FACIAL FEMINIZATION: WHAT PRICE BEAUTY?

PUBLISHED ON TGFORUM AND TRANSGENDER NEWS
CERISE RICHARDS, M.D.

We as a group are concerned more than most about our aesthetic appearances in order to achieve the full potential of our transformation. Since hormones cannot rearrange facial bone structure, we are most vulnerable to the promise of Plastic Surgery. While Morgan Stevens and I have told you about what you should not have injected in Silicone: What Price Beauty?, I shall now tell you what you can do to feminize your face beneath the makeup. This is the first in a series of three articles to introduce you to the various procedures used by Plastic Surgeons and Dermatologists to feminize your facial features.

Today we shall look at the simplest of treatments in the area of Soft Tissue Augmentation (STA). Over the past decade many synthetic and biologically derived materials have been developed which are compatible with the skin and underlying fat without producing an allergic reaction. It is easy to categorize them based on the duration of lasting effect since the easiest to inject are the quickest to disappear. The shortest acting agent known commercially as Botox can be administered during lunch allowing you to return to work without any sequelae. Botox is a purified neurotoxin derived from the common bacteria Clostridia botulinum. As the most poisonous of toxins accidentally ingested by man it can lead to paralysis and death in a complex of symptoms known as “botulism”. But in a refined and diluted state the toxin has been shown to selectively paralyze the nerves and muscle groups of the face only where it is injected. The principle of facial injection is based upon opposing muscle groups pulling the skin in opposite directions giving it what is known as facial tone. If you paralyze only one muscle at a time the antagonistic muscle group will rearrange your skin removing wrinkles, furrows, and move whole muscle groups elevating your brow approximately 1 centimeter. It is now probably the gold standard for the temporary eradication of “crows feet” and vertical lip lines. The FDA has approved its use for the treatment of crossed eyes and eyelid spasm.

The cosmetic use of Botox was first described in 1998 in the Dermatology literature. Since then it has gained wide international acceptance and dosages have been developed for each facial muscle. Patients are usually examined on a return visit at 2 weeks to judge the effectiveness of the injection. On rare occasions as doses are increased with repeat injections, weakness and sagging of a nearby muscle group can occur. Normally when a muscle is denervated it atrophies and begins a slow growth process of new nerve budding to regain its tone. The effect of a single injection becomes evident by 48 hours and usually lasts about 3 months before returning to its original appearance. The preparation, not the toxin, contains albumin, a human blood product, but has not been identified with any human viral transmission.

The next group of biologically derived material includes the injectable Collagens. Collagen is the most abundant protein found in the Dermis of the skin. It is the matrix of the skin composed of elastin, collagen fibers and proteoglycans. The first purified bovine (calf) collagen was developed in 1977 but produced mild skin reactions of redness and swelling. Today it has been refined and the allergic properties removed so that it is the most commonly injected material for STA. Its effects will last 3 to 6 months and will slowly be reabsorbed into the body. It is immunologically compatible with human tissue provided a test dose has been administered and observed over 1 month. A second skin test is recommended at that time in the opposite arm. The complications of cyst formation and skin death have been reported as rare severe allergic reactions. These are commercially sold as Zyderm I and II and Zyplast. They are best utilized to resurface the vermilion lip border and to fill certain wrinkles and folds like forehead creases and nasal-lip indentations.

Normal human dermal collagen is now being processed commercially as an injectable product known as Cymetra. It is a decellularized and micronized collagen derived from human cadaveric skin removing the allergic and immunologic problems of bovine collagen. While there may be some initial redness and swelling at the injection site it is very transient lasting only a few days. It can be injected with a fine needle into a subcutaneous space, massaged and molded into place. It is ideal for lip enhancement and filling nasolabial folds delivered in 3 separate injections. It has been available in sheet form as Alloderm for about 8 years and has been used in over 100,000 grafts. Alloderm can be rolled into a cylinder and placed as a soft tissue graft by a tunneling technique in the upper lip or nasolabial fold. Typically its effect can remain for over 6 months.There has not been a single case report of viral transmission since this material is obtained from US Tissue Banks after screening for Hepatitis, HIV, HTLV and syphilis. It is then freeze dried, examined to determine that it is pathogen free and shipped to your doctor. No skin testing is required.

But even better is using your own skin for the production and extraction of collagen. If you are having a procedure where excess skin is being removed as in eyelid or abdominal correction, that skin can be processed by Collagenesis Labs to give you 1mm of Autologen for every 2 square inches of skin donated. If you are having only a small amount of tissue removed, with as little as 3mm of skin you can have your own dermal fibroblasts grown in tissue culture and returned to your doctor as Isologen in a month for reinjection. Your own tissue is more likely to remain and promote matrix growth resulting in an 80% correction observed at 2 years. A more common procedure is the recovery of Autologous (your) fat by micro liposuction using a suction syringe and a fine cannula. After office preparation the fat cells are reinjected to produce lip enhancement and fill deeper defects as chin depressions by microlipoinjection. The main problem is the variability of the life span and percent graft take of the fat cells. In most cases a 30-50% over correction is needed which produces swelling for a few weeks. These areas also require reinjection as fat cells die, but at least they are your own compatible tissue and what lives will remain forever like other fat that you are familiar with. Intact linear fat grafts may be removed with incisions and placed as pull through grafts as previously described with Alloderm.

Finally for completeness sake there are the synthetic biomaterials as Bioplastique and PTFE produced as Softform and Gore-Tex. While these may encourage the growth of surrounding matrix into the sheets and are permanent, they have the larger problems of infection, extrusion and delayed fibrous reaction i.e. scarring, reminiscent of silicone. These problems are quoted as extremely low but I would think very significant and should only be used for large defects and corrections where the volume of the biomaterials required cannot be achieved with collagen. Tune in next month when we shall look at Chemical Peels and Laser Skin resurfacing.

The link to Silicone: What Price Beauty? is http://www.3dcom.com/tgfs/docs01/medical0106a.html