J Clin Aesthet Dermatol. 2024;17(5):48–52.
by Jonathan Nevin Yu, MD, FPDS; Camille Angeles, MD, FPDS; Hester Bueser, MD, FPDS; and Antonio Sison, MD, FPPA, FPDS
Drs. Yu and Sison are with the Skin and Cancer Foundation, Inc., in Pasig, Philippines. Dr. Angeles is with the University of the East Ramon Magsaysay Memorial Medical Center in Quezon City, Philippines. Dr. Sison is with the University of the Philippines General Hospital in Manila, Philippines. Dr. Bueser is with the Cebu Institute of Medicine in Cebu, Philippines.
FUNDING: Merz Aesthetics Philippines funded and provided all the products used in this study as part of investigator initiated research support.
DISCLOSURES: Dr. Yu is an advisory board member of Merz Aesthetics Philippines. Dr. Angeles is a key opinion leader in Merz Aesthetics Philippines.
ABSTRACT: Objective: Gender nonconformity refers to individuals whose gender identity, roles, or expressions do not adhere to societal standards and norms. Affirmative care is an approach to healthcare delivery in which organizations, programs, and providers recognize, validate, and support the identity stated or expressed by the individuals served. This study examined the effects of nonsurgical interventions performed by dermatologists, specifically botulinum toxins (BoNTA) and dermal filler injections, on the physical and mental health of Filipino gender nonconforming individuals.
Methods. Six gender nonconforming patients received filler and BoNTA injections to enhance their desired facial features. The patients were interviewed before and three months after the treatment session. Baseline and three months post-treatment photos were used to examine treatment results, including the facial width-to-height ratio (FWHR). Three months after treatment, the patients answered a five-question Likert-scale satisfaction survey.
Results. Patients reported high satisfaction with the treatment outcomes (median=5) and agreed that the treatment met their expectations (median=5). They reported improved fine lines and wrinkles (median=5) and increased self-confidence (median=5). All participants strongly recommended the treatment to others (median=5). Changes in FWHR varied among participants who requested a feminine appearance, except for one participant who sought a masculine appearance and whose FWHR increased.
Conclusion. Sensitivity, openness, and knowledge regarding the facial aspirations and treatment preferences of gender nonconforming patients can improve outcomes and increase patient satisfaction in this patient population.
Keywords: Gender affirmation, gender identity, botulinum toxins, dermal fillers, mental health
Introduction
Motivation to seek facial cosmetic dermatological procedures often improves self-esteem. Determining factors in pursuing these procedures may include the desire to achieve a youthful appearance or to enhance perceived masculinity or femininity. This preference is based on a patient’s gender identity.
Gender identity is the internal identification of male, female, and other individuals on the gender spectrum. Gender nonconformity describes an individual whose gender identity, role, or expression is not typical for individuals in each assigned sex category.1 Often stigmatized and neglected, there is a lack of medical resources to address these issues, particularly in the dermatology community.2–7 Affirmative care can improve the physical and mental health of gender nonconforming patients and is defined as an approach to healthcare delivery in which organizations, programs, and providers recognize, validate, and support the identity stated or expressed by the individuals served.8 It may be utilized to effectively address the complex needs of this patient population through a holistic, multidisciplinary approach that includes collaboration with specialists.
Awareness of the intricate relationship between facial features and gender perception is crucial in serving this patient population. The precise administration of botulinum toxins and fillers to alter facial features and allow them to feminize or masculinize, based on the patient’s gender affirmation goals, is paramount.9
Using expertise in facial aesthetics, dermatologists can assist gender nonconforming individuals in attaining a more harmonious and gender-affirming facial appearance, which can positively affect their self-image, self-confidence, and overall well-being.
Injectable dermal fillers, such as hyaluronic acid (HA) and calcium hydroxylapatite (CaHA), offer versatile instruments for contouring and enhancing facial features. In areas such as the cheekbones, lips, chin, and jawline, dermatologists can use fillers to create softer, more rounded contours for feminization or a more angular, defined facial structure for masculinization.10
This study aimed to investigate the impact of nonsurgical interventions on the physical and mental well-being of gender nonconforming patients in the Filipino community, considering their specific needs and goals.
