Transgender Patients

75 Transgender Patients

Steven Gabel

Summary

Transgender patients pursue hair restoration surgery with the goal of reshaping their existing hairline to match their preferred gender identity. Follicular unit transplantation allows the patient to have a hairline and hairstyle that most appropriately fit the gender with which they identify. There are several studies that demonstrate that gender reassignment surgery is highly satisfying for this patient population. Most transgender hair transplants involve the male-to-female patients who desire to lower their hairline, round the frontotemporal angles, and increase density in the midscalp, ultimately creating a natural, feminine appearance. Depending on the extent of hair loss, one of the most challenging aspects of hair restoration for the transgender female patient is the amount of donor hair available for the hair transplant versus the degree of androgenetic alopecia that has affected the individual. The surgeon must completely analyze the patient’s facial features, skin color, hair characteristics, and degree of hair loss in developing a realistic treatment plan. Options for lowering the hairline for the transgender female include follicular unit transplantation and surgical hairline advancement. Less commonly, transgender male patients seek to masculinize their appearance by transplanting hair to the beard, goatee, mustache, and chest.

Keywords: transgender gender dysphoria gender identity gender identity disorder transgender male transgender female male-to-female female-to-male

Key Points

•Hair restoration for the transgender patient is a vital component in the overall treatment of gender dysphoria.

•An in-depth analysis of the patient’s expectations, facial structures, and hair characteristics are essential in developing a successful treatment plan.

•Hair restoration for the transgender female patient requires the surgeon to balance the degree of feminization of the hairline and frontal zone versus the amount of donor hair available to transplant.

•Facial and chest hair transplantations are the most common hair restoration procedures for transgender male patients in masculinizing their appearance.

75.1 Introduction

Gender dysphoria or gender identity disorder (GID) is the psychological dysphoria (distress) a person experiences as a result of the sex and gender they were assigned upon their birth misaligning with their preferred gender identity. The most universal definition of a transgendered individual occurs when one’s gender identity does not correspond to that person’s biological sex assigned at birth. Hence, a biological male who identifies their gender as being female is a transfemale and a biological female who identifies their gender as male is a transmale.1

Follicular unit transplantation has made gender reassignment a much more aesthetically desirable procedure as modern techniques have made it possible to create gender-appropriate hairline patterns and facial hair transplants. Of the various procedures that are available for gender reassignment, hair restoration is one of the least invasive forms of surgery delivering a large impact for the patient. The ability to create a meaningful cosmetic difference for an individual who brings them aesthetically closer to their gender identity is one that carries unique social, ethical, and legal considerations that nontransgendered patients rarely encounter. Properly performed hair restoration allows transgender individuals and others to physically identify them in correlation with their preferred gender.

Studies show that individuals who have undergone gender reassignment surgery have been highly satisfied with the results.² For individuals considering gender reassignment surgery, there are several modalities of treatment, which include counseling, hormonal therapy, and surgical therapy. In this chapter, the focus will be upon the techniques and challenges in transgender hair transplant surgery (Video 75.1 and Video 75.2).

75.2 Incidence

The exact size and extent of the transgender community is a statistical unknown. In the United States, efforts to determine the scope of the population have been inconclusive due to a variety of reporting and social factors that are thought to have made all existing census numbers inaccurate or incomplete.

While no official national data have been compiled, studies have attempted to quantify and describe the transgender population within the United States. According to a 2011 study conducted by the Williams Institute at UCLA, an estimated 0.3% of the population, or 700,000 adults, identified as transgendered.³ The U.S. Census Bureau released a statement confirming that it does not plan to collect data on transgender people in the 2020 census but that it is working in tandem with other agencies to improve the measurement of lesbian, gay, bisexual, and transgender people in federal surveys.⁴

Reliable statistics concerning the number of transgendered individuals that seek gender reassignment surgery are also difficult to obtain. The most trustworthy estimates suggest that between 100 and 500 are conducted each year within the United States.⁵ The exact number of transgender hair restoration procedures is undocumented and cannot be accurately quantified with existing data. However, in this author’s experience, a greater demand has been observed for transgender hair transplantation over the past decade with a majority being transgender female patients.

75.3 Ethical Considerations

The Standards of Care for the Health of Transsexual, Transgender, and Gender: Nonconforming People by the World Professional Association for Transgender Health (WPATH), previously known as the Benjamin Standards of Care, is the most widespread standards of care (SOC) used by professionals working with transsexual, transgender, or gender variant patients.⁶

The WPATH-SOC are periodically updated and revised ever since their introduction in 1979, the latest revision being released on September 25, 2011. WPATH-SOC recommends that mental health professionals document a patient’s relevant history prior to any surgical intervention.7

75.4 Hair Transplantation: Male to Female

The overall goals of the male-to-female (MTF) hair restoration procedure consist of reshaping an existing male hairline into a female pattern and adding density throughout the scalp to camouflage any existing alopecia. The result should be aimed at producing a natural, feminized overall appearance to the facial frame and hair of the patient. The expectations of the patient must be aligned with the realistic results that are possible with surgical hair restoration. This is accomplished through an in-depth consultation between the physician and the patient.

In this author’s experience, by the time a transgender patient has decided to pursue a hair transplant, treatment with hormonal therapy has been initiated, which, in addition to feminizing the patient’s face and body, also benefits in slowing the progression of hair loss caused by hereditary male-pattern baldness.⁸^,⁹ Additionally, patients considering facial feminization plastic surgery such as contouring of the forehead, brow lifting, or facial implants are encouraged to perform these procedures prior to a hair transplant. The surgical approaches for facial feminization surgery often involves incisions at the hairline (frontal trichophytic), the frontal scalp (endoscopic forehead lift), or bicoronal flaps. The resultant scars can subsequently be camouflaged with follicular unit grafts (Fig. 75.1).

Fig. 75.1 (a) Scars from prior facial contouring are clearly visible (arrows) on this transgender female patient with thin hair. (b) The scars are camouflaged 2 years after hair restoration surgery.

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