Facial determinants of female gender and feminizing forehead cranioplasty

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World Renowned Boston Plastic Surgeon, Dr. Jeffrey Spiegel Speaks About The Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty

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Facial determinants of female gender and feminizing forehead cranioplasty

  1. 1. Page 1 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 1 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  2. 2. The Laryngoscope Page 2 of 47 Facial Determinants of Female Gender and Feminizing Forehead CranioplastyAbstract Information determined by viewing a face includes familiarity, emotion, attractiveness,and gender. However, the specific facial characteristics that enable one to identify gender arelargely 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 orfemale.(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) thejaw. Each change a, b, or c is done in isolation in both frontal and profile views. Subjects wereshown the three profile and the three frontal photographs and asked to rate which of each set isthe 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 personin each picture.(3) Medical records and operative reports of 168 patients who underwent feminizing foreheadcranioplasty were evaluated for surgical technique, and complications.Results: Page 2 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  3. 3. Page 3 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 3 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  4. 4. The Laryngoscope Page 4 of 47 Facial Determinants of Female Gender and Feminizing Forehead CranioplastyIntroduction: Facial plastic surgeons use analysis of facial proportion, lengths, and angles toevaluate patients for attractiveness and make recommendations for surgicalprocedures. Several of the proportions taught are based upon canons hundreds ofyears old. Most of these do not have a scientific basis and are not representative ofactual human shapes and preferences when subjected to scientific examination.(1) From an evolutionary standpoint, it is logical that for women attractiveness andfemininity are closely related; i.e., those individuals who are most attractive to potentialmates have a reproductive advantage. Accentuation of feminine characteristics wouldtherefore evolve as a defining characteristic of female beauty. However, while it is ourrapid, 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 genderdetermination. For example, a woman with a large “masculine” nose or wide jaw is stillidentified 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. Page 4 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  5. 5. Page 5 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 5 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  6. 6. The Laryngoscope Page 6 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyupon and determined by a combination of symmetry, balance, averageness, andinterestingly, femininity.(2,3) The relationship between attractiveness, youthfulness,and femininity is complex, however, certainly any woman who presents with “smalleyes, a relatively large nose, and wide thin lips will look older and more masculine andwill be seen as less attractive. To look feminine is to look young.”(4) This relationshipbetween youthfulness and attractiveness has an evolutionary basis again in that age-related changes in women are associated with decreased fertility. It is supportive torecognize at this point that many of the facial features of women become moremasculine with age. Thus, femininity, which is closely related to youthfulness, is to adegree fleeting and correlated with fertility. In reproductive competition, certainly themore feminine one looked the more attractive she would be to potential mates. Thesefindings appear to be independent of ethnicity. When evaluating femininity andattractiveness for female faces in both Chinese and Caucasian faces, it was found thatenhanced feminizing of the face resulted in increased attractiveness for faces of bothraces.(5) With regards to familiarity, and face recognition, a number of facialcharacteristics are thought to be significant. The features most commonly ascribed tosuch functions include the eyes, mouth, and nose, though in 2003 Sadr and colleaguessuggested that the eyebrows might be the most significant factor. (6,7,8) Our ability torecognize 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, andseem to also be very significant in determining gender, as will be addressed below. Page 6 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  7. 7. Page 7 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 7 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  8. 8. The Laryngoscope Page 8 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyover the nose slowed gender decisions most significantly, suggesting that the nose wasmost important in gender recognition.(14) The female nose is smaller, proportionallywider, and more concave than the male nose.(15) Not coincidentally, the female nasalcharacteristics mimic those of the noses of children, suggesting that youthfulness andfemininity are intimately associated as conveying information regarding fertility. It hasbeen proposed, in fact, that beauty is really interpreted as a combination of youth andfemininity.(4) In one prior study, faces that were computer altered to be “juvenilized”(made more youthful in appearance) when considered attractive, were described tohave augmented femininity by research subjects.(16) Controversy exists as additional studies suggested that noses alone could not beused to determine facial gender beyond random chance. In fact, a subsequent studysuggested that the eye region presented in isolation provided the greatest cue to facialgender. In this study, the nose presented in isolation appeared to provide no significantcue to gender of the individual.(14) These authors also suggested that the “overallshape of the head” is significant, when specific features are not highlighted or masked. Additionally, Brown et al, noted that “all features except the nose carriedinformation about gender when they were seen in isolation.” They did note, that theirdata is not conclusive as they only showed frontal views and the gender cues of nasalshape may be most significant in profile.