
Being the daughter of two doctors, Bianca Viscomi, M.D., did not initially plan to go into the field of dermatology. She explains, "Before choosing to be a dermatologist, I chose to be a doctor. I am the daughter of a mother and father who are doctors, and since I was a child, I followed this work routine and became passionate about 'taking care of others'."
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Being the daughter of two doctors, Bianca Viscomi, M.D., did not initially plan to go into the field of dermatology. She explains, "Before choosing to be a dermatologist, I chose to be a doctor. I am the daughter of a mother and father who are doctors, and since I was a child, I followed this work routine and became passionate about 'taking care of others'."
After earning her medical degree in 2004 from the Pontifical Catholic University in Sao Paulo, Brazil, Dr. Viscomi chose to do her first residency in Internal Medicine. The sudden passing of her father at the end of residency led Dr. Viscomi to change course and enter her second residency in Dermatocosmiatrics from the ABC Faculty of Medicine. Shortly after, in 2008, she started her practice. By mid-2016, when her work with transgender patients began, she had a well-established practice, ready to take on the mission that would transform lives.
The Start of a Movement
The LGBTQIA+ movement has come to represent acceptance, freedom and self-expression. However, transgender and gender-diverse communities in particular are in need of support and care from medical professionals, and those in aesthetics specifically, in the form of gender-affirming care and treatments aimed at aligning gender expression and identity. Dr. Viscomi became aware of the increasing need for research and the development of aesthetic techniques to provide gender-affirming care and treatments, such as facial feminization and masculinization, to help transgender patients through their transition process.
She remembers, “I saw this possibility of working with trans people in 2016. It all started with a patient who asked me to look more androgynous. He wasn't trans, but he wanted a more feminine face. So, I went to PubMed to study and, to my surprise, I found nothing in the entire international literature. That was in 2017. There was nothing for us to feminize a male face. There was only little information about how to feminize a cis female face or how to masculinize a cis male face. And then the seed of this project was born in my head.”2
Dr. Viscomi spent these first years researching and developing treatment techniques for transgender patients going through a transition process. She recalls, “A good friend of mine worked with a trans person and I asked him to consult her to see if she would be willing to participate. Then she came to me and was my first patient, the first trans woman I treated. Through her, Beta, I ended up meeting other women who brought other women, and things got going."
Dr. Viscomi knew once she started this project that she would need to gain adequate resources and support to begin a thorough study of these techniques that could be published and bring awareness of this need for gender-affirming care in the transgender community. She states, “I wanted to publish studies to bring these people into science, this agenda into the scientific space. They are on the margins of many things, including science. There are 4 million people in Brazil, and in São Paulo there are only 10 care centers for trans people. I always wanted to bring them into my dermatological office, but not in a niche way.”3
Amplifying the Voices of Transgender Women
Transgender individuals live in a constant state of vulnerability, at high risk of encountering violence and harassment, with lack of access to fundamental human rights that many of us take for granted. Aesthetic practitioners have the unique ability to change transgender patients’ lives, helping them to look, feel and live better. Practitioners can help free transgender individuals from being trapped in bodies that don’t express their internal identities.
Dr. Viscomi explains the dangers posed to transgender individuals seeking gender-affirming treatments from unqualified practitioners, “Although the estimated number of transgender individuals in the U.S. is increasing, this community still struggles to get adequate health care access. Transgender patients face several healthcare barriers, among which are social stigmatization or discrimination, economic marginalization and lack of specialized healthcare providers. Due to hurdles to receiving adequate medical care or aesthetic procedures, transitioning patients may submit themselves to serious risks during the gender transition process, such as injection of liquid silicone or other illegal products directly into tissues, often performed in unsanitary conditions by untrained, unqualified providers. Moreover, transgender beauty differs from a regular cis-women aesthetic approach since it involves not only rejuvenation and/or beautification, but rather acquiring feminine or masculine attributes that best align with the patient’s self-affirmation.”
The vulnerable situation of transgender individuals and the need for more aesthetic practitioners to provide gender-affirming treatments is apparent when considering the very serious danger they live with stemming from social stigmatization and discrimination. What’s more, these dangers can be mitigated with aesthetic treatments for transitioning patients. Dr. Viscomi gives the example, “In Brazil, where the life expectancy of a transgender individual is 35 years of age, half of the age of the general population, mainly due to violence and suicide, medical transitioning assistance has an even more profound impact since it may improve patient’s acceptance in the society and result in protection from violence and increase in life expectancy. Thus, it is paramount that health care providers are well trained in caring for that part of the population.”
Dr. Viscomi continued her research into providing transitional assistance to transgender patients and the details of translating minimally invasive techniques for facial feminization in cisgender women into techniques that can be utilized for facial feminization of transgender women. During her investigation, she realized this was an issue that deserved more attention, and needed someone who could step up to the plate and make transgender individuals’ voices heard. She recalls, “When you study the issue of trans people in-depth, you get the feeling that you need to do something. One thing leads to another because science has this very beautiful thing about enabling inclusion. When you think about improving people's quality of life and solving problems, you understand how much of an impact it can have across the board. I felt safe starting the work because I was protected by the umbrella of science. Then it dawned on me that I, a white cis woman doctor with a well-established practice and privilege, could help amplify these voices."
