Abstract
Facial gender-affirming surgery (FGAS), historically termed facial feminisation surgery, has evolved into a highly specialised field characterised by increasing technical refinement, safety, and patient expectations. Based on a consecutive cohort of 3582 patients treated between 2008 and 2025, this Special Topic paper presents a state-of-the-art overview of contemporary FGAS practice, focusing on surgical sequencing, anatomical planning, and quality standards. The manuscript is organised by facial thirds—upper, middle, lower—and the cervical region, which reflects both anatomical logic and clinical workflow. Current surgical strategies are described for each region, emphasising bone-driven structural feminisation as the foundation for predictable outcomes, followed by staged soft-tissue adaptation when required. The role of advanced diagnostic protocols, three-dimensional imaging, patient-specific cutting guides, piezoelectric instrumentation, and biologically adjunctive therapies is highlighted. Beyond technical aspects, this work underscores the importance of meticulous preoperative assessment, realistic management of expectations, and ethical responsibility in a heterogeneous and vulnerable patient population. By synthesising nearly two decades of focused clinical experience, this article aims to define contemporary standards and provide practical guidance for safe, systematic, and patient-centred FGAS practice.
Introduction
Facial gender-affirming surgery (FGAS), historically termed facial feminisation surgery, has advanced substantially in technique, safety, and clinical outcomes over the past two decades. Drawing upon a large cohort of patients (n = 3582) treated between 2008 and 2025, this article provides a state-of-the-art overview of contemporary practice, procedural sequencing and quality standards in FGAS. A detailed summary of the surgical procedures performed across the cohort is provided in Table 1 .
Table 1
Distribution of facial gender-affirming surgical procedures in 3582 patients.
| Procedure | Number of cases |
|---|---|
| Forehead reconstruction: | |
| Coronal approach | 2891 |
| Hairline lowering surgery | 89 |
| Rhinoplasty | 1904 |
| Chin contouring | 1419 |
| Lower jaw contouring | 1261 |
| Adam’s apple contouring | 1228 |
| Hair transplant: | |
| Simultaneous hair transplant a | 1342 |
| Deferred hair transplant b | 61 |
| Lip lift | 563 |
| Malar augmentation | 42 |
| Total | 10,800 |
The discipline has evolved rapidly in recent years, with procedures now achieving outcome quality and safety benchmarks comparable with those of established maxillofacial and facial plastic surgical interventions. Concurrent with this evolution is an unprecedented accessibility to clinical information for patients, which has heightened patient engagement and expectations. Surgeons practising in this domain must consequently adopt advanced surgical techniques and standardised treatment protocols to deliver safe, reproducible, and predictable outcomes.
Despite the proliferation of surgeons offering FGAS, formalised training pathways and accredited educational programmes remain limited. , This disparity may contribute to inconsistent outcomes, a higher frequency of revision or secondary procedures following suboptimal primary surgeries, and an increased incidence of avoidable complications. , Recognising and addressing these challenges is essential for advancing care quality.
Patients seeking FGAS present a unique psychosocial profile. They often have specific, high-level expectations and limited tolerance for prolonged recovery periods. For many individuals, FGAS represents a pivotal transition with profound implications for identity, social functioning and psychological well-being. , Successful outcomes are associated with high levels of patient satisfaction; however, unmet expectations can adversely affect perceived success and patient quality of life.
The aim of this special topic is to define contemporary quality standards in FGAS. For clarity, the discussion is organised around anatomical regions—upper, middle and lower facial thirds and the cervical region—while emphasising the importance of holistic assessment and tailored treatment planning. Empathic patient communication, active listening and clear alignment of clinical judgement with patient goals are fundamental to optimising outcomes. Misconceptions and unrealistic expectations are common; therefore, informed patient education and shared decision-making are critical. Failure to address patients’ objectives may compromise the final outcome.
