As of 2017 an estimated 1.4 million U.S. adults identify as transgender, according to a report by The Williams Institute, UCLA School of Law1. Nonetheless, gender affirmation surgery has only recently come out of the shadows to become a leading edge of aesthetic medicine, according to San Francisco plastic surgeon Dev Gurujal, MD, who has devoted his career to specializing in male-to-female and female-to-male operations.
Dev Gurujal, MD, MS Plastic Surgeon
Artur Diaz-Carandell, MD Facial Plastic Surgeon
Sumanas Wanant Jordan, MD, PhD
To learn more about why this area of aesthetic medicine is like no other, we spoke to specialists from around the world about their surgical experiences and best practices when performing common gender affirmation procedures.
Gender affirmation surgery uses principles of cosmetic surgery applied via the context of what is in reality reconstructive surgery. And it has a purpose; performing these surgeries can have a profound impact on patients’ lives, Dr. Gurujal shared.
“We’re doing surgery for the purpose of addressing gender dysphoria, which typically is the distress some people feel when their internal sense of gender is not aligned with their external or physical body,” Dr. Gurujal explained. “Having the sense that you are trapped in the wrong body is seriously and profoundly difficult. It leads to some really heartbreaking things. For example, among transgender patients there is a 62% depression rate, a 45% attempted suicide rate and a 47% sexual assault rate. These are difficulties in life that nobody would want to experience by choice.”
According to Dr. Gurujal, when done successfully, gender affirmation surgery has been shown in studies to alleviate distress from gender dysphoria. It changes a patient’s body to be more aligned with the gender that patient feels.
Facial feminization procedures. Surgeons performing facial feminization surgery should be well trained in the deep planes, deep structures and bony structures of the face. The general goal of facial feminization is to reshape the appearance of the bony structures to create more narrow feminine features, according to Artur Diaz-Carandell, MD, a facial plastic surgeon at the Instituto De Benito in Barcelona, Spain.
The resulting facial shape should resemble an inverted egg, with high cheekbones tapering to a narrow chin and jaw, Dr. Gurujal highlighted.
Starting at the top, or the hairline, men transitioning often have evidence of temporal recession. Aesthetically, the goals might be to advance the hairline and round it out, so it is less square in appearance.
“We perform hair transplantation to lower the hairline, using the follicular unit extraction (FUE) technique,” Dr. Carandell noted.
The next goal may be to soften the bony shape of the frontal ridge. “Oftentimes, males have a ridge or bar going across the eyebrow area. You can identify this very readily with a light reflex, where it looks like a straight line across the brows. The objective is to use a burr to shave bone away and create a smoother contour. In some cases, we do a frontal sinus setback, where we will take out the outer cortex of the frontal bone over the frontal sinus and inset it to a more posterior position using plates,” Dr. Gurujal reported.
Some patients request ear surgery to make the ears slightly smaller, Dr. Carandell added.
Dr. Gurujal often uses fat grafting in the area of the malar eminence to create that inverted egg shape, emphasizing high cheekbones and cheek projection.
When it comes to rhinoplasty, often the goal is to create an overall smaller nose, with a more refined and upwardly rotated tip.
“The next thing is the length of the upper lip. Often the female appearing lip has a shorter height, so if necessary, we can offer an upper lip lift. We can also add some fat to the upper and lower lips,” Dr. Gurujal said.
Feminizing the projection and height of the chin is often a next step. “Addressing the mandibular contour, we use an intraoral incision and a burr to subtract bone from the angle and body of the mandible. The goal is not always to severely narrow the jaw. The goal is to smooth out the flare or outward angle of the inferior portion of the mandible so that it is less sharp,” Dr. Gurujal explained. “The goal is to narrow the chin, in some cases to recess the chin and sometimes decrease the height. This can be done using a formal genioplasty.”
Moving further down, using a tracheal shave, Dr. Gurujal can reduce the prominence of the Adam’s apple.
Conversely, Dr. Carandell does a surgical reduction of the Adam’s apple submentally, which avoids visible scarring in the middle of the neck. The Adam’s apple is actually thyroid cartilage, so through the submental area we reach the Adam’s apple and cut it,” he said.
