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Forehead recontouring

Forehead recontouring

Table of contents:

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.

Difference between the male and female forehead

The 3 main differences between the male and female forehead are:

Brow arch

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.

Difference between male and female zone of the larynx

Flat spot

A flat spot may be visible between the edges of the two eye sockets. Because women do not have this, the flat spot between them is also not present.
Notice the flat spot as well as the brow arch on the male forehead (left) compared to the female forehead (right).

Slope of the forehead

A flat spot may be visible between the edges of the two eye sockets. Because women do not have this, the flat spot between them is also not present.
In the male skull (left), the angle between nose and forehead is sharper than in the female (right).

Feminization of the forehead

Forehead recontouring is a procedure in which the brow bone is surgically filed. The outer part of the bone edge - where the eyebrows are - consists of solid bone and can be partially filed away.
Filing the side of the eyebrow bone.

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.

The central part of the brow bone often cannot be filed during recontouring of the forehead due to the sinus that lies behind it.
The central part of the brow bone must be reconstructed with a saw because of the frontal sinus beneath it.

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. 

Type 1 — Files

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%). 

Good indication for a type 1: Some patients have a very small sinus with a thick frontal sinus wall. In this case, the excess bone can simply be planed away during a brow bone reduction.
Before and after recontouring of the forehead type 1 (good indication)
Contrary to what some surgeons may tell you and despite the fact that there are a few exceptions, it is safe to say that in general it is not possible to bring a male forehead within normal female margins without forehead reconstruction.
Bad indication for a type 1: Large frontal sinus (frontal sinus)

Possible complications

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.

Type 2 — Planing and filling

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).

Bad indication for a type 2: If the procedure is performed when there is no good indication, a dolphin-like forehead is created.
Comparison of the type 2 and type 3 procedure when you have a heavy forehead.

Type 3 — Forehead reconstruction

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.

INDICATION for a type 3: large sinus and prominent brow bone
Reconstructed forehead after a type 3.
Rx of the forehead before (left) and after (right) the type 3 procedure.
Before and after type 3

Type 4 — Reconstruction and filling of the forehead

Sometimes it is necessary to use a combination of forehead reconstruction and bone cement filling to achieve the desired forehead slope. Dr. Bart van de Ven uses bone cement more and more often to get exactly the desired result.
Before and after type 4

Procedure

  • General anesthesia is administered.
  • An incision is made along the hairline. The incision is made in the same way as for a hairline reduction.
  • The forehead skin is pulled forward to expose the bone.
  • The sturdy bone edge above eye sockets is refined.
  • During a type 3 recontouring, the central piece of bone covering the frontal sinus is removed, then thinned until the desired thickness is achieved, and then remodeled.
  • Finally, the modified piece of bone is secured with titanium microscrews. The heads of the screws are removed so that they cannot be felt or seen through the skin.
The frontal sinus plate is secured with screws.
  • As with lowering the hairline, the skin is attached to the bone with the help of Endotins to prevent the skin from receding.
The frontal sinus plate is secured with screws.

Recovery

  • Hospital—You will stay in the hospital for one night after the operation.
  • Pain—May occur for several days and can be controlled with normal painkillers.
  • Work—Many patients can return to work within two weeks of this surgery (if this was the only procedure).
  • Exercise—Avoid any form of physical activity that would make you sweat or increase your blood pressure for 8 days. 
  • Sutures—The sutures are dissolvable. They dissolve in about a week.
  • Forehead Numbness—Keep in mind that your forehead will be numb for about 3 months.
  • Blurred vision (rare, 5%)—Because of the swelling around the eyes, some patients have had some degree of blurred vision from 1 to 4 months.

Complications

  • Altered sensation of the scalp—Because the skin is loosened from the bone during the procedure, the sensation in this skin may change. Most patients regain normal sensation in this zone after a year, but in some not 100%. However, most do not report this as a problem, but rather something they noticed;
  • Infection;
  • Asymmetry;
  • Unsatisfactory aesthetic result;
  • Double vision in certain directions (usually temporary, rarely permanent);
  • Decreased sensation of the forehead skin (usually temporary, rarely permanent);
  • Changes to the shape of the frontal sinus can alter resonance (amplification of vocal sounds). (Semi-)professional singers should be aware of this risk and weigh the pros and cons;
  • Temporary spasm of the frontal muscle causing a 'surprised look'.