(15) Indeed, other research has found that sexjudgment 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 infemininity and attractiveness, it is not significant in gender identification. This is Page 8 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  9. 9. Page 9 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 9 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  10. 10. The Laryngoscope Page 10 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastydiffer between men and women in general with attractiveness and femininity beingdirectly correlated for women, but with attractiveness and masculinity lacking correlationor even being inversely correlated in men.(5,18,19) The very fact that human faces are relatively hairless compared to other primatesand yet maintains a distinct, contrasting eyebrow may lend support to the eyebrow’ssignificance in facial attractiveness and sexual dimorphism, and thus competitiveness inmate selection.(6) Studies documenting the differences between male and female eyes andeyebrows have shown that a man’s eyebrows are heavier, straighter, and closer to theeyes.(15) In contrast, a woman’s eyebrows are more arched, rising to a peak at thelateral limbus. With age, however, the woman’s eyebrows descend becoming straighterand closer to the eyes. This effectively reduces the relative size of the eyes and leads toa more masculine appearance. Looking at this another way, Russell has shown thatluminance (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 luminancearound the eyes than did male faces and attractiveness increased with the degree ofincreased luminance. Interestingly, overall facial luminance changes had no effect, butrelative changes to luminance of eye and mouth areas affected the perceived facialattractiveness.(20) Indeed, cosmetic use further accentuates these differences andmuch cosmetic use is around the eyebrows, eyes, and cheeks which all affect eyeregion luminance. Cosmetics thus are used to enhance a sexual dimorphism around theeye region, perhaps enhancing attractiveness by enhancing femininity. Page 10 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  11. 11. Page 11 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 11 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  12. 12. The Laryngoscope Page 12 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastygender of the features described. This work tested this hypothesis throughexperimental manipulation of photographs, as well as through the direct result ofsurgical alteration of the forehead and its effect on gender perception.Methods The fundamental hypothesis of this work is that the forehead (including the shapeof the frontal bone and brow ridges along with eyebrow position and shape) is the mostsignificant area in facial gender identification. To test this hypothesis, two experimentswere conducted.(1) Experiment 1 The first set of experiments was designed to identify the region(s) of the facemost significant in determining gender. To do this, photographs of men were digitallyaltered to adjust (a) the forehead (b) the midface (nose / lip), and (c) the jaw. Thechanges to each region were done to “feminize” that region by adjusting the features ofthat area from a male standard to a more female standard. For the forehead region, eyebrow shape and position were altered. While nostandardized percents, or degrees of change exist that were applicable, it is known thatwomen lack, in general, the prominent glabellar ridging seen in male skulls. Thus, tofeminize the eyebrows were positioned in a more female arched fashion, the hairlinewas advanced and temporal recession reduced, and the curve of the forehead wasmade smoother. Specifically, the glabellar prominence was softened and set backposteriorly towards a more feminine ideal. In lateral view the glabellar prominence Page 12 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  13. 13. Page 13 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 13 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  14. 14. The Laryngoscope Page 14 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyreadily 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 individualswho underwent “gender-confirming” surgery (surgery to enhance the identifiablecharacteristics of the gender with which the individual most identifies) of the upper thirdof the face, middle third of the face, and lower third of the face are identified as male orfemale. This experiment determined if patients who were born male and had an area ofthe face “feminized” were in fact seen as women according to that facial area. Thisdetermines if feminization surgery of the face is successful. Forehead modificationconsisted of frontal cranioplasty with feminizing scalp advancement and brow lift.Midface modification consisted of rhinoplasty with lip lift. Lower face modificationconsisted of chin and jaw shaping (mandibuloplasty and genioplasty). To test if feminization cranioplasty was successful in leading observers to identifythe patient as a women, photographs of male-to-female (MTF) transgender patientswho had forehead surgery were shown to subjects. Subjects were asked the gender ofthe person in each picture. To compare the degree to which forehead modifications aresignificant versus midface or lower face surgical feminization, selected postoperativefaces were shown for all three regions. As most patients who have gender-confirmingsurgery typically have surgery on multiple areas on the face, the face is masked otherthan the area being tested. Masking was such that midface images attempted to maskthe eyebrows, and lower face images attempted to obscure the upper lip and above. Page 14 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  15. 15. Page 15 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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) Page 15 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  16. 