This article and next week’s article on hair are the last ones planned in our series on gender affirming surgeries and procedures. We started with general prep for bottom surgeries in October, wrote about a different surgery or procedure each week, and we’re ending up here: all about using fillers in gender affirming ways. Next week we’ll finish up the series with treatments to encourage or discourage hair growth.
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 Are Fillers?
Fillers are injectable substances that add volume to body tissues. Some fillers create volume just by themselves. Some encourage the body to create new collagen. Some do both of these things.
But first, what’s collagen?
Collagen is a protein and one of the main building blocks in the body. It’s like a fiber, and is mainly used by the body to create structure and support within the body. It surrounds organs and holds them in place (fascia,) helps blood to clot (fibrin,) provides structure and elasticity to skin and blood vessels, and helps new cells, especially skin cells, grow. It also forms connective tissues like ligaments and tendons and helps keep cartilage supple and resilient in joints.
A very common application of fillers is to smooth out wrinkles in the face and neck from the inside. Wrinkles form when collagen in the skin starts to wear after repeated use (like smile lines and forehead creases) or from age, or when the body doesn’t replace it as quickly as it once did. All fillers can cause nodules (little bumps) to form where they are injected. Most can be dissolved, removed, or broken up with massage.
What types of fillers are available?
Fillers that add volume:
- Collagen! Human, cow (bovine,) and pig (porcine) collagen are used to supplement already existing collagen in tissues.
- Bovine and porcine collagen may re-absorb more slowly than collagen from human cells.
- May last a few months to up to a year.
- Some people are allergic to bovine collagen
- Lipofilling! Fat is often used in body contouring, where fat from one part of the body is removed and used to add volume to another part of the body. It can also be used for facial changes.
- It’s your own tissue, so very low risk of allergic reactions
- About half of the fat is reabsorbed, and half stays in the new location.
- Hyaluronic acid (HLA)
- you already have HLA in your body! It’s found in skin, joint fluid, cartilage, and connective tissue
- low likelihood of allergic reactions
- may be particles suspended in a gel or a gel without particles
- may last up to 18 months
- has been tested in individuals with darker skin
- does not cause keloid scar formation, hypersensitivity, or loss of pigmentation (light spots)
- may cause mild hyperpigmentation (dark spots)
- reversible with injection of hyaluronidase
- you already have HLA in your body! It’s found in skin, joint fluid, cartilage, and connective tissue
Fillers that encourage the body to create new collagen:
- LaViv (autologous fibroblasts – a type of collagen that is sourced from your own body)
- now that’s a mouthful!
- lasts 6+ months
- this technique uses a sample of your skin from behind your ear to grow more of your own collagen
- this biologically-matched collagen is injected and encourages new collagen formation
- requires punch biopsies followed by three to six months of lab time
- may require multiple injections spaced three to four weeks apart
- minimal testing in individuals with darker skin (test group was 92% white)
- not advised for individuals prone to keloid scarring
- not recommended for individuals with collagen disorders such as Ehlers-Danlos
Fillers that do both
- calcium hydroxyapatite (CaHA)
- semi-permanent (12 – 18 months)
- synthetic bone microspheres in a cellulose carrier gel
- new collagen forms around the microspheres
- the gel is absorbed by the body and the microspherers slowly break down
- if nodules form, they can be reduced with massage or treatment to reduce new collagen formation
- polymethyl methacrylate (PMMA)
- first used as a biocompatible cement
- microspheres in a bovine collagen base
- carrier gel is absorbed in 1-3 months
- microspheres are foundation for new collagen formation
- requires sensitivity testing
- mulitple treatments spaced four weeks apart may be needed
- nodules may be treated with steroids or surgical removal
- Poly-L-lactate acid (PLLA)
- commonly used in absorbable sutures
- triggers a response from the body to build collagen in the injected area
- results can last for several years
- may require multiple sessions spaced four to eight weeks apart
- requires massage to the treated area to prevent nodules
- if nodules form, they can be removed or treated
- silicone
- is approved to treat retinal bleeds or retinal detachment
- is not approved for facial injection in the USA
- causes a local inflammatory response
- may cause complications years after use
- surgical removal only
How are these used in gender affirming care?
