Facial determinants of female gender and feminizing forehead cranioplasty

of 47 The Laryngoscope

Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty


Jeffrey H. Spiegel, MD, FACS

Chief Facial Plastic and Reconstructive Surgery
Boston University School of Medicine
Department of Otolaryngology – Head and Neck Surgery
830 Harrison Avenue, Suite 1400
Boston, MA 02118
(617) 414-5058
Jeffrey.Spiegel@bmc.org

Financial disclosure: The author has no relevant financial interests to disclose.
Conflict of interest: The author has no conflict of interest.

Key words:

Facial Feminization, Gender Determinants, Cranioplasty, Gender Perception, Forehead

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The American Laryngological, Rhinological and Otological Society, Inc.

The Laryngoscope Page 2 of 47


Abstract

Information determined by viewing a face includes familiarity, emotion, attractiveness,

and gender. However, the specific facial characteristics that enable one to identify gender are

largely unknown. Research suggests that femininity is a critical component of beauty; however,

the most important identifiers of a woman’s face are unknown.

Objective / Hypothesis:

(1) Determine the area of the face most significant in identifying female gender,

(2) Determine if individuals with gender-confirming surgery of the face are identified as male or

female.

(3) Review the efficacy and safety of a series of feminizing forehead cranioplasties.

Study Design:

(1) Prospective evaluation of computer simulated changes and postoperative patient images,

(2) Retrospective review of medical records.

Methods:

(1) Photographs of men were digitally altered to adjust (a) the forehead (b) the nose / lip, (c) the

jaw. Each change a, b, or c is done in isolation in both frontal and profile views. Subjects were

shown the three profile and the three frontal photographs and asked to rate which of each set is

the most feminine.

(2) Photographs of male-to-female (MTF) transgender patients who may have had forehead,

midface, or jaw surgery were shown to subjects. Subjects were asked the gender of the person

in each picture.

(3) Medical records and operative reports of 168 patients who underwent feminizing forehead

cranioplasty were evaluated for surgical technique, and complications.

Results:

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For experiment (1), in frontal views of all subjects the forehead modification was selected as the

most feminine while in no cases was the forehead modification selected as least feminine by a

majority of respondents. For the profile view, again the forehead modification was selected as

most feminine by respondents for the majority of subjects, but surprisingly, the strength of the

association between frontal modification and femininity, while strongly statistically significant,

was more evident in the frontal view. For experiment (2), among transgendered faces shown to

viewers, 82% of postoperative forehead modifications were judged as women, 87% of

postoperative midface modifications were judged as women, and 85% of postoperative lower

faces were judged as women. For section (3), the review of safety and technique in 168

feminizing forehead cranioplasties, there were three basic surgical techniques utilized with only

3 complications for an overall complication rate of 1.8%.

Conclusions:

Feminization of the forehead through cranioplasty is safe and has a significant impact in

determining the gender of the patient. The strong association between femininity and

attractiveness can now be more specifically attributed to the upper third of the face and the

interplay of the glabellar prominence of the forehead, along with the eyebrow shape and

position, and hairline shape and position. These results have strong implications for a paradigm

shift in the method of facial analysis used to select aesthetic procedures and illuminates the

processes by which femininity and attractiveness are interpreted in faces.

Level of Evidence: Part I and II: 1a, Part III: 3a

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Introduction:

Facial plastic surgeons use analysis of facial proportion, lengths, and angles to

evaluate patients for attractiveness and make recommendations for surgical

procedures. Several of the proportions taught are based upon canons hundreds of

years old. Most of these do not have a scientific basis and are not representative of

actual human shapes and preferences when subjected to scientific examination.(1)

From an evolutionary standpoint, it is logical that for women attractiveness and

femininity are closely related; i.e., those individuals who are most attractive to potential

mates have a reproductive advantage. Accentuation of feminine characteristics would

therefore evolve as a defining characteristic of female beauty. However, while it is our

rapid, automatic, and subconscious ability to determine the gender of an observed face,

it is unknown what characteristics of that face are most significant in allowing for gender

determination. For example, a woman with a large “masculine” nose or wide jaw is still

identified as a woman (not mistaken for a man), but why?

The primary objectives of this research are threefold:

(1) To evaluate how facial characteristics are used to determine the gender of an

individual. Specifically, this project was designed to elucidate which of the

forehead region, midface, or lower third of the face (jaw region) is most

significant in determining female gender (femininity).

(2) To describe the degree to which feminized upper, middle, and lower thirds of the

face in male-to-female transgendered persons are interpreted as feminine.

(3) To describe the safety and techniques involved in feminizing the upper third of

the face in a series of 168 consecutive patients.

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The fundamental hypothesis is that the forehead region (including the prominence of

the forehead at the glabella and the position and shape of the eyebrows) is most

significant for determining female gender.

Background

Within a fraction of a second of viewing a person’s face, the observer is able to

determine familiarity (do they know this person), attractiveness, and gender. Other

characteristics that may be determined include emotional state, ethnicity, age, and

health status. The mechanisms for determining these last four characteristics are

readily described. For example, the specific facial changes associated with ill temper

(e.g., furrowed down-tilting brow, frowning lips) are well known, as are facial

expressions for many emotions. Similarly, differences between ethnic groups are well

known and describable. Determinants of age and health status can also be discussed

in that facial changes with age are known and categorized and the specific markers of

various disease states on the face (e.g. – butterfly shaped rash in Lupus) are reported.

