Feminization of the Face: Systematic Review

Feminization of the Face: Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Feminization of the Face: Systematic Review Erlândia Thais Tavares Cabral, Sarah Teixeira Costa, Lucas Perez Lahr, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9285713/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Facial features are essential for gender recognition. Facial feminization involves modifying facial features to make them more feminine. Facial feminization encompasses many surgical and other procedures to transform male facial features into female ones. The present study aimed to systematically review literature that critically evaluated the procedures currently used for feminizing the human face. Methods The methodology employed was conducted in the MEDLINE databases via PubMed, Cochrane Library, SciELO, and LILACS, using controlled and uncontrolled terms, Boolean Operators, and previously chosen Health Sciences Descriptors (DeCS/MeSH). The bibliographic search was carried out without time restrictions. The Patient-Intervention-Comparison-Outcome (PICO) strategy was used to construct the guiding research question. After applying the search strategies and eligibility criteria, 17 articles were included. The characteristics collected from the studies were author, year, sample size, surgical procedure, complications, non-surgical procedures, outcome, and patient satisfaction. Most studies addressed surgical procedures. Results There is a lack of studies on non-surgical procedures applied to the face for feminization, especially in a sample of trans women. Conclusions The evidence from this study indicates that facial feminization procedures are effective, safe, and satisfactory for patients. Level II: Evidence obtained from well-designed controlled trials without randomization, or systematic review of randomized controlled trials. Feminization Face Female Facial Transgender Male-to-Female Surgery Non-surgical Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 INTRODUCTION Facial aesthetics goes beyond technique; it requires professionals to understand each patient's individuality. More than performing procedures, it is essential to understand and respect individuals' desires and expectations, analyze the impacts of interventions, and clarify the limitations and possibilities of the results. This care becomes even more relevant when we consider facial feminization procedures, which have gained prominence, especially among patients whose gender identity does not match the sex assigned at birth and who suffer from gender dysphoria [ 1 ]. The differences between male and female faces have a hormonal etiology: high estrogen levels in females result in prominent zygomatic regions, a more tapered, more proportional nose, fuller lips, and a small, narrow chin. In contrast, high testosterone levels result in a prominent supraorbital ridge, linear eyebrows, a flat midface, a more prominent nose, thin lips, and a square jawline with a strong chin [ 2 ]. Facial features play a crucial role in gender recognition. Procedures aimed at facial feminization, both surgical and non-surgical, have emerged as powerful tools for aligning physical appearance with desired gender identity. Facial feminization is a complex set of interventions that seek to modify facial features in bones and soft tissues to make them more feminine based on the anatomical differences between the male and female faces [ 3 ]. Facial feminization surgeries involve procedures that accentuate feminine features in trans women. Doctor Douglas Ousterhout pioneered such methods in the 1980s, focusing on the forehead, orbits, nose, chin, mandible, and thyroid region [ 1 , 4 ]. Among surgical approaches, facial feminization surgery encompasses a wide range of craniomaxillofacial procedures aimed at transforming male facial features into female ones [ 5 ]. Recently, this surgery has gained popularity for its ability to significantly transform the male face into a female one, offering a true transformation for transgender patients. This term refers to the combination of surgical approaches, a dual and reversible technique in plastic and reconstructive surgery that involves modifications in both hard and soft tissues, simultaneously a reductive and augmentative intervention [ 6 ]. Among the modifications most sought by transgender women, the following stand out: remodeling and reduction of the frontal bone region and supraorbital ridge, increased volume of the zygomatic region and lips, laryngeal chondroplasty, mandible reduction, rhinoplasty, and mentoplasty [ 4 , 5 , 7 , 8 ]. The literature on facial feminization is sparse regarding dermal fillers, toxins, and other minimally invasive aesthetic procedures [ 2 ]. A literature review on the non-surgical management of facial feminization found that most studies focus on case reports examining outcomes and surgical techniques [ 9 ]. Therefore, the present study aimed to conduct a systematic review of databases on approaches and procedures, surgical or otherwise, used to achieve a more feminine face and meet the desire of patients seeking to reaffirm their gender identity. Furthermore, the review was complemented with a clinical case report of rhinoplasty and osteoplasty of the mandible and chin in a transgender patient to accentuate the feminine aspects of her face. MATERIALS AND METHODS This literature review and the Clinical Case Report were previously submitted for analysis by the São Leopoldo Mandic College, Campinas/SP Research Ethics Committee, approved under CAAE 75767623.1.0000.5374. No funding was received for this work, and there are no conflicts of interest to declare. Protocol The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [ 10 ] to ensure the integrity and reliability of the review process, under Protocol no CRD420251155687. The review underwent a comprehensive literature search strategy, a selection process based on predetermined inclusion and exclusion criteria, thorough data extraction, and an assessment of the quality of the included studies. A search-and-selection methodology was employed to prepare this literature review. Four databases were selected to apply the search strategies (MEDLINE via PubMed, Cochrane Library, SciELO, and BIREME). The search deadline was set for August 10, 2024. Eligibility criteria The literature search was conducted without time restrictions. The Patient-Intervention-Comparison-Outcome (PICO) strategy was used to construct the research question. The PICO (problem, intervention, comparison, and outcome) strategy was defined in Table 1. By using the elements of this strategy, it was possible to develop the guiding question for this study: "What are the procedures and treatment methods currently used for the feminization of the human face?" The following inclusion criteria determined the eligibility of studies: (i) the article should present data on any facial feminization treatment; (ii) the study should be original and interventional, and a case report; (iii) studies should be written in English and Spanish. Based on these results, exclusion criteria were assigned, which included: (i) studies involving patients undergoing procedures combined with interventions in other regions; (ii) patients undergoing other concomitant surgical procedures; (iii) syndromic patients; (iv) wrong type of publication (book chapters and conference abstracts); (v) lack of information on clinical cases; (vi) studies with a different focus; (vii) references with no full texts available. Information sources An electronic search to identify relevant studies was developed for multiple bibliographic databases, including 1) PubMed ( https://pubmed.ncbi.nlm.nih.gov ); 2) Lilacs ( https://lilacs.bvsalud.org/ ); 3) Scielo ( https://www.scielo.br/ ), and 3) Cochrane Library ( https://www.cochranelibrary.com/ ). The search included all