American Society of Plastic Surgeons
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American Society of Plastic Surgeons releases first-ever facial, breast/chest and genital data for gender affirmation procedures

Gender affirmation surgery, also commonly referred to as gender confirmation, is complicated – all the way down to what you call it – but the unique complexities of these procedures haven't stopped an increasing number of patients across the United States from seeking the procedure.

For the first time ever, there's data to support that claim. This week, the American Society of Plastic Surgery (ASPS) released a report outlining statistics for the number and variety of gender confirmation surgeries performed by ASPS member surgeons in 2020. Despite the pandemic and its accompanying difficulties, the report shows a double-digit increase of 12 percent in procedures performed from 2019 to 2020.

Two of the country's leading gender affirmation plastic surgeons shared their insights on the report and how they expect these procedures to evolve over the next year.

Most performed procedures: Trans men vs trans women

Gender affirmation procedures are not a one-size-fits-all option. Procedures ranging from in-patient to outpatient, as well as those that involve one area or a collection of procedures performed at once across one or more areas – similar to a mommy makeover – all fall under the gender confirmation umbrella.

Data from ASPS focused on three main gender affirmation surgery categories for both trans men and trans women: facial refinement, body contouring of the breast or chest area and genitalia reconstruction. Trans male patients seeking a breast or chest surgical procedure saw the highest increase, with a 15 percent jump from 2019 to 2020, closely followed by trans female patients who underwent facial and breast or chest procedures, charting a 14 percent increase in 2020.

It shouldn't be considered surprising that there are double-digit increases for gender confirmation surgery during a pandemic, either, according to Chicago-based plastic surgeon and ASPS member Loren Schechter, MD, who specializes in gender confirmation procedures.

"I think the trend line over the last eight to 10 years has been an increase in the number of individuals seeking surgery – across most types of procedures," he says, adding that COVID-19 presented a "confounding" issue, given the various restrictions and limits on surgeries.

"Some of the more complex surgeries, which required longer inpatient stays, like the male bottom surgeries, were down – not necessarily because of interest, but practical issues related to COVID-19," Dr. Schechter says.

Even in procedures that saw a decrease, such as the 7 percent dip in male bottom surgeries, Dr. Schechter maintains that was more than likely due to medical limits posed by the pandemic. The average plastic surgery practice shutdown time was about eight weeks in 2020.

"I think the procedures that were more outpatient, like chest surgeries, facial surgeries, breast augmentations, saw an increase," Dr. Schechter says.

UCLA plastic surgeon and ASPS member, Justine Lee, MD, who specializes in facial gender affirmation, noticed an uptick in recent cases.

"I think most of us will agree on this: We're currently busier than we've ever been," she says. "I'm booking now for 2023."

Overall, and across all procedures, trans female patients surged 13 percent in 2020, while trans male patients rose 11 percent, with nearly 32,000 gender affirmation procedures total performed.

Ripple effects

Even after the reinstatement of elective outpatient procedures in June (for most states), lingering complications continued to touch nearly every aspect of a gender affirmation procedure.

Take travel, for instance, which ostensibly doesn't seem like a tricky barrier for surgery. However, Dr. Schechter estimates that two-thirds of his patients – along with family, friends and partners – travel to his Chicago practice for operations. That couldn't happen in 2020.

"Even though we could restart surgery, we couldn't allow people to stay with them, and that affected either decisions as to when to proceed, or a lot of the planning around post-operative surgery," he explains, adding that it was difficult to figure out logistics of who could help the patient after being discharged – particularly when the patient and caretaker alike are required to stay in the area for several weeks.

Without substantial traveling restrictions, Dr. Schechter says there's "no doubt" these numbers would be higher, adding that his practice alone canceled half a dozen cases due to asymptomatic patients testing positive.

"Everyone's been thinking twice and getting a little bit introspective about what their priorities are in life," Dr. Lee says, calling 2020 a "huge reset" for the trans community especially. "Patients are telling me they've asked themselves, 'Are we doing the things that are super important to us, or are we just going through the motions of life and work?'"

'True' reconstructive procedures

Facial and genital gender-affirming surgery, according to Dr. Lee, are "true reconstructive procedures," meaning that surgeons are working on multiple areas while patients "endure a serious recovery." More often than not, surgery takes all day.

Dr. Lee's focus is on facial gender affirmation, yet she estimates that more than 90 percent of patients request feminization.

"Even my non-binary patients lean towards feminine features rather than more masculine features," she says.

Patients who are trans feminine, according to Dr. Lee, typically undergo a brow bone reduction and brow lift to make the forehead less prominent and the eyes wider, along with "a feminizing rhinoplasty" to refine the nasal tip and make the nose narrow. There is also fat grafting to the temple and cheeks to give the upper face a fuller look while making the lower face appeared tapered, as well as a lip lift and surgical lip augmentation, before wrapping up with a jaw and chin procedure to "soften the wide angles of a masculine mandible."

The final step, depending upon the patient's needs, is a tracheal shave, performed in Dr. Lee's practice by an ENT colleague.

"Of course, everyone needs individual tweaks," Dr. Lee notes, adding that at her speediest, a facial-affirmation surgery spans six hours, with a minimum of one hospital overnight.

She says she has extensive pre-op discussions with patients, even moreso for the non-binary population, often giving patients homework to find photos of facial features they admire.

"It's very hard for the surgeon to picture in our head what their vision of non-binary is; every single person is unique and there is no 'normal' standard of beauty anymore," Dr. Lee says.

Now with more than 332 million COVID-19 vaccine doses and administered in the United States, time will tell whether gender affirmation procedures will continue to climb or if 2021 ushers in new trends or procedures within this realm.

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