Perceptions of Femininity: Exploring the Influence of Eyelid Morphology and Periocular Features on Facial Feminization

PURPOSE: Facial feminization surgery includes craniofacial and soft-tissue procedures intended to soften traditionally masculine features. Although upper and midface skeletal changes are often emphasized, the periocular region plays a central role in gender perception. Few studies have examined which eyelid or canthal characteristics are most consistently perceived as feminine, limiting alignment between surgical techniques and patient-driven priorities. METHODS: A cross-sectional online survey was conducted from January 2023 to September 2025 among individuals in academic, community, and private practice settings. A total of 763 participants completed the survey, including 75 transgender or nonbinary respondents. Participants viewed paired, digitally modified periocular images that differed by a single feature (eyelid crease height, tarsal platform show, superior sulcus depth, lateral canthal tilt, or brow contour) and selected the more feminine-appearing image. RESULTS: Preferences for eyelid crease height and superior sulcus depth varied. Thirty-six point two percent preferred a higher crease, whereas 63.8% felt a fuller upper eyelid was more important; 66.5% of cisgender patients preferred a deeper sulcus, versus almost all transgender respondents who favored a fuller eyelid. An upward lateral canthal tilt was endorsed almost unanimously. Brow contour preferences were mixed. Free-text descriptors most commonly referenced long eyelashes, an arched brow, and an upward outer canthus. Transgender women consistently preferred a fuller upper eyelid and smoother brow contour more often than cisgender respondents. CONCLUSIONS: An upward lateral canthal tilt was a strong determinant of perceived femininity, whereas other periocular preferences varied by gender identity. These differences suggest that cis-derived aesthetic norms may not reflect the goals of transgender and nonbinary patients. Integrating identity-specific perspectives may enhance periocular planning in gender-affirming care.