published articles with no time limit. Duplicate articles were removed using the Rayyan 12® software reference manager. The search strategy was standardized and consistently applied across all subsequent updates. Boolean operators ('OR,' 'AND,' and 'NOT') were used to join terms related to facial feminization treatment. Then, a systematic search was carried out using the Health Sciences Descriptors (DeCS/MeSH): "Feminization," "Face," "Female Facial," "Transgender," and "Male-to-Female," as well as their respective Portuguese translations, for searches in Lilacs and SciELO. Search strategies Table 2 shows the search strategies, including controlled terms and combinations of Boolean operators, for the different databases used. Study selection process. The authors went through two phases to include the studies. In the first phase, two authors (E.T.T.C. and M.O.C.D.L.) independently reviewed the titles and abstracts of all references using Rayyan 12® software to determine which studies met the inclusion criteria and which did not. In any disagreement, a third author (C.R.P.J.) was consulted. In the second phase, the same two authors evaluated the full-text articles to confirm that they included both feminization and facial region treatments. The three authors discussed the controversies, and only full-text articles that met the criteria were included in the analysis. Data collection The authors of the first (E.T.T.C.) and second (M.O.C.D.L.) collected pertinent data from the selected references. In contrast, the third author (C.R.P.J.) ensured the accuracy of the collected information by performing cross-validation checks. Any controversy was resolved through group discussion and consensus among the three authors. When the necessary information could not be obtained from the selected articles, efforts were made to contact the corresponding authors to acquire the missing data. Data list Data extracted from each selected study included general characteristics (first author and year of publication), study participants (sample size), surgical procedure, complication, non-surgical procedure, and outcome. Risk of bias in studies To assess the risk of bias, two authors (E.T.T.C. and M.O.C.D.L.) independently used the Critical Appraisal Checklist for Studies Reporting Prevalence Data [ 11 ] and the Critical Appraisal Checklist for Case Reports [ 12 ] from the Joanna Briggs Institute. In case of disagreements, the third author (C.R.P.J.) was consulted to reach a consensus. The full text of each article was identified and presented as having a high, moderate, or low risk of bias. Two reviewers evaluated the articles independently and discussed the differences to reach a consensus. Before conducting critical appraisals, all authors discussed and decided on the scoring criteria. Based on the scoring, a study was designated as having a high risk of bias if it obtained a "yes" score of up to 49%, moderate if it received a score between 50% and 69%, and low if it obtained a score above 70%. RESULTS Study selection In the first phase of identification and selection, 48 studies were obtained from searches for controlled and uncontrolled terms using Boolean operators in the databases. Three duplicate references were removed, 45 full texts were read to assess eligibility for the established inclusion criteria, and 24 articles were subsequently excluded. Seven references were not retrieved because their full texts were unavailable. Three references were excluded after full-text review, bringing the total to 34 exclusions. In the search of the reference lists of the selected articles, six references of interest were identified. No gray literature was selected. Therefore, 17 articles met the eligibility criteria and were included in the qualitative analysis. A total of 467 patients underwent interventions for facial feminization. Figure 1 shows the PRISMA flowchart for further reviews of identifying, including, and excluding studies. Characteristics of the studies The data collected from the previously selected studies included general characteristics (first author and year of publication), sample size, surgical procedure, complication, non-surgical procedure, and outcome. The characteristics of the included studies are summarized in Table 3. Risk of bias in studies The Critical Appraisal Checklist for Studies Reporting Prevalence Data [ 11 ] was used to assess the risk of bias in prevalence studies. The results are shown in Table 3 and Fig. 2. The risk of bias in clinical case reports was assessed using the Critical Appraisal Checklist for Case Reports by [ 12 ]. The results are shown in Table 4 and Fig. 3. CASE REPORT Transgender patient, 31 years old, white, born in Campinas/São Paulo/Brazil, with no previous medical history relevant to the surgical procedure in question. The main complaints related to the face with masculine characteristics were protuberance on the nasal dorsum, widening of the alar base, and square jaw and chin. Photographs were taken on the day of surgery and after 60 days. An excess of cartilaginous bony dorsum and a lack of support of the nasal apex were observed on clinical examination. Open rhinoplasty was proposed and performed under general anesthesia in a hospital setting. The excess dorsal osseocartilaginous cartilage was reduced, and the septal cartilage was resected to create a septal extensor (SE) graft to support the nasal apex, preserving the L-shaped support. The bone base was thinned, and low to high-lateral bone fractures were performed to close the bony dorsum ("open roof"). Expander grafts in the upper lateral cartilages (ULCs) were performed to maintain the internal nasal valve. After evaluation of the projection and rotation of the nasal apex, the SE graft was sutured to the caudal portion of the septum. The ULCs were removed from the vestibular mucosa of the nasal cavity, thereby exposing the Domus. The excess cephalic cartilaginous tissue of the lateral crura was resected, and the turn-in flap technique was performed, in addition to transdermal and internal sutures. The allectomy completed the surgical intervention. The cephalic margins of the domus of both lower lateral cartilages (LLCs) were fixed by sutures at the apex of the SE. The sutures were placed at the caudal margin of the medial crura. The surgical field was closed with non-absorbable sutures. A microporous adhesive was carefully applied, along with a thermoformable dressing, to contain edema and maintain fracture immobilization. Mandibular osteoplasty was also performed in the parasymphysis region (thinning and flattening) to make the chin more delicate (smaller). Given that the patient had previously undergone bimaxillary orthognathic surgery with mentoplasty, the chin height was reduced. Bilateral osteotomy was performed at the bases of the mandible in the body region, and V-Y plication on the upper lip labial to make the lips more voluminous. The post-surgical result showed a tapered nose with more feminine characteristics, a more delicate dorsum, and a more acute nasolabial angle (Figs. 3–11). DISCUSSION Facial feminization is an area of growing interest in plastic surgery and aesthetic dermatology [13,14], especially in contexts where gender identity is in focus. This systematic literature review identified 17 studies that addressed surgical and non-surgical procedures aimed at facial feminization, highlighting the variety and complexity of these interventions. However, it was noted that the focus remains on studies of surgical procedures. The literature highlights the following surgical procedures: frontal reduction and recontouring with a brow lift, increased prominence of the zygomatic complex, rhytidoplasty, rhinoplasty, lip elevation, reduction of jaw angles and contour, and genioplasty [4,5,8,15-18]. Orthognathic surgery can also be used as a surgical treatment for feminization [8,19]. The most common facial