BACKGROUND: In transfeminine patients seeking facial gender-affirming surgery, temporal recession of the hairline is a common feature that contributes to a masculine appearance. Standard central hairline advancement lowers the hairline without substantially improving hairline shape. In this article, we describe our technique utilizing bilateral rotational flaps of the temporal hair-bearing scalp to facilitate excision of the area of alopecia and compare outcomes of our technique to central hairline advancement alone. METHODS: This cohort study used data collected prospectively from patients who underwent facial feminization surgery in the Kaiser Permanente Southern California system. Intraoperative measurements of patients who underwent advancement of the central hairline only were compared to those of patients who underwent hairline advancement with temporal rotation flaps. Changes in the distance between 4 anatomic points were measured and compared between groups. RESULTS: A total of 86 patients were included. Twenty-four control patients who underwent central hairline advancement only were compared to 62 intervention patients who underwent temporal rotation flaps as well. Patients in the intervention group had greater improvement in the shape of their hairline as demonstrated by greater advancement of their temporal recession peak inferiorly and toward midline in the oblique (3.02 vs 1.31 cm
p <
0.0001), lateral height (1.30 vs 2.11 cm
p <
0.0001), and width (2.03 vs 0.15 cm
p <
0.0001) measurements. There were no major complications. CONCLUSION: The use of temporal rotation flaps in conjunction with a direct central hairline advancement procedure is a safe and effective method to feminize hairline shape in patients with temporal recession.