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BackgroundFeminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft.MethodsTransgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019–2023) were included for retrospective review and comparison of techniques.ResultsIn the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002).ConclusionsThe current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

There is a literature gap regarding facial feminization surgery (FFS) access and coverage. Our goal is to compile information from previous studies and assess the current policy landscape for these surgeries in the US. We also explored why some policies do not cover them, identify states with better coverage, and determine the most covered procedures. PubMed, Medline, Embase, and Scopus were searched for studies that reviewed policies on FFS coverage. Studies on surgical techniques or other gender-affirming surgeries (GASs) that did not involve FFS were excluded. Seven studies were included for analysis. In 2014, the Department of Human Health Services (HHS) lifted the transgender exclusion policy, leading to an increase in policies regarding GASs for both private and state insurance. However, there are differences in medical necessity requirements among policies, which may not align with the World Professional Association for Transgender Health (WPATH) criteria. States that prohibit exclusion tend to offer better coverage for FFS. These states are mainly located in the western and northeast regions, whereas states in the southern and middle east regions have less coverage. Among the procedures, chondrolaryngoplasty is the most covered, while facial and cervical rhytidectomy are the least covered. To enhance transgender care, it is crucial to reach a consensus on how to offer coverage for facial feminization surgery. However, there is a lack of adequate research on this topic, and there is a need for resources and tools to assess the results of FFS procedures. One significant constraint of this study is that it does not provide a systematic review of the literature.

Objectives To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery. Methods Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study. Results Mental health-related quality of life was statistically diminished (P < 0.05) intransgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation. Conclusions Transwomen have diminished mental health-related quality of life compared with thegeneral female population. However, surgical treatments (e. g. FFS, GRS, or both) are associated with improved mental healthrelated quality of life.

Background: Upper-face feminization is a frequently executed procedure in sexual reassignment surgery, owing to its ability to influence gender identity through adjustments to the hairline, forehead, and peri-orbital area. The procedure includes reducing the hairline, lifting the brows, shaving the orbital region, and applying specific techniques to reduce the frontal bone. This research aims to assess the outcomes, results, and potential complications associated with this surgery among transgender patients. Material and Method: Retrospective review of medical records of 20 patients who attended for facial feminization surgery of the upper face between June 2022 and June 2023, analyzing the previously performed procedures, complications and revision surgery outcomes, and first-time procedures. A literature review was performed for similar studies. Results: 20 patients were included in the study. Among the cohort treated elsewhere (n = 11), the primary complaint was insufficient browbone reduction and anterior frontal sinus table setback. They underwent poorly performed Type 1 reduction when full forehead reconstruction (Type 3/4) was indicated (n = 3), or no reduction was performed during hairline advancement (n = 4). Type 3 forehead reduction with orbital shaving and hairline advancement with simultaneous temporal browlift was most commonly performed in both revision and first-time surgical upper face feminization (n = 15) (75%). Type 1 osteoplasty was performed in four patients (10%), one Type 3 revision surgery was performed after insufficient Type 3 reduction, and one case of shock-induced alopecia was reported, treated with PRP/peptides and a FUE hair graft. Conclusions: The author’s preferred technique, ‘whole-in-one’ upper face feminization by modified bi-coronal incision with frontal trichophytic hyper-beveled incision, provides sufficient insight into the frontal bone and orbital region, the desired forehead osteoplasty and the most efficient insight into the temporal area, enabling safe dissection between fasciae, ligamentous adhesion removal, and periosteal attachment, providing full soft and hard tissue feminization. Nevertheless, feminization procedures should be meticulously planned, and all concerning issues should be addressed during the first surgery in order to prevent revisions, complications, and patient dissatisfaction.

