Keywords
body contouring - transgender - shoulder feminization
Introduction
Recently, there has been an increased awareness as well as better acceptance of gender
incongruent individuals in the society.[1] Accordingly, gender affirming surgeries have grown in volume and finesse in the
recent past as a result of better awareness in addition to the efforts of various
organizations. There is an increase in gender incongruent individuals seeking gender
affirming surgeries, requesting more specific surgeries at a younger age.[2] Studies have shown that gender reaffirming surgery has a positive effect on life
satisfaction and quality of life,[3] reducing insecurity and improving self-perception of attractiveness and self-confidence.[4]
The various gender affirming surgeries sought after by transwomen are orchiectomy,
vaginoplasty, breast augmentation, facial feminization, and reduction thyroid chondroplasty
with or without voice change.[5] The usual sought-after masculinization surgeries are chest masculinization surgery
(top surgery), metoidioplasty, phalloplasty, and hysterectomy. There is still a subset
of individuals who after having undergone gender affirming surgeries still want improvement
of the body contour so that the overall body shape is congruent to the body image.
In this article, we discuss body contouring as an adjunct to these surgeries in both
male to female and female to male transgender individuals.
The Difference in the Male and Female Body Habitus
The Difference in the Male and Female Body Habitus
There are significant differences between the skeletal and soft tissue characteristics
of males and females ([Figs. 1], [2]). Body contouring in transgender individuals can be achieved by altering the skeletal
structure or the overlying soft tissues or combining both.
Fig. 1 Difference in skeletal framework in females and males.
Fig. 2 (A, B) Differences of body habitus and fat distribution in females and males.
Surgical alteration of the skeletal framework, especially the pelvis, carries higher
risks and morbidity; thus, soft tissue contouring is preferred. In the thorax and
shoulder; however, there is less scope for soft tissue contouring due to the lesser
proportion of body fat than the pelvic and gluteal regions.
Skeletal Framework of Thorax and Shoulder
The biacromial diameter is the measurement of shoulder width and averages 15.6 (14.3–17.0)
inches in males. The female biacromial diameter is lesser, with an average value of
13.9 (12.8–15.2) inches.[6] The male rib cage is also larger compared with the female counterparts, with average
lateral rib cage diameter of 14.16 cm/m (measurements normalized to standing height
in meters) compared with 13.68cms/m[7] The torso of females is more hourglass shaped as compared with a much straighter
waistline in males.[8]
This might be in part due to the acute angulation of the ribs in females, an evolutionary
adaptation designed to expand and accommodate for the increased volume during pregnancy.[7]
The Pelvis
The female pelvis is designed to be wide to be conducive for childbirth. In contrast,
human male pelvis is optimized for bipedal locomotion. The female pelvis has a larger
pelvic inlet and outlet than the male pelvis. Also, the hip is widely set in females
than males.[9] Male iliac crests are higher than females, causing their false pelves to look taller
and narrower.
Body Fat Distribution
Body fat distribution in both sexes, though comparable in childhood and old age, varies
maximally after the effects of sex hormones come into action. Testosterone leads to
preferential deposition of fat in the abdomen and inhibits deposition of fat in the
hip area and the gluteal area leading to an android body habitus. On the other hand,
estrogen produces a gynoid body habitus by preferential fat deposition in the hip
and gluteal regions, leading to a narrow waistline and wide hips.
Role of Waist–Hip Ratio
Waist–hip ratio (WHR) in the ideal range is associated with increased physical attractiveness
and considered a sign of a healthy body by both sexes. WHR can determine the female
and male body fat distribution patterns by measuring the waist and hip circumferences.
Waist circumference is measured at the narrowest part of the body between the ribs
and the iliac crest, whereas hip circumference is measured at the level of the maximum
projection of the buttocks ([Fig. 3]).
Fig. 3 Waist to hip ratio in a female. Ideal WHR in females is 0.67 to 0.80 and in males
is around 0.90.
In females, there is preferential fat deposition in the hips and gluteal due to effect
of estrogen, leading to a lower WHR, whereas in males the testosterone leads to more
fat deposition in the abdomen area, leading to higher WHR.
Singh has proposed that though there are slight differences across various cultures,
the ideal WHR range that men find attractive in females across ethnicities is 0.67
to 0.80.[10] In males, ideal WHR ranges from 0.80 to 0.95.[11]
Body Changes after Hormone Therapy
Body Changes after Hormone Therapy
Sex steroid hormone is an important factor in the body form and habitus. It is a principal
factor in the distribution of body fat, resulting in a gynoid or android appearance
to the body. Though not mandatory as per guidelines, we advise body contouring surgeries
after 1 year of hormone therapy, as hormone therapy will bring about favorable changes
in the body habitus, mainly in the abdominal and gluteofemoral region.
