Welcome back to our article series on gender affirming surgeries and procedures. We started with bottom surgeries in the Fall of 2022 and the final two installments will be on fillers for the face and managing hair growth. This installment is all about botox in gender affirming care. It’s not just about smoothing wrinkles!
Content advisory: we will use anatomical terms and discuss clinical procedures in this article and this series. External sites that we link to may contain graphic images.
What is Botox?
A bacteria called Clostridium botulinum is found in soils all over the world. When this bacteria is stressed, it creates protective coatings and goes into a kind of hibernation-like state as a spore. In certain conditions, these spores can grow and produce a dangerous chemical, which can change the way nerves operate by stopping brain signals from reaching their targets. When ingested, this chemical can cause botulism, a type of food poisoning that can be very serious.
This same chemical, when carefully lab grown and injected in very small doses under the skin, is Botox.
You’ve probably heard of Botox being used to smooth wrinkles at the corner of the eyes or forehead lines. You may have also heard of Botox being used to prevent migraines or to stop overachieving sweat glands from sweating so much. When injected into a muscle, impulses from the brain that say “contract now!” are stopped or slowed, so the muscle remains relaxed.
We can use Botox in specific facial muscles to change facial characteristics like contour, shape, and firmness.
Cool!
Botox in Gender Affirming Care
The effects of Botox are temporary (often lasting between 3 and 12 months) so Botox can be used as a trial to see how your face looks with subtle alterations. Botox can also be used to alter targeted areas of the face as an alternative to facial remodeling surgery or as detail refinements after surgery. Repeated over time, Botox injections can cause muscles to decrease in size and prominence. Botox can be used by itself or be paired with fillers (more on fillers next week!) to help shape and sculpt facial features non-surgically.
Common Gender Affirming Botox Applications
You may find the tables from our facial surgeries article helpful here. Understanding some facial muscular anatomy may also be helpful.
In the top third of the face:
- The orbicularis oculi muscle surrounds the eye and controls the eyelids. An injection into the upper outside of this muscle can raise the brow by relaxing that portion of the muscle.
- Injections below the lower eyelid can relax the eyelid and widen the open eye.
- Injections into the Depressor supercilii and Procerus muscles can smooth and widen the glabella (the space between the eyebrows.)
- Injections into the medial and lateral frontalis muscles can drop the arch of the eyebrow.
- And, injections across the forehead can reduce the depth of “dynamic” wrinkles and skin movement in individuals with thinner skin.
In the middle third of the face:
- Injections in the glabella can flatten the nasal-frontal angle where the forehead dips at eye level before becoming the nose. A flatter angle suggests an estrogen-based puberty.
- The depressor septi muscle is just beneath the nose. Injections here relax the base of the nose and let it fall some, which results in raising the tip of the nose.
- Nasalis muscles are on the sides of the nostrils and the curve of the nostril close to the lip. These muscles can be seen sometimes when a person takes a big breath in and their nostrils flare. Some people can consciously control these muscles and move them on purpose. Injections here can soften and narrow the nostrils.
In the bottom third of the face:
- The masseter muscle is on the side of the jaw close to the gonion (the back corner.) If you clench your teeth, the increased bulk in your back cheek is the masseter muscle contracting. Injections here can relax this muscle and make the back jaw less prominent. Repeated injections over time can cause muscle atrophy and reduce the overall size of the muscle.
- The mentalis muscle is a paired set of muscles that attach to the lower jaw underneath the teeth and travel down to the skin of the chin. If you make some duck lips, you’ll see the skin on your chin move and maybe pucker. That’s some mentalis action. Injections here can soften the contour and projection of the chin, and change the overall impression of the face into more of a heart shape. ?
- Injections in the upper portion orbicularis oriscan create a fuller appearing upper lip.
- The platysma muscle is a fan-shaped muscle extending from the chin to the collarbone. Injections in this muscle can soften the jawline and make the neck appear longer.
Prep and Recovery For Botox
Botox injections happen in an office or clinic and don’t take long. You may be able to have your consultation and treatment in the same appointment. You may be asked not to use some medications like blood thinners, muscle relaxers, or cold medicines prior to getting Botox.
Reasons you might not be able to get Botox include:
- Your skin is prone to keloid scarring
- You are allergic to any part of the Botox solution
- Some versions of Botox include a bovine protein (cow milk allergies, beware)
- You have a neurological condition that affects your muscles.
Your skin should be clean, and your provider will swipe an alcohol pad over the area to be injected, and they may apply a topical anesthetic. The needles used for Botox are very fine (often a 30-gauge, 1-inch needle,) and very little solution is injected into each site.
Your provider will likely ask you to make facial gestures that use the targeted muscles so that they can visualize the proper injection location for your anatomy. You may experience some burning or stinging sensations at the injection sites, but that should go away quickly. Each area targeted will receive multiple injections. You can treat multiple areas of your face in the same appointment.
Recovery
You may have injection marks on your skin and light swelling or bruising. Your provider will likely ask you to alter your activities slightly for the rest of the day – no strenuous exercise, and avoid activities that could cause your face to flush, such as long hot baths, deep forward bends, or alcohol use. They might ask you not to lie down for a few hours after your injections, and to not massage or rub the injection sites for a few days. Avoid heat, but cold compresses can be used to help reduce swelling. You may get a headache.
