Facial Feminization Surgery (FFS) broadly encompasses a series of surgical procedures offered by craniomaxillofacial surgeons designed to modify facial features and transform both skeletal and soft tissues to create a more feminine appearance. Techniques, initially pioneered by Dr. Douglas Ousterhout, have been modified to include preoperative virtual planning and evolving aesthetic preferences. Computed Tomography (CT) imaging assists with morphologic typing of the brow, supraorbital, chin, and lateral mandible regions. Advancements in instrumentation increase the efficiency and accuracy of FFS procedures. More recently, trends in transgender acceptance have led to improved insurance authorization for FFS procedures. Objective outcome studies have shown success in achieving goals of (1) minimizing mis-gendering in public (appropriately identifying trans-women as female) and (2) reduction in dysphoric feelings (improved patient satisfaction).
ColemanEBocktingWBotzerM, et al. Standards of care for the health of transsexual, transgender and gender-nonconforming people, version 7. Int J Transgend. 2012;13(4):165-232.
2.
PlemonsED.Description of sex difference as prescription for sex change: On the origins of facial feminization surgery. Soc Stud Sci. 2014;44(5):657-679.
3.
AinsworthTASpiegelJH.Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19(7):1019-1024.
4.
OusterhoutDK.Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg. 1987;79(5):701-713.
5.
GrayRNguyenKLeeJC, et al. Osseous transformation with facial feminization surgery: improved anatomical accuracy with virtual planning. Plast Reconstr Surg. 2019;144(5):1159-1168.
6.
AltmanK.Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg. 2012;41(8):885-894.
7.
SedghJ.The aesthetics of the upper face and brow: male and female differences. Facial Plast Surg. 2018;34(2):114-118.
8.
MorrisonSDVyasKSMotakefS, et al. Facial feminization: systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770.
9.
HageJJBeckingAGde GraafFHTuinzingDB.Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg. 1997;99(7):1799-1807.
10.
Deschamps-BralyJC.Approach to feminization surgery and facial masculinization surgery: aesthetic goals and principles of management. J Craniofac Surg. 2019;30(5):1352-1358.
11.
SalgadoCJNugentAGSatterwaiteTCarruthersKHJoumblatNR.Gender reassignment: feminization and masculinization of the neck. Clin Plast Surg. 2018;45(4):635-645.
12.
BellingaRJCapitánLSimonDTenórioT.Technical and clinical considerations for facial feminization surgery with rhinoplasty and related procedures. JAMA Facial Plast Surg. 2017;19(3):175-181.
13.
TelangPS.Facial feminization surgery: a review of 220 consecutive patients. Indian J Plast Surg. 2020;53(2):244-253.
14.
FacqueARAtencioDSchechterLS.Anatomical basis and surgical techniques employed in facial feminization and masculinization. J Craniofac Surg. 2019;30(5):1406-1408.
15.
HerfordASStringerDETandonR.Mandibular surgery: technologic and technical improvements. Oral Maxillofac Surg Clin North Am. 2014;26:487-521.
16.
FuXQiaoJGirodS, et al. Standardized protocol for virtual surgical plan and 3-dimensional surgical template–assisted single-stage mandible contour surgery. Ann Plast Surg. 2017;79:236-242.
17.
SteinbacherDM.Three-dimensional analysis and surgical planning in craniomaxillofacial surgery. J Oral Maxillofac Surg. 2015;73(12 Suppl):S40-S56.
18.
TawaPBraultNLuca-PoznerV, et al. Three-Dimensional custom-made surgical guides in facial feminization surgery: prospective study on safety and accuracy. Aesthet Surg J. 2021;(11):NP1368-NP1378.
19.
SpiegelJH.Facial feminization for the transgender patient. J Craniofac Surg. 2019;30(5):1399-1402.
20.
Deschamps-BralyJ.Feminization of the Chin: Genioplasty using osteotomies. Facial Plast Surg Clin North Am. 2019;27(2):243-250.
21.
KawamotoHK.Osseous Genioplasty. Aesthet Surg J. 2000;20(6):509-516.
22.
SpiegelJHRodriguezG.Chondrolaryngoplasty under general anesthesia using a flexible fiberoptic laryngoscope and laryngeal mask airway. Arch Otolaryngol Head Neck Surg. 2008;134:704-708.
23.
DavisAMSimonsRLRheeJS.Evaluation of the Goldman tip procedure in modern-day rhinoplasty. Arch Facial Plast Surg. 2004;6(5):301-307.
24.
ChoiJY.Alar base reduction and alar-columellar relationship. Facial Plast Surg Clin North Am. 2018;26(3):367-375.
25.
RohrichRJAfroozPN.Primary Open rhinoplasty. Plast Reconstr Surg. 2019;144(1):102e-117e.
26.
TrusslerAPKawamotoHKWassonKL, et al. Upper lip augmentation: palmaris longus tendon as an autologous filler. Plast Reconstr Surg. 2008;121(3):1024-1032.
27.
SpiegelJH.The modified Bullhorn approach for the lip-lift. JAMA Facial Plast Surg. 2019;21(1):69-70.
28.
KaufmanMRMillerTAHuangC, et al. Autologous fat transfer for facial recontouring: is there science behind the art?Plast Reconstr Surg. 2007;119(7):2287-2296.
29.
CapitánLGutiérrez SantamaríaJSimonD, et al. Facial gender confirmation surgery: a protocol for diagnosis, surgical planning, and postoperative management. Plast Reconstr Surg. 2020;145(4):818e-828e.
30.
ChayaBFBermanZPBoczarD, et al. Current trends in facial feminization surgery: an assessment of safety and style. J Craniofac Surg. 2021;32(7):2366-2369.
31.
RaffainiMPerelloRTremoladaCAgostiniT.Evolution of full facial feminization surgery: creating the gendered face with an all-in-one procedure. J Craniofac Surg. 2019;30(5):1419-1424.
32.
RaffainiMMagriASAgostiniT.Reply: full facial feminization surgery: patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;138(4):766e-767e.
33.
DubovAFraenkelL.Facial feminization surgery: the ethics of gatekeeping in transgender health. Am J Bioeth. 2018;18(12):3-9.
34.
JamesSEHermanJLRankinSKieslingMMottetLAnafiM.The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality; 2016.
35.
AlmazanANBensonTABoskeyERGanorO.Associations between transgender exclusion prohibitions and insurance coverage of gender-affirming surgery. LGBT Health. 2020;7(5):254-263.
36.
GadkareeSKDeVoreEKRichburgK, et al. National variation of insurance coverage for gender-affirming facial feminization surgery. Facial Plast Surg Aesthet Med. 2021;23(4):270-277.
37.
GorbeaEGidumalSKozatoAPangJHSaferJDRosenbergJ.Insurance coverage of facial gender affirmation surgery: a review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. Published online March 16, 2021. doi:10.1177/0194599821997734.
38.
BakkoMKattariSK.Transgender-Related insurance denials as barriers to transgender healthcare: differences in experience by insurance type. J Gen Intern Med. 2020;35(6):1693-1700.
39.
ChenKLuSMChengR, et al. Facial recognition neural networks confirm success of facial feminization surgery. Plast Reconstr Surg. 2020;145(1):203-209.
40.
FisherMLuSMChenKZhangBDi MaggioMBradleyJP.Facial feminization surgery changes perception of patient gender. Aesthet Surg J. 2020;40(7):703-709.