Hormone therapy with estrogen and antiandrogens in male to female transgender individuals
resulted in increase in subcutaneous fat deposition, mainly in the thigh region.[12] Hormone therapy with testosterone causes reduction in subcutaneous fat with increase
in visceral fat, along with increase in thigh muscle mass.[12] Hence, hormone therapy has an important role in bringing about changes in body contour
as well as physical transformation and should be emphasized before undertaking a body
contouring surgery.
Body Contouring in Male to Female
Body Contouring in Male to Female
Body contouring in male to female transgender individuals can be brought about by
either soft tissue or skeletal contouring or a combination of both. Most transgender
individuals who come for body feminization request breast augmentation as the initial
surgery. However, other secondary contouring procedures that can be offered are waist
and hip lipoplasty, buttock augmentation, torso contouring by excision of lower ribs
and shoulder width reduction by clavicle reduction.
Soft Tissue Contouring
Soft tissue contouring methods like liposuction and fat grafting, though requires
expertise and aesthetic sense, are much easier and safer to perform than skeletal
modifications and is the mainstay of body contouring in male to female transgender
individuals.
Liposculpturing of the Waist and Hip
As discussed earlier, the ideal female body has a narrower waist and a wider hip,
with a smaller WHR. Male to female transgender individuals who undergo sex hormone
therapy for a period of around a year develop changes in their body habitus with more
fat distribution in the thighs and gluteofemoral region, leading to a more feminine
form ([Fig. 4]).
Fig. 4 A male to female transgender individual planned for body contouring for feminizing
the waist hip ratio.
If the individual desires a more feminine look, liposculpturing can be done to augment
the feminine form. Typically, it consists of selectively performing liposuction in
the waistline and abdomen, leading to a much slimmer waistline and grafting this fat
to augment the hips and buttocks ([Fig. 5]).
Fig. 5 Markings for liposculpturing. Areas marked in black are planned for liposuction,
whereas areas marked in blue are planned for fat grafting.
Special Considerations
Unlike genital or breast surgeries, World Professional Association for Transgender
Health (WPATH) Standards of care doesn't specify definite criteria that must be met
to undergo body contouring. Though liposculpturing in male to female transgender individuals
is ideally performed after at least a year of hormone therapy to give time for fat
redistribution, there are a subset of individuals who does not have a substantial
change in the body habitus or who are not candidates or unwilling to take hormonal
therapy.
Owing to the more intra-abdominal deposit of fat due to testosterone, transgender
individuals have less available fat deposits for fat grafting and liposuction compared
with cisgender individuals.
Creating a feminine WHR involves creation of a waistline by liposuction of the waist
and augmenting the hip diameter by fat grafting.
Roberts et al[13] have suggested few characteristics of an ideal buttock shape, consisting of a gentle
inward sweep of the lumbosacral area and waist, a feminine gluteal cleavage as the
buttocks separate superiorly and inferiorly, maximum prominence in the middle and
upper buttock, minimal intragluteal crease with no ptosis below this line.
Surgical Technique
Preferred donor areas for fat harvesting are the abdomen, flanks, waistline, and lumbosacral
area. However, in most cases, fat available for harvest might be a limiting factor
and hence prioritization of the injection sites needs to be done in discussion with
the patient beforehand.[14] It is our experience that liposuction of the bra rolls rarely yields significant
fat in transgender individuals.
Marking is done with the patient in the standing position, and different color markings
are done for areas that are planned for liposuction and fat grafting ([Fig. 5]). The waistline is marked at the level 1 inch above the umbilicus.[15]
We perform liposuction using power-assisted suction liposuction (PAL) under general
anesthesia using tumescent infiltration. Standard liposuction and fat grafting techniques
are used. To minimize damage to the fat cells, we limit the negative suction pressure
to 560 mm Hg.[13] For large volume fat grafting, we employ expansion vibration lipofilling.[16]
Surgery is started initially in the supine position. The already marked waistline
is accentuated with liposuction, continuing along the flanks to obtain a feminine
gentle inward sweep. Paucity of fat deposits in these areas in transgender individuals
might limit the extent of change that can be brought about.
In case of individuals in whom there is no paucity of fat obtained for correction
of the hip dip, fat grafting to the hips is done before the patient is positioned
to prone, to minimize the time from harvest to fat grafting. Any further fat grafting
can be done using the fat obtained by liposuction in the prone position.
The patient is positioned prone and liposuction proceeds in the usual fashion. In
our experience, our patients seldom ask for a shelf like transition between the lower
back and buttock. Fat grafting is done using expansion vibration lipofilling method
with priority given to the correction of the hip dip as well as projection of the
centromedial buttock region.
