Female Forehead Osteoma Removal Case Example

Forehead osteomas are benign (non-cancerous) bone tumors that commonly appear on the frontal bone of the skull—basically the forehead area.

What they are

• Made of dense, mature bone
• Typically slow-growing
• Feel like a hard, immovable lump under the skin
• Usually painless

Why they occur

The exact cause isn’t always clear, but possible factors include:

• Genetics (sometimes seen in conditions like Gardner’s syndrome, though most cases are isolated)
• Prior trauma (occasionally)
• Developmental bone growth abnormalities

Symptoms

Most people notice:

• A visible bump on the forehead
• Firm, smooth, round or oval shape
• No redness or tenderness

They’re usually cosmetic concerns, not medical problems.

Diagnosis

• Often diagnosed by physical exam
• CT scan is the gold standard if confirmation is needed (shows dense bone growth)

Treatment

Not required unless bothersome. Options include:

1. Observation

• If small and not noticeable

2. Surgical removal (most common)

• Done for cosmetic reasons
• Typically outpatient
• Can be performed via:
  • Direct excision (small incision over lesion)
  • Endoscopic approach (hidden incisions behind hairline)

Risks of removal

• Scar (usually minimal)
• Temporary swelling/bruising
• Rare: contour irregularities

When to get evaluated

• Rapid growth (unusual)
• Pain or tenderness
• Multiple lesions (may warrant further workup)

Case Example

This middle aged female developed a slow growing hard bump in her left upper forehead. It was very firm and immobile. No x-rays were obtained as it apepare t0 be a classic osteoma.

Under anesthesia a frontal hairline incision was narked above it (red marled the osteoma). Through the fromtal hairline incision the osteoma was exposed.

Using a sharp chisel the osteoma was separated from  the underlying forehead bone and removed.

The frontal hairline inision was closed with small resorbable sutures and a smooth forehead was restored.

Discussion

Here’s a practical, surgical comparison of open vs. endoscopic forehead osteoma removal:

Open (Direct) Excision

Technique

• Small incision directly over the osteoma
• Skin and soft tissue elevated
• Osteoma removed using:
  • Osteotome (chisel)
  • Burr (to smooth contour)
• Closure in layers

Best for

• Large osteomas
• Very hard/dense lesions
• Lesions needing precise contouring
• Patients with forehead wrinkles (scar can be hidden)

Advantages

• Direct visualization ? maximum control
• More complete removal (especially deep lesions)
• Easier to feather edges for smooth contour
• Shorter operative time

Disadvantages

• Visible scar (though often minimal)
• Slightly more soft tissue disruption

Endoscopic Removal

Technique

• 1–3 small incisions behind the hairline
• Endoscope inserted under the forehead soft tissue
• Subperiosteal dissection to reach osteoma
• Osteoma removed with burr or osteotome under camera visualization

Best for

• Small to medium osteomas
• Patients wanting no visible forehead scar
• Lesions located higher on the forehead

Advantages

• Scar hidden in hairline
• Less visible evidence of surgery
• Good for cosmetic-focused patients

Disadvantages

• Limited exposure
• Technically more demanding
• May be harder to fully contour large lesions
• Slightly longer operative time
• Risk of incomplete smoothing if not ideal access

Key Technical Considerations

Plane of dissection

• Typically subperiosteal for both approaches
• Protects supraorbital and supratrochlear nerves

Contouring

• Critical step: burring the base after removal
• Prevents visible step-offs or recurrence-like appearance

Nerve preservation

• Supraorbital nerve exits:
  • Notch or foramen (~2.5 cm from midline)
• Must be identified/protected, especially endoscopically

? Decision Algorithm (Simplified)

• Small + patient wants no scar ? Endoscopic
• Large / very prominent ? Open
• Low forehead (near brow) ? Usually open
• High forehead (behind hairline access possible) ? Endoscopic

? Recovery Differences

Factor	Open	Endoscopic
Swelling	Mild–moderate	Moderate (forehead elevation)
Bruising	Minimal	Can track to eyelids
Scar	Visible but small	Hidden
Downtime	~5–7 days	~7–10 days

Pearl (from a surgical standpoint)

The biggest mistake is under-contouring—leaving a subtle bump.
A slightly more aggressive burring and feathering almost always gives the best aesthetic result, regardless of approach.

Dr. Barry Eppley

Plastic Surgeon