title: Facial determinants of female gender and feminizing forehead cranioplasty.
abstract: OBJECTIVE
  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. The objectives of this article were: 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.
  
  
  METHODS
  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
  For Experiment 1, in frontal views of all subjects the forehead modification was selected as the most feminine, whereas 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 three 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.
authors.affiliation: Boston University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Boston, Massachusetts 02118, USA. Jeffrey.Spiegel@bmc.org
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Spiegel
mesh_terms: D000293:Adolescent; D000328:Adult; D003198:Computer Simulation; D019066:Facies; D005260:Female; D005546:Forehead / Q000033:anatomy & histology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000379:methods*; D012886:Skull / Q000601:surgery*; D014189:Transsexualism