Gender-typing of Isolated Horizontal Facial Thirds Before and After Facial Feminization Surgery.

[OBJECTIVE] Evaluation of facial feminization surgery (FFS) outcomes in the published literature has taken a panfacial perspective. However, horizontal facial thirds analysis may elucidate current deficiencies in facial feminization. In this study, the authors surveyed the general public to determine how FFS influences gender typing of the upper, middle, and lower thirds of the face.

[METHODS] Standardized frontal and lateral images of isolated horizontal facial thirds from 1 cis -man control, 1 cis -woman control, and 8 consecutive patients before and after FFS were prepared (n = 108 images). Reviewers were asked to determine whether segment images were of a man or woman, indicate their response confidence on a scale from 0 to 10, and specify whether a particular feature influenced their answer.

[RESULTS] A total of 4182 image ratings were collected from 48 survey respondents. For all 3 segments, there was a significant increase in female gender typing after FFS ( P < 0.001). Male gender typing of the upper segment was significantly higher than the middle and bottom segments regardless of FFS status ( P < 0.001). Confidence in female gender typing increased significantly for only the middle ( P = 0.045) and bottom ( P = 0.041) segments after FFS. Male gender typing of the upper segment after FFS was mostly due to the hairline (49%) or forehead (23%).

[CONCLUSIONS] Facial feminization surgery increases female gender typing of isolated horizontal facial thirds. However, general public surveys attribute less effective feminization of the upper third to persistent masculine hairlines. Adjuncts such as hair transplantation may further decrease male gender typing after FFS.

[LEVEL OF EVIDENCE] Level IV.