“Frontal Sinus Setback in Facial Feminization Surgery: Emphasizing Anatomical Landmarks Over Virtual Planning and Cutting Guides”

Background: Demand for facial feminization surgery (FFS) is growing amidst increasing recognition of its significant impact on gender affirmation. Forehead contouring via frontal sinus setback is a powerful procedure for feminizing the upper facial skeleton. While Virtual Surgical Planning (VSP) has been described as a useful tool in these surgeries, the associated cost may limit access for patients seeking these transformative interventions, especially those who lack insurance coverage for FFS. This study challenges the emerging notion that VSP is critical for the successful execution of frontal sinus setbacks. Methods: We present a technique that relies on well-defined anatomical landmarks of the frontal sinus and standard maxillofacial CT imaging for pre-operative planning, eliminating the need for expensive, pre-operatively prepared cutting guides. Key steps in this technique include obtaining detailed measurements of the frontal sinus dimensions and contour, visualizing the nasofrontal junction, reshaping the frontal sinus, resecting the corrugator muscle, and finally, performing a direct browlift. Results: In our cohort of 13 patients, including a 65-year-old transgender female with significant forehead prominence, this approach consistently achieved satisfactory outcomes without complications. Conclusion: By demonstrating that high-quality results can be achieved without VSP, we present a cost-conscious approach to FFS for a more inclusive and equitable provision to gender-affirming care. Surgical expertise and understanding of patient-specific anatomy are crucial in achieving these results, emphasizing the importance of skill over reliance on technology.