The characteristics that are identified to determine familiarity, attractiveness, and

gender are more difficult to discuss. Certainly attractiveness and facial analysis have

been well researched. However, traditional teachings regarding facial proportions may

be incorrect. Similarly, the widely accepted concept that “beauty is in the eye of the

beholder,” which implies that ideals of attractiveness vary between cultures and ethnic

groups, has been questioned with more recent research suggesting that while fashion

preferences may vary, attractiveness and beauty are more likely universally agreed

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upon and determined by a combination of symmetry, balance, averageness, and

interestingly, femininity.(2,3) The relationship between attractiveness, youthfulness,

and femininity is complex, however, certainly any woman who presents with “small

eyes, a relatively large nose, and wide thin lips will look older and more masculine and

will be seen as less attractive. To look feminine is to look young.”(4) This relationship

between youthfulness and attractiveness has an evolutionary basis again in that age-

related changes in women are associated with decreased fertility. It is supportive to

recognize at this point that many of the facial features of women become more

masculine with age. Thus, femininity, which is closely related to youthfulness, is to a

degree fleeting and correlated with fertility. In reproductive competition, certainly the

more feminine one looked the more attractive she would be to potential mates. These

findings appear to be independent of ethnicity. When evaluating femininity and

attractiveness for female faces in both Chinese and Caucasian faces, it was found that

enhanced feminizing of the face resulted in increased attractiveness for faces of both

races.(5)

With regards to familiarity, and face recognition, a number of facial

characteristics are thought to be significant. The features most commonly ascribed to

such functions include the eyes, mouth, and nose, though in 2003 Sadr and colleagues

suggested that the eyebrows might be the most significant factor. (6,7,8) Our ability to

recognize familiar faces is so fine that it is highly accurate even when impaired by dual-

task conditions.(9) The eyebrows are significant in emotion as mentioned above, and

seem to also be very significant in determining gender, as will be addressed below.

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Facial attractiveness, familiarity, and gender are each readily discerned in

viewing a person’s face. While interrelated, each is likely determined through a parallel

processing rather than by the same factors. Additionally, while several processing

strategies are used to determine these characteristics (for example, the motion of

women’s faces differs in measurable ways from the motion of men’s faces) this project

sought to evaluate identifying factors in still images.(10)

How does one tell the difference between male and female faces? In short, the

precise method is unknown although prior publications suggest an interplay between a

number of factors, including hairstyle, facial hair patterns, and use of cosmetics and

jewelry. However, gender identification is possible in the absence of these. In studies of

gender recognition on faces stripped of the secondary gender characteristics described

above, there is a 96% ability to correctly identify the gender by face alone.(11) Women

appear to do better than men at identifying female faces.(12, 13) Interestingly, most

errors were in incorrectly considering a female face to be male. One can thus conclude

from the available data that it is more difficult to look feminine than to look masculine, or

that looking feminine is a distinct appearance that is absent in most men and some

women. Indeed, there is an evolutionary basis for this. As women age their facial

appearance (nose, lip, skin, and eyebrow position) becomes more masculine in

character, which may be an evolutionary cue to fertility status.(4)

So femininity is closely related to attractiveness, but what specifically allows

gender recognition? In 1988 Roberts and Bruce masked various regions of the face

and found that masking over the eyes slowed familiarity decisions the most but masks

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over the nose slowed gender decisions most significantly, suggesting that the nose was

most important in gender recognition.(14) The female nose is smaller, proportionally

wider, and more concave than the male nose.(15) Not coincidentally, the female nasal

characteristics mimic those of the noses of children, suggesting that youthfulness and

femininity are intimately associated as conveying information regarding fertility. It has

been proposed, in fact, that beauty is really interpreted as a combination of youth and

femininity.(4) In one prior study, faces that were computer altered to be “juvenilized”

(made more youthful in appearance) when considered attractive, were described to

have augmented femininity by research subjects.(16)

Controversy exists as additional studies suggested that noses alone could not be

used to determine facial gender beyond random chance. In fact, a subsequent study

suggested that the eye region presented in isolation provided the greatest cue to facial

gender. In this study, the nose presented in isolation appeared to provide no significant

cue to gender of the individual.(14) These authors also suggested that the “overall

shape of the head” is significant, when specific features are not highlighted or masked.

Additionally, Brown et al, noted that “all features except the nose carried

information about gender when they were seen in isolation.” They did note, that their

data is not conclusive as they only showed frontal views and the gender cues of nasal

shape may be most significant in profile.(15) Indeed, other research has found that sex

judgment by the nose alone is more accurate in profile than in frontal view.(17)

Alternately, the research may suggest that while nasal shape has some role in

femininity and attractiveness, it is not significant in gender identification. This is

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supported by our ability to recognize without difficulty a woman with a masculine nose

as a woman.

The literature on masking eyes and determining gender is mixed in its

conclusions. In 1988 Roberts and Bruce suggested that masking the eyes had little

effect on gender determinacy while masking the nose had a more significant effect.(14)

Subsequent review of their methods, however, showed that eye masking in their

protocol masked only the eyes, not the eyebrows, while nose masking obscured part of

the eyebrows. If, the eyebrows and the forehead shape are most significant in gender

determination, the 1988 study by Roberts and Bruce is unrevealing. In a subsequent

study, Bruce and colleagues recognized the error and had the eyebrow masked as part

of eye region masking, but not as part of nasal masking.(11) In this experiment, eye

masking was the most significant in disturbing effective gender recognition. This

suggests that the upper third of the face is the most significant in gender determination

but does not clarify if it is the eye, eyebrow, or facial shape which is most contributing to

correct gender identification. Indeed, Sadr et al suggested that the “…brow ridge may

have been an important sexually distinctive characteristic of our early ancestor’s

faces”.(6) They note that many cosmetic procedures including tweezing, cosmetics,

botulinum toxin, tattooing, and surgical lifting target the appearance of the eyebrows.

