionally to help create a virtual simulation of the surgery. These simulations can then be partnered with 3D printing technology to create surgical cutting guides that may help in enhancing the consistency and symmetry of the surgical results.
How is Transgender Surgery of the Head and Neck performed
The procedure being referred to is called a frontal cranioplasty, which also sometimes includes a brow lift and hairline adjustment. This is a surgery that people usually undergo to improve the look of their forehead, brow and hairline.
Mostly, surgeons start this surgery with a special cut called a ‘pretrichial incision’. This incision begins at the junction where the outer ear meets the face and extends across the forehead, following the hairline. This technique allows the surgeon to easily access the area to be worked on, while also providing an opportunity to adjust the hairline without needing to make another cut.
After making the cut, special clips are used to control bleeding. Next, a separate layer of skin is developed in the center of the forehead, all the way to the brow. Care is taken to avoid certain facial nerves to prevent issues like brow paralysis.
At this point, once the forehead flap has been formed and released, the brow ridge can be accessed. The brow ridge is a bony notch that sits just above your eye sockets. A step in the process involves carefully elevating a fibrous layer, called the periosteum, from one outer corner of the eye (the lateral canthus) to the other. Certain nerve and blood vessel structures need to be identified and preserved during this step.
Once this is done, the forehead part of the skull bone, and specifically the bone above the eye sockets, can be worked on. Surgeons may make use of a high-speed drill and some other tools to carefully remove and then replace this bony area in a more desired position.
In certain cases, where there’s no sinus or the bone is unusually thick, the surgeon may just smoothen down the bone to get the right shape. Also, some surgeons might choose to make the eye sockets a bit more open to feminize the eyes. However, this should be done carefully so as not to cause a hollowing effect. Ideally, the surgical process is completed in a way that your bony brow has been efficiently reduced.
Possible Complications of Transgender Surgery of the Head and Neck
Facial gender affirmation surgery, which is designed to make a person’s face look more like the gender they identify with, can sometimes have complications. The most common issue is that people might not be happy with the way they look after the surgery. This can happen for several reasons including:
1. Mistakes during surgery
2. Scars that are easily seen
3. An infection after surgery
4. Hair loss, or alopecia
5. Bone loss
6. Expecting more dramatic changes than what can be achieved by surgery.
Because the entire process can be quite lengthy, there’s a significant risk of developing blood clots after the surgery. This is why it’s important for the medical team to be on the lookout for symptoms of deep vein thrombosis, a dangerous blood clot in a deep vein, and pulmonary embolism, a blockage in one of the lungs’ arteries. Additionally, each procedure comes with its own set of risks.
Specific surgeries that are part of the facial gender affirmation process have additional risks:
1. A procedure to change the forehead might lead to reduced sensation, brow weakness, blocked ducts, blood collection, and a type of cerebrospinal fluid leak which might happen if the thickest part of the frontal sinus is damaged.
2. Nose surgeries can sometimes result in blocked nasal passageways or a hole in the nasal septum, the thin wall that separates your nostrils.
3. Lip lifting could lead to visible scars. But this is rare if the wound is taken care of properly and sunlight is avoided after surgery.
4. Genioplasty, a surgery to reshape the chin, can lead to reduced sensation of the chin and lower lip and a condition known as ‘witch’s chin’, if the mentalis muscle, which controls the chin’s movements, is not appropriately readjusted.
5. Reducing the size of the jaw might lead to unintentional fractures or damage to a nerve that will cause numbness to the chin, lower lip, and teeth on the same side.
6. Overzealous reduction of the thyroid cartilage, a noticeable feature in masculine necks, can harm the anterior commissure of the vocal folds, leading to issues in talking and swallowing.
7. Lastly, when combined with procedures that are meant to lessen the signs of aging, risks include issues with the brow position, fat resorption, skin death, and potentially harm to nerves in the face and ear, in addition to ‘pixie ear’ and ‘cobra neck’ deformities.
What Else Should I Know About Transgender Surgery of the Head and Neck?
Transgender individuals often face a high risk of mental health issues, with a survey revealing 39% experienced severe psychological distress in the month before taking the survey. It also shows an alarming 40% had attempted suicide at some point in their past. They are also highly likely to be victims of different forms of assault including verbal (46%), physical (9%), and sexual (47%).
Discrimination against transgender individuals is widespread and can take many forms, such as unfair job termination or denial of promotion (30%), being evicted or denied a lease/mortgage (23%), lack of support from family (18%), rejection by religious communities (19%), and poor treatment from law enforcement (58%). This discrimination is even more pronounced for transgender people of color.
Despite some insurance companies regarding facial surgeries for gender transition as optional or merely cosmetic, many surgeons see such operations as critically important for the patient’s wellbeing. These surgeries can significantly benefit patients, especially since facial features largely determine how other people perceive an individual’s gender. Transgender women who have had facial surgery tend to be consistently recognized as female, making them less likely to become targets of harmful actions for not conforming to traditional gender roles. Therefore, these surgeries play a significant role in protecting them from physical and emotional harm.