Presurgical Laser Hair Removal: Protocoling a Safe and Effective Procedure for Transgender Patients (2024)

Abstract

Keywords: dermatology, laser hair removal, neovaginoplasty, transgender, transgender health

Introduction

In recent years, there has been increasing public acceptance and access to health care for gender minority patients. As we seek to improve care for the transgender (TG) population, it is imperative to use a multidisciplinary approach and interprofessional communication to coordinate care related to gender-affirming treatment. The medical care of TG individuals can include hormone therapy and behavioral health/psychotherapy. A large subset of these patients also elects to undergo one or more gender-affirming surgeries (GAS).¹ These surgeries can include breast augmentation, orchiectomy, neovaginoplasty, thyroid cartilage reduction, facial feminization, mastectomy, phalloplasty, and/or facial masculinization. Surgical reconstruction of the genitals to match the patient's identified gender requires months of preoperative preparation and patient interaction with many different medical and surgical specialists.

The Center for Transgender Medicine and Surgery (CTMS) at Boston Medical Center (BMC) brings together providers from several medical and surgical disciplines to support TG patients before, during, and after gender transition, tailored to the treatment goals of each patient. The breadth of providers includes endocrinology, plastic surgery, urology, primary care, pediatric and adolescent medicine, behavioral health, obstetrics and gynecology, dermatology, otolaryngology, behavioral health, pelvic floor physical therapy, and social work.

Transfeminine dermatological care frequently involves permanent removal of unwanted hair in the facial and genital regions. Permanent hair removal by either electrolysis or laser hair removal (LHR) of the genital region is required before neovaginoplasty surgery to prevent complications such as folliculitis, hairballs, and dyspareunia. Permanent hair removal has also been shown to improve patient satisfaction with their postsurgical results.^2,3 Historically, electrolysis was the only option for preoperative hair removal. LHR has since been approved and has the advantages of treating a larger area in less total treatment time. However, not all patients are candidates for LHR over electrolysis. Because LHR targets melanin in the hair shaft, patients with white or gray hairs are not candidates for LHR and may have electrolysis as the only option.⁴

Unfortunately, many patients seek permanent hair removal from nonmedical personnel who may not be fully informed about the location to treat and the extent of clearance required. They also may not be providing the required counseling regarding expectations that are unique to this procedure. In some cases, when additional treatments are required to improve previously missed areas or are in need of additional clearance, patients may be left with further financial burden and time delays in scheduling their surgery. Both financial and time concerns are major barriers for TG patients seeking dermatological treatment, with financial barriers being the most prevalent.⁵ In the CTMS at BMC, patients who have scheduled or anticipate scheduling their neovaginoplasty surgery are referred for on-site genital LHR, where participating dermatologists are aware of proper laser usage, along with the extent and location of LHR required by the surgeons.

With increasing numbers of TG patients seeking hormonal and/or surgical interventions but relatively few locations that provide them, there is an increased need for guidelines surrounding procedures that are frequently performed in this population. The protocol contained herein outlines the procedure that board-certified dermatologists in the CTMS at BMC use to successfully perform permanent genital LHR for presurgical patients.

LHR Protocol

The most important step in treating TG patients before surgery is making them feel comfortable, both with the provider and the procedure at hand. This starts before the patient enters the examination room; it is imperative that all staff are aware of the name and pronouns that each patient uses when they arrive. This can be achieved by intentionally including these items on intake forms for record keeping. Patient forms ideally will have write-in (rather than checkbox) sections for legal name, preferred name, pronouns, and gender identity. In the interview setting, one can directly ask the patient how they would like to be addressed. In addition, the pretreatment consultation should include important information regarding medical history such as history of cold sores and herpes simplex virus, with appropriate treatment prophylaxis if deemed necessary.

The genital region is a physically and emotionally sensitive area of the body to treat, especially for TG individuals. Care should be taken to properly drape the patient so that only the treatment area is exposed and to minimize the number of people in the room. Some patients prefer to have a friend, family member, or significant other with them for support. The goal is to make the patient feel as comfortable, accepted, and respected as possible.