Sadr further suggests that the particular femininity of the eyebrow shape as two

disconnected arcs underlies the impetus to target this area with cosmetic procedures.(6)

The characteristics of the female eyebrow and forehead is in stark contrast to the male

brow area which protrudes and can be seen as intimidating or even resembling that of a

Neanderthal when accentuated.(3) Sexual dimorphisms and attractiveness seem to

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differ between men and women in general with attractiveness and femininity being

directly correlated for women, but with attractiveness and masculinity lacking correlation

or even being inversely correlated in men.(5,18,19)

The very fact that human faces are relatively hairless compared to other primates

and yet maintains a distinct, contrasting eyebrow may lend support to the eyebrow’s

significance in facial attractiveness and sexual dimorphism, and thus competitiveness in

mate selection.(6)

Studies documenting the differences between male and female eyes and

eyebrows have shown that a man’s eyebrows are heavier, straighter, and closer to the

eyes.(15) In contrast, a woman’s eyebrows are more arched, rising to a peak at the

lateral limbus. With age, however, the woman’s eyebrows descend becoming straighter

and closer to the eyes. This effectively reduces the relative size of the eyes and leads to

a more masculine appearance. Looking at this another way, Russell has shown that

luminance (the amount of light that is reflected, emitted, or passes through a given area)

attributes between male and female faces differ; female faces had greater luminance

around the eyes than did male faces and attractiveness increased with the degree of

increased luminance. Interestingly, overall facial luminance changes had no effect, but

relative changes to luminance of eye and mouth areas affected the perceived facial

attractiveness.(20) Indeed, cosmetic use further accentuates these differences and

much cosmetic use is around the eyebrows, eyes, and cheeks which all affect eye

region luminance. Cosmetics thus are used to enhance a sexual dimorphism around the

eye region, perhaps enhancing attractiveness by enhancing femininity.

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Support for jaw shape as significant in gender identity also exists. Inoue and

colleagues isolated facial parts of young Japanese men and women and found that a

certain lower jaw shape is characteristic of males, and when removed significantly

interfered with correct gender identity.(21) Other researchers have suggested that jaw

and forehead geometry are very significant but only in the lateral view.(22, 23) These

authors suggest that the attractive female jaw is smaller and more pointed at the chin

with less prominent alveolar prognathism (anterior projection of the teeth / gums).(22)

These authors found the differences in the jaws between attractive and unattractive

females to be striking, with a trend towards attractive female faces having jaw geometry

that was significantly different from the male norm.

Support for each of the aforementioned areas without prioritization comes from

Baudouin and Tiberghien who found that female facial attractiveness is associated with

large eyes, prominent cheekbones, thick lips, thin eyebrows, and a small nose and

chin.(24) All of these areas appear to be potential indicators of femininity, but the

relative importance of each remains unclear.

Thus, it can be seen that the published research suggests a tight relationship

between attractiveness and femininity. Yet the determinants of femininity remain

unclear, particularly with regards to their significance with various authors supporting

the nose, eye region, eyebrows, and jaw shape as being most important.

The experiments conducted further elucidate which area of the face is most

significant in defining femininity in both the frontal and profile views. The hypothesis is

that the forehead region (including the prominence of the forehead at the glabella and

the position and shape of the eyebrows) is the most significant for determining female

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gender of the features described. This work tested this hypothesis through

experimental manipulation of photographs, as well as through the direct result of

surgical alteration of the forehead and its effect on gender perception.

Methods

The fundamental hypothesis of this work is that the forehead (including the shape

of the frontal bone and brow ridges along with eyebrow position and shape) is the most

significant area in facial gender identification. To test this hypothesis, two experiments

were conducted.

(1) Experiment 1

The first set of experiments was designed to identify the region(s) of the face

most significant in determining gender. To do this, photographs of men were digitally

altered to adjust (a) the forehead (b) the midface (nose / lip), and (c) the jaw. The

changes to each region were done to “feminize” that region by adjusting the features of

that area from a male standard to a more female standard.

For the forehead region, eyebrow shape and position were altered. While no

standardized percents, or degrees of change exist that were applicable, it is known that

women lack, in general, the prominent glabellar ridging seen in male skulls. Thus, to

feminize the eyebrows were positioned in a more female arched fashion, the hairline

was advanced and temporal recession reduced, and the curve of the forehead was

made smoother. Specifically, the glabellar prominence was softened and set back

posteriorly towards a more feminine ideal. In lateral view the glabellar prominence

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changes tend to be more significant while in frontal view the eyebrow position tends to

be more evident.

For the nose and lip, in frontal view the lip shortening and nasal width change

were done. In the lateral view, nasal dorsum changes are more evident as well as lip

shortening and protrusion. The lip was shortened in order to reduce the distance

between the columellar and vermillion border in the feminized version. In frontal view

the nose was made narrower and less bulbous at the tip, and in lateral view the

changes to the dorsum served to create an increased concavity to the dorsum with a

smaller tip.

For the jaw, in frontal view the jaw and chin width are evident. In lateral view, the

chin and jaw height and anterior projection are altered. These alterations were done to

narrow proportionally to the face, the width of the jaw at the angle and chin.

It has been shown that face discrimination take just over 100ms, thus the 5-10

seconds subjects were given to view the faces is adequate.(25)

Each change a, b, or c was done in isolation in both frontal and profile views.

Research subjects were shown the three grouped profile and the three grouped frontal

photographs and asked to rate which of each set is the most and least feminine. The

position of each modification within each set was randomly placed. Figures 1 and 2

show two of the sixty photo sets shown to research subjects.

(2) Experiment 2

The specific hypothesis of the second experiment was that gender-confirming

forehead surgery in Male-to-Female transgender women results in a face being more

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readily judged as that of a woman (when other features are masked) than gender-

confirming midface or jaw surgery.

Thus, a second series of experiments were conducted to determine if individuals

who underwent “gender-confirming” surgery (surgery to enhance the identifiable

characteristics of the gender with which the individual most identifies) of the upper third

of the face, middle third of the face, and lower third of the face are identified as male or

female. This experiment determined if patients who were born male and had an area of

the face “feminized” were in fact seen as women according to that facial area. This

determines if feminization surgery of the face is successful. Forehead modification

consisted of frontal cranioplasty with feminizing scalp advancement and brow lift.

Midface modification consisted of rhinoplasty with lip lift. Lower face modification

consisted of chin and jaw shaping (mandibuloplasty and genioplasty).

