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Facial gender identity is highlighted by several facial areas or zones. One of these facial areas in the upper third of the face or forehead. The relevance of this is seen in facial feminization surgery where the most consistent procedure performed is forehead reshaping surgery in most transgender male to female patients. The more convex shape and lack of brow bones in female foreheads is in contrast to the broader and flatter forehead shape with brow bones that a male has.

In traditional transgender male to female forehead reshaping surgery the central brow bone prominences are most commonly reduced. Usually through bone removal, reshaping  and replacement, the brow bone prominences that are the result of frontal sinus expansion are successfully treated.

But for some patients brow bone reshaping alone represents an incomplete forehead reshaping approach. What lies above the brow bones still occupies a lot of forehead surface area. In further feminizing the forehead its dimensions of width, slope and convexity are also shape issues to consider.

The male and even some female foreheads are naturally wider from the frontal view. Width is a reflection of how far the bony temporal lines are to the sides as well as the thickness of the anterior temporalis muscle that lies lateral to it. Making the forehead more narrow requires eliminating the presence of the vertical temporal line of the frontal bone which represents a sharp transition between the bony forehead and the temporalis muscle. This can be done at the time of brow bone reduction or can be done secondarily. Either way it requires an extended scalp incision to do so.

Once the bony forehead is exposed, the temporalis fascia is released from its attachment to the temporal line. The upper muscle fibers usually retract inferiorly a small amount which is all the exposure usually needed. Using a high speed handpiece and burr the bony temporal line is shaved down from the tail of the brow bone back up into the forehead. By reducing the sharper 110 degree or so bony transition a more convex shape to the forehead results in addition to a more narrow frontal appearance.

Of the bony prominences that can be reduced in forehead reshaping that of the temporal lines is often overlooked. Given that it is in the same surgical field as brow bone reduction it is the most convenient time to incorporate this forehead width reduction dimensional change if indicated.

Dr. Barry Eppley

Indianapolis, Indiana

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