Frontal bossing is a not uncommon forehead condition marked by variable amounts of upper frontal bone protrusion. This can appear as smaller bilateral concentric horns or as an overall larger convexity of the whole forehead. Such frontal bone development throws the whole forehead out of aesthetic balance for either male or female and becomes an inadvertent facial focus. For those so affected camouflage is a frequent management strategy with hairstyles or hats.
In infants and very young children forehead reconstruction can be done by removal and replacement of the reshaped bone. But in adults such an aggressive approach is neither possible or warranted as it is an aesthetic concern. Burring reduction of the prominent portions of the forehead is the contouring procedure used. (frontal bossing reduction)
How successful burring reduction is for frontal bossing depends on the thickness of the frontal bone and the amount of bony protrusion. The best way to determine how much forehead bone can be reduced is by getting a 3D CT scan. Cross-sections of the forehead will beautifully show the thickness of the bone and the three skull layers. Seeing the layers is critical as it is the thickness of the outer cortical layer that matters since this is the location of the skull bone that can be reduced. Burring reduction does not usually go into the central diploic space due to the amount of bleeding that is encountered.
Burring reduction is usually very effective as few people need more than 4 to 6mms of bone reduction to substantially lessen or eliminate their bossing.
Beyond how much bone can be removed is the issue o the incisional location to do it. In most cases either a hairline (pretrichial) or hemi-coronal incision is placed several centimeters behind the frontal hairline. The key is that the incision must allow for a direct line of sight to the bossing to be able to get the rotary instrument in to reduce it. This picture one side reduced compared to the bossing side through a scalp incision.
Dr. Barry Eppley
Indianapolis, Indiana