Written by Nhuhao Do
Edited by Dr. Tuan Tran
September 10, 2020
Transgender is an umbrella term that describes those who do not identify with their assigned gender at birth. Although such labels may sound abruptly broad, each individual may identify themselves with a rather specific gender that can be permanently transitioned into with transgender surgery or also known as gender-affirming surgery. Which uses a combination of different techniques from plastic surgery and reconstructive surgery to achieve the final results. In an attempt to touch base on this complicated, yet compelling topic, we have identified major benefits and key differences in surgical options of Gender-Affirming Surgery that best express one’s unique gender identity.
WHAT IS GENDER-AFFIRMING SURGERY?
A transsexual individual may seek gender affirmation to overcome societal stigma and risky body modification practices along with other risk behaviors associated with gender dysphoria. Moreover, gender affirmation is the process by which individuals are affirmed in their gender identity through social interactions and being able to express their physical appearance in accordance with their identified gender. The journey to gender affirmation is achieved through multiple dedicated regimens. Which often includes checkups with a primary care provider, counseling sessions with a psychiatrist, hormone therapy and gender-affirming surgery.
In turn, gender-affirming surgery and hormone therapy significantly alter the patient’s physical appearance that serves as an important medical component in treating gender dysphoria. For that very reason, this article aims to inform our patients and family members on essential surgical options for male-to-female (MTF), female-to-male (FTM) and non-binary gender to achieve an appearance in congruence with their gender identity.
Gender-affirming surgery is separated into two categories, genital and non-genital surgery. This article will purely address non-genital surgery, including top surgery and facial surgery. Different procedures are elected based on the individual’s gender expression and medical advice from their surgeon.
Transmen, aka female-to-male or transmasculine individuals, are those who were born with female anatomy and were assigned at birth as female but identify themselves as male. A 2015 research has revealed a staggering 97% of transmen reported either having already received or desiring to undergo chest masculinization in the future. Given that chest masculinization is one of the most common surgeries among transmen, it is important to understand what it actually entails. Your surgeon may elect among various techniques to perform chest masculinization depending on the shape, size and skin elasticity of the breasts.
- Liposuction incision can be performed in combination with another incision technique to remove excess tissues in patients with smaller breasts. Rarely may liposuction be performed alone to achieve the desired result as it does not remove excess skin.
- A mastectomy with free nipple graft can be done in patients with larger breasts to reconstruct a more masculine structured chest.
- At the consultation appointment with your surgeon, he/she will discuss in detail the technique and incision type he plans to perform to achieve a natural and ideal result.
Transwomen, aka male-to-female or transfeminine individuals, are those who were born with male anatomy and were assigned at birth as male but identify themselves as female. Those who desire to transition their physical appearance to align with the typical feminine attributes may undergo breast augmentation and facial feminization surgery.
- Breast Augmentation: Most transwomen who have been on hormone therapy for 1-2 years noticed an increase in breast growth but often not prominent enough and breast augmentation can be done to achieve fuller volume and proportional size to fit the individual’s frame. Breast implants with saline or silicone can be placed based on your preference and your surgeon recommendation. Both provide a natural feeling and lift to the breasts.
- Facial Feminization Surgery (FFS) is a combination of multiple procedures to construct feminine facial features consistent with societal norms. The most common areas of concern in patients seeking FFS are the forehead and jaw.
- Forehead contouring: The typical female forehead is more concave, and the brow bone is smoother and higher in comparison to male. To feminize the forehead in transwomen, shaving of the brow bone can slightly reduce the bulkiness of the frontal bossing. Due to the anterior wall of the frontal sinus being relatively thin, major shaving cannot be done with this technique if the patient requires significant reduction. Fillers can often be injected to the forehead above the burred brow bone to form an overall smoother and concave forehead. Patients with more protruding forehead can achieve prominent results from forehead recontouring with frontal sinus setback, where the anterior wall of the frontal sinus bone is removed, remodeled and secured back in place for a contoured forehead.
- During a forehead contouring procedure, your surgeon can also lower the hairline and give you a brown lift, which reduces the heaviness of the brow ridge and deep eye sockets.
- Temporal augmentation/fat graft: Soft silicone implants or fat graft can add volume to the temporal concavity.
- Cheeks recontouring: Malar augmentation with silicone implants or fat grafts can add volume to the cheeks to create the effects of high, prominent cheekbones that are often associated with feminine beauty.
- Reduction rhinoplasty: Rhinoplasty may be elected to reduce the dorsal hump and contour to fit cohesively with the rest of the feminized face.
- Lip lift permanently enhances the upper lip through surgery in contrast with temporary effects from noninvasive lip fillers.