Body revision. For plastic surgeons, breast augmentation is a staple surgery. Nevertheless, breast augmentation on a male-to-female patient has important nuances, Dr. Gurujal emphasized.
Gender-affirming breast augmentation has some of the same principles as traditional breast augmentation, yet, “There are things to pay particular attention to in a transbreast augmentation,” Dr. Gurujal indicated. “Number one, pocket control is very important. The pectoralis muscle is often larger and stronger in males, so if you are not very careful with creating the pocket it is easy for the implants to shift to either side over time. You are trying to create a natural appearing female breast, where there is a good cleavage line medially, so you want to avoid having the implants shift laterally over time.”
Surgeons should not violate the medial border of the pectoralis muscle. Dr. Gurujal avoids this by doing minimal pocket dissection laterally, which forces the implant to lay more medially and creates the desired cleavage.
It is also critical that surgeons match the base diameter of the implant to the width of the chest to avoid placing an implant that is too narrow for a male chest.
“This introduces another issue; because you are using wider implants to match the chest width, you can get a top-heavy appearance. However, this is something we address later through body contouring,” Dr. Gurujal asserted. “We can do fat grafting to the hips and liposuction to narrow the waist. All these things can end up creating a proportional female form, with breast, waist and hip ratios in the appropriate ranges.”
Surgeons should inform patients about the balance between creating cleavage and having the nipples centered over the breast mound, according to Sumanas Wanant Jordan, MD, PhD, a plastic surgeon who specializes in gender affirming surgery with Northwestern Medical Group in Chicago, Ill.
“Often, hormone therapy results in some degree of tuberous breast deformity, which may be dealt with by traditional augmentation mastopexy methods,” Dr. Jordan expressed.
Vaginoplasty. These procedures encompass the creation and lining of the vaginal space, clitoroplasty and vulvoplasty, according to Dr. Jordan, who learned the Thai technique for penile skin inversion vaginoplasty. She does the procedure in conjunction with urology colleagues and added that post-operative care, specifically dilation, wound care and hygiene, as well as access to pelvic floor and sexual rehabilitation, are some considerations for success.
Plastic surgeon Thiti Chaovanalikit, MD, who practices in Bangkok, Thailand, said he generally uses penile skin and skin grafts, tissue from the small or large intestine, or peritoneum to create the vaginal lining. Each has benefits and drawbacks.
“The benefit of using penile skin and grafts is there is no donor morbidity because we use excess skin to create the lining and the skin can tolerate shearing during intercourse. The disadvantage is lubrication and vaginal color,” Dr. Chaovanalikit began. “Conversely, the benefits of using the intestinal tissue includes good lubrication and adequate depth. The disadvantage is we have to operate via the abdomen and excise some part of the bowel which could result in some risk for gut obstruction in the future, and we cannot control the secretion from the vagina,” Dr. Chaovanalikit continued. “The newest approach, using the peritoneum offers the benefit of color matching to the vagina and getting some lubrication without cutting the intestines, so it might be less risky in comparison, but long-term results still need to be evaluated.”
Fundamentally, the goal with vaginoplasty is to have a fully functioning and sensitive clitoris, a normal appearing labia majora and labia minora and to have a full-depth vaginal canal to allow for penetrative intercourse, Dr. Gurujal detailed.
“Top” surgery, or mastectomy, to create a male chest. Top surgery is not simply removing breast tissue and closing the incisions, Dr. Gurujal clarified.
“In my view it is actually quite difficult to get what is a natural appearing male chest,” he acknowledged. “If you think of the chest in terms of different elements – scar location, scar shape, position of the nipple-areola complex, the diameter of the areola, the diameter and projection of the nipple, and overall contour – all of these elements have to be composed in relation to each other and to the underlying muscular and bony anatomy in order to accurately recreate the male-appearing chest,” Dr. Gurujal explained.
