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Quantitative Framework For Lower Face Feminization: Skeletal And Soft Tissue Determinants Of Facial Squareness
Yomna E. Dean, MD, Kate Jensen, MS, Isaac Mordukhovich, BS, Emanuella Brito, BS, R'ay Fodor, MD, Niayesh Najafi, BS, Natalie Hoffner, BS, Kyle Barclay, BS, Abigail Meyers, MD, Antonio Rampazzo, MD, PhD, Bahar Bassiri Gharb, MD, PhD.
Cleveland Clinic Foundation, Cleveland, OH, USA.
PURPOSE: The contributions of skeletal and soft tissue structures to facial squareness as the main determinant of facial masculinity remain poorly defined. This study aimed to develop a quantitative framework for the determinants of lower face squareness to guide lower face feminization.
METHODS: Seventy maxillofacial computed tomography scans were segmented and reconstructed using Mimics and 3-Matics softwares to measure mandibular flare distance, chin, bicondylar, and bigonial width, gonial, mandibular body, and flare angles, ramus height, and masseter and parotid thickness. Horizontal measurements were normalized to interzygomatic width and vertical to lower facial height. Facial squareness was rated on a 0-3 Likert scale. Reliability was assessed by intraclass correlation coefficient (ICC). Regression, and variance partitioning quantified skeletal and soft tissue contributions.
RESULTS: Males demonstrated greater ramus height (p=0.002), larger parotid (p=0.002) and masseter volumes (p<0.001). Mandibular flare trended to be greater (p=0.09), while gonial angle was smaller (p=0.01) in males. Ramus height was the strongest predictor of squareness (β = 1.72, p = 0.005), while increased gonial angle was inversely associated with ramus height (p = 0.02). Mandible accounted for 50% of squareness variance, while parotid and masseter accounted for 30%. Increasing age was positively associated with squareness (β=0.15, p=0.04).
CONCLUSION: Mandibular ramus height is the dominant skeletal determinant of lower facial squareness, with soft tissue contributing more than one-third of total squareness. These findings provide a quantitative framework for lower face feminization planning, supporting combined skeletal and soft tissue modification to optimize outcomes.
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