Dr. Paul Mittermiller
Highly Experienced FFS Surgeon in Los Angeles
Dr. Paul Mittermiller, MD, is a board-certified plastic and craniofacial surgeon with a strong focus on gender-affirming facial surgeries. Practicing in Santa Monica, California, Dr. Mittermiller stands out for his unique dual training in both craniofacial surgery and Facial Feminization Surgery (FFS). This specialized expertise allows him to offer highly personalized, transformative procedures for transgender, nonbinary, and gender-diverse patients, all aimed at helping them achieve their gender identity goals. Dr. Mittermiller joined Align Surgical Associates as an associate surgeon in 2023.
Education and Training
Dr. Mittermiller’s educational background is extensive and diverse. He earned a B.S. in Biomedical Engineering from Yale University before pursuing his M.D. at the University of California, San Francisco (UCSF). His early career was shaped by a pre-medical research internship in surgical robotics in Germany. He further honed his surgical expertise through a residency in Plastic and Reconstructive Surgery at Stanford University. Following this, he completed a prestigious fellowship in Craniofacial Surgery at New York University (NYU), where he trained under Dr. Eduardo Rodriguez. During his fellowship, he participated in pioneering procedures, including the world’s first successful face and double hand transplant. In addition, Dr. Mittermiller received comprehensive training in Facial Feminization Surgery. After returning to Los Angeles, he worked alongside Dr. Kyle Keojampa, a leader in high-volume FFS surgery, further refining his skills.
Dr. Mittermiller is a member of the following professional organizations:
- World Professional Association for Transgender Health (WPATH)
- American Society of Maxillofacial Surgeons
- California Society of Plastic Surgeons
- American Society of Plastic Surgeons
- AO – Craniomaxillofacial
- The Rhinoplasty Society
Research and Contributions to FFS
Dr. Mittermiller has a substantial academic footprint, with over 29 published articles in peer-reviewed journals focusing on plastic surgery, craniofacial techniques, and gender-affirming facial procedures. He co-authored a groundbreaking study titled “Facial Feminization Surgery: Region-Specific Importance Recognized by Artificial and Human Intelligence Gender Recognition Correlates with Patient Satisfaction,” which was presented at the 2023 AAPS Annual Meeting. This research examines how specific facial features influence the perception of gender identity, combining artificial intelligence and human assessments to improve patient satisfaction in FFS outcomes.
Additionally, Dr. Mittermiller actively contributes to the broader medical community through his blog, where he shares insights on the latest advancements in FFS, such as robotic jaw contouring, virtual surgical planning, and innovative procedures like cleft chin feminization and forehead reduction. His publications and blog posts highlight his dedication to advancing both the science and practice of gender-affirming facial surgery.
Facial Feminization Surgery Overview
Facial Feminization Surgery is designed to modify typically masculine features of the face to create a more feminine appearance. The procedures are carefully tailored to each patient's anatomy and goals, considering the unique needs of transgender women, nonbinary individuals, and even cisgender women who seek to feminize their facial features. Dr. Mittermiller offers a comprehensive approach to FFS, often broken down into three key regions of the face.
In the upper third of the face, procedures focus on modifying the hairline and brow area to achieve a more feminine contour. Techniques like scalp advancement or hair grafting are used to create a rounder, higher hairline. Brow lifts and brow bone reduction (forehead contouring) soften the prominence of the brow ridge, creating a more open and youthful expression.
The middle third targets the midface, which includes the eyes, cheeks, and nose. Orbital rim contouring smooths the bony ridge around the eyes, while cheek augmentation—through implants or fat grafting—adds volume to create fuller, more feminine cheeks. Feminizing rhinoplasty reshapes the nose to reduce a wide nasal bridge, refine the tip, and achieve a more delicate and balanced appearance.
The lower third focuses on the chin, jawline, lips, and neck. Lip feminization techniques such as lip lifts or augmentation help to achieve fuller, more prominent lips with enhanced dental show. Jaw contouring and genioplasty are used to soften the angles of the mandible and chin, creating a more tapered, feminine jawline. A tracheal shave (chondrolaryngoplasty) can also be performed to reduce the prominence of the Adam’s apple, providing a smoother, more refined neck contour.
Virtual Surgical Planning
Dr. Mittermiller is an advocate for the use of virtual surgical planning (VSP) in facial feminization surgery and other complex procedures. He recognizes that VSP significantly enhances the precision and outcomes of surgeries by allowing for a detailed, 3D visualization of a patient's anatomy prior to the actual procedure. This technology enables surgeons to plan and simulate surgeries, taking into account individual variations in facial structures.
By using VSP, Dr. Mittermiller can refine his approach to each patient's unique facial features, ensuring that the planned procedures will yield the most natural and aesthetically pleasing results. The process also allows for better communication with the patient, as they can visualize and understand the anticipated changes to their face. This fosters a collaborative environment, where patients feel more involved and confident in their surgical journey.
Furthermore, VSP improves the efficiency and safety of surgeries. With a more precise plan in place, the risk of complications is reduced, and the need for intraoperative adjustments is minimized. This not only leads to quicker recovery times but also ensures a smoother, more predictable surgical process.
In his professional blog, Dr. Mittermiller has written about how VSP contributes to the advancement of facial feminization surgery, particularly in complex procedures like jaw contouring and forehead reduction. He believes that virtual surgical planning is a valuable tool that allows surgeons to push the boundaries of precision and personalization in gender-affirming surgeries.
Insurance & Medicaid Coverage
Dr. Mittermiller accepts various private insurance plans, as well as some managed Medi-Cal plans in California. Medi-Cal, which is California's Medicaid program, operates through private insurance companies that manage healthcare for low-income residents. These plans may have specific requirements, such as using in-network providers or obtaining prior authorization for specialty care, including FFS procedures.
Facial Feminization Surgery is often categorized as cosmetic by many insurers, even when deemed medically necessary for gender dysphoria. Insurance coverage for FFS varies widely, so patients are encouraged to call the member services number on the back of their insurance card and inquire about whether gender-affirming surgery is covered. Additionally, it’s recommended to request written documentation of your insurance policy and request clarification of the requirements for prior authorization and necessary documentation (such as mental health letters.)
Surgical Requirements
Dr. Mittermiller adheres to the WPATH Standards of Care for all gender-affirming facial surgeries. Patients must meet the following criteria:
- Be at least 19 years of age
- Have a formal diagnosis of gender dysphoria from a qualified mental health provider
- Provide one or two letters of medical necessity (depending on insurance)
- Have undergone at least one year of hormone therapy, unless contraindicated
Consultation Process
Each individual’s facial anatomy and aesthetic desires are unique. Dr. Mittermiller offers both in-person and virtual consultations to thoroughly assess each patient’s face, goals, and expectations. During these consultations, he works closely with patients to develop a customized surgical plan that aligns with their identity, providing natural and affirming results.
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