Effect of Facial Feminization Surgery (FFS) on Eyelid Anatomic Features

Abstract

Facial feminization surgery (FFS) improves gender dysphoria. The brows and eyes are crucial in perceived gender, yet brow and eyelid surgeries are relatively underutilized. This study aimed to determine rates of brow and eyelid surgeries as part of FFS and characterize pre- and postoperative periocular features. We conducted a retrospective review to identify all patients with the diagnosis of gender dysphoria who underwent FFS at a single academic institution from 2019 to 2022. Thirty-four patients comprising 38 surgical cases were included. Twelve (35%) eyelid surgeries and 27 (79%) brow lifts were performed. Baseline eyelid measurements did not differ between brow lift and nonbrow lift cases. Those undergoing brow lift and eyelid surgery were older in age (p = 0.022), had a higher rate of negative canthal tilt (p = 0.050), and smaller baseline margin-reflex distance 1 (p = 0.014) than patients who had brow lift alone. Brow lift increased tarsal platform show (p ≤ 0.001) and lash-to-brow distance (p ≤ 0.001), and upper blepharoplasty increased tarsal platform show (p = 0.01). Rates of brow lift are high at our institution, and patients are appropriately selected for eyelid surgery in FFS. Brow lift and upper blepharoplasty can feminize anatomical features when using standards described for cisgender cohorts. The impact of periocular features on gender perception in transgender patients warrants further study.

Keywords

facial feminization surgery - gender-affirming surgery - brow lift - blepharoplasty - eyelid

Rates of facial feminization surgery (FFS) have risen exponentially in the past decade.[1] FFS encompasses a range of surgical procedures on bone and soft tissue elements, including hairline advancement, brow lift, forehead contouring, lateral and superior orbital rim osteotomy and contouring, rhinoplasty, and mandibular contouring. FFS has been shown to improve gender dysphoria among transgender female patients.[2] Individuals who have undergone a single or multiple FFS procedures report high satisfaction,[2] enhanced quality of life,[2] and greater alignment between social perception and gender identity.[3] Recent data examining outcomes exclusive to feminization of the upper facial third report a 67.2% satisfaction rate.[4]

The highest demand in those seeking FFS is for procedures of the upper facial third.[1] In particular, the brows and eyes are among the most important facial features in perceived gender.[5] Yet, there is relatively minimal utilization of brow and eyelid surgeries in FFS. In one systematic review of 8,506 FFS procedures, only 146 (1.7%) brow lifts and 7 (0.08%) eyelid procedures (all blepharoplasty) were performed.[6] And, according to an analysis of the American College of Surgeons National Surgical Quality Improvement Program from 2009 to 2018, there were 9 (11.7%) brow lifts and 0 eyelid surgeries performed out of 77 procedures identified.[1] In this context, we conducted a retrospective review to determine rates of brow and eyelid surgeries in all patients undergoing FFS at our institution and describe pre- and postoperative eyelid anatomic features.

Materials and Methods

This study was deemed exempt by the Mayo Clinic Institutional Review Board. A retrospective review was performed to identify all adult patients with the diagnosis of gender dysphoria or equivalent diagnosis code who underwent FFS at a single academic institution from 2019 to 2022 performed by two board-certified plastic surgeons. Demographics and surgical history for each subject were recorded.

Eyelid parameters were measured independently by author A.S.L. and L.H.W. using the measuring tool inherent to QREADS, a proprietary imaging viewer (Mayo Clinic, Rochester, MN). These included margin-reflex distance 1 (MRD1), measured from the corneal light reflex to upper eyelid margin; palpebral fissure, measured from the upper to lower eyelid margins through the center of the pupil; tarsal platform show, measured from the upper edge of the lash line to the lowest eyelid skin fold; lash-to-brow distance, measured from the upper edge of the lash line to the lowest brow hairs at mid-pupil ([Fig. 1]); and canthal tilt, measured as a positive, neutral, or negative angle between the medial and lateral canthi.

Fig. 1 Original screenshots taken from a patient photograph measuring (A) margin-reflex distance 1, (B) palpebral fissure height, (C) tarsal platform show, and (D) lash-to-brow distance. Red line: measured parameter; yellow line: white-to-white distance used as reference scale.

All analyzed photos were full face photographs of neutral facial expression magnified to 300%. Photographs adhered to our plastic surgery clinic's facial photography protocol and were taken in a standardized fashion by a professional photographer under the same lighting conditions, studio, and camera settings. Pixel values were converted to millimeters using a corneal white-to-white distance of 12 mm as a reference scale. Intra- and interobserver reliabilities of measurement technique were assessed on 10 sample photographs prior to obtaining study measurements ([Fig. 2]). Repeat measurements were compared for each observer, and means of multiple measurements were compared between observers with Pearson's correlation coefficient (PCC). Photographs closest to the FFS date were selected as the preoperative photo for each surgical case. Postoperative photos selected met the following criteria: taken at least 3 months after surgery (to allow for resolution of edema) but no later than 1 year, and no other surgery in the interim between FFS and photography ([Fig. 3]). Exclusion criteria were incomplete surgical notes or lack of pre- and postoperative photographs with neutral facial expression.