feminization surgical procedures include frontal recontouring, rhinoplasty, mandibular recontouring, and implants in the zygomatic region [20]. These procedures are often performed together, leading to cost savings and fewer postoperative comorbidities [6,8]. The age range of the samples of patients who underwent feminization procedures ranged from 18 to 93 years, with a follow-up of at least 20.58 weeks and a maximum of 32 months. Forehead recontouring, often combined with brow lifting, has also been highlighted as a crucial procedure. The bony prominence of the frontal region is less pronounced in female faces, and brow lifting contributes to a more open, soft expression, a characteristic typically associated with femininity [3,4,5,7,8,9,18]. Rhinoplasty surgery techniques for feminization emphasize a more delicate nasal dorsum and a more acute nasolabial angle, which have been consistently highlighted in literature as markers of a feminine appearance [4,5,7,8,15]. The present systematic review of the literature and the clinical case report that exemplifies it highlight the importance of rhinoplasty in achieving a more feminine facial appearance. Countries such as the United States, Thailand, and Spain lead the world in the number of facial feminization surgeries due to greater social acceptance, favorable legal frameworks, and the consolidated experience of specialized professionals. Thailand is a popular destination for surgeries related to gender transition, offering high-quality procedures at affordable costs [21]. In Brazil, gender confirmation surgeries for trans women have been available in the Unified Health System since 2008 [22]. Many of the studies included in this literature review are from the United States. Other countries, such as Spain, France, Italy, the Netherlands, and Brazil, also appear but with a lower incidence. In addition, the legalization of sex reassignment surgery in several countries has stimulated the demand for facial feminization procedures, as many patients seek to harmonize their facial appearance with their gender identity. Despite this, the lack of specific data on the prevalence of these procedures across countries underscores the need for epidemiological studies to map this practice better globally. The present study contributes to this panorama by revealing that most references do not describe patients' origins in the study samples. References on complications suggest that surgeries are safe [3,6,8,18]. The complications cited were temporary neurosensory loss of the inferior alveolar nerve, sensory disturbances of the lip and chin due to damage to the inferior alveolar nerve, hematoma, damage to the tooth root, surgical site infections, disjunctions, salivary fistulas or resorption of osteotomized bone segments, for [16]; infection, pulmonary embolism [7]; sinocutaneous fistula [3]; excessive mobility in the frontal bone, minor fluid accumulation, cartilaginous edema [5,18]. The patient in the case report did not present any complications after rhinoplasty and jaw osteoplasty. Regarding non-surgical procedures, BT type A, HA, and calcium hydroxyapatite were the most cited. These minimally invasive treatments have gained popularity due to their non-invasive profile, safety, shorter recovery time, reversibility, and the ability to precisely adjust small areas [2]. Such procedures can also be considered complementary to surgery and viable alternatives for individuals who may be ideal candidates for surgical procedures [2]. BT type A, for example, is widely used to smooth dynamic wrinkles and prominent facial musculature, particularly in the glabellar and masseteric regions, contributing to a smoother, more youthful appearance often associated with femininity [23]. Using dermal fillers, such as HA, allows modulation of facial volumes, including the lips and the zygomatic region, essential elements for facial feminization [17]. When comparing the findings of this systematic review with the existing literature on minimally invasive (non-surgical) procedures, it is observed that these procedures aim to achieve a more balanced and attractive facial aesthetics [9]. Facial feminization requires a more specific approach in which the tradition associated with femininity must be significantly enhanced or, in many cases, created. This may be the main reason for the large number of studies on surgical procedures and the few works describing minimally invasive (non-surgical) procedures. The sparse primary literature on non-surgical facial feminization in transgender patients limits the present study. Few studies were found that exclusively address the topic [2,9,17]. Future studies should describe technique modifications for injectables, such as neurotoxins and fillers, and, ideally, provide data on clinical outcomes, patient satisfaction, and the protocols to be followed. The present study does not discuss technique variations for patients of different ethnic backgrounds or ages. Transgender patients can seek feminization at any age. Gender nonbinary patients can also seek gender-affirming facial surgery, and feminization goals and shared decision-making should be pursued before intervention. STATEMENTS AND DECLARATIONS Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Ethics approval: This literature review and the Clinical Case Report were previously submitted for analysis by the São Leopoldo Mandic College, Campinas/SP Research Ethics Committee, approved under CAAE 75767623.1.0000.5374. Consent to participate: Informed consent was obtained from an individual participant included in the study. Consent to publish: The authors affirm that human research participants provided informed consent for publication of the images in Figures 4-1. References Ellis M, Choe J, Barnett SL, Chen K, Bradley JP. (2024) Facial Feminization: Perioperative Care and Surgical Approaches. Plast Reconstr Surg 153(1): 181e-193e. 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Gupta N, Wulu J, Spiegel JH (2019) Safety of Combined Facial Plastic Procedures Affecting Multiple Planes in a Single Setting in Facial Feminization for Transgender Patients. Aesthetic Plast Surg 43(4):993-999. La Padula S, Hersant B, Chatel H, Aguilar P, Bosc R, Roccaro G, Ruiz R, Meningaud JP (2019) One-step facial feminization surgery: The importance of a custom-made preoperative planning and patient satisfaction assessment. J Plast Reconstr Aesthet Surg 72(10):1694-1699. Ascha M, Swanson MA, Massie JP, Evans MW, Chambers C, Ginsberg BA, Gatherwright J, Satterwhite T, Morrison SD, Gougoutas AJ (2019) Non-surgical Management of Facial Masculinization and Feminization. Aesthet Surg J 8;39(5): NP123-NP137. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 29;372:n71. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C (2015). 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Glorion A, Perrillat A, Foletti JM, Cristofari S (2022) Surgical techniques used in chin feminization: Literature review and knowledge update. J Stomatol Oral Maxillofac Surg 123(6):e883-e887. Viscomi B (2022) From Anatomical Modifications to Skin Quality: Case Series of Botulinum Toxin and Facial Fillers for Facial Feminization in Transgender Women. Clin Cosmet Investig Dermatol 14(15):1333-1345. Spiegel JH (2011) Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope 121(2):250-61. Kannan A, Chakranarayan A, Pisharody RR, Kumari P, Gadad R, Nagori SA (2022) Atypical Orthognathic Surgical Protocol for Facial Feminisation as an Adjunct to Gender Affirmation Therapy: a Case Report. J Maxillofac Oral Surg 21(4):1296-1303. Tirrell AR, Abu El Hawa AA, Bekeny JC, Chang BL, Del Corral G (2022) Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes. Plast Reconstr Surg Glob Open 10(3):e4210. Chokrungvaranont P, Selvaggi G, Jindarak S, Angspatt A, Pungrasmi P, Suwajo P, Tiewtranon P (2014) The development of sex reassignment surgery in Thailand: a social perspective. Scientific World Journal. 