Just as she gained the support to put this study into action on a larger scale, the pandemic came along and halted Dr. Viscomi’s project and mission for a time. However, it did give her the time to fine-tune her approach. She states, “I continued writing, thinking about the basics. And then, as soon as the pandemic eased up, I called five patients for scientific work. At that point, I had practically all the work written.” Thus, it ended up being a blessing in disguise, as the finished study she published in Clinical, Cosmetic and Investigational Dermatology (July 2022), detailing her work utilizing minimally invasive procedures for facial feminization in five transgender women and the vital role physicians play in a transgender patient’s journey through the transition process, gained worldwide attention. The movement Dr. Viscomi has spent so long championing is finally getting the attention it deserves. The lives, identities and voices of transgender women she has worked so hard to free are now being heard on an international scale.
Dr. Viscomi begins by explaining, “A transgender individual is someone who does not identify with his or her biological sex. Trans beauty imposes a unique aesthetic task, since transgender women may seek feminization, but the aesthetic goal may not be achievement of femininity or masculinity itself, but rather acquiring feminine or masculine attributes that best align with the patient’s self-affirmation. In order to recognize themselves as women, transgender women go through a transition process, which includes hormonal therapy, psychological support and physical alterations that can be accomplished by surgery or minimally invasive procedures. According to literature data, transgender women often prefer to modify their faces, prior to body alterations.”1
MIP & Facial Feminization in Transgender Women
These procedures are not new for aesthetic professionals, as aesthetic treatments in general are gender-affirming, even if they are performed on cisgender patients. Minimally invasive treatments to feminize or masculinize a face are commonplace when it comes to cisgender patients, so whether they realize it or not, aesthetic practitioners already know how to do these procedures and have the experience to provide these services for transgender patients. Dr. Viscomi states, “While the literature upon facial remodeling of cis-women with MIP is abundant, the use of MIP for facial remodeling in the scope of the transitioning process of transgender women is still scarce.”
For transgender individuals, minimally invasive cosmetic facial feminization and masculinization treatments can go a long way toward relieving their gender dysphoria by creating better harmony between their physical and innermost selves. These treatments can free transgender patients’ true faces and identities, helping them transcend the physical form they feel trapped in. Dr. Viscomi explains why minimally invasive procedures for transgender facial feminization are such a vital part of transitioning, saying, “Minimally invasive procedures (MIP) play an important role in the transition process for many reasons: MIP provides fast, reversible and impactful results, with lower risks and downtime, whilst results with hormonal therapy, for example, may take 2 years to fully develop. There is minimal need for psychological assessment, pre-medication or other delays that would routinely be needed before surgery. Especially for patients who are unsure about proceeding with definitive surgery, injectables can serve as a reversible surrogate for what patients can potentially expect from a definite facial surgery. Moreover, for those patients who are not suitable for surgery, MIP may remain the only option. Healthcare providers should be familiar with the needs of the transgender patient population.”
Facial Feminization Techniques
1. Comparing Male & Female Facial Structure: When first approaching facial feminization for transgender patients, taking into account traditional ideas of what characterizes a face as female is an important starting point to understand how the traditionally male facial structure can be feminized depending on the patient. “Generally accepted characteristics of a female face include smooth forehead with some convexity, small narrow nose, arched eyebrows, wider eyes, prominent and full cheekbones, heart-shaped lower face, and full vermilion lips,” states Dr. Viscomi.
2. Feminization of the Forehead/Upper Face: In comparison to female skull structures, males characteristically have a prominent supraorbital region. The female forehead, on the other hand, is straighter, with a more curved and less pronounced glabella, as well as a less noticeable supraorbital rim. Dr. Viscomi explains that the use of neurotoxin injections can feminize the forehead, eyebrows and periorbital skin, serving to eliminate rhytids and widen the eyes. HA injections can be used to improve forehead convexity, creating a smoother supraorbital-forehead transition. However, she adds the caveat, “Transgender women may require higher doses of neurotoxin in all treatment areas because individuals assigned male at birth tend to have greater muscle mass compared to individuals assigned female.”
3. Feminization of the MidFace: The female facial structure of the midface area is characterized by more curvilinear and prominent cheekbones with angles that are more subtle than that of males. Dr. Viscomi advises injecting HA laterally on the zygomatic arch and inferolateral to the lateral canthus to minimize the greater angles typical of male cheekbones and achieve the approximate female apex. She adds that for transgender women, “The volume of HA required to achieve the desirable results is greater than compared to the amount needed for a cis female of the same age.”
However, using a biostimulator injection in the malar in addition to HA can provide immediate correction, which is enhanced as the body’s natural collagen is stimulated over time and new tissue forms, resulting in long-term accumulation of new collagen. This increases structural support of the feminization in the mid-third and reduces the volume of HA needed.
