Facial gender-affirming surgery: a state-of-the-art overview based on 18 years of specialised practice

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.