19(2014):182981. Kuhnen B, Barros F, Fernandes CMS, Serra MC (2020). Facial feminization surgery in transsexuals: ethical and forensic reflections. Rev. Bioét 28(3): 432-9. MacGregor JL, Chang YC (2020). Minimally Invasive Procedures for Gender Affirmation. Dermatol Clin 38(2):249-260. Tebbens M, Nota NM, Liberton NPTJ, Meijer BA, Kreukels BPC, Forouzanfar T, Verdaasdonk RM, den Heijer M (2019). Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures. J Sex Med 16(5):746-754. Tables Tables 1 to 7 are available in the supplementary files section Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Table6.docx Table7.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor assigned by journal 02 Apr, 2026 Submission checks completed at journal 02 Apr, 2026 First submitted to journal 31 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9285713","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":628454122,"identity":"e3555ed0-e690-4f9a-b60d-9b3a413b0273","order_by":0,"name":"Erlândia Thais Tavares Cabral","email":"","orcid":"","institution":"Faculdade São Leopoldo Mandic","correspondingAuthor":false,"prefix":"","firstName":"Erlândia","middleName":"Thais Tavares","lastName":"Cabral","suffix":""},{"id":628454123,"identity":"f68a05ef-47a9-4fad-a9a4-40ed6e267dc2","order_by":1,"name":"Sarah Teixeira Costa","email":"","orcid":"","institution":"State University of 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Jodas","email":"data:image/png;base64,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","orcid":"","institution":"Faculdade São Leopoldo Mandic","correspondingAuthor":true,"prefix":"","firstName":"Cláudio","middleName":"Roberto Pacheco","lastName":"Jodas","suffix":""}],"badges":[],"createdAt":"2026-04-01 02:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9285713/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9285713/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108807946,"identity":"188a5869-4a15-44fa-847a-75059fa41ad5","added_by":"auto","created_at":"2026-05-08 15:38:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":120590,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA 2020 flowchart for new systematic reviews that included searches in databases and other sources.\u003c/p\u003e\n\u003cp\u003eCaption: Reason 1: Study with a different focus; Reason 2: Patient underwent concomitant surgical procedure; Reason 3: Study in a different language; Reason 4: Different type of publication.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/bb2fa331a52a2806d0db142b.jpg"},{"id":108807944,"identity":"219dbc40-71fc-4d4d-b7b6-cd0fec52fe78","added_by":"auto","created_at":"2026-05-08 15:38:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":108970,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of the result of the critical evaluation of the methodological quality of the included studies using the JBI tool for critical appraisal of studies with prevalence data.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/ad28af046894d550b1ff1926.jpg"},{"id":108811373,"identity":"993f2759-c632-47c2-a14d-d99af09ce7e6","added_by":"auto","created_at":"2026-05-08 16:04:33","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":101799,"visible":true,"origin":"","legend":"\u003cp\u003ePresentation of the result of the critical appraisal of the methodological quality of the included studies using the tool for critical assessment of clinical case reports.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/0c1dc4847a557a1808f338a4.jpg"},{"id":108807999,"identity":"64da1cdf-7ef8-4758-9fb9-27dc7ac0e9ab","added_by":"auto","created_at":"2026-05-08 15:38:24","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":40222,"visible":true,"origin":"","legend":"\u003cp\u003eFrontal view of the patient before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/f063eca29c7b5329cfa17bad.jpg"},{"id":108807931,"identity":"42699f8a-797a-4367-8129-36f9c5bbbe3b","added_by":"auto","created_at":"2026-05-08 15:37:01","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":35094,"visible":true,"origin":"","legend":"\u003cp\u003eLeft profile of the patient before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/4694f654d2ad8b6cb14472a9.jpg"},{"id":108807991,"identity":"5bb4e228-30f2-41c2-a246-6d0908da9717","added_by":"auto","created_at":"2026-05-08 15:38:23","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":38716,"visible":true,"origin":"","legend":"\u003cp\u003eRight profile of the patient before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/2f8e2a36feb5958517aafcfd.jpg"},{"id":108807998,"identity":"b2b5e299-11d7-4edc-93d8-478ff59f019c","added_by":"auto","created_at":"2026-05-08 15:38:24","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":31802,"visible":true,"origin":"","legend":"\u003cp\u003eRight patient profile before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/8f20bc6f6e53f181b2e61efc.jpg"},{"id":108808013,"identity":"b4101a5b-1ae3-48ff-abc1-31d294d920b5","added_by":"auto","created_at":"2026-05-08 15:38:38","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":35225,"visible":true,"origin":"","legend":"\u003cp\u003eLower view of the patient before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/5cd6022d5e094aafe44056b2.jpg"},{"id":108807990,"identity":"0e720c5e-2ea2-4ec2-af03-e53c1af7403d","added_by":"auto","created_at":"2026-05-08 15:38:22","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":49235,"visible":true,"origin":"","legend":"\u003cp\u003eTop view of the patient before and after rhinoplasty and osteoplasty.\u003c/p\u003e","description":"","filename":"Figure9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/7d5bada07aa8cf40145a3a55.jpg"},{"id":108807995,"identity":"d673d2a7-742c-4b5b-9019-2301cba7d84e","added_by":"auto","created_at":"2026-05-08 15:38:23","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":39942,"visible":true,"origin":"","legend":"\u003cp\u003eSeptal extensor (SE) graft, side view (rhinoplasty).\u003c/p\u003e","description":"","filename":"Figure10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/c1d771e7fc253e3d34b6eb16.jpg"},{"id":108977427,"identity":"9032c347-97ce-4ffc-9f28-6fe7e9d0b7ab","added_by":"auto","created_at":"2026-05-11 11:31:45","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":152134,"visible":true,"origin":"","legend":"\u003cp\u003eLower lateral cartilages (LLCs) are positioned with a septal extensor (SE) graft with a side view (rhinoplasty).\u003c/p\u003e","description":"","filename":"Figure11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/0f40ca671e5de08cce04fb5d.jpg"},{"id":109082695,"identity":"da5bbdad-5e8e-4f66-bf9e-21d9e229e3e9","added_by":"auto","created_at":"2026-05-12 12:42:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":948343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/3c00f1f1-0e12-416c-897a-839d92c40992.pdf"},{"id":109081271,"identity":"808a16b7-5b76-4cde-9e8c-e497d56c600e","added_by":"auto","created_at":"2026-05-12 12:12:11","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15147,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/25d64486fb6e7bd28f9629d7.docx"},{"id":108808009,"identity":"3f09aad0-db6f-41ab-9b38-7c0102e4529f","added_by":"auto","created_at":"2026-05-08 15:38:36","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":15374,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/43ee910b7476aa4e789a0bfb.docx"},{"id":108807992,"identity":"3c5c6a49-829a-40cc-b228-efd76637caf4","added_by":"auto","created_at":"2026-05-08 15:38:23","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":71255,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/d6d54a248b4d5edbd555d8a3.docx"},{"id":108807930,"identity":"8f1b8b2f-3b76-4442-9850-a2b56e7bf3b9","added_by":"auto","created_at":"2026-05-08 15:37:01","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":41713,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/90153f58c1ba3dc5b250824d.docx"},{"id":108807929,"identity":"938564ff-6d75-401b-bd69-c57ebe2c5352","added_by":"auto","created_at":"2026-05-08 15:37:01","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":16318,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/1d90cd64ddb22af0413c6792.docx"},{"id":108807993,"identity":"fb323656-85aa-48f2-b3e0-f6932082ec93","added_by":"auto","created_at":"2026-05-08 15:38:23","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":19141,"visible":true,"origin":"","legend":"","description":"","filename":"Table6.