Assessing the Relationship Between Mandibular Contouring and Iatrogenic Jowling in Facial Feminization Surgery

Lower-third facial feminization procedures have been associated with the development of postoperative jowling, yet quantitative evaluations of this outcome remain limited. This study evaluated the relationship between patient risk factors and bony volume reduction with postoperative jowling. Chin and gonial angle bony measurements were obtained from preoperative and postoperative computed tomography imaging, whereas changes in jowling were assessed using a validated photonumeric jowling scale on preoperative and postoperative patient images. Associations between skeletal changes, demographic variables, and soft tissue outcomes were statistically analyzed. The study included 35 patients with a mean age of 36 ± 12 years. The average time between surgery and postoperative photographs was 10.0 ± 7.5 months. Gonial angle volume decreased by 9.48% ( P < 0.001), whereas chin volume decreased by 3.06% ( P = 0.051). Average jowling grade increased significantly from 2.3 to 2.6 postoperatively ( P = 0.03), with higher age correlating to a greater increase in jowling ( r = 0.35, P = 0.037). Postoperatively, only body mass index was significantly correlated with absolute jowling score ( r = 0.51, P = 0.0018). However, no significant associations were found between changes in bony measurements and changes in jowling scores. These findings underscore the importance of further investigating the interplay between patient risk factors and bony and soft tissue changes in facial feminization surgery. Future studies will focus on expanded cohorts and more sensitive assessment tools to better define risk factors and optimize surgical strategies for minimizing jowling.