Brow Bone Reduction (Central)
Considered one of the cornerstones of FFS surgery is the shape of the upper third of the face. The elimination of protruding brows and altering the appearance of the forehead to a more convex shape with a straighter vertical angulation is a critical gender difference between men and women. Always done through a superior incisional approach, the options are either the coronal (behind the frontal hairline) or pretrichial (at the frontal hairline) incision. This will be highly dependent on the location and hair density of the front hairline which is often not good in many male to female transgender patients. The pretichial incision offers more direct access to the brow bones and other forehead manipulations and is less traumatic to the hair. If hair transplantation is being considered to fill in or lower the frontal hairline the bony work should always be done first.
Reduction of the brow bones is most effectvely done through a bone flap removal and replacement technique. While burring may be effective for a small number of patients, it can not create the more significant brow bone reduction often needed due to the presence of the underlying frontal sinus. Taking the bone off over the front sinus off, reshaping it and reducing the sinus perimeter edges, and then bone flap inset allows for a ore significant central for brow bone reduction. One critical area that is often overlooked is the frontonasal angle where the lower end of the bone meets the upper nasal bones. Ensuring that this one is deepened (lower radix height) is one of the defining measures of the success of the brow bone reduction procedure.
In some secondary cases where the amount of desired brow bone reduction that have been achieved, maxima reduction can be assured by obliteration of the frontal sinus. The bone flap is used in a particulate fashion instead as a bone graft for the frontonasal duct and the frontal sinus cavity obliterated with hydroxyapatite cement. This allows the central brow bone to be reduced as far back as needed. (extreme brow bone reduction)
Brow Bone Reduction (Lateral)
While much focus is often placed on the central brow bone area, not to be forgotten is the outer half of the supraorbital rims. (tail of the brow bones) Laying outside of the frontal sinus cavities the outer brows can be reshaped by burring to create a tail of the brow that has less projection and sweeps more upward which opens up the outer eye. This is a distinct female feature that helps soften the appearance of the forehead and when done with a temporal browlift can have a significant eyebrow reshaping effect. This should be part of most feminizing brow bone procedures and the bone in this area can be liberally reduced due to the lack of any underlying frontal sinus.
In patients who did not have the outer brow reshaped during their primary brow bone reduction or only need the tail of the brow bones treated, a more direct approach can be taken through an upper eyelid incision. It is not necessary to use a scalp or frontal hairline incisions to do so. This not only provides very direct access but also allows both horizontal and vertical bone reduction of the tail of the brow bone. It only requires a partial or lateral upper eyelid incision of which the scar outcome is similar to a traditional upper blepharoplasty for anti-aging effects.
Dr. Barry Eppley