16. The Laryngoscope Page 16 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty The first photographic series (Experiment 1) was used as the primary hypothesisto 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. Underequiprobability of selection, X has an expected value of 1/3. The 100 subject samplesize offered excellent power (>80%) to detect preferential selection of one photographicview 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 consecutiverespondents to a request for participants in a research study served as evaluators of themodified 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 educatedwith 54% having completed college, and 29% completing additional post-graduateeducation. There were 53 women and 47 men who participated as subjects. Subjectswere paid a nominal amount for their efforts. As described, thirty male faces were modified using computer imaging softwareto 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 ingroups of three from either the front view or right profile view). The position of each Page 16 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  17. 17. Page 17 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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. Page 17 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  18. 18. The Laryngoscope Page 18 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty Subjects were also asked to rate which image modification (upper, middle, orlower 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 ofrespondents. In 30% of the photo sets the midface modification was considered leastfeminine by a majority of respondents and in 70% of photo sets the lower face wasconsidered 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 profileview. These faces were modified to feminize either the upper face, midface, or lowerface and subjects were asked to select the most and least feminine from each set ofthree modifications. The upper face modification was selected by the majority of respondents as mostfeminizing in 25/30 (83%) of the photo sets, with the midface modification selected asmost feminine in 4/30 (13%) and the lower face modification selected as most feminineby 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 suchthat on average 55% of subjects chose the forehead modification (range 31-71%). Anaverage of 30% of individual subjects (range 11-56%) selected the midface modificationas most feminine, and the lower face modification was selected as most feminine withinany 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 ofrespondents in no (0%) cases and by a plurality in only 1/30 (3%) of photo sets. Even Page 18 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  19. 19. Page 19 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 19 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  20. 20. The Laryngoscope Page 20 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty (O j − E j )2 χ2 = j Ejby the formula . The chi-square statistics is next calculated by adding the 3 (O j − E j ) 2three 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 leastfeminine versus that of random selection by the respondents was similarly formulatedand tested. For the frontal view, 100% of the time the forehead view was selected as mostfeminine 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 selectedas creating the least feminine image. Chi squared equals 74.000 with 2 degrees offreedom. The two-tailed P value is less than 0.0001. Thus, in both situations (mostand least feminine) we find a significant correlation between forehead modification andfemininity in the frontal view. For the profile view, 83% of the time the forehead view was selected as mostfeminine overall. Performing a chi-square test assuming a predicted frequency ofselection 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 betweenforehead modification and femininity. Similarly, in selecting the least feminine face in profile view, we achievestatistical significance but less strongly (p=0.0365). Chi squared equals 6.620 with 2degrees of freedom. Page 20 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  21. 21. Page 21 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 Page 21 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  22. 22. The Laryngoscope Page 22 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyfemale, 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, theoverall percent of respondents who judged them male averaged 61% (range 55 – 78%),thus transgendered women whose foreheads were still considered male (61%) tendedto be considered less strongly male than were transgender patients whose foreheadwere considered female considered female (82%). As a comparison, the foreheads of four natal women who had undergoneforehead surgery were evaluated as well. Among these, one of the four was stronglyrated as male (83% of respondents) and the other three were strongly consideredfemale (mean: 89%, range: 80-96%). Two men who underwent forehead surgery werepresented and both were rated as men (mean: 90%, range 82-96%). Results for the midface postoperative evaluation also suggest successfulfeminization through surgery. Among 31 transgendered postoperative patients fourpatients (13%) were judged by a majority of respondents to be male, and the remaining87% were considered female. Those judged male were considered male by a mean of61% of viewers (range 51-77%). Transgendered MTF women who were postoperativefrom midface feminization and judged to be female were considered to be female onaverage 81% of the time (range 57-100%). Thus the data suggests that not only aremost postoperative transgendered patients evaluated as female (87%), but further,those that are judged to be male (61%) by the midface area alone were less stronglyconsidered male than were those judged female considered female. Page 22 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  23. 23. Page 23 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  24. 