The forehead occupies a major part of the face, up to one-third of its total length. It is a major contributor to facial aesthetics even though it appears largely as a blank slate. Because it has few identifiable features (only the eyebrows) other than wrinkles, it is often overlooked as a facial feature which can be modified. Botox and browlifts affect change in the overlying soft tissue, but the bony shape of the forehead
The forehead is outlined by three features which create the visual impression of its overall size. The top of the forehead is marked by the variable position of the frontal hairline which differs greatly by female vs. male gender. The bottom of the forehead is evidenced by the eyebrows and the supraorbital rims, which is the ridge of skull bone just above the eyes. The sides of the forehead are defined by the temporal ridges, the edges of the bony forehead where it meets with the large temporalis muscle.
It is the shape of the bony forehead (amount of convexity) and the prominence of the brow ridges that help define a more masculine or feminine appearance. In times past, its shape was also thought to impart the degree of intellect of an individual. This is most commonly portrayed in movies where the villians, monsters and other evil-doers will usually have big and bulging foreheads, often being grotesquely distorted.
As a gender marker, the forehead has some well-defined features. The forehead differs in the areas of the brows and the mid forehead and the skull’s shape affects the drape and contour of the skin. A long forehead is generally more acceptable in a male, largely because the variability of a receding hairline (particularly in an M-shaped pattern) is well known and expected. The bone ridge running across the forehead above the eyes, known as brow bossing (supraorbital rims), is more pronounced in males. The degree of acceptable brow protrusion is not well-defined and it can certainly become excessive causing an over-masculinized or Neanderthal appearance. Male brow protrusion should be enough to create a noticeable break between the brow ridge and the forehead bone above it. It may also extend off to the side tapering down onto the lateral orbital rim. No where is such difference more evident than in male to female feminization surgery and in the management of the brow bone.
While a long forehead is generally acceptable for the male, it is not in a female. Females have almost no discernable brow bossing because their foreheads are more rounded with a fairly flat front. In profile, female foreheads are more vertical instead of backward sloping. This means that some brow bossing may be aesthetically acceptable but there is no break between the brow ridge and vertical forehead bone above it, it should flow very confluently without a noticeable transition. The amount of convexity in profile view, however, is important and it should not stick out further than the lowest edge of the brow ridge. The sides of the brow ridges are also more tapered towards the temples unlike the male which can be more boxy or square-shaped.
These aesthetics considerations are critical when it comes to performing recontouring of the forehead in men and women. While forehead reshaping is often thought of as exclusively being done in facial feminization surgery, it is not in my experience. I have done as many if not more forehead surgeries in gender-stable patients. It is the nuances of the brow shape and how it flows into the upper forehead in both frontal and profile views that can make the difference between a good vs. an unhappy surgical outcome.
Dr. Barry Eppley
Indianapolis, Indiana