Background
The forehead is one of the most gender-defining areas of the face. Many transfeminine patients choose to undergo brow bone reduction as part of facial feminization surgery (FFS) to create a smoother, more feminine appearance.
There are two main ways to perform brow bone reduction:
- Type 1 (burring technique): The bone over the brow is simply thinned or shaved down. This works best when the brow bone isn’t very thick and the sinus cavity underneath is close to the surface.
- Type 3 (bone flap technique): The outer layer of the brow bone is temporarily removed, reshaped, and then repositioned. This allows for a greater reduction and is used when the brow bone sticks out more.
Each person’s frontal sinus anatomy (the air spaces inside the forehead) is unique. Because of natural differences between the left and right sides, it’s common for each side to need a slightly different surgical approach.
Case Example
A transfeminine patient came to Dr. Eppley wanting to soften her forehead and lift her brows through an incision placed just along her hairline. From the outside, her brow bones looked symmetrical, but during surgery, the underlying anatomy proved different on each side.
On the left side, the bone covering the sinus was thin, so Dr. Eppley used the Type 3 bone flap technique — carefully removing, reshaping, and replacing the bone.
- On the right side, the bone was thicker, so a Type 1 burring technique was used — the bone was gently thinned down without removing it.
On the left side, the bone covering the sinus was thin, so Dr. Eppley used the Type 3 bone flap technique — carefully removing, reshaping, and replacing the bone.
After both sides were sculpted to match, the brow lift was performed. The change was immediately visible: her forehead looked smoother, her brow position higher and softer, and her overall facial balance more feminine.
Discussion
This case shows that even when the forehead looks even on the outside, the bone and sinuses beneath can be quite different. Understanding and adapting to each patient’s unique anatomy ensures the safest and most natural-looking result.
The surgical access for a brow bone reduction can be done two basic ways, directly at the frontal hairline or behind the frontal hairline. The choice between the two depends on what other changes to the foerhead are being done if any. In many transfemale brow bone reduction other forehead changes are heing done (frontal hairline advancement, browlift or both) When such comprehensive forehead reshaping is being done the only choice is a direct frontal hairline incision. This is the only incision that can be used for hairline advancement and a convenient one for a browlift as well. In this patient it was not done for a frontal hairline advancement since this was not needed. Rather it was done to avoid any chance of the hairline moving back from a browlift as well as to avoid a long coronal scalp scar. The healing of the frontal hairline scar made it barely perceptible even at just 6 weeks after surgery.
Key Takeaways
? Every patient’s forehead anatomy is different — one side may require a different approach than the other.
? Both Type 1 (burring) and Type 3 (bone flap) techniques can be combined in the same surgery.
? The result is a smoother, softer, more feminine forehead contour.
Dr. Barry Eppley
World-Renowned Plastic Surgeon