The forehead is one of the most visible gender indicators. Brow bone reduction (also known as brow recontouring or brow contouring) is very effective and can transform a prominent masculine forehead into one that falls within the average feminine range. Brow bone reduction is one of the most important Facial Feminization Surgery (FFS) procedures.
The 3 main differences between the male and female forehead are:
The main difference between the male and female forehead is that males often have a ridge of bone around the upper edge of the eye sockets called the "brow ridge." Female foreheads rarely, if ever, have a brow ridge.
Men have a sharper slope between the forehead and nose.
In women this angle is more obtuse.
The portion of the bone rim that is between the eyebrows sits above an area called the frontal sinus. Because the frontal sinus is hollow, it is more difficult to remove bone. This portion of bone can be removed, reshaped (reconstructed), and then replaced. Titanium screws are used to hold the bone in place while it heals (this is a type 3 procedure).
Although the above method is most often used, we can distinguish 4 different types of methods to achieve a recontouring of the forehead. The one the surgeon chooses depends on how prominent the brow bone is, the thickness of the sinus wall, and the size of the forehead in general.
Some patients have a very small sinus with a thick frontal sinus wall. In this case, the excess bone can simply be planed away. This is explained by Dr. Ousterhout is called a 'type 1 forehead'. To this day, many surgeons only know this procedure: scraping away the small amount of bone and calling it 'feminization of the forehead'. However, only a small percentage of patients will have a good result: those who do not have a large bone rim or a small sinus (10%).
With a type 1 forehead recontouring, bone is milled off and the sinus remains closed. However, it often happens that the bone is so thin at the end of the procedure that after weeks/months a hole still appears in the front wall of the forehead cavity. If bone has too little blood flow, it can disappear.
Usually the patient will not notice this because it is a small hole. Because the skin around the hole is fused to the bone, air cannot get under the skin from the sinus.
However, if the hole is larger, a dent in the bone may become visible. That dent can possibly be filled with some fat from the abdomen or legs (lipofilling). Another solution may be a new forehead recontouring in which the front wall of the sinus is removed and the sinus is filled with bone cement. This way the desired shape can be given to the forehead.
This is something that happens regularly with all FFS surgeons. It therefore says nothing about the quality of the operation or the surgeon. Some patients simply heal differently than other patients.
This option has limited indication and is overused by surgeons who do not perform type 3 forehead reconstructions. This can be performed when one is already satisfied with the angle between the nose and the forehead (type II according to Ousterhout). In that case, only the cavity behind the bone edge needs to be addressed. The hollow area is then filled with bone cement (methyl methacrylate).
If a type 2 is performed when the indication is not really there, a dolphin-like forehead is created. As you can see, although the new forehead is smooth, it is bulging compared to the “ideal” female forehead line (shown in red in the drawing below).
The most commonly performed (because most often indicated) recontouring procedure is called the 'type 3' procedure by Dr. Ousterhout. In this procedure, the anterior wall of the frontal sinus is removed, remodeled, and replaced. The forehead reconstruction is the most complex technique, but also the most impressive. Sometimes it is necessary to use a combination of forehead reconstruction and bone cement filling to achieve the desired forehead shape.
Sometimes it is necessary to use a combination of forehead reconstruction and bone cement filling to achieve the desired forehead slope.