24. The Laryngoscope Page 24 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyphotograph as that of a woman) > 0.5. In other words, it is found with statisticalsignificance that feminizing forehead cranioplasty results in likelihood that the patientwill 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: X N Sample p 95% CI P-Value 27 31 0.870968 (0.701664, 0.963698) 0.000and for the lower face: X N Sample p 95% CI P-Value 27 28 0.964286 (0.816522, 0.999096) 0.000 In each situation we find with statistical significance that the postoperative face inthe 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 patientsundergoing feminizing forehead cranioplasty over the 53-month inclusive periodbetween February 2005 and July 2009 were reviewed. The purpose of the procedure isto reduce the projection of the forehead and glabella, as well as to soften the superiororbital rims to a more feminine aesthetic. Three basic surgical techniques were employed. In all cases, there are fourprimary goals of the procedure. These include (1) feminization of the frontal bones andorbital rims, (2) advancement (when necessary) and feminization of the hairline withreduction of the temporal recession typical of male pattern hair loss, (3) increased Page 24 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  25. 25. Page 25 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  26. 26. The Laryngoscope Page 26 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyan oscillating saw is used to create an osteoplastic flap of anterior table bone. Thisbone is then shaped to a smaller size so that it can be recessed into the opening in thefrontal 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 duringremoval and stored during the procedure. At the conclusion of the bone shaping, apaste of this bone with a small amount of saline and blood is used to fill in gaps anddeficits 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 from2 to 53 months. Four patients were revisions from a prior procedure by other physicianswhere the results were not satisfactory to the patient due to inadequate reduction of theforehead glabellar prominence and orbital rims. Figures 4 and 5 present representativepatients. 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 foreheadreduction procedure done prior to seeing the author. All three involved excessivemobility of a bony fragment resulting from nonunion. In each case the patient presentedwith 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 nosemay have resulted in mobility of the segments during normal respiration and periods ofincreased intranasal pressure such as sneezing. Page 26 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  27. 27. Page 27 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  28. 28. The Laryngoscope Page 28 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyview, as it was found that a greater percentage of the time the nose was selected asmost feminizing in the profile (13%) than in the frontal view (0%).(15, 17) What can we conclude from this finding? This new information appears tosupport 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% ofphoto sets were judged to have the feminized forehead as most feminine overall. In theprofile view, the glabellar prominence is a significant factor in conjunction with theeyebrows. However, in profile view the eyebrows are less visible than in the frontalview. Further, it is noted that the degree of forehead frontal bossing (glabellarprominence) is not consistent amongst people. It is likely that in those individuals forwhom forehead modification was less significant from the profile view in determiningfemininity than other facial sections, that the upper third of the face was already in amore gender neutral or even feminine shape, and thus the further modification was notas readily evident nor as significant. Alternately, another facial structure (e.g. the noseor chin) may be particularly pronounced thus increasing the feminizing significance ofmodification of that structure for that individual, though overall the foreheadmodifications were still most significant. Additionally, the shape of the hairline plays a significant role in determininggender. A receding or thinning hairline is distinctly masculine and may serve to skewobservers to judging the area as masculine even in the face of feminine eyebrows andglabellar bone shape. A determination of which specific part of the forehead (glabellarshape, eyebrow position, and scalp shape) is of the greatest significance is beyond thescope of this work, but can be pursued with confidence as it is now shown that it is Page 28 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  29. 29. Page 29 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 American Laryngological, Rhinological and Otological Society, Inc.
  30. 30. The Laryngoscope Page 30 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastythe feminizing power of forehead cranioplasty with hair pattern and thickness masked toisolate that factor. Nonetheless, these data do not support the work of other authorswho have suggested that forehead and jaw shape are most significant predictors ofgender identification in the profile view (22,23). Interestingly, among those images that were not interpreted as the intendedpostoperative gender by a majority of viewers, the results were more likely to beequivocal than statistically indicative of a masculine appearance. This suggests thateven in those patients in whom the postoperative results were not clearly feminine, theresults at least tended to shift towards a more ambiguous appearance rather thanovertly masculine. Of particular note in this report is the overall safety of the forehead feminizingcranioplasty procedure as described in section 3 (the review of successive patientsundergoing this procedure). In 168 patients there were only three who had identifiedcomplications for an overall complication rate of < 2% overall. Using the “island”setback technique a higher complication rate of 6% was identified. Other authors havedescribed this technique of setting back the bone without fixation, but complication rateshave not been published.(27) The burring and osteoplastic flap setback methods havealso been reported, again without complication rates included. In this report, there wereno complications in these groups (0/119). A prior report by Habal described feminizingcranioplasty in 13 patients using a burring type technique where the forehead wascontoured 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 The American Laryngological, Rhinological and Otological Society, Inc.
