Background: The shape of the forehead is largely controlled by the development of the frontal bone of the skull. Frontal bossing is the term given to describe a prominent bulging forehead. This is usually most manifest in the upper forehead which can project outward beyond the wide profile of the brow bones in some cases. There are a variety of medical conditions that can cause frontal bossing from congenital skull deformities to hormonal abnormalites. (e.g., acromegaly)
But for many patients this is an aesthetic deformity that has no specific cause other than this is just how the forehead developed. The prominent upper forehead usually appears as a bulge across the upper forehead. It is obvious because it has a size bigger than the patient’s brow bones and also causes a high or long forehead in some patients. A large surface area forehead causes a facial imbalance and disrupts the aesthetic thirds of facial proportions.
Frontal bossing can be reduced to improve facial aesthetics. How much the prominent frontal bone can be reduced depends on the thickness of the bone. Burring reduction is the surgical technique, not formal bone removal (frontal craniotomy) and split bone reduction as would be done in more severe craniofacial deformities.
Case Study: This 23 year-old female had a prominent upper forehead that was aesthetically bothersome to her. She wore her hair short so the entire shape of the forehead was clearly evident.
Under general anesthesia a pretrichial hairline incision was used to access the forehead. Burring reduction of 5 to 6mms was done throughout the forehead bulge down to a bleeding diploic space. The frontal hairline was then advanced 1 cm from upper temporal to upper temporal areas. The combination of some reduction of the frontal bossing and skin shortening of the forehead created a more balanced looking forehead region.
There are limits as to how much frontal bossing can be burred down. It may be able to be burred down completely or only partially. The hairline advancement provides an adjunctive improvement as it alone creates the appearance of a smaller forehead.
Highlights:
1) Frontal bossing is an aesthetic forehead deformity that is associated with an enlarged upper forehead and a high hairline.
2) The amount of reduction possible for frontal bossing depends on the thickness of the frontal bone.
3) A pretrichial approach to forehead bony reduction allows for frontal hairline advancement as well.
Dr. Barry Eppley
Indianapolis, Indiana