To test if feminization cranioplasty was successful in leading observers to identify

the patient as a women, photographs of male-to-female (MTF) transgender patients

who had forehead surgery were shown to subjects. Subjects were asked the gender of

the person in each picture. To compare the degree to which forehead modifications are

significant versus midface or lower face surgical feminization, selected postoperative

faces were shown for all three regions. As most patients who have gender-confirming

surgery typically have surgery on multiple areas on the face, the face is masked other

than the area being tested. Masking was such that midface images attempted to mask

the eyebrows, and lower face images attempted to obscure the upper lip and above.

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Of necessity some patients were photographed within one month of surgery, thus

a degree of bruising, swelling is evident in their skin but not enough to alter the

perceived overall position of the eyebrows or brow bones. Analysis was then made to

determine if female gender is identified more readily with the isolated forehead changes

than with isolated midface or jaw changes.

As in experiment 1 all photos in experiment 2 were shown in random order.

Subjects had five seconds to review each photograph in Experiment 2. In each case

subjects then recorded their response on a written answer sheet. These times are more

than adequate as face discrimination take just over 100ms.(26)

Figure 3 shows an example of a question from experiment 2.

(3) Feminizing Forehead Cranioplasty: Safety and Technique review

The third aim of this report is to evaluate a series of 168 successive patients over

53 months who underwent feminizing cranioplasty. Patient medical records were

reviewed with specific attention to surgical methods and occurrence of complications.

Feminizing cranioplasty was typically done as part of a constellation of procedures

selected to feminize the overall appearance of the face.

Sample size and statistical power

Thirty test faces (modified photographs) were used with enrollment of N=100

subjects. We obtained an even distribution of men and women (47 men, 53 women)

which compensates for findings in prior studies that women may have an enhanced

ability to determine gender in photographs.(12)

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The first photographic series (Experiment 1) was used as the primary hypothesis

to power the study. Let X be a random variable denoting the proportion of photographs

(out of 30 in the test series) for which a subject selects the view of interest. Under

equiprobability of selection, X has an expected value of 1/3. The 100 subject sample

size offered excellent power (>80%) to detect preferential selection of one photographic

view with effects as small as 45-50% (compared to a null value of 33%).

Results

(1) Experiment 1

One hundred adults, aged 18 – 62 (mean 31.5) years that were consecutive

respondents to a request for participants in a research study served as evaluators of the

modified faces. The majority of subjects were self-described as white (67%), with 15%

black, 8% Latino, 6% Asian-Indian, and 4% Asian. The subject group was well educated

with 54% having completed college, and 29% completing additional post-graduate

education. There were 53 women and 47 men who participated as subjects. Subjects

were paid a nominal amount for their efforts.

As described, thirty male faces were modified using computer imaging software

to alter the upper face (forehead shape, eyebrow position / shape, and hairline position /

shape), midface (nose shape and upper lip length / fullness), or lower face (chin shape /

length, and jaw width / shape). Research subjects were shown the modified faces in

groups of three from either the front view or right profile view). The position of each

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modification (upper, middle, or lower) on the slide was randomized and different from

one face to another. Subjects were asked to rate the most and least feminine of the

faces within each image set. Subjects were not aware of the hypothesis or goal of the

study other than that we were interested to learn which of the male faces seemed most

and least feminine, with the understanding that all of them may still look masculine

overall.

Results for evaluation of frontal view

Thirty faces were shown in a frontal view. These faces were modified as

described into three varieties: feminized upper face, feminized midface, and feminized

lower face.

Subjects were asked to rate which of the images was the most feminine. In

100% of the photo sets the modified forehead option was considered the most feminine

by the most respondents, being selected for each set on average by 70% of

respondents (range 46-89%). In no situation was the midface modification selected as

most feminine by a majority of respondents from the frontal view, though it was selected

for any individual photo set as the most feminine by on average 17% of the subjects

(range 8-35%). The lower face was similarly never selected by a majority of

respondents as the most feminine view when seen from the front, though for any

individual photo set an average of 13% (range 0-30%) of subjects selected the lower

face modification as most feminine. Please see Table I.

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Subjects were also asked to rate which image modification (upper, middle, or

lower face) resulted in the least feminine appearance from the frontal view. In no (0%)

cases was the forehead modification selected as least feminine by a majority of

respondents. In 30% of the photo sets the midface modification was considered least

feminine by a majority of respondents and in 70% of photo sets the lower face was

considered to be the least feminine. Please see Table II.

Results for evaluation of profile view

As for the frontal view, thirty modified face sets were shown from the right profile

view. These faces were modified to feminize either the upper face, midface, or lower

face and subjects were asked to select the most and least feminine from each set of

three modifications.

The upper face modification was selected by the majority of respondents as most

feminizing in 25/30 (83%) of the photo sets, with the midface modification selected as

most feminine in 4/30 (13%) and the lower face modification selected as most feminine

by a majority of respondents in 1/30 (3%) of photo sets. Please see Table I.

The overall strength of selecting the forehead (upper third modification) was such

that on average 55% of subjects chose the forehead modification (range 31-71%). An

average of 30% of individual subjects (range 11-56%) selected the midface modification

as most feminine, and the lower face modification was selected as most feminine within

any particular photo set by an average 15% of the observers (range 8-57%).

The upper face modification was selected as the least feminine by the majority of

respondents in no (0%) cases and by a plurality in only 1/30 (3%) of photo sets. Even

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then the strength of this selection was not high as the plurality vote here was

represented by only 38% of the group of 100 subjects. The mid face modification was

chosen as least feminine by the most respondents in 7/30 (23%) profile view photo sets

while the lower face modification was selected as the least feminine most often in 22/30

(73%) of the grouped images. Please see Table II.

The upper face modification was selected as being least feminine within each

photo set by on average only 23% of subjects (range 14-38%). An average of 33% of

subjects (range 22-5%) selected the midface modification as least feminine, while an

average of 43% of the subjects (range 11-61%) selected the lower face modification as

the least feminine within any specific profile view image set.