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/299ca7f5b5ac2485de79dee2.docx"},{"id":108807996,"identity":"40b70664-cbe2-42df-9238-1891a82e3b73","added_by":"auto","created_at":"2026-05-08 15:38:23","extension":"docx","order_by":14,"title":"","display":"","copyAsset":false,"role":"supplement","size":16767,"visible":true,"origin":"","legend":"","description":"","filename":"Table7.docx","url":"https://assets-eu.researchsquare.com/files/rs-9285713/v1/2e766e36e79aafba60af37d6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFeminization of the Face: Systematic Review\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFacial aesthetics goes beyond technique; it requires professionals to understand each patient's individuality. More than performing procedures, it is essential to understand and respect individuals' desires and expectations, analyze the impacts of interventions, and clarify the limitations and possibilities of the results. This care becomes even more relevant when we consider facial feminization procedures, which have gained prominence, especially among patients whose gender identity does not match the sex assigned at birth and who suffer from gender dysphoria [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe differences between male and female faces have a hormonal etiology: high estrogen levels in females result in prominent zygomatic regions, a more tapered, more proportional nose, fuller lips, and a small, narrow chin. In contrast, high testosterone levels result in a prominent supraorbital ridge, linear eyebrows, a flat midface, a more prominent nose, thin lips, and a square jawline with a strong chin [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFacial features play a crucial role in gender recognition. Procedures aimed at facial feminization, both surgical and non-surgical, have emerged as powerful tools for aligning physical appearance with desired gender identity. Facial feminization is a complex set of interventions that seek to modify facial features in bones and soft tissues to make them more feminine based on the anatomical differences between the male and female faces [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFacial feminization surgeries involve procedures that accentuate feminine features in trans women. Doctor Douglas Ousterhout pioneered such methods in the 1980s, focusing on the forehead, orbits, nose, chin, mandible, and thyroid region [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong surgical approaches, facial feminization surgery encompasses a wide range of craniomaxillofacial procedures aimed at transforming male facial features into female ones [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Recently, this surgery has gained popularity for its ability to significantly transform the male face into a female one, offering a true transformation for transgender patients. This term refers to the combination of surgical approaches, a dual and reversible technique in plastic and reconstructive surgery that involves modifications in both hard and soft tissues, simultaneously a reductive and augmentative intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the modifications most sought by transgender women, the following stand out: remodeling and reduction of the frontal bone region and supraorbital ridge, increased volume of the zygomatic region and lips, laryngeal chondroplasty, mandible reduction, rhinoplasty, and mentoplasty [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature on facial feminization is sparse regarding dermal fillers, toxins, and other minimally invasive aesthetic procedures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A literature review on the non-surgical management of facial feminization found that most studies focus on case reports examining outcomes and surgical techniques [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to conduct a systematic review of databases on approaches and procedures, surgical or otherwise, used to achieve a more feminine face and meet the desire of patients seeking to reaffirm their gender identity. Furthermore, the review was complemented with a clinical case report of rhinoplasty and osteoplasty of the mandible and chin in a transgender patient to accentuate the feminine aspects of her face.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e This literature review and the Clinical Case Report were previously submitted for analysis by the S\u0026atilde;o Leopoldo Mandic College, Campinas/SP Research Ethics Committee, approved under CAAE 75767623.1.0000.5374. No funding was received for this work, and there are no conflicts of interest to declare.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProtocol\u003c/h2\u003e \u003cp\u003eThe authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] to ensure the integrity and reliability of the review process, under Protocol no CRD420251155687.\u003c/p\u003e \u003cp\u003eThe review underwent a comprehensive literature search strategy, a selection process based on predetermined inclusion and exclusion criteria, thorough data extraction, and an assessment of the quality of the included studies. A search-and-selection methodology was employed to prepare this literature review. Four databases were selected to apply the search strategies (MEDLINE via PubMed, Cochrane Library, SciELO, and BIREME). The search deadline was set for August 10, 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eThe literature search was conducted without time restrictions. The Patient-Intervention-Comparison-Outcome (PICO) strategy was used to construct the research question.\u003c/p\u003e \u003cp\u003eThe PICO (problem, intervention, comparison, and outcome) strategy was defined in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eBy using the elements of this strategy, it was possible to develop the guiding question for this study: \"What are the procedures and treatment methods currently used for the feminization of the human face?\"\u003c/p\u003e \u003cp\u003eThe following inclusion criteria determined the eligibility of studies: (i) the article should present data on any facial feminization treatment; (ii) the study should be original and interventional, and a case report; (iii) studies should be written in English and Spanish. Based on these results, exclusion criteria were assigned, which included: (i) studies involving patients undergoing procedures combined with interventions in other regions; (ii) patients undergoing other concomitant surgical procedures; (iii) syndromic patients; (iv) wrong type of publication (book chapters and conference abstracts); (v) lack of information on clinical cases; (vi) studies with a different focus; (vii) references with no full texts available.\u003c/p\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cp\u003eAn electronic search to identify relevant studies was developed for multiple bibliographic databases, including 1) PubMed (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e); 2) Lilacs (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://lilacs.bvsalud.org/\u003c/span\u003e\u003cspan address=\"https://lilacs.bvsalud.