The scope of aesthetic practice has widened over recent years, with varying trends in buying patterns and consumer expectations and sociocultural and economic changes, such as the normalisation and promotion of aesthetic procedures through social media and the greater accessibility of non-surgical procedures, presenting new opportunities for growth and development. Indeed, 43% of UK adults increasingly consider non-surgical procedures as a normal part of their beauty and personal care routine, which is mirrored by a 40% drop in cosmetic surgeries since 2015, according to the British Association of Aesthetic Plastic Surgeons (Mintel Group, 2021). The demographics of aesthetic clinic attendees are changing, and the aesthetic practitioner should be cognisant of the needs and patient-related factors of the growing variety of individuals they may encounter in their practice.
This includes transgender individuals who wish to seek gender-affirming surgical or non-surgical procedures as part of their transition. In recent years, there has been a 240% increase in referrals to gender dysmorphic clinics; these individuals are only beginning their journey to access medical support and intervention, which, for many, will conclude in an aesthetic clinic (Niemier, 2020). Indeed, aesthetic care said to be ‘last on the list after a long life of appointments, consultations and interventions’, with transgender patients waiting up to 2 years for an appointment, despite NHS guidelines stating that the first appointment for hormone therapy and surgery should be within 18 weeks (Niemier, 2020). Therefore, the transgender patient's presentation at an aesthetic clinic is often a highly important and anticipated event in their transition, and aesthetic practitioners have a duty to provide empathetic, equitable, non-judgmental care and informed care for this vulnerable population, who face both individual and institutional discrimination (Jarvis et al, 2022).
The transformative power of gender-affirming healthcare
Aesthetic interventions, whether surgical or not, are said to be an important step in the treatment of gender dysphoria in transitioning individuals, with the overarching treatment goal being lasting personal comfort with the gendered self, in order to maximise overall health, psychological wellbeing and self-fulfilment (Coleman et al, 2022). The impact of well-informed and personalised healthcare interventions is not to be underestimated. A secondary analysis of the 2015 US Transgender Survey found that, for trans and nonbinary patients, undergoing at least one type of gender-affirming surgery (GAS) was associated with a 42% reduction in psychological distress and a 44% reduction in suicidal ideation (Almazan et al, 2021). In an online survey exploring the experiences of transgender individuals who had undergone non-surgical injectable procedures (NSIPs), encompassing 101 respondents, a history of NSIPs was associated with greater self-esteem (P < 0.01), less anticipated discrimination (P < 0.01), greater physicality and gender identity congruence (P < 0.001), greater body image quality of life (P < 0.001), and greater satisfaction with overall facial appearance (P < 0.01) (Kelly et al, 2021). Similarly, 48 transgender female patients were recruited to complete the FACE-Q, a validated patient-reported outcome measure to assess facial outcomes, and the World Health Organization's QoL Scale—Short Form (WHOQOL-BREF) prior to and following facial feminisation surgery (FFS), which comprises frontal sinus setback, brow contouring, blepharoplasty, hairline advancement, rhinoplasty, mandibular shave, genioplasty, chondrolaryngoplasty and fat grafting (Alper et al, 2023). Following FFS, FACE-Q scores increased significantly for all facial attributes (P < 0.05), and both the WHOQOL-BREF's psychological and physical domains also improved significantly (P < 0.05) (Alper et al, 2023).
Postoperative regret is often cited as a barrier to the provision of gender-affirming healthcare; however, in a systematic review of 27 studies encompassing 7928 transgender patients who underwent any type of GAS, the pooled prevalence of regret after GAS was found to be 1% (95% CI <1%–2%), with a total of 77 patients regretting having had GAS (Bustos et al, 2021). Interestingly, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by the patient's return to society with the new gender in both social and family environments (Bustos et al, 2021).
Considerations and recommendations for gender-affirming non-surgical procedures
The majority of the literature on gender-affirming healthcare largely focuses on surgical procedures, but there is growing demand in the transgender community for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, to achieve facial remodelling and transformation. To guide non-surgical practice for transgender individuals, some authors offer experience-based treatment considerations and recommendations. For instance, while De Boulle et al (2021) remind practitioners that there are different goals related to what constitutes stereotypical ‘female’ and ‘male’ features, they have also compiled a list of characteristics associated with the ideal masculine and feminine face to aid aesthetic professionals, which is presented in Table 1.
