Background: Reshaping the upper third of the face, as opposed to more commonly known rejuvenation techniques has a different objective and patient population. Forehead rejuvenation strives to make the upper face look less aged primarily by reduction of skin wrinkles and changing the position and arc of the eyebrows. Conversely the primary goal of forehead reshaping surgery is to change the surface contours and landmarks through various augmentation and reduction procedures. Often forehead rejuvenation procedures are done on younger patients while forehead rejuvenation is done on older patients with more advanced signs of aging.
In forehead reductive reshaping this could mean decreasing its vertical length through hairline lowering or even browlifts which are soft tissue changes. It could also mean reduction of undesired bony prominences usually through high speed burring tools. Some forehead reduction patients only get soft or bony tissue changes based on their aesthetic needs. But occasionally some patients have multiple forehead shape issues that require both bony and soft tissue alterations. If a frontal hairline advancement/lowering is to be done there is now open access to do any type of forehead bony reduction.
Case Study: This female was bothered by multiple issues of her forehead including a long vertical distance (7cms centrally), an inverted u-shaped frontal hairline, upper forehead bossing and small medial brow bone prominences. She also wanted a more vertical forehead slope. A comprehensive forehead reshaping plan was devised including a frontal hairline advancement (14mms centrally) and burring bony reductions of the frontal bossing and small medial brow bone prominences.
Under general anesthesia the frontal hairline incisions was made and the forehead flap elevated down to the brow bones. Using a high speed hand piece 2mms was removed from the brow bones and 4mms from the frontal bossing.
The scalp was then fully mobilized to the back of the head at the subperiosteal level as well as along the deep temporal fascia. The frontal hairline was advanced 14mms centrally, the intervening forehead skin removed and the incision closed in multiple layers putting the little zigzags together for the creation of an irregular hairline.
The change in the forehead shape was immediately apparent with a smaller and straighter forehead shape.
Forehead reduction surgery can be more challenging than augmentation as tissues need to be removed. (as opposed to being added with an implant) While bony forehead reductions can be done alone access is improved and greater areas of frontal bone removed when there is a concomitant hairline advancement being performed. The obvious tradeoff for this enhanced access is the frontal hairline scar…but that is needed anyway. It is also important to appreciate the synergistic effect of a hairline advancement on frontal bossing. As the frontal hairline is brought forward the hairline turns the corner onto the forehead and helps camouflage some of the bossing. The bony bossing still needs to be reduced but not ass much a much as one may initially think.
Key Points:
1) Options in forehead reduction surgery include both soft tissue and bony modifications.
2) Soft tissue modifications include decreasing forehead length through hairline lowering or eyebrow elevations.
3) Bony forehead reductions include treating horns, bossing or brow bone protrusions.
Dr. Barry Eppley
World-Renowned Plastic Surgeon