Our surgical philosophy rests on three core principles. First, preservation of individual identity while achieving maximal anatomical feminisation, targeting craniofacial configurations reflective of developmental patterns that are uninfluenced by androgens. Second, the pursuit of natural-appearing results that align with established facial aesthetic norms; exaggerated modifications are associated with increased dissatisfaction and complication rates. Third, minimisation and concealment of surgical scars, given their permanence and potential psychosocial impact.
Over recent years, clinical observation has revealed that many individuals prioritise facial feminisation before body or genital surgery, which probably reflects the central role of the face in gender perception and social integration. The average age of FGAS patients has also decreased, which is consistent with broader access and earlier engagement in care pathways. FGAS may also be combined safely with other gender-affirming procedures, such as breast augmentation, body contouring or vaginoplasty, provided that careful attention is paid to operative duration and the demands of recovery. Common practice in our series has been to integrate these procedures when the perioperative risk remains acceptable.
Diagnostic assessment and surgical sequencing
Before addressing the gender-related anatomical considerations and the specific surgical procedures associated with each facial third, it is pertinent to outline the diagnostic protocol that underpins contemporary FGAS. A comprehensive understanding of the patient’s priorities, which are often related to specific anatomical features that act as dysphoria triggers, is the cornerstone of treatment planning and is initially established through a structured sequence of clinical interviews.
This qualitative assessment is subsequently consolidated through a standardised diagnostic workflow that includes systematic photographic documentation (static and dynamic views, facial expression analysis, and video recording), three-dimensional computed tomography (CT) with volumetric reconstruction to allow detailed evaluation of skeletal anatomy (including bone thickness, frontal sinus morphology and extension), and the use of virtual feminisation tools. Virtual facial simulation enables realistic visualisation of potential surgical outcomes, facilitates patient understanding of achievable changes and inherent anatomical limitations, and plays a key role in aligning expectations with surgical reality.
Beyond its communicative value, this diagnostic framework forms the basis for accurate surgical planning, and it is frequently supported by patient-specific cutting and positioning guides, which are generated through dedicated software platforms. These tools improve precision, reproducibility, and predictability in technically demanding procedures.
In delineating surgical sequencing, we typically describe a two-phase approach. The first phase focuses on structural feminisation of bone and cartilaginous elements. The second phase addresses soft tissue adaptation and refinement when spontaneous physiological adaptation is insufficient. This staged strategy reflects the differing biological responses to skeletal reduction versus soft tissue repositioning, as well as the pragmatic need to limit prolonged anaesthesia and operative risk.
Figs. 1–4 present representative cases of primary FGAS, illustrating the application of diagnostic assessment and surgical sequencing to individualised combinations of procedures. Postoperative images span multiple time points, from the early postoperative period (8 days) to long-term follow up (up to 2 years).
Preoperative and 8-day postoperative clinical views following facial gender-affirming surgery. Procedures included forehead reconstruction, rhinoplasty, chin contouring, and Adam’s apple contouring. Published with the patient’s consent.
Preoperative and 2-month postoperative clinical views following facial gender-affirming surgery. Procedures included forehead reconstruction with simultaneous hair transplantation, rhinoplasty, and Adam’s apple contouring. Published with the patient’s consent.
Preoperative and 1-year postoperative clinical views following facial gender-affirming surgery. Procedures included forehead reconstruction with simultaneous hair transplantation, rhinoplasty, lower jaw and chin contouring, and Adam’s apple contouring. Published with the patient’s consent.
Preoperative and 2-year postoperative clinical views following facial gender-affirming surgery . Procedures included forehead reconstruction, rhinoplasty, and lower jaw and chin contouring. Published with the patient’s consent.
