The forehead is one of the most visible gender indicators. Brow bone reduction (also known as forehead recontouring or forehead contouring) is very effective and can transform a prominent masculine-looking forehead into one that falls within the average feminine range. The reduction of the brow bone is one of the most important Facial Feminization Surgery procedures.
The 3 main differences between the male and female forehead are:
The main difference between the male and female foreheads is that the males often have a ridge of bone around the upper edge of the eye sockets called a 'brow arch'. Female foreheads rarely if ever have a brow arch.
The portion of the bone between the eyebrows sits above an area called the frontal sinus. Because the frontal sinus is hollow, it is more difficult to remove bone from it. This part of the bone can be removed, adjusted in shape (reconstruction), and then replaced. Titanium screws are used to hold the bone in place while it heals.
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 recontouring procedure we perform most often (because it is most often indicated) is done by Dr. Ousterhout called the 'type' procedure. During this procedure, the anterior wall of the frontal sinus is removed, remodeled and replaced. 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. Dr. Bart van de Ven uses bone cement more and more often to get exactly the desired result.