BACKGROUND: Conflicting data exist regarding increased perioperative venous thromboembolism (VTE) risk with feminizing hormone therapy. The effect has been poorly studied within the transgender population. Acute perioperative cessation of feminizing hormone therapy often leads to unpleasant side effects and exacerbates gender dysphoria in the perioperative period. The authors sought to identify VTE incidence in patients undergoing facial feminization surgery while continuing hormone replacement therapy throughout the time of surgery. METHODS: A 38-year retrospective cohort study within a 2-surgeon practice (D.K.O. and J.C.D.-B.) was designed to evaluate postoperative VTE in patients continuing hormone therapy. The primary outcome variable was postoperative VTE. RESULTS: A total of 1715 patients underwent facial feminization surgery within our search window. A total of 953 patients met final inclusion criteria. One patient (0.10%) was diagnosed with a VTE postoperatively, comparable to reported literature rates for similar cosmetic and orthognathic procedures. The average Caprini score of all patients was 3.1 ± 1.0 and the average case length was 491.9 ± 111.0 minutes. Subgroup analysis of patients before and after internal practice changes identified 714 patients (77.7%) continuing full-dose hormonal therapy perioperatively, 197 (20.7%) undergoing hormonal dose reduction to 25% to 50% perioperatively, and 8 who were either not taking hormonal therapy or stopped in the perioperative period. There was no significant difference in VTE incidence among the 3 subgroups ( P > 0.99). CONCLUSIONS: Perioperative use of feminizing hormonal therapy does not increase risk for perioperative VTE in patients undergoing facial feminization surgery. Therefore, it is reasonable to continue these medications through the time of surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.