Subjecting these results to statistical analysis, the hypothesis that the modified

forehead view was considered to be the most feminine versus that of random selection

by the respondents was formulated for testing as follows:

H0: P(forehead modification) = P(mid face modification) = P(lower face modification) =

1/3

H1: the null hypothesis (H0) is false

where P(forehead modification) denotes the probability that a respondent selects

forehead modification as the most feminine.

The above hypothesis is tested by the chi-square test wherein we are given the

observed frequencies (O) of the three cells. The expected frequency (E) of each cell,

assuming the null hypothesis is true, is calculated as E = 100 x (1/3). The chi-square

deviation between the observed and expected frequencies for each cell were computed

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(O j − E j )2
χ2 =
j
Ej
by the formula . The chi-square statistics is next calculated by adding the
3
(O j − E j ) 2
three individual chi-square values computed in according to 2
χCALC = ∑
j =1
Ej
.

The P-value for the above calculated chi-square statistic is obtained from the chi-

square cumulative distribution function with 2 degrees of freedom.

The hypothesis that the modified forehead view was considered to be the least

feminine versus that of random selection by the respondents was similarly formulated

and tested.

For the frontal view, 100% of the time the forehead view was selected as most

feminine overall. The Chi squared equals 200.000 with 2 degrees of freedom. The two-

tailed P value is less than 0.0001. For least feminine, the forehead was never selected

as creating the least feminine image. Chi squared equals 74.000 with 2 degrees of

freedom. The two-tailed P value is less than 0.0001. Thus, in both situations (most

and least feminine) we find a significant correlation between forehead modification and

femininity in the frontal view.

For the profile view, 83% of the time the forehead view was selected as most

feminine overall. Performing a chi-square test assuming a predicted frequency of

selection of 33.33%, chi squared equals 115.152 with 2 degrees of freedom. The two-

tailed P value is less than 0.0001. Again, we see a high degree of correlation between

forehead modification and femininity.

Similarly, in selecting the least feminine face in profile view, we achieve

statistical significance but less strongly (p=0.0365). Chi squared equals 6.620 with 2

degrees of freedom.

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Thus, in selection of most and least feminine in both the frontal and profile views,

the null hypothesis of random selection within the three groups (forehead, midface, and

lower face modification) is comfortably rejected in favor of the conclusion that the

forehead modification (feminization of the forehead) results in a significant likelihood

that that face will be selected as most feminine, and that the lower face modification is

seen to have the least effect in feminizing in the frontal view.

The profile view more readily shows the modification of the forehead projection

so it was anticipated that a preference for upper face modification as an indicator of

femininity would be strongest for profile view images. Unexpectedly, this was not the

case. While the upper face modification (forehead alteration) in profile view was still

most highly rated as feminizing, the relative strength of the finding was less than for the

frontal view. For least feminizing, the forehead view was never selected in either frontal

or profile view, though the correlation was more significant for frontal view.

(2) Experiment 2

Photos of men, women, and transgendered MTF women were edited to show

only the upper third, middle third, or lower third of the face. Photos of faces ranged from

one week after surgery to 6 months after surgery with most images being 2-4 months

postoperatively. All photographs were of the frontal view.

Thirty-four pictures of the upper third of the face were shown. Twenty-eight of

the faces were of transgendered women who had undergone feminization cranioplasty.

Among these 18% (5/28) were judged by a majority of reviewing subjects as male, and

the remainder (82%) were considered female. Among those that were considered

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female, the percent of respondents who judged them female averaged 79% overall

(range: 53-98%) with more than half of the postoperative transgender patients’

foreheads being rated as female by more than 85% of respondents.

Among patients’ foreheads judged to be male by a majority of reviewers, the

overall percent of respondents who judged them male averaged 61% (range 55 – 78%),

thus transgendered women whose foreheads were still considered male (61%) tended

to be considered less strongly male than were transgender patients whose forehead

were considered female considered female (82%).

As a comparison, the foreheads of four natal women who had undergone

forehead surgery were evaluated as well. Among these, one of the four was strongly

rated as male (83% of respondents) and the other three were strongly considered

female (mean: 89%, range: 80-96%). Two men who underwent forehead surgery were

presented and both were rated as men (mean: 90%, range 82-96%).

Results for the midface postoperative evaluation also suggest successful

feminization through surgery. Among 31 transgendered postoperative patients four

patients (13%) were judged by a majority of respondents to be male, and the remaining

87% were considered female. Those judged male were considered male by a mean of

61% of viewers (range 51-77%). Transgendered MTF women who were postoperative

from midface feminization and judged to be female were considered to be female on

average 81% of the time (range 57-100%). Thus the data suggests that not only are

most postoperative transgendered patients evaluated as female (87%), but further,

those that are judged to be male (61%) by the midface area alone were less strongly

considered male than were those judged female considered female.

Page 22 of 40



Three female patients who were post rhinoplasty surgery were also evaluated.

Among these, all three were rated as female (on average by 89% of respondents, range

82-94%). It is interesting that women undergoing rhinoplasty were judged as women by

an average of 89% of the subjects, and transgendered MTF persons undergoing

feminization of the midface were judged as women by an average of 81% of the

subjects.

For the lower face, 28 transgendered postoperative faces were shown to viewing

subjects. Among these, only 1 was judged as male (by 79%) of viewers. The

remaining 27 patients were seen as females by an average of 85% of subjects overall

(range: 54-100%). Four women who had undergone jaw surgery were evaluated as

well and all were correctly judged as women overall (mean 94% of subjects).

Statistical testing of our hypothesis may be based upon the assumption that all

transgendered faces should still be considered the original (birth) gender, i.e. male.

However, a more challenging null hypothesis was selected which supposed that there

was an even chance that the image could be judged as belonging to a man or a woman.