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e); 3) Scielo (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scielo.br/\u003c/span\u003e\u003cspan address=\"https://www.scielo.br/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), and 3) Cochrane Library (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cochranelibrary.com/\u003c/span\u003e\u003cspan address=\"https://www.cochranelibrary.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The search included all published articles with no time limit. Duplicate articles were removed using the Rayyan 12\u0026reg; software reference manager. The search strategy was standardized and consistently applied across all subsequent updates. Boolean operators ('OR,' 'AND,' and 'NOT') were used to join terms related to facial feminization treatment. Then, a systematic search was carried out using the Health Sciences Descriptors (DeCS/MeSH): \"Feminization,\" \"Face,\" \"Female Facial,\" \"Transgender,\" and \"Male-to-Female,\" as well as their respective Portuguese translations, for searches in Lilacs and SciELO.\u003c/p\u003e\n\u003ch3\u003eSearch strategies\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;2 shows the search strategies, including controlled terms and combinations of Boolean operators, for the different databases used.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy selection process.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe authors went through two phases to include the studies. In the first phase, two authors (E.T.T.C. and M.O.C.D.L.) independently reviewed the titles and abstracts of all references using Rayyan 12\u0026reg; software to determine which studies met the inclusion criteria and which did not. In any disagreement, a third author (C.R.P.J.) was consulted. In the second phase, the same two authors evaluated the full-text articles to confirm that they included both feminization and facial region treatments. The three authors discussed the controversies, and only full-text articles that met the criteria were included in the analysis.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe authors of the first (E.T.T.C.) and second (M.O.C.D.L.) collected pertinent data from the selected references. In contrast, the third author (C.R.P.J.) ensured the accuracy of the collected information by performing cross-validation checks. Any controversy was resolved through group discussion and consensus among the three authors. When the necessary information could not be obtained from the selected articles, efforts were made to contact the corresponding authors to acquire the missing data.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData list\u003c/h2\u003e \u003cp\u003eData extracted from each selected study included general characteristics (first author and year of publication), study participants (sample size), surgical procedure, complication, non-surgical procedure, and outcome.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRisk of bias in studies\u003c/h3\u003e\n\u003cp\u003eTo assess the risk of bias, two authors (E.T.T.C. and M.O.C.D.L.) independently used the Critical Appraisal Checklist for Studies Reporting Prevalence Data [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the Critical Appraisal Checklist for Case Reports [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] from the Joanna Briggs Institute. In case of disagreements, the third author (C.R.P.J.) was consulted to reach a consensus.\u003c/p\u003e \u003cp\u003eThe full text of each article was identified and presented as having a high, moderate, or low risk of bias. Two reviewers evaluated the articles independently and discussed the differences to reach a consensus.\u003c/p\u003e \u003cp\u003eBefore conducting critical appraisals, all authors discussed and decided on the scoring criteria. Based on the scoring, a study was designated as having a high risk of bias if it obtained a \"yes\" score of up to 49%, moderate if it received a score between 50% and 69%, and low if it obtained a score above 70%.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eIn the first phase of identification and selection, 48 studies were obtained from searches for controlled and uncontrolled terms using Boolean operators in the databases. Three duplicate references were removed, 45 full texts were read to assess eligibility for the established inclusion criteria, and 24 articles were subsequently excluded. Seven references were not retrieved because their full texts were unavailable. Three references were excluded after full-text review, bringing the total to 34 exclusions. In the search of the reference lists of the selected articles, six references of interest were identified. No gray literature was selected. Therefore, 17 articles met the eligibility criteria and were included in the qualitative analysis. A total of 467 patients underwent interventions for facial feminization.\u003c/p\u003e \u003cp\u003eFigure 1 shows the PRISMA flowchart for further reviews of identifying, including, and excluding studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the studies\u003c/h2\u003e \u003cp\u003eThe data collected from the previously selected studies included general characteristics (first author and year of publication), sample size, surgical procedure, complication, non-surgical procedure, and outcome.\u003c/p\u003e \u003cp\u003eThe characteristics of the included studies are summarized in Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003eRisk of bias in studies\u003c/p\u003e \u003cp\u003eThe Critical Appraisal Checklist for Studies Reporting Prevalence Data [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] was used to assess the risk of bias in prevalence studies. The results are shown in Table\u0026nbsp;3 and Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eThe risk of bias in clinical case reports was assessed using the Critical Appraisal Checklist for Case Reports by [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The results are shown in Table\u0026nbsp;4 and Fig.\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCASE REPORT\u003c/h2\u003e \u003cp\u003eTransgender patient, 31 years old, white, born in Campinas/S\u0026atilde;o Paulo/Brazil, with no previous medical history relevant to the surgical procedure in question. The main complaints related to the face with masculine characteristics were protuberance on the nasal dorsum, widening of the alar base, and square jaw and chin. Photographs were taken on the day of surgery and after 60 days.\u003c/p\u003e \u003cp\u003eAn excess of cartilaginous bony dorsum and a lack of support of the nasal apex were observed on clinical examination. Open rhinoplasty was proposed and performed under general anesthesia in a hospital setting. The excess dorsal osseocartilaginous cartilage was reduced, and the septal cartilage was resected to create a septal extensor (SE) graft to support the nasal apex, preserving the L-shaped support. The bone base was thinned, and low to high-lateral bone fractures were performed to close the bony dorsum (\"open roof\"). Expander grafts in the upper lateral cartilages (ULCs) were performed to maintain the internal nasal valve. After evaluation of the projection and rotation of the nasal apex, the SE graft was sutured to the caudal portion of the septum. The ULCs were removed from the vestibular mucosa of the nasal cavity, thereby exposing the Domus. The excess cephalic cartilaginous tissue of the lateral crura was resected, and the turn-in flap technique was performed, in addition to transdermal and internal sutures. The allectomy completed the surgical intervention. The cephalic margins of the domus of both lower lateral cartilages (LLCs) were fixed by sutures at the apex of the SE. The sutures were placed at the caudal margin of the medial crura. The surgical field was closed with non-absorbable sutures. A microporous adhesive was carefully applied, along with a thermoformable dressing, to contain edema and maintain fracture immobilization.