Facial anthropometric considerations in facial feminization surgery: a systematic review

Facial feminization surgery (FFS) is a key component of gender-affirming care, yet the field has historically been shaped by Eurocentric esthetic norms, with limited consideration of racial and ethnic differences in facial structure and sociocultural perceptions of femininity.

To systematically evaluate existing literature on racial and ethnic considerations in FFS, including disparities in access, craniofacial anthropometric variability, gender perception, and postoperative outcomes.

A systematic review was conducted following PRISMA 2020 guidelines and registered with PROSPERO. A comprehensive search of PubMed, Scopus, and Embase (through March 2025) identified studies assessing racial and ethnic variations in FFS access, surgical outcomes, craniofacial anthropometry, and gender perception. Studies were evaluated for risk of bias using the Newcastle-Ottawa Scale (NOS), the Joanna Briggs Institute (JBI) Checklist, and the CASP Qualitative Checklist. A narrative synthesis was performed due to heterogeneity in study designs and outcome measures.

Nine studies comprising 778 patients were included. Findings highlighted significant racial disparities in procedural selection, with African American, Asian, and Hispanic patients being less likely to undergo cranioplasty or rhinoplasty. Anthropometric studies revealed racial differences in nasolabial angle, chin dimensions, and mandibular flare. Social perception studies indicated an implicit whitening of femininity in FFS esthetics. However, race was not a significant predictor of revision rates or postoperative complications.

There is a paucity of research on race and ethnicity in FFS. Future studies should integrate race-conscious surgical planning, assess long-term patient-reported outcomes, and address systemic barriers to equitable access.