  31. 31. Page 31 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  32. 32. The Laryngoscope Page 32 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastywhich area of the face has the greatest significance in determining attractiveness, norwhat features within that region may be most efficiently modified to achieve the goal ofincreased attractiveness and youthfulness. (Recall that attractiveness and youthfulnessare directly related to femininity.) It is likely that a paradigm shift in facial analysis is necessary to advance facialplastic surgery in concert with evolving understanding of the neural processes forperception of beauty. Given the significance of the upper third of the face indetermining 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 significantlyalter the way that facial analysis is done by facial plastic surgeons. While it is clear thata disproportionately large nose may be considered unattractive, and rhinoplasty(possibly with chin augmentation) is the appropriate treatment, in another situation apatient with an unattractive face may in fact appear unattractive due to a problem withan area of her face that most defines femininity (but which is currently unknown to or notunderstood 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 besttherapeutic recommendation. Reliance on traditional procedures and approaches maynot be most direct in targeting the most significant areas of concern. Further, as newconsiderations are brought to analysis of facial attractiveness, it is likely that Page 32 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  33. 33. Page 33 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  34. 34. The Laryngoscope Page 34 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyand significance in influencing perception of gender (and thus attractiveness) suggestthe need for increased familiarity with these techniques. Page 34 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  35. 35. Page 35 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty References (1) Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and horizontal proportions of the face in young adult North American Caucasians: Revisions of neoclassical canons. Plast Reconstr Surgery 75, 1985:329-338. (2) Perrett DI, May KA, Yoshikawa S. Facial shape and judgments of female attractiveness. Nature (368); 1994:239-242. (3) Cellerino A. Psychobiology of facial attractiveness. J. Endocrinol. Invest. 26 (Suppl. To no. 3) 2003:45-48. (4) Etcoff N. Survival of the Prettiest: The science of Beauty. Anchor Books, NY. 2000: page 155. (5) Rhodes G, Hickford C, Jeffery L. Sex-typicality and attractiveness: Are supermale and superfemale faces super-attractive? Br J Pschol 2000; 91:125-140. (6) Sadr J, Jarudi I, Sinha P. The role of eyebrows in face recognition. Perception 2003; 32:285-293. (7) Haig ND, Exploring recognition with interchanged facial features. Perception 1986; 15:235-247. (8) Davies G, Ellis H, Shepherd J. Cue saliency in faces as assessed by the ‘photofit’ technique. Perception 1977;6:263-269. (9) Reddy L, Reddy L, Koch C. Face identification in the near absence of facial attention. Vision Research 2006; 46:2336-2343. (10) Hill H, Johnston A. Categorizing sex and identity from the biological motion of faces. Current Biology 2001; 11:880-885. Page 35 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  36. 36. The Laryngoscope Page 36 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty(11) Bruce V, Burton AM, Hanna E, Healey P, Mason O. Sex discrimination: how to wetell the difference between male and female faces? Perception 1993;22:131-152.(12) Lewin C, Herlitz A. Sex differences in face recognition – Women’s faces make thedifference. Brain and Cognition 2002; 50:121-128.(13) O’Toole AJ, Peterson J, Deffenbacher KA. An ‘other-race effect’ for categorizingfaces by sex. Perception 1996; 25:669-676..(14) Roberts T, Bruce V. Feature saliency in judging the sex and familiarity of faces.Perception 1988;17:475-481.(15) Brown E, Perrett DI. What gives a face its gender? Perception 1993;22:829-840.(16) Ishi H, Gyoba J, Kamachi M, Mukaida S, Akamatsu S. Analyses of facialattractiveness on feminized and juvenilised faces. Perception 2004: 33:135-145.(17) Chronicle EP, Chan MY, Hawkings C, Mason K, Smethurst K, Stallybrass K,Westope K, Wright K.. You can tell by the nose – judging sex from an isolated facialfeature. Perception 1995;24:969-973.(18) O’Toole AJ, Deffenbacher KA, Valentin D, McKee K, Huff D, Abdi H. Theperception of face gender: The role of stimulus structure in recognition andclassification. Memory & Cognition 1998: 26(1):146-160.