As opposed to liposculpturing in females, in transgender individuals the body contouring
relies heavily on the effects of liposuction and creating a lumbosacral inward sweep
rather than on the augmentation by fat grafting. [Fig. 6] shows an individual who underwent liposuction of the waist with simultaneous fat
grafting of the hips to create a more feminine WHR.
Fig. 6 Pre- and postoperative view of the patient who underwent liposuction of the abdomen
and waist with fat grafting of the hips and buttocks.
Postoperative Care
Customized compression garments are worn on the operation table. The garments are
designed in such a way that the grafted areas are not under too much compression.
A foam dressing is applied over the sacrum to promote skin adhesion and to prevent
tenting up of the skin due to edema. This maintains the superior gluteal cleavage
that is an important anatomical feature.[13] Patient is nursed in the prone position. Standing and walking are allowed but sitting
is prohibited for 2 weeks.
Skeletal Contouring
Shoulder Width Reduction
Shoulder feminization by surgical shortening of clavicle is a less researched procedure
with hardly any published literature on it. The clavicle is the only skeletal structure
that connects the upper limb to the axial skeleton. Any reduction in the clavicle
length should therefore cause an equal decrease in the biacromial diameter. Shoulder
width is measured in terms of biacromial diameter. On an average, the biacromial diameter
in female is around 4.3 cm less than that of males.
The main concern about clavicle reduction is the potential functional disability to
the shoulder joint. However, multiple studies done in clavicle fractures that were
managed conservatively have shown that reduction in clavicle length of 2 cm or even
greater does not affect the shoulder movements significantly.[17]
[18]
The middle of the clavicle is the part that has least soft tissue attachments and
is usually the site of a fracture in trauma. This part is also away from the articulation
with the sternum medially and the acromioclavicular joint and the coracoclavicular
ligament.
Clavicle reduction essentially consists of surgically removing a segment of the clavicle
from the medial aspect of the middle third and an internal fixation using compression
plates.
Surgical Technique
Markings are done in the standing position as the surface anatomy changes when the
patient lies down. The skin is held stretched over the clavicle and the marking made
so that the final scar is positioned in the supraclavicular fossa, which makes it
less visible.
We perform clavicular reduction under general anesthesia. A skin incision around 4
to 5 cm long is made with the skin held stretched so that the marked incision site
comes to lie over the clavicle. Incision is deepened through the clavipectoral fascia.
Branches of supraclavicular nerves are safeguarded if encountered. Incision goes directly
to the periosteum, which is incised and separated circumferentially. A segment of
clavicle to be removed (around 2–2.5 cm long) is marked on the bone and it is excised
with oscillating saw ([Fig. 7A–E]).
Fig. 7 (A) Skin incision made over the stretched skin and branches of supraclavicular nerves
retracted. (B) 2–2.5 cm of clavicle bone (2.2 cm in this case) is removed with a saw. Underlying
neurovascular structures are safeguarded. (C) A zig-zag step osteotomy is done for more stability and greater surface area of
approximation. (D) Completion of internal fixation. (E) Same patient 10 days postsurgery showing complete range of motion of the shoulders.
This part of the procedure is to be performed keeping in mind the vital structures
lying underneath—the brachial plexus, the subclavian vessels, and the apex of the
lung.
After removal of the bone segment, congruence of the cross section of cut bone is
confirmed. We plate the segments using a 3.5mm 6-hole dynamic compression plate with
bicortical screws in the superior aspect of the clavicle. The approximation is confirmed,
and incision closed meticulously to avoid contour abnormalities. The suture line retracts
up into the supraclavicular fossa ([Fig. 8]).
Fig. 8 Pre- and postoperative photos showing reduction in biacromial diameter by 5 cm.
Postoperative Care
After plate and screw fixation, some authors advocate early full range mobilization
of the shoulder the very next day.[19] We, however, rest the upper limb in slings for the first week during which the patient
performs activities of daily living with limited shoulder movements. It is followed
by active motion of the shoulder. Full strength movements and sports are commenced
at 3 months.
Outcomes
Two patients underwent clavicle shortening and both patients had uneventful recovery
with return of full range of motion. Both patients described shoulder reduction as
one of the most satisfying procedures they underwent (both patients had undergone
facial feminization, feminization rhinoplasty and breast augmentation). However, a
larger series of patients need to be studied to draw conclusive evidence.
Rib Cage Contouring
Ferreira et al in their review article has concluded that there is not enough scientific
evidence to support the practice, effectiveness, and safety of the resection of ribs
for aesthetic purposes.[20]
Rib excision has the potential to affect lower lung inflation and can affect the structural
integrity of the lower chest wall[21] and the authors do not condone this procedure. Readers are encouraged to go through
this article by Davison et al for detailed procedure.[8]
Body Contouring in Female to Male
Body Contouring in Female to Male
Masculinizing procedures in female to male transgender individuals relies heavily
on soft tissue rather than skeletal alteration.