\u003c/p\u003e \u003cp\u003eMandibular osteoplasty was also performed in the parasymphysis region (thinning and flattening) to make the chin more delicate (smaller). Given that the patient had previously undergone bimaxillary orthognathic surgery with mentoplasty, the chin height was reduced. Bilateral osteotomy was performed at the bases of the mandible in the body region, and V-Y plication on the upper lip labial to make the lips more voluminous.\u003c/p\u003e \u003cp\u003eThe post-surgical result showed a tapered nose with more feminine characteristics, a more delicate dorsum, and a more acute nasolabial angle (Figs.\u0026nbsp;3\u0026ndash;11).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFacial feminization is an area of growing interest in plastic surgery and aesthetic dermatology [13,14], especially in contexts where gender identity is in focus. This systematic literature review identified 17 studies that addressed surgical and non-surgical procedures aimed at facial feminization, highlighting the variety and complexity of these interventions. However, it was noted that the focus remains on studies of surgical procedures.\u003c/p\u003e\n\u003cp\u003eThe literature highlights the following surgical procedures: frontal reduction and recontouring with a brow lift, increased prominence of the zygomatic complex, rhytidoplasty, rhinoplasty, lip elevation, reduction of jaw angles and contour, and genioplasty [4,5,8,15-18]. Orthognathic surgery can also be used as a surgical treatment for feminization [8,19]. The most common facial feminization surgical procedures include frontal recontouring, rhinoplasty, mandibular recontouring, and implants in the zygomatic region [20]. These procedures are often performed together, leading to cost savings and fewer postoperative comorbidities [6,8]. The age range of the samples of patients who underwent feminization procedures ranged from 18 to 93 years, with a follow-up of at least 20.58 weeks and a maximum of 32 months.\u003c/p\u003e\n\u003cp\u003eForehead recontouring, often combined with brow lifting, has also been highlighted as a crucial procedure. The bony prominence of the frontal region is less pronounced in female faces, and brow lifting contributes to a more open, soft expression, a characteristic typically associated with femininity [3,4,5,7,8,9,18].\u003c/p\u003e\n\u003cp\u003eRhinoplasty surgery techniques for feminization emphasize a more delicate nasal dorsum and a more acute nasolabial angle, which have been consistently highlighted in literature as markers of a feminine appearance [4,5,7,8,15]. The present systematic review of the literature and the clinical case report that exemplifies it highlight the importance of rhinoplasty in achieving a more feminine facial appearance.\u003c/p\u003e\n\u003cp\u003eCountries such as the United States, Thailand, and Spain lead the world in the number of facial feminization surgeries due to greater social acceptance, favorable legal frameworks, and the consolidated experience of specialized professionals. Thailand is a popular destination for surgeries related to gender transition, offering high-quality procedures at affordable costs [21]. In Brazil, gender confirmation surgeries for trans women have been available in the Unified Health System since 2008 [22]. Many of the studies included in this literature review are from the United States. Other countries, such as Spain, France, Italy, the Netherlands, and Brazil, also appear but with a lower incidence. In addition, the legalization of sex reassignment surgery in several countries has stimulated the demand for facial feminization procedures, as many patients seek to harmonize their facial appearance with their gender identity. Despite this, the lack of specific data on the prevalence of these procedures across countries underscores the need for epidemiological studies to map this practice better globally. The present study contributes to this panorama by revealing that most references do not describe patients' origins in the study samples.\u003c/p\u003e\n\u003cp\u003eReferences on complications suggest that surgeries are safe [3,6,8,18]. The complications cited were temporary neurosensory loss of the inferior alveolar nerve, sensory disturbances of the lip and chin due to damage to the inferior alveolar nerve, hematoma, damage to the tooth root, surgical site infections, disjunctions, salivary fistulas or resorption of osteotomized bone segments, for [16]; infection, pulmonary embolism [7]; sinocutaneous fistula [3]; excessive mobility in the frontal bone, minor fluid accumulation, cartilaginous edema [5,18]. The patient in the case report did not present any complications after rhinoplasty and jaw osteoplasty.\u003c/p\u003e\n\u003cp\u003eRegarding non-surgical procedures, BT type A, HA, and calcium hydroxyapatite were the most cited. These minimally invasive treatments have gained popularity due to their non-invasive profile, safety, shorter recovery time, reversibility, and the ability to precisely adjust small areas [2]. Such procedures can also be considered complementary to surgery and viable alternatives for individuals who may be ideal candidates for surgical procedures [2]. BT type A, for example, is widely used to smooth dynamic wrinkles and prominent facial musculature, particularly in the glabellar and masseteric regions, contributing to a smoother, more youthful appearance often associated with femininity [23]. Using dermal fillers, such as HA, allows modulation of facial volumes, including the lips and the zygomatic region, essential elements for facial feminization [17].\u003c/p\u003e\n\u003cp\u003eWhen comparing the findings of this systematic review with the existing literature on minimally invasive (non-surgical) procedures, it is observed that these procedures aim to achieve a more balanced and attractive facial aesthetics [9]. Facial feminization requires a more specific approach in which the tradition associated with femininity must be significantly enhanced or, in many cases, created. This may be the main reason for the large number of studies on surgical procedures and the few works describing minimally invasive (non-surgical) procedures.\u003c/p\u003e\n\u003cp\u003eThe sparse primary literature on non-surgical facial feminization in transgender patients limits the present study. Few studies were found that exclusively address the topic [2,9,17]. Future studies should describe technique modifications for injectables, such as neurotoxins and fillers, and, ideally, provide data on clinical outcomes, patient satisfaction, and the protocols to be followed.\u003c/p\u003e\n\u003cp\u003eThe present study does not discuss technique variations for patients of different ethnic backgrounds or ages. Transgender patients can seek feminization at any age. Gender nonbinary patients can also seek gender-affirming facial surgery, and feminization goals and shared decision-making should be pursued before intervention.\u003c/p\u003e"},{"header":"STATEMENTS AND DECLARATIONS","content":"\u003cp\u003eFunding:\u0026nbsp;The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eCompeting Interests:\u0026nbsp;The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eEthics approval:\u0026nbsp;This literature review and the Clinical Case Report were previously submitted for analysis by the São Leopoldo Mandic College, Campinas/SP Research Ethics Committee, approved under CAAE 75767623.1.0000.5374.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to participate:\u0026nbsp;Informed consent was obtained from an individual participant included in the study.\u003c/p\u003e\n\u003cp\u003eConsent to publish: The authors affirm that human research participants provided informed consent for publication of the images in Figures 4-1.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEllis M, Choe J, Barnett SL, Chen K, Bradley JP. (2024) Facial Feminization: Perioperative Care and Surgical Approaches. Plast Reconstr Surg 153(1): 181e-193e.