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Virtual Surgical Planning in Facial Feminization Surgery

Expert reviewed by Dr. Kriya Gishen.

Virtual Surgical Planning (VSP) is a powerful tool used in Facial Feminization Surgery (FFS). It employs advanced imaging and computer technology to plan and simulate surgical procedures with a high degree of precision. By enhancing the precision, customization, and safety of FFS, VSP leads to better outcomes and improved patient satisfaction.

What Is Virtual Surgical Planning?

VSP involves preoperative imaging and analysis, surgery simulation, end result visualization, and 3D printing of patient-specific surgical guides and plates.

During the initial VSP imaging session, the patient undergoes Computed Tomography (CT) scans to produce three-dimensional images of the face. This detailed model of bone and soft tissue anatomy is analyzed using specialized software to determine skeletal spatial relationships and identify the specific areas that need surgical modification.

The surgeon can then simulate different surgical techniques and outcomes using the 3D models and software. Based on these simulations, a customized surgical plan is developed.

VSP software can also guide the design of custom surgical guides used during surgery. These guides are similar to woodworking jigs, which are tools used to perform repetitive tasks such as measuring, cutting, and drilling. By using jigs, woodworkers can improve the accuracy and efficiency of their work. Similarly, surgical guides enhance the precision and predictability of surgical procedures, reducing operative time and improving patient safety. These devices are 3D printed based on designs produced by VSP software.

Patient-specific plates are similar to guides but serve a different purpose. They provide structural support and stabilization, holding bones or tissues in their corrected positions during and after surgery. Plates are usually made from durable and biocompatible materials like titanium or high-strength polymers and are securely fixed to the bone.

Comparing VSP with Traditional Surgical Planning Methods

Prior to the advent of VSP, surgical planning for Facial Feminization procedures relied on the surgeon's skill to analyze facial anatomy, create the surgical plan, and perform the surgery in real time. The difficulty with this approach was the limited access and visibility of facial bone anatomy. While CT scans are helpful, the full suite of VSP adds precise analysis and surgery simulation aided by software.

VSP enables the surgeon to visualize crucial structures—such as nerves running through the bones or the brain beneath the frontal bone. As a result, the surgeon can achieve more dramatic outcomes by safely removing or reshaping more bone with precise knowledge of its surrounding anatomy.

Additionally, although surgeons could manually construct their own surgical guides, 3D-printed surgical guides created with VSP software can be made much faster and are considerably more precise.

Cost and Accessibility of VSP

VSP sounds impressive! So, what’s the catch? The primary drawback of using VSP is the additional time required and the resulting cost. The cost of using VSP varies from $3000 to $15,000 USD, with an average of $9000 with surgical guides. This added cost can be covered by insurance. Dr. Kriya Gishen, a highly skilled facial feminization surgeon in Beverly Hills has had excellent success getting insurance companies to cover the cost of VSP.

Applications of VSP in Facial Feminization Surgery

Not all FFS procedures benefit from using VSP. For example, soft tissue procedures like Lip Augmentation or a Lip Lift can be performed without VSP. The procedures that gain the most benefit from VSP are bone contouring surgeries, such as:

• Forehead Contouring: CT imaging reveals the patient's frontal sinus anatomy, which helps surgeons design the surgical approach.
• Orbital Rim Contouring: 3D-printed patient-specific guides help surgeons execute this procedure with accuracy to ensure symmetry.
• Jaw Contouring: One of the original applications of VSP was for Orthognathic surgery, a type of surgery that helps align the upper and lower jaw. When planning a Jaw Contouring procedure, surgeons use VSP to analyze relevant structures, plan implant placements with precision, and create custom guides to ensure symmetrical bone cuts.
• Chin Contouring: In addition to creating surgery guides for Chin Contouring, surgeons can also fabricate patient-specific plates with VSP to support and stabilize chin segments in their pre-planned positions.

VSP also helps with creating custom implants. The scans and VSP software help surgeons perfectly size implants to the underlying bone. This is particularly useful for jaw and chin implants.

Patient-Centered Advantages of VSP

VSP offers numerous benefits for surgeons, such as accuracy in assessing facial anatomy and enhanced precision in procedure design and execution. While these benefits extend to patients, VSP also offers additional patient-centered advantages. First and foremost, VSP can reduce surgical complications.

“VSP generates a detailed map of each patient’s unique anatomy, allowing surgeons to avoid critical functional structures like nerves,” says Dr. Kriya. “At the same time, it provides guidance to ensure outcomes remain natural and not overdone. And since everyone has some degree of facial asymmetry, VSP helps correct those imbalances for a more harmonious final result.”

VSP also improves patient safety in the operating room by:

• Reducing the need for unplanned adjustments during surgery, which can lead to errors;
• Reducing surgery time, thereby decreasing the risk of complications; and
• Ensuring accurate placement of surgical instruments and implants, which reduces the chance of human error through the use of patient-specific guides.

The accuracy of VSP also benefits surgery recovery. “Precision is key,” says Dr. Kriya. “If I can measure twice and have it confirmed with a guide and cut once, I eliminate trauma to the tissues. Gentle, precise, atraumatic tissue handling makes recovery faster and easier.”

Generating visualizations of surgical outcomes using VSP software serves as a powerful communication tool for surgeons and patients. VSP helps set realistic expectations by showing patients simulated outcomes, which can improve patient satisfaction and align surgical goals with the patient’s desires. When patients see potential results in a 3D visualization, they can provide more informed consent based on their understanding of what the surgery will entail.

"VSP transforms surgical planning into a more visual and interactive experience for both the surgeon and the patient,” says Dr. Kriya. “It helps patients better understand their anatomy and how specific goals can be achieved. Additionally, it streamlines the procedure, making it— in my opinion—safer, ultimately enhancing the patient experience.”

The use of outcome visualization predates VSP. For example, many surgeons have used 2D images to show patients the expected results of a Rhinoplasty. The Virtual FFS website has provided this service to patients for more than 20 years. While visualization alone is a useful tool that can lead to better outcomes, it does not constitute VSP. The visualizations generated with VSP software are much more detailed and presented in full 3D.

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Virtual Surgical Planning is emerging as a best practice for some types of facial surgery and is increasingly used in the field of gender-affirming facial surgery. Like any tool, the full benefits of VSP depend on the skill and experience of the technician; simply employing VSP does not guarantee a better outcome. However, in certain situations, VSP can provide many benefits that ultimately enhance the precision, customization, and safety of facial feminization surgery. Despite the added time and cost, many people seeking FFS find the use of such technology both appropriate and warranted.

Relevant Studies

1. Simone La Padula, Barbara Hersant, Harold Chatel, Paola Aguilar, Romain Bosc, Giovanni Roccaro, Robin Ruiz, Jean Paul Meningaud. One-step facial feminization surgery: The importance of a custom-made preoperative planning and patient satisfaction assessment. Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 72, Issue 10, 2019, Pages 1694-1699, ISSN 1748-6815, https://doi.org/10.1016/j.bjps.2019.06.014.

2. Michael Alperovich. Commentary: Virtual Surgical Planning and Patient-Specific Implants in Facial Feminization Surgery. Facial Plastic Surgery & Aesthetic Medicine, Vol. 24 (S2):S20-S23. Published Online: 27 September 2022. doi:10.1089/fpsam.2022.0302

Last updated: 03/04/25