The need to change the shape of the forehead or brow bone is very uncommon. Reshaping the forehead or the brow bone (the bone below the eyebrows) is possible but there are different procedures that can be done based on the shape of the forehead and the brow bone.
The shape of the skull between a male and a female is often quite different .The male forehead often has fullness over the brow bone known as brow bossing or a supraorbital prominence with a flatter forehead above this area. The female forehead, conversely, has a more convex or curved forehead shape and little or no significant supraorbital bossing. Such forehead shapes confer a masculine or a feminine look.
The degree of brow bossing and the forehead shape helps determine what type of surgical recontouring needs to be done. With the exception of one other important consideration…the frontal sinus. The frontal sinus, an air-filled bone cavity, sits right under the brow bone and how developed it is will affect surgical choices. For this reason, any surgical efforts at forehead/brow modification should have a simple skull x-ray (side view) prior to surgery.
In those patients with mild to moderate brow bossing and thick skull bone over the frontal sinus (or are missing a frontal sinus), bone reduction by burring can be done with a nice result. When brow bossing is present but the bone thickness over the frontal sinus is thin, simple bone reduction contouring is impossible without entering the frontal sinus. Many try just a little bone reduction, without entering the sinus, but this does not make enough difference to justify the effort. Removal of only 1 or 2 mms of bone is not enough to make a difference. In these situation, one option is to open the frontal sinus, burr down the edges of the bone and put the ‘outer lid’ back in a more inward contour, thus preserving the frontal sinus. The other option is to obliterate and fill the sinus with a bone substitute material, making a more flatter brow contour with the bone paste or cement. (and not put the outer table of bone back) I have done both and both of them will work. If I can get a good brow contour and still leave the frontal sinus present and functioning, that is my preferred choice.
Any forehead and brow contouring requires an open approach through a scalp or hairline incision. The forehead skin must be ‘peeled back’ to get good access for the surgery. An endoscopic approach or more limited approach is not adequate to do a good job. In most females, the hairline and hair density patterns make an open approach possible. When this procedure is considered in males, the hair issue makes an open scalp approach potentially more problematic.
One of the most common patient, in my experience, for brow bone reduction is in female feminization surgery (FFS) where reducing the prominence of the brow bone helps in the overall facial conversion of the male to a female appearance. In a few select males with very prominent brow bones, this procedure can make a big difference in softening the more ‘neanderthal’ facial appearance.
Dr. Barry Eppley
Indianapolis, Indiana