One of the many important areas to change in facial feminization surgery (FFS) is that of the forehead. The typical male forehead has a prominent brow bone, a visible brow bone break into the upper forehead and a central forehead area that is often flat or even slopes backward to some degree. This is a major phenotypic difference from that of a female forehead who has or desires a rounder smoother and more vertically oriented forehead.
The cornerstone of a male to female forehead shape change begins at the brow bones. While the brow bones can have variable thicknesses before entering the underlying frontal sinus, simple burring down of the brow bones is minimally effective and inadequate for many patients. It may be useful when there is little brow bone protrusion or the outer table of the frontal sinus is very thick. (thus the importance of preoperative x-rays)
But the most consistent and effective technique for brow bone reduction is that of the osteoplastic bone flap. Also known as the frontal sinus setback procedure the outer table of the frontal sinus (brow bone) is removed and reshaped. When the bone is replaced, which is necessary to cover the exposed frontal sinus cavity, it is put back so the brow bone contour is flatter. The much smaller segments of bone are usually best secured by small titanium microplates and screws. (1mm is thickness) The tail of the brow bones also needs to be reduced to create more of a lateral reduction and upward swoop. This can be done by bone burring since there is no underlying frontal sinus in this portion of the brow bone.
But reduction of the brow bones alone is often insufficient to create a more optimal female forehead shape. The central portion of the forehead also needs to be augmented to create a more vertical forehead inclination and a rounder shape from side to side between the temporal lines. Various bone cements can be used and both PMMA and hydroxyapatite compositions are effective. The optimal choice is, however, hydroxyapatite cement due to direct bonding to the bone without a scar interface due to its calcium phosphate composition.
Combining flattening of the inner half of the prominent brow bones, reduction of the outer or tail of the brow bones and increasing the convexity and vertical slop of the forehead are all important forehead feminization techniques. In some cases a hairline advancement to shorten a vertically long forehead can also be done at the same time tio provide the most complete forehead shape change.
While the skull is prone to have a variety of lumps and bumps, they are more of an aesthetic concern when they occur on the forehead. Any forehead irregularity becomes a very noticeable entity as the surface area of the forehead occupies up to 1/3 of the visible face. Commonly seen as a smooth surface, with the exception of the bilateral brow break in men, any outcrop of bone becomes very apparent and is often aesthetically bothersome.
While there are numerous types of hard and soft tissue lumps that can occur on the forehead, the most common bony types are osteomas, exostoses and midline ridging. Osteomas can occur randomly anywhere on the forehead and are often the result of trauma and usually appear due to an osteoblastic response to a small subperiosteal bleed. They are like a mushroom growth on the bone. Bony exostoses, also called forehead horns, are symmetric bilateral natural growths or thickenings of the outer cranial table. (although they can be asymmetric or appear on just one side) They do not have a distinct base like that of an osteoma. Midline ridging is a raised area of bone that runs down the upper central region of the forehead. It is a variant of the neonatal metopic suture and may be considered an expression of a microform of metopic craniosynostosis.
Reduction of any of these forehead lumps and bumps can be done by a variety of surgical methods but they all share the common need for bone reduction/bony contouring. How the bony deformity is accessed will influence, favorably or unfavorably, what bony reduction can be used. Endoscopic techniques will almost exclusively limit one to using an osteome and thus is really only used for osteoma removal which can easily be severed from its more narrow base. But every other forehead bony deformity must use a more effective contouring method and needs to be done through an open hairline or scalp incision.
A handpiece and burr is the most rapid and effective method for forehead bony deformity reduction. The high speed of the rotating burr can make quick work of any projecting bony areas. But access is often a problem. Most handpieces are straight and coming from an incision above across a convex upper forehead keeps the working end (burr) of yhe instrument away from the bony surface. This is simply solved by using an angled handpiece which is also longer than the standard straight handpiece. The angle of the handpiece overcomes the curvature of the upper forehead.
The other useful tool for forehead bump reduction is a large rhinoplasty rasp. Its teeth may work a lot slower than a rotating burr but with repetitive stroking a slow and smooth reduction can be achieved. Even though it is a straight instrument and is a bone reduction manuever that is done only by feel, it is a very safe technique that creates a safe and even bone surface. It is especially good for smoothing out any areas that were initially reduced by endoscopic burring.
Various forehead lumps and bumps can be reduced through minimal incision techniques using a variety of instruments including osteotomies, burrs and rasps. By working though small scalp incisions, forehead contouring can be done without visible skin scars if desired.
What influence does the forehead have on one’s appearance?
The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.
The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.
A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women.
2. How is forehead reshaping done?
Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.
They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.
3. How is brow bone reduction done?
In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only hasthin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.
In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.
A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone.
4. How is brow bone augmentation done?
Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.
PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.
Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.
5. Can other areas of the forehead be reshaped besides the brow bone?
The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.
Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.
Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?
7. What can I do if my forehead is too long?
Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.
The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference.
Contouring of the forehead is an uncommon procedure in plastic surgery but the techniques to do it are not. Whether it is to reduce frontal bossing, soften prominent brow bones, or change the slope of the forehead, the forehead can be reshaped in a variety of dimensions. Most reduction changes are more subtle to moderate due to the limitations of the thickness of the skull and the presence of the underlying brain or frontal sinuses. Building up the forehead can produce changes that are more significant as there are no such anatomic restrictions.
Forehead contouring developed from craniofacial plastic surgery techniques. One of the basic craniofacial tenets is that of the approach and using direct vision to see the entire surgical field. Using a coronal or scalp incision, the forehead tissues are degloved or peeled back from the scalp down to the orbital rim. With this amount of access, forehead bone manipulation is fairly straightforward. Whether it is bone reduction by burring, sinus osteotomies for reduction, or adding synthetic materials for augmentation, one is unrestricted in options with this exposure.
More males than females desire forehead and skull reshaping in my Indianapolis plastic surgery practice experience. The limiting factor for males fulfilling that desire is the scalp scar. Males are more limited in having a hidden scar due to the location of their hairline and hair density. Most plastic surgery procedures are about making trade-offs…trading off one problem for another. The trade-off of a scalp scar for a better shaped forehead must be considered carefully in most males. This is rarely such an issue for females.
As craniofacial surgery techniques has evolved, more limited incisional or endoscopic approaches have been tried. In general, these are not particularly effective for most forehead procedures. They can be used to remove small osteomas or soft tissue masses and are very effective for cosmetic browlift and supraorbital nerve decompressions. But the access is too limited and the instrumentation is not sufficiently developed to allow for much bone manipulation. I have done a few synthetic augmentations endoscopically but only partial or subtotal areas can be done satisfactorily this way.
The only other incisional option is an upper eyelid incision but this can only be used for brow bone shaping. The eyelid incision provides good access to the mid- and lateral brow. But the inner brow area is blocked by the important sensory nerves that exit out from the bone there.
The bottom line is…most forehead contouring must be done using the full coronal incision. The magnitude of the deformity will determine whether the scalp scar is a reasonable aesthetic ‘problem’ to replace it. The forehead deformity and one’s concerns about it should be sufficiently significant to make coronal incision worth it.
Facial feminization surgery (FFS) is an assortment of plastic surgery procedures that changes a genetically male face to bring its features closer in shape to that of a female. FFS is sought after largely by transsexual women and psychologically it is often more important than sex reassignment for social integration. FFS works on both the bone and the overlying soft tissues and, as a result, has much of its origins from craniomaxillofacial surgery as well as traditional cosmetic plastic surgery. For this reason, those few plastic surgeons who perform FFS usually have such backgrounds.
I like to think of FFS as three potential zones of change… upper, middle, and lower face. Within these zones, the primary plastic surgery procedures include frontal hairline alteration/brow lift, forehead/brow recontouring, rhinoplasty, cheek/submalar augmentation, upper lip enhancement, jaw/chin modification, and thyroid cartilage reduction. To no surprise, many of these changes deal with facial prominences ….lessening the amount of bony and cartilage convexities. Each patient usually has one primary zone for change and two others for some modification. In essence, every patient has at least one dominant facial feature which must be changed onto which other procedures are complementary. While it is true that it takes many changes to create amore convincing change of appearance, one or two of the procedures usually has a dominant effect.
FFS, philosophically, consists of a combination of reconstructive and cosmetic plastic surgery procedures. Changing the bony prominences, or changing the skeletal foundation of the face, is based more on the reconstructive heritage of the procedures. Modifying or lifting of soft tissues of the face encompasses more standard cosmetic procedures used for a primary anti-aging or more youthful effect.
Every FFS procedure has differing levels of difficulty and degrees of change. Some are easy to go through, while others are more extensive with prolonged swelling and social recovery. The procedures of tracheal shave, upper lip lift and cheek implants are very effective and relatively simple with little downside or complications. More difficult procedures are forehead contouring and brow reduction and the alteration of the chin and jawline. These have issues of surgical access and bone manipulation, of which makes for more swelling. Rhinoplasty and standard plastic surgery procedures such as facelift, blepharoplasty or browlift, falls between the two with a few weeks of relatively easy recovery.
The key to a successful FFS outcome is to plan a combination of facial procedures that can most effectively soften one’s appearance and make for a convincing change. There is no one standard set of procedures that will work for every patient. While some patients need just three or four, others may benefit by twice that many. Most patients have a good feel for what they think will be effective and a careful discussion and computer imaging is essential to create a reasonable working list of procedures. While some patients may want the most change possible by number of procedures, it is important to have a realistic outcome and work within one’s budget for maximal facial change.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.