The upper facial third
Forehead feminisation
Feminisation of the fronto-naso-orbital complex is a key determinant in the perception of gender, as widely reported in the literature. ,,,, Consequently, the vast majority of patients seeking FGAS require some degree of modification in this anatomical area, representing 83% of cases in our database. Feminisation of the upper third of the face, in addition to the hairline, requires consideration of multiple anatomical structures, including the frontal bone surface, the frontal bossing and supraorbital ridge, the frontomalar buttresses, the temporal ridges, and the frontonasal transition.
Surgical access and hairline management
Our clinical approach has evolved through several stages. Initially, cases were routinely approached via a trichophytic incision at the hairline. While outcomes were generally satisfactory, the resultant scar in a highly visible location often became a concern over time, with patients expressing a desire for improved concealment. Despite multiple attempts to reshape the hairline naturally using this approach, we concluded that consistently aesthetic and natural results were not achievable.
With increasing experience and patient feedback, the incision site has been moved progressively further back. The hairline approach is now reserved for patients with a naturally rounded hairline who specifically desire forehead shortening (hairline lowering surgery) and decline hair transplantation. These patients must be counselled regarding the potential need for subsequent hair restoration or alternative treatments in cases of poor scar healing or visible scarring.
Redefinition of the anterior hairline represents another critical component of FGAS. The integration of hair transplantation techniques with coronal access to the frontal region constituted a pivotal advancement. In patients with mild to moderate temporal recession (M-shaped hairlines), this combined approach allows complete feminisation in a single-stage procedure. After more than 1300 cases over a 10-year period using this technique, we have confirmed its viability and graft survival and currently consider it the gold standard.
For patients with more pronounced recession requiring a greater number of follicular units than can be harvested from a coronal strip, follicular unit extraction (FUE) may be performed concurrently (in single-forehead or short combined procedures) or staged as a second intervention to optimise density and shape.
The standard coronal approach provides excellent scar concealment and facilitates brow repositioning through a dual technique (skin strip resection and placement of resorbable fixation anchors). However, it carries a slightly higher risk of hypertrophic scarring due to increased wound tension, although the incidence remains low (<2% in our series). Currently, incisions are planned in the occipital region below the crown, avoiding hair whorls that complicate closure and concealment. This posterior approach offers four advantages: complete scar coverage by downward-growing hair; higher follicular density, facilitating strip harvesting when hair transplantation is combined; shorter circumference, which results in a shorter scar and reduced operative time, and; lower wound tension, which reduces the risk of hypertrophic scars, and improves camouflage if scarring occurs.
The main drawbacks include increased early postoperative discomfort related to dorsal decubitus positioning, a less pronounced immediate brow-lifting effect, and more technically demanding brow anchoring.
Dissection and haemostasis
Following the incision, dissection is performed above the subgaleal plane, extending laterally to the frontomalar sutures and from the frontonasal suture posteriorly to the coronal suture. Preservation of this extended flap ensures adequate osseous vascularisation and serves as a therapeutic reserve in the event of complications involving the posterior frontal sinus wall or diploic space.
Scalp bleeding is managed using controlled hypotension, cold compresses, and judicious electrocautery, which avoids proximity to hair follicles to prevent thermal injury and alopecia. Closure with interrupted sutures allows improved haemostatic control, although it is more traumatic to follicles and slower than staple closure.
Fronto-naso-orbital reconstruction
Classic techniques for fronto-naso-orbital reconstruction remain valid. However, in our experience, the majority of cases are optimally managed through osteotomy of the anterior frontal sinus wall combined with global frontal bone contouring using high-speed burs. Across nearly 3000 cases, this approach has proven to be one of the safest and most predictable procedures, yielding consistent and reproducible outcomes across our surgical protocol.
We generally recommend global volume reduction of the frontal bone with high-speed burs, combined with osteotomy of the anterior sinus wall to achieve the required setback. Cases amenable to shaving alone are exceedingly rare (<1%). Shaving-only techniques are limited to setbacks of 2–3 mm, constrained by the average thickness of the anterior sinus wall (3 mm ± 0.7), and frequently result in suboptimal aesthetic outcomes. Even in cases with solid sinuses, we favour osteotomy-based reconstruction, as exposed cancellous bone demonstrates unpredictable resorption.
