“When you look at someone’s face, how do you know if you’re looking at a man or a woman?”
It is the day after Caitlyn Jenner debuted as a woman on the cover of Vanity Fair , and Dr. Jeffrey Spiegel, chief of Facial Plastic and Reconstructive Surgery, and a professor at the Boston University School of Medicine, posed — and answered — the question of the day.
“If you see a woman with facial hair, you don’t think it’s a man,” he said. “If you see a man with makeup or a wig, you don’t think it’s a woman. It’s not the superficial things. What I’ve discovered I don’t think is intuitive.”
On Tuesday, between performing his second and third facial feminization surgeries of the day, Spiegel, who not was involved with Jenner’s surgeries, described what more than a decade of research has taught him and explained the constellation of surgeries.
“The most important area we look at in deciding if it’s a man or a woman happens to be the part of the skull bone under the eyebrows. Men tend to have a brow bone that protrudes forward more than women do. This affects where the eyebrows are, how much light we reflect from around our eyes.
“I will actually take [the brow bone] off, and sculpt it and put it back,” Spiegel said, adding that as drastic as that sounds, the procedure takes him about 90 minutes.
“Women have more light reflected in their eyes,” he said, “so if I need to make someone, like, more feminine, I will think about how much light is reflecting from their eyes, and how can I maximize that.”
Men and women also have very different hairlines, he said. Women’s are typically rounder and lower than men’s. “I reshape it so it’s curved, and we bring it forward [by pulling the scalp,]” he said. “We see a lot of women who come in for that, too.”
He moved down the face a few inches. “I need to make sure the cheeks are full, not only to the side, but a woman’s cheeks are full in front, too. For a man, often times that area is very flat. We can treat this with a permanent implant, which goes in through the mouth so there is no scarring on the face, but also with long-lasting, temporary filler injections or fat grafting.”
Spiegel then discussed the center of the face. “We need to adjust the nose. Men’s noses are larger and bumpier. A beautiful woman’s nose tends to be smoother and have fewer characteristics.”
He paused to reflect on the importance of youth and beauty from an evolutionary perspective, and then moved on to the area between the lips and the nose, which turns out to be crucial.
“The distance from the bottom of the nose to the top of the lip is shorter in attractive young women than in a man,” he said, “so I need to shorten the vertical length to the lip.”
“It’s sort of a complex analysis of light and shadows and proportions.”
Spiegel said the jaw and throat require extensive work during facial feminization surgery. “I will also narrow the chin and jaw. We’re creating a more delicate jaw line and a narrower chin, and we’ll reduce the size of the Adam’s apple, and sometimes we do an operation to raise the pitch of the voice.”
That can be really important, he noted. “If you think of James Earl Jones, even if I made him look like a woman he would not be good with that voice.”
As extensive as all that sounds, there’s more. “If necessary, we do anti-aging procedures,” he said, explaining that as women get older, they start to look more like men. “We’ll do a face lift, an eye lift, a neck lift, anything that’s needed.”
Costs range from a few thousand dollars to tens of thousands, and the recovery generally takes from 10 days to three weeks. “Many people who come to see me two weeks later are back to work. They might have a little bruising, but they cover it up with makeup.”
Most surgeries, he said, are done on an outpatient basis. “Believe it or not, we can adjust your skull bone, and you can go back to your hotel room.”