•Biological sex may not represent social identity of transgender people.•Lack of research on transgender identification in forensic anthropology.•Trans-women (male-to-female) may undergo facial feminization surgery.•Impact of facial feminization surgeries on craniometric sex assessment.•Evidence of facial feminization surgery is detectable on crania of trans-women. In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Background Facial feminization surgical procedures are involving several surgical disciplines in multiple surgical sites and therefore may carry the risk of developing infections. Data on the development of postsurgical infection (PSI) and contributing factors in male-to-female transgender people (transwomen) undergoing facial feminization surgery are scarce. The aim of this study was to investigate the contributing factors to develop PSIs in facial feminization surgical procedures. Methods Data from the medical records of 40 transwomen who underwent facial feminization surgeries in our institution between 2019 and 2021 were analyzed. The independent variables included demographic parameters (weight, body mass index, medical comorbidities and age), details of the surgical procedure (type, duration and whether another procedure had been performed concomitantly), type, dosage and route of administration of postoperative antibiotics and steroids, length of hospitalization and follow-up duration. Postsurgical infection was designated a dependent variable. Results Five out of 40 patients (12.5%) developed PSI. The surgery of those with PSIs involved more sites, and the duration of nasal tamponade was more than four times longer than for patients who did not develop a PSI. Conclusions The current study revealed higher postsurgical infections rates after lengthy surgeries or when it involves several surgical facial feminization procedures. Multicenter clinical trial on a big cohort may enable better evidence-based results. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BackgroundWe designed a survey to evaluate preferences of facial appearance in transgender male (TM), transgender female (TF) and gender nonbinary patients to better inform goals of facial gender affirming surgery (FGAS) in gender nonbinary patients.MethodsTM/TF and nonbinary patients > 18 years old were identified via retrospective chart review and distributed an anonymized survey via email from October 3 to December 31, 2022. To assess facial preferences, AI-generated and open-source portraits were edited to create five image sets with a range of features from masculine to feminine for the forehead, mandible/chin and hairline. Data were analyzed using Fisher’s exact tests and ANOVA in R-Studio.ResultsSurvey response rate was 32% (180 patients identified via chart review, 58 respondents; TM = 5, TF = 39, nonbinary = 14). TM and TF patients as well as TF and nonbinary patients had significantly different preferences for all regions (p < 0.005; all series), while TM and nonbinary patients did not (p => 0.05; all series). TF patients consistently selected 4s with neutral or more feminine features. TM and nonbinary patients, however, demonstrated no consistent preference for either male or female features but rather a range of responses spanning extremes of both masculine and feminine options. When stratified by sex assigned at birth, nonbinary patients consistently identified preferences opposite to their assigned gender.ConclusionGender nonbinary and TM patients appear to have uniquely individual preferences regarding facial appearance that do not fit into classically masculine or feminine patterns/phenotypes. As a result, we recommend individualized preoperative planning for FGAS to achieve the optimal result in these patient populations.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Facial Feminization Surgery (FFS) is a transformative surgical approach aimed at aligning the facial features of transgender women with their gender identity. Through a systematic analysis, this paper explores the clinical differences between male and female facial skeletons along with the craniofacial techniques employed in FFS for each region. The preoperative planning stage is highlighted, emphasizing the importance of virtual planning and AI morphing as valuable tools to be used to achieve surgical precision. Consideration is given to special circumstances, such as procedure sequencing for older patients and silicone removal. Clinical outcomes, through patient-reported outcome measures and AI-based gender-typing assessments, showcase the efficacy of FFS in achieving proper gender recognition and alleviating gender dysphoria. This comprehensive review not only offers valuable insights into the current state of knowledge regarding FFS but also emphasizes the potential of artificial intelligence in outcome evaluation and surgical planning to further advance patient care and satisfaction with FFS.

•Biological sex may not represent social identity of transgender people.•Lack of research on transgender identification in forensic anthropology.•Trans-women (male-to-female) may undergo facial feminization surgery.•Examining impact of facial feminization surgeries on craniometric sex assessment.•Evidence of facial feminization surgery is detectable on crania of trans-women. In the cases of transgender and gender non-conforming people, a description of their physical remains, including biological sex, may have little correlation with their social identity, delaying and often confusing the issue of identification. Some transgender individuals have sought to alter their physical appearance in order to better reflect their gender. One group of surgical modifications for trans-women, or individuals transitioning from MTF (male-to female), is known as facial feminization surgery (FFS) which involves the reduction and contour of the forehead, chin and jaw contour, and rhinoplasty, to give trans-women smoother, smaller facial features. The purpose of this research is to examine the impact of FFS on measurement-based methods of cranial sex assessment, such as discriminant function analysis. The goal is to develop guidelines for correctly recognizing and supporting the identification of trans-women. The results of this study demonstrate that evidence of gender can be found in the facial skeletons of MTF transgender individuals who have undergone facial feminization surgery, and that forensic anthropologists should consider individuals who do not fit into the traditional sex binary when assessing the sex of unidentified skeletal remains.

Background: Facial feminization surgery (FFS) is critical to gender-affirming surgery, consisting of craniomaxillofacial procedures to align facial features with a patient’s gender identity. Central to FFS is genioplasty, which reshapes or repositions the chin; however, limited research exists on genioplasty in FFS. This review and cohort analysis aim to evaluate current practices and outcomes for individuals undergoing FFS with genioplasty. Methods: A systematic review included transfeminine individuals undergoing FFS with genioplasty. A retrospective study reviewed FFS cases with genioplasty between 2017 and 2024. Data collected included demographics, imaging, virtual surgical planning (VSP), complications, and patient-reported outcomes (PROs). Results: The review included 12 studies with 1417 patients, with 34.2% undergoing genioplasty. The mean age was 37.3 years, and 60.1% were White. Preoperative imaging and VSP were used in 66.7% of studies, 3D-printed cutting guides in 37.5%, and 3D reconstruction in 75.0%. Reduction genioplasty was the most common technique. All PROs indicated high satisfaction, with a 2.67% revision rate. Complications were low (0.55%), with infections being most frequent (0.48%). In the institutional cohort, 351 patients underwent FFS, with 64.4% undergoing genioplasty, significantly higher than in the review (p < 0.001). Sliding genioplasty was preferred without preoperative imaging or VSP. Postoperative dissatisfaction was 3.54%, with 0.88% requiring revision (p = 0.063). Complication rates (1.77%) were similar to those of the review (p = 0.065). Conclusions: Genioplasty is important in FFS, with low complication and revision rates and high patient satisfaction. However, gaps remain in validated PROs and technique-specific outcomes. While preoperative imaging and VSP show benefits, comparable outcomes are achievable without them.