4. Feminization of the Lower Face: The difference in structure between the male and female lower face is a particularly important one when it comes to feminizing a transgender woman’s overall facial structure, as a male jawline is distinctly more square and prominent than the accepted ideal of the more heart-shaped female jawline. Thus, emphasizing the more pointed chin and softer angles of the female jawline, and decreasing the wider, square jawline typical of the male facial structure is important for facial feminization. When it comes to feminizing the jawline in transgender women, Dr. Viscomi advises, “In Western cultures, the ideal width of the female chin is approximately the same width as the intercanthal distance and special care must be taken not to masculinize a female face by making the chin too wide.”
Injecting HA filler into the supraperiosteal can help project the chin, while neurotoxin injections in the masseter will gradually decrease the prominence of the muscles around the jawline and help achieve the more heart-shaped contour desired in a feminized face. To feminize the lips using HA filler, Dr. Viscomi explains that, “an optimal lip contour, comprising a well-defined upper and lower vermilion border, cupids bow, and a J-shaped curve,” is desirable.
5. Skin Quality: Modifying facial structure is not the only important element of facial feminization for transgender women. Dr. Viscomi points out that skin quality is equally as important to feminization, and can make a distinct difference in the gender perception of an individual. She states, “Skin quality significantly influences perception of age, attractiveness, health and youth. Good skin quality is defined as healthy, undamaged and youthful in appearance.”
When it comes to improving skin quality, the four main attributes that comprise this are the evenness of skin tone and skin surface, skin firmness and skin glow. The differences in hormones and hormone levels of females and males have a major influence on skin quality. Dr. Viscomi explains that while, “Testosterone may yield a denser collagen network, the skin becomes thicker with more visible pores and higher secretion of sebum and sweat.” Minimally invasive treatments are also useful for improving skin quality in facial feminization. Neurotoxin injections can be used, “in the malar area and forehead, leading to pore size and sebaceous activity minimization,” says Dr. Viscomi, adding that using highly diluted forms of biostimulator injections can also be used to stimulate tissue remodeling over time and improve skin quality.
Challenges & Revelations: We Are Born & Die Androgynous
One of the most interesting aspects of Dr. Viscomi’s work with feminization of transgender women is the realization that came about when she began working with older transgender women, as the aging process makes facial feminization more challenging because it brings with it a masculinization process. This holds true for cisgender women as well as transgender women. Due to the hormonal changes that occur throughout our lives, we are all born androgynous and as we age, we once again gradually return to that androgynous state.
Dr. Viscomi explains, "Anatomically, the human body is born and dies androgynous. This project has brought me a lot of reflection, in the most different parameters. It gave me tools to better understand the aging process of cis women, for example. This completely changed my approach to aging in general. Binarism is a thing about the hormonal phase of the human being. It is a matter of human anatomy being androgynous in two very important phases, the pre-pubertal phase and the post-menopausal phase. This changed my approach to aging and my cis female patients became much more beautiful after I started treating trans patients, because I understood a lot about the anatomy of the face. I understood anatomy from a perspective of beauty that really opened my eyes.”
In the end, all women, whether cisgender or transgender, can benefit from facial feminization as we age, as the hormonal changes that occur during menopause gradually masculinize our faces. Therefore, to feel and appear more like our younger selves, facial feminization is paramount to once again seeing our feminine selves looking back at us in the mirror. As Dr. Viscomi so eloquently puts it, “In the end, all these treatments are about us recognizing ourselves in the mirror, both for trans women and cis women who are aging. It's a matter of us seeing ourselves.”
Freeing the Trans Woman Within
As these revelations about the aging process and its effect on facial feminization demonstrate, the various details of treatment plans for transgender patients to aid in their transition process are dependent on the individual being treated. Dr. Viscomi advises, “Clinicians should be aware that there are different steps to be taken in the transition process, and that the needs and expectations may vary at each stage. For instance, changes in facial structure, soft tissue distribution and skin quality vary if a patient has not yet started hormone therapy compared to the patient who has been on hormone therapy for many years. Thus, the treatment plan should be tailored for each patient’s needs and transitioning phase.”
The most important thing to keep in mind when tailoring a feminization treatment plan for transgender women is to maintain respect for and enhance their individual beauty rather than change them into cisgender women. Like most women desiring aesthetic treatments, they don’t want to look like someone other than themselves in the end, but instead to have their individual beauty enhanced and feminized so they see the person they have always felt they were inside reflected in the mirror. “The idea is not to transform them into cis women but to perform feminization according to the patient and highlight trans beauty. They have more masculine features that I don't like to take away, that's what makes them beautiful. The minimally invasive, reversible procedure allows the person to try other techniques, try themselves in the mirror and recognize themselves,” says Dr. Viscomi.
References:
1. Viscomi B. From Anatomical Modifications to Skin Quality: Case Series of Botulinum Toxin and Facial Fillers for Facial Feminization in Transgender Women. Clin Cosmet Investig Dermatol>. 2022;15:1333-1345