Using a test and confidence interval for one proportion the hypothesis that p=0.5 (even

chance of identifying as man or woman) was compared to p > 0.5 (that subjects were

preferentially identified as women).

So, for a test of p = 0.5 vs. p > 0.5 when considering the upper face:

X N Sample p 95% CI P-Value
23 28 0.821429 (0.631067, 0.939357) 0.001

The null hypothesis H0: P(respondent will identify photograph as that of a

woman) = 0.5 is comfortably rejected in favor of H1: P(respondent will identify

Page 23 of 40



photograph as that of a woman) > 0.5. In other words, it is found with statistical

significance that feminizing forehead cranioplasty results in likelihood that the patient

will be identified as a woman according to the upper third of the face.

Similarly, for the midface consideration, we test p=0.5 vs. p> 0.5:

27 31 0.870968 (0.701664, 0.963698) 0.000

and for the lower face:

27 28 0.964286 (0.816522, 0.999096) 0.000

In each situation we find with statistical significance that the postoperative face in

the transgendered individuals is interpreted as female for each facial area tested.

(3) Evaluation of safety and technique for feminizing forehead cranioplasty

Medical records including operative reports of 168 consecutive patients

undergoing feminizing forehead cranioplasty over the 53-month inclusive period

between February 2005 and July 2009 were reviewed. The purpose of the procedure is

to reduce the projection of the forehead and glabella, as well as to soften the superior

orbital rims to a more feminine aesthetic.

Three basic surgical techniques were employed. In all cases, there are four

primary goals of the procedure. These include (1) feminization of the frontal bones and

orbital rims, (2) advancement (when necessary) and feminization of the hairline with

reduction of the temporal recession typical of male pattern hair loss, (3) increased

Page 24 of 40



volume in the temporal hollow lateral to the forehead, and (4) elevation and feminization

of the eyebrows through brow lift.

The first surgical technique is utilized when the patient’s frontal sinus is small,

relatively posterior, covered in thick anterior table bone, or doesn’t project anterior to the

desired plane of the forehead. This technique involves using an assortment of burs to

sculpt the frontal bones and orbital rims and was utilized in 63/168 (38%) of patients.

This technique is desirable for its relative ease, but is limited in application to

those whose bony anatomy meets the criteria described above. In many cases, this

burring method is begun as an initial technique, but needs to be abandoned as the

anatomy of the forehead becomes more evident.

The second technique utilized involves creating “islands” of bone over the frontal

sinus which are then set back in an interlocking fashion to the desired shape. Bone

between “islands” is removed until the segments can be relocated posteriorly to the

desired position. The “islands” technique is a variation of the technique popular by

surgeons in Thailand wherein the bone over the frontal sinus is thinned to the point that

it can be selectively fractured and effectively repositioned posteriorly. This “islands”

technique was utilized in 49/168 (29%) of patients. The frontal sinus mucosa is not

violated in this technique and the bony islands are supported by this sinus mucosa on

the deep surface, by friction between segments, and by hydrostatic forces to the

overlying periosteum superficially.

The third technique is similar to that used in the osteoplastic flap procedure for

frontal sinus disease. The burring technique is begun at the periphery of the forehead

working medially and inferiorly. When clinical signs suggest that the bone is thinning,

Page 25 of 40



an oscillating saw is used to create an osteoplastic flap of anterior table bone. This

bone is then shaped to a smaller size so that it can be recessed into the opening in the

frontal bone of the forehead. It is then secured in place with miniplates and screws.

This technique was used in 56/168 (33%).

In all techniques, bone removed with the cutting bur is cooled with water during

removal and stored during the procedure. At the conclusion of the bone shaping, a

paste of this bone with a small amount of saline and blood is used to fill in gaps and

deficits between islands of bone or the osteoplastic flap and the surrounding bone.

Patients ranged in age from 19 to 65 years of age. Patient follow-up ranged from

2 to 53 months. Four patients were revisions from a prior procedure by other physicians

where the results were not satisfactory to the patient due to inadequate reduction of the

forehead glabellar prominence and orbital rims. Figures 4 and 5 present representative

patients.

There were three complications in our series. All three occurred with the “island”

technique of bone repositioning for a complication rate of 3/49 (6%) for this technique.

One of the three complications occurred in a patient who had previously had a forehead

reduction procedure done prior to seeing the author. All three involved excessive

mobility of a bony fragment resulting from nonunion. In each case the patient presented

with a large, thin walled, highly aerated sinus as with pneumosinus dilatans frontalis.

The very large sinus cavity with large frontal sinus recess and opening into the nose

may have resulted in mobility of the segments during normal respiration and periods of

increased intranasal pressure such as sneezing.

Page 26 of 40



Two of the patients underwent revision procedures. One had the area of

nonunion plated with placement of additional bone from a calvarial bone graft. The

other patient had a small area of absent bone over the intact frontal sinus mucosa

repaired with hydroxyapatite cement. In both cases, there were no further

complications and the patients were satisfied with their outcome. The third patient

chose to have a revision procedure done elsewhere.

All three of these complications were early cases before bone paste from the

burred bone was replaced to fill in small areas of bony gaps. Since incorporating that

technique no further complications have occurred. Nonetheless, in order to prevent

problems, the “island” technique was largely abandoned in the last 24 months of the 53

month period reviewed. No complications have resulted from the modified osteoplastic

flap procedure.