Methods
Patients who provided consent were enrolled in this study. An eligibility questionnaire was administered by a psychiatrist and dermatologist. Patients were excluded if they had been previously diagnosed with any medical conditions, such as heart disease, any autoimmune disease, bleeding disorders, or any past psychiatric illness. Patients were included if they had refrained from receiving dermal filler injections and/or toxins in the year prior to enrollment. All patients signed a written informed consent agreement and agreed to have case details and any accompanying images published. IRB reviewed the protocol and deemed to be a case report/series therefore did not need approval for IRB to publish case details.
Medical history, mental health history, hormone use, sex preference, and desired treatment outcomes for noninvasive procedures were obtained. Two board-certified dermatologists performed the noninvasive facial transformation (NFT) procedure using cohesive polydensified matrix hyaluronic acid fillers (Belotero®; Anteis S.A. Geneva, Switzerland), incobotulinumtoxinA (Xeomin®; Merz Pharmaceuticals GmbH, Frankfurt, Germany), and calcium hydroxylapatite CaHA: Calcium hydroxylapatite (Radiesse®; Merz North America, Raleigh, NC, USA). Blunt cannulas and needles were used depending on patient comfort, safety, desired outcomes, and the injector’s experience.
The patient’s goals for gender affirmation served as a guide for the injection of HA or CaHA fillers (Table 1). CaHA, which had the highest G’ value, was used on the jawline. HA was injected into other facial areas depending on the intended result. HA was injected into the lateral and medial cheeks to enhance or restore the ogee curves and shorten the lid-cheek margin for those who desired a more feminine appearance. Lip augmentation was performed in patients who desired more defined or fuller lips, whereas nasal tip augmentation was performed to increase nasal projection. Temple and chin augmentation resulted in an oval-shaped face. Filler injections to attain a well-defined, angular jawline and a wider chin would result in a more masculine appearance (Table 1).
Upon completion of the filler injections, treatment with BoNTA was performed. BoNTA was injected into the forehead, glabella, and periorbital region to diminish dynamic wrinkles and improve the eyebrow position. BoNTA injection into the masseter produced a more oval facial shape, whereas injections into the platysma muscle created a more defined jawline. Dosing and injection locations were individualized (Table 2 and Figure 1).
Patient follow-up appointments occurred after two weeks and three months for necessary touch-ups. A stereovision digital camera (LifeViz™; Quantificare S.A., Sophia Antipolis, France) was used to capture two-dimensional (2D) photographs at baseline, immediately after treatment, and at two weeks, 60, and 90 days post-treatment. Digital photographs were reconstructed in three dimensions (3D) using LifeViz™ App software (Quantificare S.A., Sophia Antipolis, France). The lighting, aperture, speed, and camera distance were standardized. Images taken at baseline and 90 days post-treatment were the basis for computing facial width-to-height ratios.
A psychiatrist and dermatologist conducted the patient satisfaction interviews during the final assessment. Patients were asked to rate their experiences following treatment using a five-question feedback form, with response options ranging from 1 (strongly disagree) to 5 (strongly agree).
Results
Following dermatologist and psychiatrist evaluations, six patients qualified for the treatment. They ranged in age from 21 to 51 years (median = 31.55 years) and lacked comorbidities. Patients 1, 5, and 6 did not use hormones in their gender affirmation procedures, whereas Patient 2 had taken estradiol under medical supervision for seven months. Patient 3 had used medroxyprogesterone acetate and estradiol cypionate intramuscularly every two weeks for 11 years. Since 2015, Patient 4 has been self-medicated intermittently with cyproterone. Patients 1 and 3 were the only patients with prior experience with noninvasive procedures.