While there are different approaches to achieving successful top surgery, Dr. Gurujal’s approach is based on the concept of building up from the foundation of the pectoralis muscle. He distinctly dissects the tissue around the lower and inferolateral border of the pectoralis muscle, so it is very clearly identified, then matches that shape to the skin incision.
“What I have found is that the vast majority of time, the origin of the pectoralis muscle medially is at the head of the fifth rib. This is a very useful landmark to use for gauging the starting point of your incision,” Dr. Gurujal shared.
He added that another common issue he sees is over-resection of breast tissue leading to a hollowed out or concave appearance of the chest. “I’ve found it is important to leave a small amount of breast tissue in the subareolar position in order to create proper chest width and projection,” he said.
In Dr. Jordan’s practice the most common request for masculinizing chest surgery is for double incision mastectomy with free nipple graft.
“My standard scars are along the inframammary fold medially and then angled parallel to the lateral border of the pectoralis laterally, with nipples reduced and positioned low and lateral,” Dr. Jordan explained. “However, some patients will have a specific vision for the scars, nipple position and size. Liposuction of the lateral chest wall can be a helpful adjunct. Smaller breasts can be treated in a similar manner to gynecomastia with or without staged nipple reduction.”
Phalloplasty, or creation of male genitalia. Female-to-male “bottom” surgery is extremely challenging and requires training and experience.
Dr. Jordan performs phalloplasty in conjunction with urology colleagues. “My preferred approach is the radial forearm free flap to achieve a vascularized tube within a tube,” Dr. Jordan advised. “There are many approaches with respect to flap preference and staging. For now, I believe the best practice for phalloplasty remains dependent on what works in the individual surgeon’s hands.”
If the patient desires, the goal is to create a normal anatomic-sized phallus with a glans and scrotum, and to close out the vaginal canal. Surgeons aim to also address function, including creating a functioning urethra within the phallus so that the patient can void urine from the phallus in a standing position; as well as having good sensation within the phallus and being able to orgasm through the phallus.
“Eventually, if they desire, we can use implants to create prosthetic testes. And, patients have the ability to achieve erection with the prosthetic implant,” Dr. Gurujal underscored.
A Good Time to Learn and Contribute
Despite the promise of gender affirmation surgery, there are many pitfalls, including a lack of credible training opportunities for U.S. surgeons, established guidelines or recommendations for optimal care, as well as a good understanding of transgender patients.
Dr. Gurujal recommends that surgeons who want to learn more about how to go about performing transgender surgery safely look for guidance with the World Professional Association for Transgender Health (WPATH) https://www.wpath.org/, as well as apprentice directly with experienced surgeons in this field.
Dr. Jordan agrees that WPATH is a required reference for surgeons who do gender affirming surgery. “WPATH Standards of Care version 7 recommends ‘readiness assessment by mental health providers prior to surgery and outlines some basic criteria. Specifically for chest surgery, the patient should exhibit ‘persistent, well-documented gender dysphoria; the capacity to make a fully informed decision and to consent for treatment; age of majority in a given country (if younger, follow the standard of care for children and adolescents); and if significant medical or mental health concerns are present, they must be reasonably well controlled,’” Dr. Jordan emphasized.
Dr. Jordan sees the recommended assessments by mental health providers prior to surgery as opportunities to explore medical, psychological and practical preparedness before a major life-changing event rather than technicalities or gatekeeping.
“I am fortunate to have a licensed clinical social worker on staff who can help identify and navigate any perioperative challenges,” Dr. Jordan shared.
In Dr. Gurujal’s opinion, this is an absolutely wonderful time to be doing gender confirmation surgery because it has been in the shadows for far too long. “It allows us to use our skills to help a patient population that is truly and uniquely in need. Helping patients like this can be very fulfilling,” he said. “My personal feeling is that we need additional excellent surgeons in this area. Historically, this field has not had the benefit of all the innovation which has occurred in other areas of plastic and aesthetic surgery over the past few decades. We have a huge opportunity to work together, build on each other’s ideas, and help make these operations better.”
1. https://williamsinstitute.law.ucla.edu/wp-content/ uploads/Age-Trans-Individuals-Jan-2017.pdf.