You should see changes within a 5-10 days.
Provider and Insurance Requirements
It is possible, but unlikely right now, that insurance will cover gender affirming Botox. However, the current WPATH Standards of Care (SOC 8) include lipofilling and lip augmentation in their list of gender affirming surgical procedures (Appendix E). You may be able to convince your insurance company that Botox is also medically necessary and appropriate. Depending on your spoons and finances, the prior authorization and approval process might be worth it. See the list of accessed articles at the end of this blog for studies which may be helpful in that process.
How To Find A Provider
Most dermatologists offer filler procedures. We recommend going to a provider with experience in transgender affriming care, as the techniques and volumes of filler used may differ from cisgender care. Referrals and recommendations from others in your community are invaluable.
The following directories can also help:
WPATH
The reddit community r/Transgender_Surgeries
Accessed Articles
De Boulle K, Furuyama N, Heydenrych I, Keaney T, Rivkin A, Wong V, Silberberg M. Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals. Clin Cosmet Investig Dermatol. 2021 May 13;14:513-525. doi: 10.2147/CCID.S304032. PMID: 34012284; PMCID: PMC8128506.
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 Jul 14;15:1333-1345. doi: 10.2147/CCID.S363882. PMID: 35860607; PMCID: PMC9293247.
Dang BN, Hu AC, Bertrand AA, Chan CH, Jain NS, Pfaff MJ, Lee JC, Lee JC. Evaluation and treatment of facial feminization surgery: part II. lips, midface, mandible, chin, and laryngeal prominence. Arch Plast Surg. 2022 Jan;49(1):5-11. doi: 10.5999/aps.2021.01956. Epub 2022 Jan 15. PMID: 35086301; PMCID: PMC8795653.
Rho, Nark-Kyoung & Kim, Hong & Kim, Y.S. & Kim, Yang & Kim, C.H. & Min, P.K. & Suh, S.B. & Lee, K.S. & Lee, S.J. & Lee, W.S. & Cho, H.R. & Choi, S.W. & Hwang, J.Y. & Kim, Hong Joo. (2010). Botulinum toxin type a for facial wrinkles and benign masseter hypertrophy in Korean patients. Korean Journal of Dermatology. 48. 823-831.
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 Jul 14;15:1333-1345. doi: 10.2147/CCID.S363882. PMID: 35860607; PMCID: PMC9293247.
Small R. Botulinum toxin injection for facial wrinkles. Am Fam Physician. 2014 Aug 1;90(3):168-75. PMID: 25077722.
E. Coleman, A. E. Radix, W. P. Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, L. Fraser, M. Goodman, J. Green, A. B. Hancock, T. W. Johnson, D. H. Karasic, G. A. Knudson, S. F. Leibowitz, H. F. L. Meyer-Bahlburg, S. J. Monstrey, J. Motmans, L. Nahata, T. O. Nieder, S. L. Reisner, C. Richards, L. S. Schechter, V. Tangpricha, A. C. Tishelman, M. A. A. Van Trotsenburg, S. Winter, K. Ducheny, N. J. Adams, T. M. Adrián, L. R. Allen, D. Azul, H. Bagga, K. Başar, D. S. Bathory, J. J. Belinky, D. R. Berg, J. U. Berli, R. O. Bluebond-Langner, M.-B. Bouman, M. L. Bowers, P. J. Brassard, J. Byrne, L. Capitán, C. J. Cargill, J. M. Carswell, S. C. Chang, G. Chelvakumar, T. Corneil, K. B. Dalke, G. De Cuypere, E. de Vries, M. Den Heijer, A. H. Devor, C. Dhejne, A. D’Marco, E. K. Edmiston, L. Edwards-Leeper, R. Ehrbar, D. Ehrensaft, J. Eisfeld, E. Elaut, L. Erickson-Schroth, J. L. Feldman, A. D. Fisher, M. M. Garcia, L. Gijs, S. E. Green, B. P. Hall, T. L. D. Hardy, M. S. Irwig, L. A. Jacobs, A. C. Janssen, K. Johnson, D. T. Klink, B. P. C. Kreukels, L. E. Kuper, E. J. Kvach, M. A. Malouf, R. Massey, T. Mazur, C. McLachlan, S. D. Morrison, S. W. Mosser, P. M. Neira, U. Nygren, J. M. Oates, J. Obedin-Maliver, G. Pagkalos, J. Patton, N. Phanuphak, K. Rachlin, T. Reed, G. N. Rider, J. Ristori, S. Robbins-Cherry, S. A. Roberts, K. A. Rodriguez-Wallberg, S. M. Rosenthal, K. Sabir, J. D. Safer, A. I. Scheim, L. J. Seal, T. J. Sehoole, K. Spencer, C. St. Amand, T. D. Steensma, J. F. Strang, G. B. Taylor, K. Tilleman, G. G. T’Sjoen, L. N. Vala, N. M. Van Mello, J. F. Veale, J. A. Vencill, B. Vincent, L. M. Wesp, M. A. West & J. Arcelus (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23:sup1, S1-S259, DOI: 10.1080/26895269.2022.2100644
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