Fig. 2 Scatter plots showing interrater reliability of eyelid measurements obtained by two observers. The x- and y-axes display the means of two measurements obtained by observer 1 and 2, respectively. Pearson's correlation coefficient was 0.94 for margin-reflex distance 1 (MRD1) (A), 0.96 for palpebral fissure height (B), 0.99 for tarsal platform show (C), and 0.99 for lash-to-brow distance (D).

Fig. 3 (A) Preoperative photograph and (B) 3 months postoperative photograph demonstrating increased tarsal platform show and lash-to-brow distance after hairline brow lift (without eyelid surgery) as part of facial feminization surgery.

Measurements were taken from both eyes for each surgical episode. Data analysis was conducted using Excel version 16.67 (Microsoft Corporation, Redmond, WA) and SAS version 9.4 (SAS Institute, Cary, NC). Descriptive statistics were performed on all demographics, components of FFS, and surgical history. Eyelid measurements were compared between the following groups: brow lift versus no brow lift (and no eyelid surgery) and brow lift only versus brow lift plus eyelid surgery. To account for possible confounding effects of orbital rim recontouring procedures, additional analysis was performed on all brow lift cases without orbital rim recontouring. Preoperative (baseline) eyelid measurements were analyzed using F-test two-sample for variances and two-sample t-tests. Pre- to postoperative changes in eyelid measurements were analyzed using paired two-sample t-tests. All t-tests were performed with generalized estimating equation models to account for possible correlation effects between eyes of the same subject. Canthal tilt data was analyzed using Fisher's exact test. A p-value of ≤ 0.05 was used as the cutoff for statistical significance.

Results

Thirty-four patients comprising 38 surgical cases were included. Mean age was 44 years, and 29 (85%) individuals were Caucasian ([Table 1]). Preceding genital surgery was performed in 23 (68%) patients; 19 (56%) had preceding chest surgery. Brow lift (n = 27, 79%) was the most common FFS procedure. Out of all brow lifts, 16 (59%) were performed with a hairline approach, 5 (19%) with coronal approach, 3 (11%) with temporal approach, 2 (7%) endoscopic, and 1 (4%) with direct approach. Twenty-one (62%) patients underwent orbital osteotomy/contouring, and 15 (44%) patients underwent hairline advancement. All orbital osteotomies or contouring procedures as well as hairline advancements occurred alongside brow lifts. There were 12 eyelid surgery cases: 6 upper lid blepharoplasties, 2 lower eyelid microfat grafts, 2 Müller's muscle-conjunctival resections for ptosis repair, and 2 canthopexies.

Table 1 Demographics and surgical history

Characteristic	All patients, n (%)
Demographics
Age at FFS, mean (SD)	44.0 (16.1)
Race or ethnicity
White	29 (85)
American Indian/Alaskan Native	2 (6)
African American	2 (6)
Asian	1 (3)
Components of FFS
Forehead contouring	16 (47)
Orbital osteotomy/contouring	21 (62)
Brow lift	27 (79)
Cheek augmentation	13 (38)
Rhinoplasty	20 (59)
Lip lift	8 (24)
Mandible contouring	17 (50)
Chin contouring	17 (50)
Hairline advancement	15 (44)
Tracheal shave	6 (18)
Chest surgery	19 (56)
Genital surgery	23 (68)
FFS as initial gender-affirming surgery	12 (35)

Abbreviations: FFS, facial feminization surgery; SD, standard deviation.

Inter- and intrarater reliabilities of eyelid measurements were excellent, as verified on 10 sample photographs. PCC for intrarater comparison of two repeat measurements was at least 0.98 for all eyelid parameters. For interrater comparison, PCC ranged from 0.93 to 0.99, and there were no statistically significant differences between the two observers' means for any variable. The mean difference between measurements ranged from 0.19 mm (tarsal platform show) to 0.68 mm (lash-to-brow distance) ([Fig. 2]). Interrater agreement for canthal tilt was 100%.

Baseline eyelid measurements did not differ between brow lift and nonbrow lift cases. Those undergoing brow lift plus eyelid surgery were older in age (57.0 vs. 40.7 years, p = 0.022), had a greater proportion of negative canthal tilt (p = 0.050), and smaller baseline MRD1 (p = 0.014) than patients who had brow lift alone. Brow lift without eyelid surgery increased tarsal platform show by 0.9 mm (2.4–3.3 mm, p ≤ 0.001) and lash-to-brow distance by 1.9 mm (9.3–11.2 mm, p ≤ 0.001) ([Fig. 4]). These effects persisted even after accounting for orbital osteotomy/contouring; tarsal platform show increased by 0.9 mm (2.0–2.9 mm, p ≤ 0.001) and lash-to-brow distance by 1.1 mm (10.5–11.6 mm, p = 0.03). Subjects who did not undergo brow lift or eyelid surgery did not demonstrate significant differences in pre- to postoperative eyelid parameters. Those who underwent upper lid blepharoplasty showed an increase in tarsal platform show by 1.3 mm (1.4–2.7 mm, p = 0.01).

