Gender Reassignment and Facial Feminization Surgery

Facial feminization surgery includes a range of procedures designed to align facial features with a patient’s gender identity. For medical coders, these services present unique challenges due to the number of anatomical areas involved and the variety of CPT codes that may apply. This overview identifies commonly performed facial feminization procedures—including forehead, hairline, nasal, cheek, lip, jaw, chin, and tracheal interventions—while highlighting key procedural components, potential codes for reporting and authoritative references to support accurate, compliant code assignment.

Facial feminization surgery is often performed for patients with gender dysphoria whose gender identity differs from their sex assigned at birth. In facial feminization, surgery helps align facial features to better match this identity by changing the shape of the face so it looks more female. Many facial features reflect sex differences and there are different procedures that change the look of the cheekbones, brow, lips, jaw and chin. Additional procedures for feminizing the face include hair transplant, moving the hairline to make the forehead smaller and skin-tightening surgery such as a face-lift. The procedures listed below are some of the more commonly performed procedures. These are not exclusive to men undergoing gender reassignment as women who want a more feminine appearance may also have these procedures performed.

Goals of Facial Feminization Surgery

Source: https://my.clevelandclinic.org/health/treatments/21574-facial-feminization-surgery

Hairline Alterations

Males tend to have a higher hairline than females, and they also may have receded corners that give the hairline an “M” shape. To correct this, the hairline can be advanced forward and the shape of the hairline changed to a more rounded, feminine shape by repositioning the scalp or with hair transplantation.

Procedures to alter the hairline include:

• 15775: Punch graft for hair transplant; 1 to 15 punch grafts
• 15776: Punch graft for hair transplant; more than 15 punch grafts
• 15824: Hairline lowering (Rhytidectomy; forehead)

Forehead Procedures

Forehead procedures are done to contour the forehead. This is accomplished by shaving down hard angles and reducing the prominence of the brow bone. For a larger brow protrusion, the front of the brow bone may be removed entirely, contoured and replaced. A brow lift can be done to elevate the eyebrows to a more feminine position and appearance, and an eyelid lift removes excess tissue to help feminize the eyes. Orbital contouring alters the shape of the orbit as female eye sockets tend to be smaller, located higher on the face, more sharply angled at the outer edges and closer together at the inner edges.

Procedures to alter the forehead include:

• 15820: Blepharoplasty, lower eyelid
• 15822: Blepharoplasty, upper eyelid
• 15824: Brow lift (Rhytidectomy; forehead)
• 21137: Reduction forehead, contouring only
• 21138: Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
• 21139: Reduction forehead; contouring and setback of anterior frontal sinus wall
• 21172: Orbital contouring (Reconstruction superior-lateral orbital rims and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)

Nose Procedures

A rhinoplasty contours the nose so it will fit with more feminine features and maintain its proportion with other facial features by reducing the nose’s width and re-shaping the masculine angles for a softer look.

Procedures to alter the nose include:

• 21235: Harvesting of cartilage graft for nasal septum – ear cartilage
• 21230: Harvesting of cartilage graft for nasal septum – rib cartilage
• 30400: Rhinoplasty, primary; lateral and alar cartilage and/or elevation of nasal tip
• 30410: Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
• 30420: Rhinoplasty, primary; including major septal repair
• 30430: Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
• 30435: Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
• 30450: Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

Cheek and Lip Procedures

Females tend to have more forward projection in their cheekbones as well as fuller cheeks compared to males, so cheek augmentation can be done using implants or fat harvested from other parts of the body to create more feminine appearing cheeks. Lip procedures such as lip filling are done because females often have fuller lips than males. Males also tend to have a greater distance from the base of the nose to the top of the upper lip compared to females, so a lip lift may be performed to shorten this distance so it looks more feminine.

Procedures to alter the lips include:

• 15769: Lip augmentation; Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
• 40799: Lip lift

Procedures to alter the cheeks include:

• 15773: Cheek augmentation; Grafting of autologous fat harvested by liposuction technique to face
• 21270: Cheek augmentation; Malar augmentation, prosthetic material

Chin and Jawbone Procedures

The male chin tends to be taller, wider and more squared-off at the front and the jawline larger, thicker and wider compared to a female. The chin can be reduced with recontouring to make it shorter, narrower, and rounder. This is accomplished by shaving and smoothing down bone and protrusions or with a sliding genioplasty where a section of chin bone is removed via osteotomies and the remaining bone is retracted and reattached at this new position. The jaw can also be reduced by contouring the angle of the mandible, narrowing and softening the lower jaw to make it appear more feminine.

Procedures to alter the chin and jawbone include:

• 21121: Genioplasty; sliding osteotomy, single piece
• 21122: Genioplasty; sliding osteotomy, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
• 21209: Osteoplasty, facial bones; reduction

Tracheal shave

Males tend to have a more prominent Adam’s apple than females and this can be minimized with a procedure called a chondrolaryngoplasty or tracheal shave.

Procedure to alter the trachea includes:

• 31599: Chondrolaryngoplasty (tracheal shave)

In summary, these are just some of the procedures that may be performed to achieve facial feminization when a patient is undergoing gender reassignment, also known as gender-affirming, surgery. Other feminization surgery may involve procedures on other parts of the body that help align a person’s physical appearance with their gender identity and for a patient transitioning from male to female these may include procedures such as breast augmentation and vaginoplasty.

References

• Coding Clinic for HCPCS 3rd quarter 2022 Page: 8-9
• CPT Assistant, April 2017 Page: 9
• CPT Assistant, February 2005 Page: 16
• CPT Assistant, September 1997 Page: 3
• Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
• Facial Feminization Surgery: Male to Female, Recovery Time, Cost
• Coding_Guidance_GAS_REVISED_24_10_24.pdf
• Facial feminization surgery - Wikipedia

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.