Discussion

This report supports the concept that the upper third of the face is the most

significant part of the face for determining female gender in both the frontal and the

profile views of the face. One hundred research subjects suggested with statistical

significance that it is the upper part of the face which, when modified to a feminine form,

is most likely to feminize an obviously male face. Interestingly, it was in the frontal view

that the forehead modification was selected as most feminizing more often than in the

profile view (100% vs. 83%), although in both views the upper third of the face was

considered the most feminizing section. Additionally, this data supports prior reports

that the nose is more important in gender identity in the profile view than in the frontal

Page 27 of 40



view, as it was found that a greater percentage of the time the nose was selected as

most feminizing in the profile (13%) than in the frontal view (0%).(15, 17)

What can we conclude from this finding? This new information appears to

support the work of Sadr, et al, indicating that the eyebrows play a significant role.(6)

The eyebrows were particularly evident in the frontal view, and in this view 100% of

photo sets were judged to have the feminized forehead as most feminine overall. In the

profile view, the glabellar prominence is a significant factor in conjunction with the

eyebrows. However, in profile view the eyebrows are less visible than in the frontal

view. Further, it is noted that the degree of forehead frontal bossing (glabellar

prominence) is not consistent amongst people. It is likely that in those individuals for

whom forehead modification was less significant from the profile view in determining

femininity than other facial sections, that the upper third of the face was already in a

more gender neutral or even feminine shape, and thus the further modification was not

as readily evident nor as significant. Alternately, another facial structure (e.g. the nose

or chin) may be particularly pronounced thus increasing the feminizing significance of

modification of that structure for that individual, though overall the forehead

modifications were still most significant.

Additionally, the shape of the hairline plays a significant role in determining

gender. A receding or thinning hairline is distinctly masculine and may serve to skew

observers to judging the area as masculine even in the face of feminine eyebrows and

glabellar bone shape. A determination of which specific part of the forehead (glabellar

shape, eyebrow position, and scalp shape) is of the greatest significance is beyond the

scope of this work, but can be pursued with confidence as it is now shown that it is

Page 28 of 40



indeed the upper third of the face that is most important in identifying femininity in the

masculine face in both the frontal and the profile views.

This work also finds contrary to the work of others that stress the significance of

jaw shape. (21) It should not be concluded that jaw shape is not significant in

contributing to femininity, but rather it can be stated that jaw shape was the least

significant of the areas tested. Further, while it has been prior assumed that jaw shape

may be a significant factor in the determination of gender from a profile view, the results

of this study do not support this assumption.

The data reviewed from experiment 2 supports the strong significance of

forehead modification in permitting transgendered patients to be identified as women.

As reviewed above, there is a close association between attractiveness and feminine

gender identity. In fact, several natal women have identified heavy masculine brow and

forehead as a negative factor about their appearance and have undergone feminizing

forehead cranioplasty with satisfying results.

It was seen in experiment two that postoperative images of the feminized

forehead were identified as women 82% of the time, postoperative feminized midface

images were identified as women 87% of the time, and postoperative feminized lower

thirds of the face (jaw and chin) were identified as women 85% of the time. These

results support the notion that feminizing facial surgery of each zone of the face can

independently result in a statistically significant likelihood of proper gender identification

postoperatively. However, it cannot be concluded from this data that the forehead

feminization was most effective. It is possible, however, that the ability to see subjects’

hairlines and hair thickness contributed to this finding. Subsequent work can evaluate

Page 29 of 40



the feminizing power of forehead cranioplasty with hair pattern and thickness masked to

isolate that factor. Nonetheless, these data do not support the work of other authors

who have suggested that forehead and jaw shape are most significant predictors of

gender identification in the profile view (22,23).

Interestingly, among those images that were not interpreted as the intended

postoperative gender by a majority of viewers, the results were more likely to be

equivocal than statistically indicative of a masculine appearance. This suggests that

even in those patients in whom the postoperative results were not clearly feminine, the

results at least tended to shift towards a more ambiguous appearance rather than

overtly masculine.

Of particular note in this report is the overall safety of the forehead feminizing

cranioplasty procedure as described in section 3 (the review of successive patients

undergoing this procedure). In 168 patients there were only three who had identified

complications for an overall complication rate of < 2% overall. Using the “island”

setback technique a higher complication rate of 6% was identified. Other authors have

described this technique of setting back the bone without fixation, but complication rates

have not been published.(27) The burring and osteoplastic flap setback methods have

also been reported, again without complication rates included. In this report, there were

no complications in these groups (0/119). A prior report by Habal described feminizing

cranioplasty in 13 patients using a burring type technique where the forehead was

contoured into the diploic space only using osteotomes and a tapping technique.(28)

Ousterhout reported his techniques for feminizing cranioplasty which included burring,

bony flap setback, and using methylmethacrylate to contour the forehead, but did not

Page 30 of 40



include a description of his patient volume nor the complication rate with these

techniques.(29)

Other authors have described their limited experience with feminizing surgery.

Hage, et al reported on 22 feminizing rhinoplasties in transgendered patients, and

Nouraei, et al, contributed their experience with 12 patients undergoing feminizing

rhinoplasty.(30, 31) Additionally, Becking et al reported on 16 transsexual patients who

underwent “bony facial corrections” but none of these patients had procedures on the

upper third of the face.(32) This paper reports the largest volume of patients

undergoing feminizing cranioplasty and supports the overall safety of each of the three

methods, without the necessity for preoperative imaging.

The overall significance of the data presented can potentially have far reaching

conclusions. There is a clear evolutionary relationship between gender identity,

youthfulness and attractiveness with feminization of facial features being interpreted as

more attractive in both male and female subjects.(5) What has been lacking, however,

is an understanding of which facial features contribute most to a perception of

femininity. This report demonstrates that it is the upper third of the face, in both the

frontal and profile views, which most significantly contributes to interpretation of a face

as feminine. It can thus be concluded, that it is the upper third of the face which has the

most significance overall in determining attractiveness.

Facial plastic surgeons perform facial analysis to determine methods of

improving attractiveness. However, algorithms and recommendations tend to focus on

achieving facial balance through a consideration of proportions and relationships of

facial structures to a standard ideal.(1) There has not been a focus on determining

Page 31 of 40



which area of the face has the greatest significance in determining attractiveness, nor

what features within that region may be most efficiently modified to achieve the goal of

increased attractiveness and youthfulness. (Recall that attractiveness and youthfulness

are directly related to femininity.)