- Jawline Reduction (mandibular angle reduction) can reduce the width of the lower face to transform a typical square masculine face shape to a more oval feminine face shape. However, this procedure is performed mainly in the mandibular angle which presents more noticeable reduction from the lateral view and not as noticeable from the frontal view.
- Chin recontouring (reduction genioplasty) can reduce the shape of a prominent chin in male who often have a wider, longer and squarer chin with a flat base. This procedure can reshape the chin to be smaller, less angular, and even out any asymmetries for a smoother and feminine aesthetic face.
- Tracheal shave (chondrolaryngoplasty) is a procedure that reduces the size of the thyroid cartilage to form a less prominent Adam’s apple.
A non-binary person does not confirm to the binary gender of either female or male. Some people have a gender that blends attributes of both male and female, or a gender that is entirely different than male or female, or do not identify with any gender. After consulting with their physicians and psychiatrist, one may elect a number of procedures that can assist them to better express their physical appearance and attributes in congruent with their gender identity. Many procedures mentioned above can be modified for results that align with a non-binary person identity. It is crucial to discuss your desires and expectations with your surgeon in detail at the consultation appointment.
COST OF GENDER-AFFIRMING SURGERY
Different procedures associated with gender-affirming surgery can be covered under your insurance. At Tran Plastic Surgery, our staff will request for your surgery approval and work with you and your insurance representative to maximize your coverage. However, it is crucial to keep in mind that your health insurance may cover fully, partially or none of the cost of surgery. Deductibles and out-of-pocket copay should also be taken into consideration before moving forward with these procedures as with any surgery.
Many patients with Cal-Optima are intimidated by the cost of gender affirmation surgery and afraid that their health plan will consider their elect procedures as cosmetic surgery and will not cover them. However, Dr. Tran aims to shed light on this topic. In fact, Cal-Optima covers for many members undergoing gender-affirming surgery, including chest masculinization and facial feminization. In some breast augmentation cases, the medical group covers for the surgeon fee, facility and anesthesia, which only requires the patients to be responsible for the implants cost that they have selected. As of 2020, Dr. Tran was appointed to be the sole provider for top and facial surgery under Cal-Optima in Orange County. As with any health insurance, our team at Tran Plastic Surgery will assist you throughout the process of attaining surgery authorization and through your follow up visits post-surgery.
TYPICAL PROCESS TO UNDERGO GENDER-AFFIRMING SURGERY
Below are general phases one must go through to receive gender-affirming surgery through a health insurance coverage. Keep in mind that each individual case may vary with your diagnosis and health plans.
- Office visit with a Primary Care Provider (PCP) who determines your diagnosis of transgenderism, gender dysphoria or other diagnoses and refers you to a psychiatrist.
- Counsel with a psychiatrist and obtain a psychiatric evaluation letter as well as a referral to see a plastic or reconstructive surgeon.
- Submit primary care clearance and psychiatric evaluation or support letter to your surgeon.
- Consultation with a plastic or reconstructive surgeon and determine specific procedures needed to achieve your desired outcomes. Insurance authorization will be requested accordingly.
- Complete pre-op tests, including blood work and CT scan. (These are standard for most surgeries)
- Undergo surgery
- Post-op care: restrictions and recovery time varied with the types of surgery you receive. Please refer to the post-op care given by your surgeon for the most optimal recovery.
- Post-op appointment: your first post-op appointment is between 5-7 days after surgery, where your surgeon will often remove non-dissolvable sutures and/or drains.
- Follow up with your surgeon consistently in 1 week, 1 month, 3 months, 6 months, 12 months and/or as recommended by your surgeon.
Those who smoke or is diabetic should not undergo elective surgery as their ability to recover from surgery is highly inhibited. Their tiny blood vessels may not reconnect soon enough after surgery, which can lead to serious complications.
As with any surgery, there are always risks of uncontrolled bleeding, side effects of general anesthesia, allergy to anesthesia, infection, nerve damage, paresthesia, hair loss and scarring at the incision area.
Top surgery and/or facial surgery can certainly enhance your self-esteem and body confidence. However, it is highly important to maintain realistic expectations throughout your consultation and surgical process. There are trade-offs and complications associated with almost every surgical procedure.
Each individual body is unique and heals differently. There is no way to guarantee the look and feel after surgery. Keep in mind that additional surgeries may be necessary to achieve the results you desired.
The best way to ensure you receive the highest standard of care is to choose a reputable board-certified plastic surgeon like Dr. Tran. Dr. Tuan Tran is a triple board-certified plastic and reconstructive surgeon with years of experience and expertise to provide you the best level of care.
The Report of The U.S. Transgender Surgey 2015, National Center for Transgender Equality. Available online: http://www.ustranssurvey.org/report.
Accessed September 2020.