Background
Facial feminization surgery (FFS) is a collection of structural procedures, most of which are reductive in nature. The upper and lower thirds of the face (forehead and jaw) are the primary sites for bony modifications. In the midface, the nose is also a frequent target of reduction, though it presents unique challenges due to its complex osteocartilaginous structure within a small anatomical area. Rhinoplasty, therefore, is often considered more technically demanding than other FFS procedures, such as forehead-brow bone reduction.
The forehead plays a key role in gender recognition. For this reason, most transfeminine patients undergo forehead-brow bone reduction, typically using a Type III technique. While this procedure reduces brow prominence, it can also accentuate the nasal profile—particularly if the nose is characterized by a high dorsal line, a pronounced hump, or a drooping tip. Even a well-proportioned masculine nose may appear more prominent after forehead reduction, making concurrent rhinoplasty a common adjunct.
The brow bone and nose create a central “Y-configuration” of the face. In men, this Y is narrower and more constricted (seen in the so-called “Hunter eye” look), while in women it is more open and expansive (the “Cat eye” aesthetic). Thus, reducing a dorsal hump and lowering the dorsal line at the frontonasal junction is often essential in achieving a feminine result.
Case Presentation
A young patient presented for FFS, including five major structural reductions: forehead-brow bone, nose, chin, and jaw angles. The patient’s history included three prior nasal surgeries, believed to have been performed primarily for airway improvement. The presence of a columellar scar confirmed that at least one operation had been performed via an open rhinoplasty approach.
Under general anesthesia, a brow bone reduction was performed first, followed by rhinoplasty. Through an open approach, a moderate dorsal hump was reduced, and the broad nasal bones were narrowed using low-to-low osteotomies. Tip rotation was achieved with the placement of a columellar strut graft, which was harvested from a segment of brow bone obtained during the forehead procedure. Small holes were drilled into the graft to facilitate secure suture fixation.
The immediate postoperative result demonstrated the significant feminizing effect of combining brow bone reduction with rhinoplasty.
Discussion
Feminizing the forehead directly influences nasal aesthetics in both profile and frontal views:
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Profile View: Brow bone projection and a nasal dorsal hump deepen the frontonasal angle. Reduction of both structures opens this angle, creating a softer, more feminine profile.
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Frontal View: The Y-configuration is typically constricted in men. By combining brow bone and nasal reductions, the Y shape is visually elongated and opened. While profile improvements are quantifiable, changes in the frontal Y-configuration are more perceptual.
An additional advantage in this case was the use of the brow bone flap as a graft donor site. With three prior rhinoplasties, septal cartilage availability was uncertain. A thin bone graft from the forehead provided an effective alternative for columellar support.
Key Points
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The frontonasal junction (brow bone–nose complex) is one of the most gender-defining regions of the facial profile.
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Brow bone reduction is frequently performed in conjunction with rhinoplasty in FFS to optimize feminization.
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Rhinoplasty is often more technically challenging than forehead reduction due to its complex anatomy.
Dr. Barry Eppley
World-Renowned Plastic Surgeon