Fig. 4 Comparison of pre- and postoperative eyelid measurements. Except where indicated, dark bars denote preop values and light bars denote postop values. *Signifies statistical significance at p ≤ 0.05.

Discussion

There have been several published studies on gender perception based on facial anatomic features. According to a recent survey, transgender females preferred classically feminine anthropometric features of the forehead, hairline pattern, and mandible/chin.[7] And previous studies carried out in cisgender populations note several ideal masculine and feminine eyelid anatomic features. Specifically, increased tarsal platform show with a higher supratarsal fold and higher and more arched brow are generally considered feminine and aesthetically desirable.[8] [9] Our results show that brow lift can enhance anatomic features associated with perceived periocular femininity by increasing tarsal platform show and lash-to-brow distance. The values we found were clinically significant, as prior studies have shown that untrained observers detect differences in eyelid anatomic features measuring as little as 1 to 2 mm.[10] In our study cohort, a significant proportion of brow lifts were performed with hairline advancement. Hairline advancement reduces forehead height but has not demonstrated an effect on lash-to-brow distance without simultaneous brow lift.[11] [12]

Increasing the utilization of upper lid blepharoplasty may help augment the effects of brow lift and accomplish more desirable proportions in the periocular region, especially in older adult patients. In our study, upper lid blepharoplasty increased tarsal platform show. Tarsal platform show equal to one-third of the lash-to-brow distance is highly correlated with perceived youthfulness and femininity.[9] [13] [14] Our patient cohort approached, but did not quite achieve, this ratio after brow lift, and adding eyelid surgery could optimize this ratio. In addition, patients undergoing combined brow lift and eyelid surgery were significantly older than those who had brow lift only. Age is associated with negative canthal tilt, due to increased horizontal eyelid laxity and descent of the lateral canthal tendon insertion, and smaller MRD1, attributable to involutional ptosis and dermatochalasis.[13] Both of these characteristics are graded as less attractive in female eyes.[13] By increasing the visible iris height and upward inclination of the eye axis, eyelid surgery can combat age-related changes and may offer older patients a valuable option to enhance FFS outcomes.[14]

In addition to age-related changes, individuals' racial and ethnic backgrounds may contribute to results after FFS. The vast majority of patients in this study were Caucasian. A recent systematic review and meta-analysis noted ethnic differences in mandibular and zygomatic width, facial and forehead height, and nasolabial angle.[15] Blake et al[16] described substantial racial and ethnic differences in aspects of the eyelids and orbit, including supratarsal fold, orbital fat distribution, epicanthi, globe protrusion, inner and outer canthal distances, and palpebral fissure widths. Perception of eyes' beauty has also been shown to vary by ethnicity.[13] [17] The impact of this diversity has not been thoroughly examined in the context of FFS.

Our study had several limitations. This was a retrospective study with a small number of cases, especially those with eyelid surgeries. Combined with the heterogeneity of eyelid procedure types, this limited statistical power. To our knowledge, there are no published studies on transgender patient perceptions of periocular features, and aesthetic preferences of femininity were derived from studies of cisgender populations. Intervisit variability of eyelid measurements caused by slight differences in frontalis, orbicularis oculi, and levator palpebrae muscle tone as well as differences in timing of pre- and postoperative photographs may have affected eyelid measurements. We aimed to mitigate some of these potential sources of inaccuracies by verifying intra- and interrater reliability, obtaining measurements on photos of neutral facial expression, and using a control group consisting of subjects undergoing FFS of the lower facial third. Future studies with larger cohorts of FFS patients undergoing eyelid surgery as well as assessment of transgender individuals' perceptions of periocular anatomic features are needed to expand knowledge on the impact of eyelid surgery and features in facial feminization.

Conclusion

Rates of brow lift and eyelid surgery as part of FFS at our institution are higher than those published in prior studies. However, overall eyelid surgery cases are few in number and composed of heterogeneous procedures. According to cisgender aesthetic standards, brow lift enhances perceived periocular femininity by increasing lash-to-brow distance and tarsal platform show. Upper blepharoplasty may augment these effects by further increasing tarsal platform show. Expanded incorporation of brow lift and eyelid surgery may enhance congruity between social perception and patients' gender identities as well as patient satisfaction with FFS.

Conflict of Interest

None declared.

• References

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Publication History

Accepted Manuscript online:
27 April 2024

Article published online:
28 May 2024