In examination of the location for LHR, the requirements set by the patient's surgeon should be noted. In most cases, the scrotal skin, perineum, and base of the penis is the extent of the location where permanent hair removal is required. A partial penile inversion neovaginoplasty procedure is performed by the surgeons in the CTMS of BMC. These surgeons specify that all hair should be permanently removed from the scrotal sac and the penile shaft before surgery, including a 2.5 cm area around the base of the penis. Hair from the bottom of the scrotum to 1 inch above the anus in a 6 cm strip is also to be removed. Skin from the penile shaft and mid-scrotum is used to create the neovagin*l canal; therefore, all hair in this area should be removed so the internal neovagin*l canal and all areas that will come in contact with urine will remain hair-free (Figs. 1–3). In examination of the patient, take note of skin pigmentation as well as the hair density, quality, and color(s) on the treatment area. In doing this, one can determine whether patients are a good candidate for LHR or not, choice of proper laser wavelength and settings, and how to advise them about the range of outcomes expected.

Because terminal hairs grow in an anagen/catagen cycle, multiple treatments will be required to maximize results. In our experience, sessions are well tolerated in intervals approximately every 4–6 weeks, with the total treatment time expected to be ∼6–9 months before dermatological clearance for surgery. If the patient has gray or white hairs on the scrotum, the patient should be counseled that LHR does not target these hairs since they do not have melanin, and electrolysis may be required for complete hair elimination.² Usually a patient will require multiple treatments before full clearance of the treatment area is achieved, and should be counseled about the quantity of sessions required to ensure effective and permanent hair removal. It should be noted that, depending on laser parameters and quality of hair, the number of sessions can be highly variable. If there is a long interval between LHR completion and surgery, patients may opt to come back for a touch-up session before their procedure. This may be recommended either by the dermatologist or surgeon depending on the timing of the patients' appointments. At our institution, the surgeons request that no LHR sessions occur within 3 weeks before surgery. We recommend a 3-month interval between completing LHR and neovaginoplasty to ensure clearance for the duration of one anagen/catagen growth cycle.

All hair in the treatment area should be removed before each LHR session, either by the patient or in-office before treatment. Although shaving is permissible, the patient should be advised that they should not pluck, wax, or use harsh treatments while receiving treatment. Counseling of the patient is especially important due to documented gaps in knowledge about the mechanism of action and expectations regarding LHR among TG women.⁶

Treatment of this area is notably more painful than LHR on other areas of the body for most (although not all) patients. The provider should demonstrate proper application during the first session, with the entire treatment area covered, including the groin, pubis, scrotum, and base of the penis. The numbing agent is applied at least 30 min before treatment for optimum pain control, and occlusion with plastic wrap is often used for better absorption and faster onset of action. After the anesthetic has been applied and the appropriate amount of time has passed, the plastic wrap barrier should be removed and the area wiped clean of any remaining anesthetic and also cleansed with alcohol or chlorhexidine.

The laser choice depends on the patient's skin type. Longer wavelength lasers (i.e., 1064 nm Nd:YAG should be used in those with darker skin pigmentation, whereas shorter wavelength lasers (i.e., Alexandrite 755 nm or Diode 810 nm) are preferred for those with lighter skin tones. In our practice, we used either the Nd:YAG or Alexandrite for these patients, given the immediate availability. In addition, these are two of the more common lasers available in dermatology practices. Use cooling and adequate eye protection for both patient and provider while the laser is in use. Because the skin in the scrotal area can be loose and have many folds, the skin in this area should be stretched as needed to better target the entire surface area without need for overlap. Scrotum sizes vary considerably between individuals, so the number of pulses will vary accordingly.

The immediate side effects of mild erythema and discomfort are common; swelling and crusting are rare. Postprocedure pain management includes the immediate use of ice packs for at least 5 min and application of TAC (triamcinolone acetonide) 0.025% cream or ointment in the office if the patient has increased erythema, pruritus, or discomfort. At home, if the patient continues to experience discomfort, more ice can be applied, but the treating physician should be informed. Most patients report adequate pain control and minor or no adverse effects postprocedure. Most patients also report a decrease in hair density/growth after each treatment.

Most patients completed their sessions with positive final outcomes. Typically, patients need six to nine treatments for adequate results, although this varies with individual patient needs. Additional sessions are performed until attaining satisfactory clearance of the presurgical area or until minimal interval hair regrowth is noted. In our single-center experience, most patients did not experience any adverse events from this protocol. One patient in this group had a small burn, and two patients developed a small superficial necrotic area post-treatment. All patients with these complications healed with dyspigmentation and without secondary infection. No long-term complications have occurred at this time. Similar transient events have previously been reported in patients receiving LHR in other areas, although no explanation for why this occurs in some individuals has yet been described.^7–9 It can be theorized that the relative thin nature of the skin and proximity to vasculature could potentially account for this side effect but this needs further investigation.