Testosterone therapy can cause significant masculinization in the body including distribution
of fat, increase of facial and body hair, masculine scalp hair line, masculine voice,
and increased tone and bulk of muscles.
However, there are usually areas of unresponsive fat deposits, especially in the buttock
and thigh areas that might need to be surgically contoured.
Contouring of Abdomen
The masculine WHR of 0.9 is considered as the most attractive,[22] as opposed to values of 0.67 to 0.80 in females.
The fundamental aspect of body contouring in female to male transgender individuals
is the reversal of this WHR to give a more masculine appearance. This is achieved
by a combination of liposuction as well as fat grafting techniques.
Male Abdomen
Goals of contouring in female to male transgenders include:
-
Masculinization of the WHR
-
Obtaining a masculine defined appearance to anterior abdomen
Masculinization of the Waist–Hip Ratio
The male hip has a more concave hip dip compared with the convex contour of the feminine
hip. Masculinization is accomplished by liposuction of the lateral hip and buttock
areas and in select cases, grafting the fat to the waist region.
Surgical Technique
Markings are done with the patient in the standing position.
The areas planned for liposuction are the buttock area and the lateral thigh areas,
but it needs to be tailored according to the body habitus of each patient.
The patient is positioned prone under general anesthesia and tumescent fluid is infiltrated.
Liposuction is done as per standard protocols, and fat harvested into sterile containers
if fat grafting to waist is planned. The suction pressure is maintained at no more
than 560 mm Hg to increase viability of the fat cells. The volume of aspirate is highly
variable, but around 200 to 400 cc of aspirate is obtained from one side of lateral
hip and from each buttock. Liposuction of the infragluteal fold is not done to prevent
contour abnormalities.
The patient is now made supine, and any further liposuction is performed.
The harvested fat is then grafted to the waistline to reduce the concavity as well
as to give a more boxy appearance of the torso. We prefer expansion vibration lipofilling
for fat grafting.[16] To account for resorption of grafted fat, we perform overfilling by around 20 percentage
more than the required amount. A customized compression garment is worn postoperatively
for 6 weeks ([Fig. 9]).
Fig. 9 Masculinization of the waist–hip ratio. (A) Preoperative photo. (B) One month post-surgery—liposuction of the waist along with double incision mastectomy.
(C) Effect of hormone therapy (250 mg testosterone monthly injections) showing better
muscle mass.
High-Definition Liposculpture of the Anterior Abdomen
High-definition liposculpturing is usually done along with top surgery and lateral
chest wall contouring. We use the PAL system (Microaire, Inc., Charlottesville, Virginia,
United States) for the liposculpturing. This was popularized by Hoyos[23] in 2003. Liposuction in the deeper plane is done to debulk the fat and in the superficial
plane to deepen the natural grooves.[24]
Surgical Technique
Markings are made in the supine and standing positions. The rectus muscle anatomy
is delineated by palpating and marking the inscriptions with the patient flexing the
abdominal muscles. Surgery is done in the supine position with arms abducted.
Tumescent infiltration is performed. Ports are made in the umbilicus, right and left
lower iliac fossa along the lateral border of the rectus muscle, and at the levels
of the inscriptions. Deeper followed by superficial liposuction is done.
No drains are used. Lateral chest and infra-axillary areas are also contoured to give
a better definition to the lateral border of the pectoralis major muscle ([Fig. 10]).
Fig. 10 High-definition liposuction of the abdomen using power-assisted liposuction. (Patient
has also undergone periareolar concentric mastectomy).
Postoperative Care
Compression foam or folded paraffin gauze is used for dressing over the inscriptions
and grooves. Custom compression garment is applied, and patient is instructed to continue
it for 3 weeks.
Ancillary Procedures—Abdominoplasty
Ancillary Procedures—Abdominoplasty
Lipoabdominoplasty might be required in female to male gender incongruent individuals
who ask for masculinization who had prior pregnancies. Such individuals might have
hanging panniculus and stretch marks in the lower abdomen with or without surgical
scar of cesarean section. The aim in such cases is not only to get rid of the hanging
panniculus but also to give a masculine appearance.
It differs from tummy tuck in females in that the scar is more horizontal. The umbilicus
is made more round or horizontal rather than vertical. In addition, fat grafting can
be done to the waist in order to create a more masculine WHR.
Conclusions
Body contouring procedures are on the rise due to increased awareness in the community,
starting at the primary level.[25] These are preferably performed after the individual has received hormone therapy
for a year, which helps to redistribute the soft tissues and facilitates a better
physical transformation. The surgical plan is tailored according to the wishes and
concerns of each patient. Soft tissue contouring is an effective and safer method
of physical transformation as compared with skeletal surgeries. More research is needed
in gender affirming body contouring to understand the intricacies and provide quality
healthcare to transgender individuals.
