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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.

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.

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 .

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 Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250–261, 2011). This article describes the author’s three main surgical techniques used in forehead feminization and reports on the results. Methods The type of surgery performed is based on the patient’s anatomy. Type one FGAS consists of burring the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes burring and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing. Results We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout’s methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome. Conclusions FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate. Level of Evidence IV 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.

BackgroundFacial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort.MethodsA systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations.ResultsInitial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm.ConclusionsThe core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face.Level of Evidence IIIThis 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

BackgroundThe objective is to evaluate the safety of performing multiple combined facial plastic surgical procedures affecting various planes of the face including rhytidectomy, forehead contouring with browlift, cheek implants, rhinoplasty, and mandible contouring in a single setting.MethodsThis is a retrospective study of patients undergoing facial plastic surgery with the senior author at Boston Medical Center from 2005 to 2017. Patients were included if they underwent all of the above procedures in one setting and had not had previous facial surgery. The primary outcome measure was local postoperative complications of tissue necrosis and wound dehiscence. The secondary outcome measures were general postoperative complications of venous thromboembolism and prolonged intubation.ResultsA total of 25 patients met inclusion criteria. Four patients experienced an infection—two patients had cheek implant infections delayed by months, one had a facelift hematoma that became infected, and one had an intraoral incision infection. One patient suffered from pulmonary embolism 2 months after surgery in the setting of hormone replacement therapy. All patients were extubated at the end of the case and none required reintubation. All patients had good cosmetic results.ConclusionDespite elevating multiple planes of the face at the same time, there were no complications related to vascular supply in any of the patients. Complications were limited to those known to occur with the individual procedures. This study demonstrates that concurrent procedures that elevate multiple planes in the face in a single setting may be performed safely and with good cosmetic outcomes.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.•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.