Dr. Elda Fisher: Why Oral and Maxillofacial Surgeons Should Provide Gender-Affirmation Surgery

Elda Fisher, MD, FACS 10/31/2022

Dr. Elda Fisher firmly believes facial gender-affirmation surgery is the “next frontier” for oral and maxillofacial surgeons.

Not only does she specialize in this type of surgery herself, but she’s also able to pass her extensive knowledge on to the next generation of OMS professionals as an associate professor and program director of the residency program at the University of North Carolina Adams School of Dentistry.

Below, Dr. Fisher shares her journey to this subspecialty, why she believes more OMS professionals should provide gender-affirmation surgery, and how this surgery makes a huge impact on transgender community members — helping them find belonging in their own skin and in their communities.

How did you end up in this subspecialty?

I completed a fellowship in cosmetic surgery after my residency program at UNC. Afterward, I returned to North Carolina and developed a practice in facial aesthetic surgery. One of my patients introduced me to his transfeminine friend, and I did several facial feminization procedures on her. That engaged me and got me connected to people in the trans community who wanted my help.

A challenging part of all this was so many people in the trans community have been disenfranchised. Some have been ostracized from their homes, some have had their parents or siblings disown them. In many cases, these social circumstances have made it more difficult for this population, in comparison to other populations seeking aesthetic surgery, to afford the out-of-pocket costs for these procedures.

I have always been excited about resident education, and I have always loved and been committed to the success of the residents and residency program at UNC. I was lucky and grateful to have the opportunity to move my practice of transgender surgery to UNC. As a large academic center with resources such as a multidisciplinary team for transgender health, I felt like it was a perfect match. In a hospital setting, I could perform more major complex skeletal operations, and also have the infrastructure necessary to work with the insurance companies to help our patients get coverage for these procedures.

Why is being able to access this surgery so important to trans community members?

If I suddenly started growing facial hair and looked like a man, it would be very disturbing to me. It would be very difficult to lead an everyday life looking masculine. Personal incongruence between facial features and gender is disheartening and anxiety-provoking. Gender dysphoria, which is the medical condition defined as an incongruence between one’s sex assigned at birth and their gender identity, puts those affected at risk for depression and suicide. It also puts them at risk for community violence. If a transgender woman undergoes lower-body surgery and breast augmentation, her facial features will still appear masculine as a result of the effect of testosterone on the developing craniofacial skeleton.  

The treatment of gender dysphoria through lower-body surgery has been covered by insurance for years. Faces were never covered by insurance up until the last couple of years because it was seen as ‘just cosmetic.’ In reality, it is not cosmetic at all; it is a group of surgical procedures required to effectively treat gender dysphoria.

We’re trained from when we are little to see certain facial structures as male or female — that’s not easy to erase at 40. It’s the craniofacial characteristics of the face that give this reaction. If you’re not changing these characteristics, you’re not changing that much in a social setting for these patients.

Why do you believe OMS professionals are perfectly situated to do this surgery?

I encourage oral and maxillofacial surgeons to do this surgery because they are highly trained in the bones of the face, in understanding the skeletal relationships of the face, and in treating those skeletal relationships. Furthermore, core oral and maxillofacial surgery training has a basis in the understanding of the differences in the male and female craniofacial skeleton. I don’t necessarily care if the surgeons performing facial gender-affirmation surgery are oral and maxillofacial surgeons, plastic surgeons, or otolaryngologists — what I care about is that the surgeon is highly trained and qualified and willing to provide gender-affirming care.

The Pew Research Center suggests 1.6% of the population identifies as transgender. In North Carolina, that’s 160,000 people. But there are very few people doing these operations here compared to this enormous load of patients who would benefit.

Many trans community members are looking for someone who will do these procedures, but there are very few practitioners, and the patients may need to pay out of pocket, which can be in excess of $50,000. Some of these patients will go out of the country to get it all done at one time and stay there for several days, but in my opinion, that’s not the best situation for patients because there is a lack of continuity of care. Having more access to practitioners in the U.S. and more insurance coverage is obviously better for patients.

My surgery schedule is booked out until next summer with transgender facial surgery. I see the enormous difference we can make in people’s lives. It’s rewarding to be able to have such a long-lasting and positive impact.

What do you say to people who question this type of surgery?

We as physicians or surgeons choose to do surgery on patients who are appropriate for surgery. We use the World Professional Association for Transgender Health as the barometer to determine whether someone is appropriate for surgery or hormone intervention.

For my surgery, we require a letter in support of the surgery from a mental health practitioner and a letter of support from a physician providing hormones. The letter must delineate they’re consistent with hormones and treatments. Each patient also undergoes a thorough evaluation so that treatment recommendations for facial surgery are individualized to address the features that are most salient and necessary to support their gender identity.

Some people ask, ‘What if they change their mind?’ I haven’t seen that personally, and the literature doesn’t suggest that it occurs in any significant numbers. However, I know people who had surgery on their knee as a 16-year-old who wish they hadn’t. So although there may be remorse over some surgeries — this is true across all medical specialties — they’re done for a medical rationale. For the most part, people are typically happy and more comfortable after having any type of gender-affirmation surgery because it affects their mental health so much.

What’s exciting you about the field right now?

For many years, these surgeries were done based on lateral cephalometric radiographs. Based on that, the forehead would be reduced intraoperatively with or without addressing the anterior frontal sinus table. Now with access to 3D planning, we have this technology that lets us really make patient-specific treatment plans and guides to feminize the facial bones. We enter the operative and execute these treatment plans without a lot of intra-operative changes. The patients are reassured by this also. In my pre-op meeting, I show them their plans and describe exactly what we are going to do.

How can this surgery help patients belong?

In many cases, patients have been living in their preferred gender role for 10 or more years. They’re married, have loving relationships, have children and they just want to fully belong to that group and not be misgendered by someone in public. Being called ‘sir’ if you have been presenting yourself as female for the past year or more can be so jarring over and over again, like a repeated insult to one’s own personal identity. If you can stop being misgendered, it changes so much on a day-to-day basis. When you go out the door looking like the person you feel inside, whether that is from an aesthetic standpoint or from a gender standpoint, it’s enormously important for your self-worth.