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A Framework for Gender-Affirming Surgery

Transgender Care in Otolaryngology: Facial and Vocal Gender-Affirming Surgery

On-Demand Content


Rahul Seth, MD

When it comes to transgender individuals, an otolaryngologist can make a world of difference.

Through gender-affirming facial surgery, an otolaryngologist can help a transgender person to ensure that who they really are is reflected in one of the most important ways a person presents to the world: with their face.

“The face is one of the most important stimuli, carrying social meaning, and is a primary means of social communication,” said Philip Daniel Knott, MD, of the University of California San Francisco Medical Center. And while we’ve all heard that beauty is in the eye of the beholder, the fact is that most of our eyes register the same standards of beauty.

By taking 3D facial scans of about 1,600 patients, Rahul Seth, MD, also of the University of California in San Francisco, created two average meshes to demonstrate typical facial shapes for both the male and female sexes. This provides a framework for otolaryngologists to help a patient make a plan for gender-affirming facial surgery.

In particular, the panel focused on facial feminization surgery, which is what a patient might choose to undergo if they were born with male sex organs and features but identify—and would like to present—as female.  It’s not typically a one-and-done procedure, focusing on only one area of the face.

“We need to address multiple areas of the face in order to convey a particular gender identification for the patient,” said Dr. Seth. In a facial feminization procedure, in order to present with characteristics identified in the female face mesh, a surgeon might address: 1) the forehead region to advance the hairline, lift the brow, and set back the frontal bone, 2) the lips to lift them and inject fat, 3) the cheeks for an autologous fat injection, buccal fat removal, and implants, and 4) the mandible for bone reduction, mentoplasty, sliding genioplasty, chin implant, mentalis reduction, and masseter reduction.

And this is all only the first stage. About six months after the initial bone surgeries, a patient may choose to have a rhytidectomy, fat grafting to the face, neck liposuction, blepharoplasty, or an ear lobe reduction. Patients may also have voice concerns and wish to pursue voice therapy, vocal fold surgery, and even tracheal shave to ensure that their voice presents as the gender they identify with—particularly in the age of COVID-19 when so many of our communications take place via phone or video call.

In addition to ensuring the patient is part of the planning process and understands what will be required in terms of follow-up care, an otolaryngologist is tasked with making every individual who comes into their office feels comfortable. The statistics Dr. Knott presented surrounding transgender people and healthcare are alarming:

  • 25% of transgender people have had some problem with healthcare related to being transgender.
  • 55% of transgender people have been denied healthcare coverage for transition-related surgery.
  • 33% of transgender people have had a negative experience with healthcare providers.
  • 23% of transgender people have not sought healthcare for fear of discrimination.

It is important for otolaryngologists to understand that the procedures they can perform to help transgender patients are not cosmetic, an interpretation that leads to a misunderstanding of the aim and efficacy of gender-affirming surgery, said Dr. Knott. Cosmetic procedures, he said, produce a change in degree, from less beautiful to more beautiful or from old to young.

“Gender-affirming surgery of the face,” he said, “Changes the fundamental gender identification that is objectively measurable and observable to anatomically restore health and orientation.”

This Expert Lecture was presented live on Tuesday, September 15, 3:00 – 4:00 pm (ET) but is now available in the on-demand library of education content.