After setback, redefinition of the superior orbital rim is achieved through shaving. This increases upper eyelid exposure at rest, thereby enlarging the lid-to-brow distance, which is a critical feature in feminising the gaze. Brow repositioning is then performed, elevating the brow 0.5–1 cm above the newly defined orbital rim. Among multiple techniques described, resorbable bone-anchoring devices have proven to be safe, efficient, and reproducible.
Frontal sinus reconstruction
Reconstruction of the frontal sinus is a critical determinant of surgical success. The routine use of cutting guides has simplified the procedure and appreciably reduced complications by optimising osteotomy design and minimising the need for extensive mesh reconstruction.
We do not recommend routine manipulation of the sinus mucosa beyond preserving its integrity. When mucosal resection is unavoidable, its regenerative capacity renders the intervention low risk. Prior to fixation of the anterior wall, patency of the naso-frontal duct must be confirmed by removing residual bone fragments that may obstruct drainage.
Fixation is performed using titanium osteosynthesis hardware. In most cases, two 1 mm low-profile miniplates secured with four micro screws provide adequate stabilisation. For gaps exceeding 2 mm or areas of structural weakness, titanium mesh (0.6 mm thickness) combined with micro screws is recommended. Autologous bone particulate harvested during burring, enriched with leukocyte- and platelet-rich fibrin (L-PRF), is placed beneath the mesh to promote osteogenesis. Ongoing studies from our group are evaluating the regenerative potential of this material alone or combined with mesh.
In large defects with complete loss of anterior wall integrity, calvarial bone grafts are preferred to restore native architecture and reduce reliance on titanium mesh.
Complications and secondary procedures
The complication profile observed in our series demonstrates a very low incidence of adverse events, supporting the safety and predictability of forehead reconstruction in FGAS. These findings should be interpreted cautiously, as they derive from a single-centre cohort. Moreover, reporting a single global complication rate may be misleading due to heterogeneity in aetiology and clinical relevance.
In our cohort, the surgical reintervention rate was 0.92%, corresponding to 14 reoperations among 1510 forehead reconstructions. Follow up spanned 5 years (2020–2024), with a minimum of 12 months. Only complications requiring surgical intervention were included. The most common acute complication was postoperative haematoma, requiring evacuation in fewer than 1% of cases.
The second most common indication for reoperation was hypertrophic scarring, typically managed surgically after a minimum interval of 10–12 months.
The most feared complication is frontal sinus mucocele. Four cases were observed, all successfully treated surgically. These cases shared extensive reconstructions with large mesh segments and very thin anterior walls, suggesting that calvarial grafts may be preferable in such scenarios.
The majority of secondary procedures performed by our team address complications or suboptimal reconstructions initially carried out elsewhere. Most aesthetic revisions require a more aggressive approach, combining anterior wall osteotomy with extensive bony contouring. Complex reconstructions are managed using autologous calvarial grafts with computer-assisted planning and guided harvesting ( Figs. 5–7 ). In very large defects, custom titanium or polyether ether ketone (PEEK) implants may be required.
Secondary frontal sinus reconstruction. Case 1. Failed primary surgery performed elsewhere, with partial resorption of the anterior wall of the frontal sinus. (Top and middle rows, left) Intraoperative views showing a defective anterior wall of the frontal sinus. (Top and middle rows, right) Reconstruction using a parietal calvarial bone graft shaped by controlled greenstick fracture and secured with two titanium miniplates to restore anterior contour. (Bottom row, left) Ultrasonic marking of the donor graft guided by a patient-specific surgical template matching defect curvature and dimensions. (Bottom row, centre) Guided harvesting of the graft. (Bottom row, right) Donor site coverage using autologous bone particulate and leukocyte- and platelet-rich fibrin.