It is likely that a paradigm shift in facial analysis is necessary to advance facial

plastic surgery in concert with evolving understanding of the neural processes for

perception of beauty. Given the significance of the upper third of the face in

determining femininity and the relationship between femininity and attractiveness,

surgeons are advised to reconsider the nature of facial analysis.

Conclusion

Knowledge of the facial features used in determining gender can significantly

alter the way that facial analysis is done by facial plastic surgeons. While it is clear that

a disproportionately large nose may be considered unattractive, and rhinoplasty

(possibly with chin augmentation) is the appropriate treatment, in another situation a

patient with an unattractive face may in fact appear unattractive due to a problem with

an area of her face that most defines femininity (but which is currently unknown to or not

understood by the surgeon. If the physician is not aware that she should (or how to)

evaluate a face for markers of femininity she may be uncertain as to the best

therapeutic recommendation. Reliance on traditional procedures and approaches may

not be most direct in targeting the most significant areas of concern. Further, as new

considerations are brought to analysis of facial attractiveness, it is likely that

Page 32 of 40



identification of the significant areas for facial gender identification will lead to the

introduction and popularization of a number of new facial plastic surgery procedures.

This research has little precedence within the existing facial plastic surgery

literature, but rather introduces new knowledge and methodology from other disciplines

(including psychology, perception research, anthropology, and forensic sciences) to

research in facial plastic surgery. The research is of direct benefit to individuals afflicted

with gender identity disorder (GID) for their external appearance is in conflict with their

internal gender identity. Individuals with GID believe themselves to be of the gender

opposite their appearance. It is greatly distressing to be identified by others as a

member of the opposite sex from what you believe yourself to be. (33) Improvement in

quality of life is seen following surgical facial feminization, and the anatomic knowledge

required for safe and efficacious surgery is being refined. (34, 35)

Recognizing which facial features are critical to identifying gender will permit

more effective treatment of individuals with GID. For all persons, correct gender identity

by others is important for happiness with one’s appearance. However, understanding

those areas of the face most significant to determining gender identity have application

outside of helping individuals with GID. Given the strong established relationship

between femininity and female beauty, knowledge of how gender is identified can allow

a greater sophistication in facial analysis allowing recommendation of appropriate

treatments and avoidance of procedures that only indirectly address the patient’s

appearance concerns. It is likely that the upper third of the face has the greatest

significance in permitting observers to identify gender. Surgical methods to modify the

upper third of the face have not been previously popularized, but their safety, efficacy

Page 33 of 40



and significance in influencing perception of gender (and thus attractiveness) suggest

the need for increased familiarity with these techniques.

Page 34 of 40



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attractiveness on feminized and juvenilised faces. Perception 2004: 33:135-145.

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Westope K, Wright K.. You can tell by the nose – judging sex from an isolated facial

feature. Perception 1995;24:969-973.

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classification. Memory & Cognition 1998: 26(1):146-160.

(19) Cunningham MR, Barbee A, Pike CL. What do woman want? Facial metric

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(21) Inoue K, Ichikawa R, Nagashima M, Kodama G. Sex differences in the shapes of

several parts of the young Japanese face. Appl Human Sci 1995; 14(4):191-194.

(22) Valenzano DR, Mennucci A, Tartarelli G, Cellerino A. Shape analysis of female

facial attractiveness. Vision Research 2006; 46:1282-1291.

(23) Matoula S, Pancherz H. Skeletofacial Morphology of Attractive and Nonattractive

Faces. Angle Orthod 2006; 76:204-210.

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attractiveness of women. Acta Psychologica 2004; 117:313-332.

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faces: Evidence for high-level interactions in face perception. Vision research 2005; 45:

2287-2297.

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Legends:

Figure 1

Experiment 1, Photo set showing modified faces in the profile view.

In this set forehead modification is in A, lower face modification in B, and midface

modification in C.

Figure 2

Experiment 1, Photo set showing modified faces in the frontal view.

In this set forehead modification is in A, lower face modification in B, and midface
modification in C.

Figure 3

Experiment 2. Subjects were shown 100 images such as this one, or of the

upper third of the face or middle third of the face. Each subject was asked to determine

the gender of the individual photographed based upon only the partial face shown.

Figure 4

A 24-year old transgendered MTF woman who underwent feminizing forehead

cranioplasty, rhinoplasty, lip lift, mandibuloplasty with mentoplasty, and

chondrolaryngoplasty. An osteoplastic flap setback technique was used for the

Page 39 of 40



forehead cranioplasty. Images are preoperative on the left and 1 month postoperative

on the right. No complications have developed with 3 years and 6 months.

Note the improvement in eyebrow shape and position, reduction of the forehead,

and overall facial shape.

Figure 5

A 25-year old transgender MTF woman seen preoperatively on the left and one-

week postoperatively on the right. Suture removal was just completed. She underwent

feminizing forehead cranioplasty using an “island” setback technique, as well as

rhinoplasty, chondrolaryngoplasty, mandibuloplasty, chin implantation, and neck

liposuction. No complications have developed with 4 1/2 years of follow-up.

Note the reduction in forehead projection at the glabella and the decreased

posterior slope of the forehead. Also note improved contour and transition between the

glabella and nasal dorsum.

Page 40 of 40


Table I

Frequency With Which a Plurality of
Respondants Selected a Facial
Modification as Most Feminizing

100
80
Frequency of 60 Upper
Selection 40
Middle
20
Lower
0
Frontal Profile
View



Table II

Frequency With Which a Plurality of
Respondants Selected a Facial
Modification as Least Feminizing

80
60
Frequency of
Selection 40 Upper
20 Middle
Lower
0
Frontal Profile
View



Fig 1
215x279mm (96 x 96 DPI)



Fig2
215x279mm (96 x 96 DPI)



Fig3

215x279mm (96 x 96 DPI)



Fig4

215x279mm (96 x 96 DPI)



Fig5
215x279mm (96 x 96 DPI)


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