Background: The forehead occupies a full one third of the face and is typically perceived as a flat nondescript bony surface. But its surface topography is more complex with potential brow bone prominences, a central glabellar valley, supra brow bone breaks, frontal eminence prominences and lateral temporal lines. All of which can lead to an irregular or bumpy forehead contour. Many of these bony features occur more prominently in men so they have a greater propensity for such forehead contour issues.
The most common male forehead prominence is that of the brow bones. But in forehead contouring we are not talking about major brow bone reduction which requires a bone flap setback. Rather this refers to some mild brow bone prominence or brow bone asymmetry which can be managed by burring reduction. Such prominences are of the medial or frontal sinus portion of the brow bones. How much they can be reduced is based on the thickness of the bone but 2 to 3mms is always possible. With the brow bones a valley between it and the upper forehead (supra brow bone break) is always present but it can also be excessively deep.
Another common forehead prominence, male or female, is that of the frontal eminences or frontal horns. These are upper lateral bony mounds, often paired, that stick out. Often times they are asymmetric with one side more pronounced than the other. With these horn come resultant depressions between them and any prominences that lie below. In men these depressions can become more obvious with the brow bone prominences below.
Case Study: This male desired to make his forehead smoother. His bony prominences were his medial brow bones (right more pronounced than the left), a forehead horn (there was none on the left) and paired linear indentations that went from the brow bones into the upper forehead paralleling the bony temporal lines. The valley between the right forehead horn and the brow bone was also a concern. These areas were all preoperatively marked in color. (purple for reduction and green for augmentation) The hairline incision behind the frontal hairline was the zigzag purple line.
Under general anesthesia and through the hairline incision a handpiece and burr were used to differentially reduce the medial brow bones and flatten the right forehead horn as much as possible. Even though he has short hair and the drill shaft is well inside the incision it it still important top guard it with a protective plastic sleeve.
The depressed/indented areas were augmented with a quick setting hydroxyapatite cement (Mimix QS) using a total of 10 grams. Once the cement hardened the hairline incision was closed.
The immediate smoothing of the forehead contour was apparent as would be expected.
The initial results of forehead contouring surgery for a smoothing effect will always look good due to generalized swelling and soft tissue detachments. What ultimately counts is what the forehead appearance is after all the swelling is gone and the soft tissues have contracted back down. (shrink wrap effect) This takes a full three months to occur so a final judgment on the result awaits until then.
Key Points:
1) The forehead is composed of multiple bony hills and valleys that can make for a non-smooth contour if they are large enough.
2) Brow bone and upper forehead prominences can be reduced by burring using a retro frontal hairline incision.
3) Undesired bony forehead concavities/indentations can be smoothly augmented with hydroxyapatite cement.
Dr. Barry Eppley
World-Renowned Plastic Surgeon