University of Calgary: Unique collaboration leads to evidence-based planning in gender-affirming facial surgery

The face. It is the most recognizable feature of the human body. It’s how other people identify us and how we identify ourselves.

But what if the face one sees in the mirror no longer matches who they are on the inside? This is exactly the dilemma faced by many transgender individuals as they complete their transition.

Gender-affirming facial surgeries are a collection of surgical procedures that can be performed on an individual to help them assume a facial appearance which is more in line with their gender identity, therefore reducing misgendering and gender dysphoria while improving self-perception.

Recent census data shows that there are over 100,000 transgender or non-binary individuals living in Canada and over one million transgender individuals in the United States. However, gender-affirming facial surgeries are not covered by many insurance companies and health-care systems, like Alberta Health Services, because few evidence-based criteria exist with which to support gender-affirming facial surgeries or assess its outcomes. This leaves people having to pay out of pocket for these surgeries, which can cost tens of thousands of dollars per operation.

How to prove medical necessity
Dr. Rahul Seth, MD, an associate professor at the University of California, San Francisco is a facial surgeon who had been seeking a way to prove the medical necessity of these procedures for the transgender community.

It was at a conference where Seth encountered a University of Calgary team which included biomedical engineering doctoral candidate Jordan Bannister. Bannister had been working on his main PhD project using 3D facial scans to help diagnose genetic disorders under the supervision of Dr. Nils D. Forkert, PhD, and Dr. Benedikt Hallgrimsson, PhD.

Hallgrimsson was presenting their work on genetic syndromes at a conference in San Francisco, and Seth offered him a ride to the airport afterward so they could discuss the possibility of collaboration.

Would the imaging technology work?
“He was curious if the imaging technology and methods we used for our syndrome diagnosis project could be applied to his area of facial surgery,” says Bannister.

After a few meetings between the surgeon and researchers, it was determined that the 3D imaging and subsequent shape analysis methods could be easily applied to facial scans for gender-affirming facial surgeries, specifically to provide empirical evidence for the differences in the size and shape of male and female faces. The idea for a paper was born.

The study, published in Facial Plastic Surgery & Aesthetic Medicine, shows that male faces are much larger than female faces. Moreover, there are distinct local differences in the mandible, brow, lip, nose and cheeks.


The paper gave Seth the quantitative and empirical support to show that there are structural differences in the faces of males and females, thus making GFS a necessary surgery for transgender individuals.

“One of the reasons Rahul was interested in the project was to help payors get insurance coverage for these procedures by showing how male and female faces differ,” says Bannister.

Next step: sharing the knowledge
The biggest challenge the researchers and the surgeon encountered was the knowledge translation required to write the paper.

Bannister and the other quantitative authors have a sophisticated understanding of biological shape and size, and how those things can be analyzed, but they had to figure out a way to write and present that data to a physician who could apply it in practice.

The analysis was pretty simple, but the challenge was communicating the findings in a way that was accessible to surgeons,” says Bannister.

The work in this area is just beginning for Bannister and some of his fellow co-authors, including fellow UCalgary doctoral student David Aponte. They have started Deep Surface AI here in Calgary. Deep Surface AI is a health-care software company which specializes in the medical applications of 3D facial surface scanning.

The goal is to design web-based software to help those surgeons create facial morphs and visualizations in preparation for surgery.

Funded by an Innovate Calgary Life Sciences Fellowship in 2020 and UCalgary’s UCeed Health Fund in 2021, and Alberta Innovates, the company has developed an online platform where surgeons can upload 3D facial scans of patients and then morph the face in 3D within the software to show the goals for the patient’s facial transformation post-surgery.

By using this software, surgeons save a considerable amount of time morphing the face, as other software can take 30 to 45 minutes to do a full morph for gender-affirming facial surgeries, while Deep Surface AI’s can do the 3D morphs in two to three minutes due to its data-driven algorithmic approach.

Patients are also more empowered because they can sit with the surgeon for a “morphing session” and provide input into the surgery.

Patient and surgeon can work together
“Together, the patient and surgeon are able to basically choose the surgical objective that is suited to the patient’s unique face,” says Dr. David Katz, PhD, a co-founder and CEO of Deep Surface AI.

The platform can also lend further credence to getting these surgeries covered by insurance, as the morph can show which surgeries are necessary to complete the gender-affirming facial surgeries.

“This provides the most striking evidence that can be mustered for demonstrating the value of feminizing [or masculinizing] a certain feature,” says Katz.

Instead of having a back-and-forth with insurers about whether a brow or a chin needs to be altered, Deep Surface AI can provide the data to show the male/female differences for that specific patient.

Data shows clear male/female differences
“In jurisdictions that provide insurance coverage for gender-affirming facial procedures, it has already been used to convince insurers to cover procedures that might not otherwise be covered,” says Katz.

Be it through the paper or through Deep Surface AI, the team is hoping this data-driven approach will help make GFS more accessible for transgender individuals, as it can be a life-changing surgery.

“These surgeries can help reduce feelings of dysphoria and help people curate their identity,” says Katz.

“The personal benefits and the medical benefits are extremely high.”


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