(19) Cunningham MR, Barbee A, Pike CL. What do woman want? Facial metricassessment of multiple motives in the perception of male facial physical attractiveness.Journal of Personality and Social Psychology 1990: 59(1):61-72.(20) Russel R. Sex, beauty, and the relative luminance of facial features. Perception,2003; 32:1093-1107. Page 36 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  37. 37. Page 37 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty (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. (24) Baudouin JY, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women. Acta Psychologica 2004; 117:313-332. (25) Loffler G, Gordon GE, Wilkinson F, Goren D, Wilson HR. Configural masking of faces: Evidence for high-level interactions in face perception. Vision research 2005; 45: 2287-2297. (26) Hage JJ, Vossen M, Becking AG. Rhinoplasty as Part of Gender-confirming Surgery in Male Transsexuals: Basic Considerations and Clinical Experience. Ann Plast Surg 1997; 39:266-271. (27) Whitaker KA, Morales LM, Farkas LG. Aesthetic Surgery of the Supraorbital Ridge and Forehead Structures. Plastic Reconstructive Surgery 1986; 7:23-32. (28) Habal, MB. Aesthetics of Feminizing the Male Face by Craniofacial Contouring of the Facial Bones Aesth Plast Surg 1990;14:143-150. (29) Ousterhout, DK. Feminization of the Forehead: Contour changing to improve female aesthetics. Plastic Reconstructive Surgery 1987; 79:701-711. (30) Hage JJ, Vossen MK, Becking AG. Rhinoplasty as part of gender confirming surgery in male transsexuals: basic considerations and clinical experience. Ann Plastic Surgery 1987;39 (3):266-271. Page 37 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  38. 38. The Laryngoscope Page 38 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty(31) Nouraei SAR, Randhawa P, Andrews PJ, Saleh HA. The role of nasal feminizationrhinoplasty in male-to female gender reassignment. Arch Facial Plastic Surg2007;9(5):318-320.(32) Becking AG, Tuinzing DB, Hage JJ, Gooren LJG. Facial Corrections in Male toFemale Transsexuals: A preliminary report on 16 patients. J Oral Maxillofac Surg1996; 54:413-418.(33) Spiegel, JH. Challenges in care of the transgender patient seeking facialfeminization surgery. Facial Plast Surg Clin North Am 2008;16(2):233-8, viii.(34) Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facialfeminization surgery or gender reassignment surgery. Qual Life Res. 2010 May 12.(35) Lee MK, Sakai O, Spiegel JH. CT measurement of the frontal sinus – Genderdifferences and implications for frontal cranioplasty. J Craniomaxillofac Surg. 2010 Mar22. Page 38 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  39. 39. Page 39 of 47 The Laryngoscope Facial Determinants of Female Gender and Feminizing Forehead Cranioplasty 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 The American Laryngological, Rhinological and Otological Society, Inc.
  40. 40. The Laryngoscope Page 40 of 47 Facial Determinants of Female Gender and Feminizing Forehead Cranioplastyforehead cranioplasty. Images are preoperative on the left and 1 month postoperativeon 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 underwentfeminizing forehead cranioplasty using an “island” setback technique, as well asrhinoplasty, chondrolaryngoplasty, mandibuloplasty, chin implantation, and neckliposuction. No complications have developed with 4 1/2 years of follow-up. Note the reduction in forehead projection at the glabella and the decreasedposterior slope of the forehead. Also note improved contour and transition between theglabella and nasal dorsum. Page 40 of 40 The American Laryngological, Rhinological and Otological Society, Inc.
  41. 41. Page 41 of 47 The Laryngoscope 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 The American Laryngological, Rhinological and Otological Society, Inc.
  42. 42. The Laryngoscope Page 42 of 47Table 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 The American Laryngological, Rhinological and Otological Society, Inc.
  43. 43. Page 43 of 47 The Laryngoscope Fig 1 215x279mm (96 x 96 DPI) The American Laryngological, Rhinological and Otological Society, Inc.
  44. 44. The Laryngoscope Page 44 of 47 Fig2 215x279mm (96 x 96 DPI)The American Laryngological, Rhinological and Otological Society, Inc.
  45. 45. Page 45 of 47 The Laryngoscope Fig3 215x279mm (96 x 96 DPI) The American Laryngological, Rhinological and Otological Society, Inc.
  46. 46. The Laryngoscope Page 46 of 47 Fig4 215x279mm (96 x 96 DPI)The American Laryngological, Rhinological and Otological Society, Inc.
  47. 47. Page 47 of 47 The Laryngoscope Fig5 215x279mm (96 x 96 DPI) The American Laryngological, Rhinological and Otological Society, Inc.

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