Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?

Aesthetic Plast Surg. 2021 Aug;45(4):1860-1868. doi: 10.1007/s00266-021-02378-1. Epub 2021 Jun 10.


Background: Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity.

Methods: Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image.

Results: Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05).

Conclusions: This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery.

Level of evidence iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors .

Keywords: Chest surgery; Eye-tracking; Gender-affirming; Top-surgery; Transgender.

MeSH terms

  • Female
  • Gender Identity
  • Humans
  • Male
  • Nipples / surgery
  • Sex Reassignment Surgery*
  • Transgender Persons*
  • Transsexualism* / surgery