Table 1. Facial aesthetic goals for transitioning individuals
| Ideal female face | Ideal male face |
|---|---|
| Large, smooth forehead with some convexity and arched eyebrows | Wider forehead with horizontal brow and prominent supraorbital ridge |
| Eyes that appear wide open | Deeper-set eyes that appear close together |
| Proportionally smaller, narrow nose with upturned nasal tip | Proportionally larger, wider, more projected nose |
| Obtuse nasofrontal angle | Less obtuse nasofrontal angle |
| Obtuse nasolabial angle | Less obtuse nasolabial angle |
| Heart-shaped taper in lower face with smaller lower-to-upper face ratio | More equal ratio of lower-to-upper face proportions |
| Prominent, full cheeks and cheekbones | Squared lower face and jaw |
| Full lips, especially anteroposterior axis | Wider mouth with thinner lips |
| Rounded, narrow, proportionally short chin | Long, square, flat chin |
Notes: Adapted from De Boulle et al (2021)
When the individual is transitioning from male to female, De Boulle et al (2021) note that larger and more frequent doses of both fillers and toxins may be required, as facial skin and muscle mass tend to be thicker in cisgender males than in females. In addition, the type of product and doses for medical aesthetic treatments will need adjustment depending on the patients' stage of the transition process and the time-dependent effects of hormonal therapies (De Boulle et al, 2021). Injection sites for fillers in transgender patients include the zygomaticomalar region, anteromedial cheek, nose, and submalar regions, as well as chin, jawline, temples, supra-orbital brow, forehead, tear trough, nasolabial folds and melomental folds (De Boulle et al, 2021). For proper placement of toxins with a genderising approach as the goal, it is often necessary to adjust the distribution and placement of injections outside of standard injection points—for example, retaining frontalis muscle activity above the lateral one-third of the brow can lift the eyebrow, creating a feminine arch (De Boulle et al, 2021). Further recommendations can be found in Table 2.
» Aesthetic interventions can be a vital step in the transitioning process, and aesthetic practitioners have the opportunity to play a significant role in helping an individual to become more comfortable in themselves and reach their full potential «
Table 2. Potential uses of injectable fillers and toxins for facial remodelling in transitioning individuals
| Facial remodelling goals | Dermal fillers | Neuromodulators |
|---|---|---|
| Male to female | Inject into forehead at the supraperiosteal level to help treat deep furrows and achieve a smooth, gently convex contour; improve temporal fossa volume; camouflage a prominent brow ridge, and help raise the lateral eyebrow arch | Inject into forehead, glabellar, or periorbital areas to eliminate dynamic rhytids and create a more feminine forehead, angled eyebrow shape, and widened eyes; injection into the superolateral orbital portion of the orbicularis oculi muscle may raise the lateral brow, whereas injection into the palpebral portion of the orbicularis oculi may widen the eye aperture, with injections placed inferior to the lower eyelid and lateral to the midpupillary line |
| Inject along zygomatic arch to help cheeks appear more prominent and contoured; inject into anterior malar area to create a prominent, full, and more feminine apex peaking more superiorly and laterally | Atrophy the glabellar musculature to help create a more obtuse nasofrontal angle; weaken the depressor septi nasi muscle to feminise the nose by lifting the nasal tip; weaken the nasal alar muscles to decrease alar flare | |
| Inject medially into chin to give it a more-rounded, less-square contour | Inject into the masseter and mentalis muscles to cause gradual atrophy, decreasing the prominence of the male jawline and making the face appear more heart-shaped | |
| Inject into lips to augment them and into the perioral region to improve lip contour and decrease rhytids | ||
| Address signs of ageing, such as temple volume loss, marionette hollowing, prejowl sulcus, and tear trough development | ||
| Female to male | Inject into supraorbital ridge to increase brow line prominence | |
| Inject uniformly along the zygomatic arch, inferior and medial to the malar prominence, to help broaden the malar base and reduce anterior projection of the apex | ||
| Inject at various points along the radix, dorsum, sidewall, tip, and columella to help broaden the nose, widen the nasal tip, create a dorsal bump, and narrow the nasofrontal and nasolabial angles | Inject into the medial and lateral frontalis to help cause an arched brow to drop, resulting in a more masculine appearance | |
| Inject into the chin, jawline, mandibular angle, and preauricular area to help define the jaw, enhance the angle of the mandible, and create a more prominent, square, and angular lower part of the face |
Notes: Adapted from Boulle et al (2021)
Conclusion
Aesthetic practitioners should always strive to provide individualised and person-centred care to their patients, to grant them the opportunity to make decisions that are informed and meet their needs best. This goal is even more pertinent when it comes to serving the transgender community, who face discrimination and inequity on a global scale. However, with the right patient care and support, aesthetic interventions can be a vital step in the transitioning process, and aesthetic practitioners have the opportunity to play a significant role in helping an individual to become more comfortable in themselves and reach their full potential.