\u003c/li\u003e\n \u003cli\u003eDe Boulle K, Furuyama N, Heydenrych I, Keaney T, Rivkin A, Wong V, Silberberg M (2020) Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals. Clin Cosmet Investig Dermatol 13;14:513-525.\u003c/li\u003e\n \u003cli\u003eLam K, Ho T, Yao WC (2017) Sinocutaneous Fistula Formation After Forehead Recontouring Surgery for Transgender Patients. J Craniofac Surg 28(3):e274-e277.\u003c/li\u003e\n \u003cli\u003eFacque AR, Atencio D, Schechter LS (2019) Anatomical Basis and Surgical Techniques Employed in Facial Feminization and Masculinization. J Craniofac Surg 30(5):1406-1408.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMorrison SD, Vyas KS, Motakef S, Gast KM, Chung MT, Rashidi V, Satterwhite T, Kuzon W, Cederna PS (2016) Facial Feminization: Systematic Review of the Literature. Plast Reconstr Surg 137(6):1759-1770.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRaffaini M, Perello R, Tremolada C, Agostini T (2019) Evolution of Full Facial Feminization Surgery: Creating the Gendered Face With an All-in-one Procedure. J Craniofac Surg 30(5):1419-1424.\u003c/li\u003e\n \u003cli\u003eGupta N, Wulu J, Spiegel JH (2019) Safety of Combined Facial Plastic Procedures Affecting Multiple Planes in a Single Setting in Facial Feminization for Transgender Patients. Aesthetic Plast Surg 43(4):993-999.\u003c/li\u003e\n \u003cli\u003eLa Padula S, Hersant B, Chatel H, Aguilar P, Bosc R, Roccaro G, Ruiz R, Meningaud JP (2019) One-step facial feminization surgery: The importance of a custom-made preoperative planning and patient satisfaction assessment. J Plast Reconstr Aesthet Surg 72(10):1694-1699.\u003c/li\u003e\n \u003cli\u003eAscha M, Swanson MA, Massie JP, Evans MW, Chambers C, Ginsberg BA, Gatherwright J, Satterwhite T, Morrison SD, Gougoutas AJ (2019) Non-surgical Management of Facial Masculinization and Feminization. Aesthet Surg J 8;39(5): NP123-NP137.\u003c/li\u003e\n \u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 29;372:n71.\u003c/li\u003e\n \u003cli\u003eMunn Z, Moola S, Lisy K, Riitano D, Tufanaru C (2015). Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and incidence data. Int J Evid Based Healthc 13(3):147\u0026ndash;153.\u003c/li\u003e\n \u003cli\u003eMoola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu PF (2017) Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer\u0026apos;s Manual. The Joanna Briggs Institute.\u003c/li\u003e\n \u003cli\u003eGinsberg BA, Calderon M, Seminara NM, Day D (2016). A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community. J Am Acad Dermatol 74(2):303-8.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGinsberg BA (2016). Dermatologic care of the transgender patient. Int J Womens Dermatol 3(1):65-67.\u003c/li\u003e\n \u003cli\u003eBellinga RJ, Capit\u0026aacute;n L, Simon D, Ten\u0026oacute;rio T (2017) Technical and Clinical Considerations for Facial Feminization Surgery With Rhinoplasty and Related Procedures. JAMA Facial Plast Surg 19(3):175-181.\u003c/li\u003e\n \u003cli\u003eGlorion A, Perrillat A, Foletti JM, Cristofari S (2022) Surgical techniques used in chin feminization: Literature review and knowledge update. J Stomatol Oral Maxillofac Surg 123(6):e883-e887.\u003c/li\u003e\n \u003cli\u003eViscomi B (2022) From Anatomical Modifications to Skin Quality: Case Series of Botulinum Toxin and Facial Fillers for Facial Feminization in Transgender Women. Clin Cosmet Investig Dermatol 14(15):1333-1345.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSpiegel JH (2011) Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope 121(2):250-61.\u003c/li\u003e\n \u003cli\u003eKannan A, Chakranarayan A, Pisharody RR, Kumari P, Gadad R, Nagori SA (2022) Atypical Orthognathic Surgical Protocol for Facial Feminisation as an Adjunct to Gender Affirmation Therapy: a Case Report. J Maxillofac Oral Surg 21(4):1296-1303.\u003c/li\u003e\n \u003cli\u003eTirrell AR, Abu El Hawa AA, Bekeny JC, Chang BL, Del Corral G (2022) Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes. Plast Reconstr Surg Glob Open 10(3):e4210.\u003c/li\u003e\n \u003cli\u003eChokrungvaranont P, Selvaggi G, Jindarak S, Angspatt A, Pungrasmi P, Suwajo P, Tiewtranon P (2014) The development of sex reassignment surgery in Thailand: a social perspective. Scientific World Journal. 19(2014):182981.\u003c/li\u003e\n \u003cli\u003eKuhnen B, Barros F, Fernandes CMS, Serra MC (2020). Facial feminization surgery in transsexuals: ethical and forensic reflections. Rev. Bio\u0026eacute;t 28(3): 432-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMacGregor JL, Chang YC (2020). Minimally Invasive Procedures for Gender Affirmation. Dermatol Clin 38(2):249-260.\u003c/li\u003e\n \u003cli\u003eTebbens M, Nota NM, Liberton NPTJ, Meijer BA, Kreukels BPC, Forouzanfar T, Verdaasdonk RM, den Heijer M (2019). Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures. J Sex Med 16(5):746-754.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Feminization, Face, Female Facial, Transgender, Male-to-Female, Surgery, Non-surgical","lastPublishedDoi":"10.21203/rs.3.rs-9285713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9285713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFacial features are essential for gender recognition. Facial feminization involves modifying facial features to make them more feminine. Facial feminization encompasses many surgical and other procedures to transform male facial features into female ones. The present study aimed to systematically review literature that critically evaluated the procedures currently used for feminizing the human face.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe methodology employed was conducted in the MEDLINE databases via PubMed, Cochrane Library, SciELO, and LILACS, using controlled and uncontrolled terms, Boolean Operators, and previously chosen Health Sciences Descriptors (DeCS/MeSH). The bibliographic search was carried out without time restrictions. The Patient-Intervention-Comparison-Outcome (PICO) strategy was used to construct the guiding research question. After applying the search strategies and eligibility criteria, 17 articles were included. The characteristics collected from the studies were author, year, sample size, surgical procedure, complications, non-surgical procedures, outcome, and patient satisfaction. Most studies addressed surgical procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is a lack of studies on non-surgical procedures applied to the face for feminization, especially in a sample of trans women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evidence from this study indicates that facial feminization procedures are effective, safe, and satisfactory for patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel II:\u003c/strong\u003e Evidence obtained from well-designed controlled trials without randomization, or systematic review of randomized controlled trials.\u003c/p\u003e","manuscriptTitle":"Feminization of the Face: Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-05 13:11:38","doi":"10.21203/rs.3.rs-9285713/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"130545106349025681737198698454210021941","date":"2026-04-23T14:37:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T12:44:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T08:18:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T08:17:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Plastic Surgery","date":"2026-04-01T02:45:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b39b8372-77fa-4ea6-9839-9a045a4cbeb2","owner":[],"postedDate":"May 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T13:11:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-05 13:11:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9285713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9285713","identity":"rs-9285713","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}