Facial Feminization Surgery of the Upper Third of the Face: Surgical Techniques to Optimize Outcomes.

Abstract

Facial feminization surgery (FFS) is a key component of gender-affirming care for transfeminine individuals, with the upper third of the face-particularly the forehead, brow complex, and hairline-serving as critical anatomic targets for achieving gender congruence. Subtle alterations to these regions significantly influence gender perception and social integration. This manuscript reviews contemporary surgical strategies for feminizing the upper third of the face, including both osseous and soft tissue approaches. Procedures covered include supraorbital bossing reduction, frontal sinus anterior table setback, orbital rim contouring, brow lifts, and hairline advancement. Consideration is given to preoperative consultation, anatomical variation, classification systems such as the Ousterhout schema, and surgical planning tools including virtual surgical planning utilizing computer-aided design/manufacturing. Feminization of the upper third is generally safe and highly effective when patient-specific factors are accounted for. Virtual surgical planning enhances surgical precision, while endoscopic and open approaches provide tailored access to address individual anatomic needs. Outcomes data reveal high patient satisfaction and low complication rates. When revisions are needed, they are often driven by undercorrection or evolving patient expectations. Complications are typically minor and self-limited; rare but serious risks include mucocele or sinus fistula following anterior table osteotomy. Upper-third FFS is a technically nuanced and outcome-critical aspect of facial gender-affirming care. Evolving surgical techniques and planning tools support safe, individualized interventions. As the field continues to shift toward inclusive, patient-centered standards, the integration of validated transgender-specific outcome measures will be essential for assessing success and optimizing care.