Patients 1, 2, 4, and 5 were identified as females, Patient 3 as gender fluid, and Patient 6 as male. Patients 2, 3, 4, and 5 desired a more feminine appearance; Patient 1 wanted an androgynous appearance, and Patient 6 aspired to a more masculine; appearance. Table 1 outlines the objectives of treatment using fillers and botulinum toxin, and their desired gender affirmation.
During the treatment phase, specific areas were targeted to accomplish feminization or masculinization. Botulinum toxin A (BoNTA) injections eliminated dynamic wrinkles and shaped the face (Table 2). Hyaluronic acid (HA) injections were used to feminize the temples, midface, zygoma, tear trough, pyriform fossa, nose, chin, and lips and to masculinize the chin. CaHA was used to augment the mandible as a part of the masculinization process (Table 3). Figures 2, 3, and 4 display the images before and after treatment, respectively.
After 90 days, the median rating of participants’ satisfaction with treatment outcomes was five. They perceived significant improvements in fine lines and wrinkles, resulting in increased self-confidence (median=5 of 5 for both). All participants would strongly suggested treatment to others, indicating a positive overall experience (median=5 of 5). Facial width-to-height ratio (FWHR) changes varied among participants striving for a feminine appearance, with some increasing and others decreasing. In the sole participant seeking masculinization, the FWHR increased (Table 1).
Discussion
We examined the effects of nonsurgical interventions involving neurotoxins and injectable dermal fillers on the gender affirmation process in a small group of gender nonconforming Filipino patients. The study revealed positive results regarding participant satisfaction, perceived improvement in fine lines and wrinkles, and enhanced self-confidence. The median participant rating for satisfaction with the treatment outcomes was consistently high (median=5), indicating an overall positive experience. This study suggests that neurotoxins and dermal fillers, combined with a multidisciplinary approach involving dermatologists and psychiatrists, can significantly facilitate the gender affirmation of gender nonconforming individuals.
One notable finding was the variation in facial width-to-height ratio (FWHR) changes among participants striving for a feminine appearance. The data varied between cases, and in three of the four cases seeking feminization (Patients 2, 3, and 5), FWHR increased despite the individual’s perception that they became more feminine after treatment. The disparity in FWHR after treatment could indicate that the vertical component versus horizontal width could better indicate feminization than FWHR.11 These individuals reported improvements in their lips, chin, and midface as the main reason for their perceived feminine appearance. These findings highlight the individualized nature of gender affirmation procedures and the importance of tailoring interventions to meet the specific goals and preferences of each gender nonconforming individual. Further research involving a larger patient population is warranted to explore the factors contributing to FWHR variations or vertical component changes and refine treatment approaches accordingly.12
BoNTA successfully reduced the dynamic rhytids and reshaped the faces. BoNTA injections contribute to youthful and refined appearance by temporarily weakening or relaxing specific facial muscles. In addition, dermal fillers, such as HA and CaHA, help achieve specific aesthetic objectives, restore volume, and enhance facial contours. For example, a more horizontal and lower eyebrow is masculine, whereas a more flared eyebrow is feminine.13 The targeted injections of fillers for feminization and masculinization helped create a harmonious and gender affirming facial appearance, corresponding with the participants’ desired goals.
It is crucial to note that this study focused on the needs and objectives of a gender nonconforming Filipino patient population. Individuals of Asian descent frequently develop maxillary retrusion with age, which causes midface drooping, dermatochalasis, and lengthening of the lid-cheek margin.14 Reflecting on cultural norms and preferences, optimal aesthetic outcomes for Asian gender-diverse individuals may differ from those of their Western counterparts. By recognizing and incorporating these cultural nuances, healthcare professionals can address gender dysphoria more effectively and provide individualized and culturally sensitive care.
Conclusion
Nonsurgical interventions employing neurotoxins and injectable dermal fillers may contribute to the physical and mental health of gender nonconforming members of the Filipino community. Dermatologists can better serve this population by addressing the specific needs and objectives of the Asian gender nonconforming population, while incorporating cultural perspectives. Future studies should investigate the efficacy and long-term outcomes of these interventions.
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