Virtual surgical planning guided osteotomy in facial feminization surgery.

Background: Osseous facial feminization surgery (FFS) requires precision to accurately modify craniofacial skeletal features and achieve optimal aesthetic and functional outcomes. Virtual surgical planning (VSP) has emerged as a tool to enhance preoperative planning and intraoperative accuracy in FFS. This systematic review aims to evaluate the role of VSP in guiding osteotomy during osseous FFS, assessing operative efficiency, accuracy, safety, and satisfaction, and describe potential future applications. Methods: A systematic review was conducted in accordance with PRISMA guidelines and the Cochrane Handbook. MEDLINE, EMBASE, Global Health, Scopus, Web of Science, Cochrane Central Library, and grey literature sources were searched in April 2025. Eligible studies included adult transgender women undergoing osseous FFS procedures with VSP guidance. Outcomes assessed included planning time, operative time, accuracy, safety/complication rates, and patient-reported satisfaction or femininity perception. Meta-analysis was performed for operative time using standardised mean difference (SMD). Results: Seven studies met inclusion criteria. Meta-analysis demonstrated significantly reduced operative time with VSP compared to conventional techniques (SMD = -0.72; 95 % CI -1.13 to -0.32; P < 0.05). Planning time varied substantially across studies reporting this data (5-10, 145 ± 13.2 min), reflecting heterogeneity in outcome reporting, software platforms used and workflow integration. Accuracy outcomes favoured VSP, with one comparative study reporting 95.25 ± 4.09 % accuracy with VSP versus 78.25 ± 12.92 % without. Reported complication rates were low (0-1.77 %), though comparative safety data were limited. Patient satisfaction and cosmetic outcomes were consistently high, though assessed using heterogeneous tools precluding pooled analysis. Conclusions: Current evidence suggests that VSP in osseous FFS is associated with reduced operative time, improved osteotomy accuracy, and favourable safety and patient-reported outcomes. Although methodological heterogeneity and limited comparative data constrain definitive conclusions, findings support an expanding role for VSP in precision-driven craniofacial gender-affirming surgery. Emerging integration of augmented reality (AR)-assisted intraoperative navigation may further enhance anatomical accuracy and surgical safety. Prospective comparative studies with standardised outcome measures and validated patient-reported instruments are required to define the long-term clinical and economic value of VSP and AR in FFS.