Although it is ideal to have as close to complete clearance of the area as possible to minimize postoperative hair regrowth and complications, some patients may experience hair regrowth in the neovagin*. These patients can use hair removal creams, plucking, interval removal of hairballs, or additional LHR or electrolysis treatments as needed to remove postoperative hair regrowth.^10,11

At this time, data about our patients' long-term postsurgical outcomes are limited. Future study is needed to characterize the efficacy of all preneovaginoplasty permanent hair removal approaches. At our center with this protocol, we have had success in complete clearance to the satisfaction of the GAS surgeons and patients alike. This claim is based on our anecdotal experience at this time, although we are continuing to monitor and quantify our cohort of patients' response to treatment in the years after surgery to further evaluate long-term outcomes. It should be noted that the patient will not be cleared for surgery if either the surgeon and/or dermatologist is not satisfied with the degree of hair clearance achieved. These patients also frequently self-select for additional appointments before their surgery date if they feel that their level of hair clearance is insufficient or bothersome. It is our opinion, that these patients achieve good outcomes in part due to this collaboration and communication.

Future Directions and Conclusions

Effective genital LHR of TG patients is imperative for successful completion of gender-affirming neovaginoplasty. Our experiences support an effective, tolerable, and efficient treatment of the scrotal, perineal, and penile shaft regions. Our patients are clinically satisfied with the results of their LHR in preparation for surgery, and those who have completed neovaginoplasty have not experienced hair removal-related delays. We have found that LHR in this setting also minimizes the financial burden while ensuring clearance of the entire area required for surgery. By coordinating care within the CTMS at BMC, these variables are substantially improved and lessen the burden of presurgical preparation on the patient. Even with coordination of care, we have found that these patients are frequently nervous and have many questions about the procedure. It is imperative that TG patients have access to an accepting environment without exception. The initial consultation appointments frequently are two to three times longer for preneovaginoplasty LHR, due to extensive patient counseling. Even TG patients who have previously had LHR in another region may initially be uncomfortable with disclosing their true identity. For these reasons, it is best for TG patients to see a provider who is both familiar with preneovaginoplasty LHR requirements and demonstrates sensitivity to the effective care of TG patients.

We do believe that it is important that patients requiring presurgical hair removal to be treated by medical professionals, such as board-certified dermatologists, working with the surgical team so that complete and permanent hair removal can be achieved safely in the entire region that the surgery requires. In addition, navigating insurance coverage and reimbursem*nt (when available) poses an additional challenge to providing this service. We have found that coordination with the surgeon billing for neovaginoplasty, which is tied to preoperative hair removal in our area, is imperative for reducing the out-of-pocket financial burden on patients. In settings where direct on-site coordination is not feasible, we recommend having the surgeon mark the desired boundaries of hair removal directly on the patient before the first hair removal appointment. The patient can either arrive with the markings intact or bring a photograph.

Much of TG health care is accessed through word of mouth from within the TG community, frequently found on online blogs or forums. Although these resources allow for a platform of acceptance within the community, electrolysis is still highly recommended on online forums as the preferred method of permanent hair removal.² This is in part because electrolysis is an older well-established method of permanent hair removal. However, LHR has significant benefits over electrolysis, including fewer treatment sessions, lower overall pain scores, lower occurrence of side effects, and superior efficacy.² LHR procedures are also faster to perform in-office in comparison with electrolysis. However, some patients are better candidates for electrolysis over LHR due to the presence of white or gray hairs, which lack melanin and are unable to be targeted by the lasers.² Our hope is that this detailed protocol, which has been successful in our practice, can be implemented in additional locations to improve access to care for the TG population. Dermatologists should be able to familiarize themselves with and feel confident in treating the sensitive genital skin of TG patients.

Acknowledgments

The authors thank all clinical providers and staff affiliated with the Center for Transgender Medicine and Surgery at Boston Medical Center. More information can be found online at the Center for Transgender Medicine and Surgery at Boston Medical Center website.

Abbreviations Used

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received no financial support for the research, authorship, or publication of this article.

Cite this article as: Carter EE, Saade DS, Vashi NA (2021) Presurgical laser hair removal: Protocoling a safe and effective procedure for transgender patients, Transgender Health 6:4, 201–206, DOI: 10.1089/trgh.2020.0015.

References