The charts and images in our facial surgeries and Botox articles may be helpful in visualizing how and where fillers are used. If you are considering facial surgery in the future but want to use fillers in the meanwhile, many surgeons recommend that you get temporary fillers like collagen and HLA or dissolvable ones so that they are not present for your surgery.
For those wishing to soften their face, fillers can be used to:
- Fill in dips in the forehead to create a smooth rounded contour
- Add volume to the temples
- Smooth out the brow line
- Raise the arch of the eyebrow
- Enhance cheekbone height and prominence
- Fill in a chin cleft
- Soften and round out angles in a squarer chin
- Increase lip volume
- Decrease wrinkles around the mouth
- Increase fullness in any areas that cause dysphoria
For individuals who want to emphasize angles or have a squarer face:
- Add bulk and height to the brow line
- Broaden cheekbone width and decrease the prominence of “cheek apples”
- Broaden the length of the nose
- Broaden the tip of the nose
- Add a bump to the nose
- Emphasise the dip between forehead and nose
- Emphasize the angle between the base of the nose and the lip
- Add volume to the lower lip so the upper lip appears smaller
- Add squareness and prominence to the jaw and chin
- Add volume to the tracheal area
The When: Prep and Recovery
Fillers can be done in a dermatologist’s (or ophthalmologist’s) office and procedures often take an hour or less. There’s no hospital stay needed. You may be able to have fillers done on the same day as your consultation, and return to your normal activities after your injections, although you’ll likely be advised to stay away from intense activity for the first one to two days.
Swelling, redness, and bruising at the injection sites are common. The site may look like too much product has been added at first, as some of it may reabsorb, and you may have local swelling. Depending on the filler used, you may be advised to massage the area or to leave it alone for a few days. You may experience stinging or burning at the injection site. Cold compresses for a few minutes at a time can help with discomfort and swelling. You may be instructed not to wash the injection site for 24 hours and not to wear any products like moisturizer or makeup for a few days.
The How: Insurance
Most insurance policies will not cover what they deem to be a “cosmetic” procedure. It’’s possible, but unlikely right now, that insurance will cover gender affirming fillers. However, the current WPATH Standards of Care (SOC 8) include lipofilling and lip augmentation in their list of gender affirming surgical procedures (Appendix E.) Your insurance may have already added fillers to their gender dysphoria treatment policies. Depending on your spoons and finances, the prior authorization and approval process might be worth it.
The Who: Finding 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
OutCareHealth
MyTransHealth
Accessed Articles
Lee JC, Lorenc ZP. Synthetic Fillers for Facial Rejuvenation. Clin Plast Surg. 2016 Jul;43(3):497-503. doi: 10.1016/j.cps.2016.03.002. PMID: 27363763.
Theda C. Kontis.Contemporary Review of Injectable Facial Fillers.JAMA Facial Plastic Surgery.Jan 2013.58-64.http://doi.org/10.1001/jamafacial.2013.337
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.
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.
Ascha M, Swanson MA, Massie JP, Evans MW, Chambers C, Ginsberg BA, Gatherwright J, Satterwhite T, Morrison SD, Gougoutas AJ. Nonsurgical Management of Facial Masculinization and Feminization. Aesthet Surg J. 2019 Apr 8;39(5):NP123-NP137. doi: 10.1093/asj/sjy253. PMID: 30383180.
Medical and aesthetic procedural dermatology recommendations for transgender patients undergoing transition
Dhingra, Nikhil et al. Journal of the American Academy of Dermatology, Volume 80, Issue 6, 1712 – 1721
https://www.webmd.com/beauty/collagen-injections#
https://www.realself.com/nonsurgical/collagen-injection
https://my.clevelandclinic.org/health/articles/23089-collagen
LaViv Prescribing Information: https://www.fda.gov/media/80838/download
