Brow bone reduction

Brow bone reduction

5 July 2020 Articles

Brow bone reduction

The forehead is one of the more apparent gender markers. Brow bone reduction (also known as forehead recontouring or forehead contouring) is very powerful and can transform a prominent male forehead to fall within the average female ranges. Brow bone reduction is one of the core Facial Feminization Surgery procedures.

 

Difference between the male and female forehead

The 3 most important differences between male and female foreheads are:

1 Brow bossing

The main difference between male and female foreheads is that males often have a ridge of bone around the upper edge of the eye sockets called the “brow ridge” or “brow bossing”. Female foreheads tend to have little or no bossing.

Brow bone of male (left) vs female (right) skull.

2 Flat spot

Between the ridges of the two eye sockets, a flat spot can be visible. As women don’t have these ridges, the flat spot between them is not present either.

Notice the flat spot on the male forehead (left) compared to the female forehead (right).

3 Slope of the forehead

Because of the brow ridge, the general angle of the forehead in males is steeper and the angle between the forehead and nose is sharper in lateral view. Women, because they don’t have the brow ridge, have a more vertical appearance of the forehead in lateral view. The angle between the nose and forehead is more open.

Because of the male frontal bossing the angle between the nose and forehead in men (left) is sharper than this angle in women (right).

Feminizing the forehead

Brow bone reduction is a procedure that involves brow shaving and surgically altering the bone.

The outer segments of the bossing that the eyebrows sit on are solid bone and can simply be filed down.

Burring away the lateral brow ridge with a brow bone reduction

The section of bossing between the eyebrows sits over an area called the frontal sinus. Because the frontal sinus is hollow, it is more difficult to remove bossing there. It involves removing the plate of bone in front of the frontal sinus, reshaping it, and placing it back into position with small titanium screws to hold the bone in place while it heals.

The central part of the brow ridge can often not be shaved down during a brow bone reduction because of the frontal sinus which lays behind it. Simple shaving of the bone over the frontal sinus would create a cavity.

Location of the frontal sinus in frontal view. In this area, brow bone can not simply be shaved.

The central part of the brow bone has to be remodeled with a saw because of the frontal sinus beneath.

Although the brow bone reduction process as described above is the most used, there are 4 types of brow bone reduction to be distinguished. Which one the surgeon uses depends on the prominence of your brow bone, the thickness of your frontal sinus wall and the size of your frontal sinus and forehead in general.

Type 1 brow bone reduction—Shaving

Some patients have a very small sinus with a thick frontal sinus wall. In this case, the excess amount of bone can just be burred away. This is what Dr.Mohammadimofrad calls a ‘type 1 forehead’. A lot of surgeons today can do only this: they burr away that small amount of bone and call it “feminization of the forehead”. Only a small percentage of patients will have a good result with this technique: those with only a small bossing 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 amount of bone can just be burred away during a brow bone reduction.

Before and after brow bone reduction type 1 (good indication)

Despite what some surgeons might tell you, it is generally not possible to bring a male forehead into normal female ranges (indicated by the red line) with burring only because of the frontal sinus.

BAD INDICATION for a type 1 brow bone reduction: Despite what some surgeons might tell you, it is mostly not possible to bring a male forehead into normal female ranges (indicated with the red line) by just shaving because of the frontal sinus.

Type 2 brow bone reduction—Shaving and Filling

This option has a limited indication and is overused by surgeons that don’t perform type 3 forehead reconstructions. It can be used properly when the projection angle between the nose and the forehead is already satisfying. Only the concavity behind the bossing has to be addressed in that case. The concave area above the bossing will be filled with bone cement.

If a type 2 brow bone reduction is used when not really indicated, a ‘heavy’ dolphin-like forehead will be created. As you can see, although the new forehead is smooth, it bulges forwards when compared to the “ideal” female forehead line (which is indicated in red on the drawing below).

BAD INDICATION for a type 2 brow bone reduction: If a type 2 brow bone reduction is used when not really indicated, a ‘heavy’ dolphin-like forehead will be created. As you can see, although the new forehead is smooth, it bulges forwards of the “ideal” female forehead line (the ideal female line is indicated in red).

Comparison of the brow bone reduction type 2 and 3 if you have a heavy forehead.

Type 3 brow bone reduction—Forehead reconstruction

The forehead recontouring procedure we perform the most (since it is indicated most) is called the ‘type III’ procedure by Dr.Mohammadimofrad During this procedure, the anterior wall of the frontal sinus bone is removed, remodelled and put back. Sometimes it is necessary to use a combination of forehead reconstruction and some filling with bone cement to get the desired forehead shape. Dr.Mohammadimofrad uses the bone cement more and more often to get the exact result he wants.

INDICATION for a type 3 brow bone reduction: frontal sinus wall has to be removed, shaved and placed back.

Reconstructed forehead after a brow bone reduction type 3.

Rx of the forehead before (left) and after (right) brow bone reduction type 3.

Type 4 brow bone reduction—Forehead reconstruction and Filling

Sometimes it is necessary to use a combination of forehead reconstruction and some filling with bone cement to get the desired forehead slope. Dr.Mohammadimofrad uses the bone cement more and more often to get the exact result he wants.

Brow bone reduction

Brow bone reduction

Before and after brow bone reduction type 4

Procedure

  • General anesthesia is given.
  • An incision is made along the hairline. The incision is made just like it would be made during scalp advancement surgery (forehead reduction).
  • The forehead skin is pulled forward to reveal the bone.

  • The solid orbital rims on the outside are shaved.
  • During a type 3 brow bone reduction, the central bone plate that covers the frontal sinuses is removed, thinned until the desired thickness is achieved, and reshaped.
  • Finally, the refined bone plate is fixed in place with titanium micro screws. The heads of the screws are removed so they cannot be felt or seen through the skin.

The plate of the frontal sinus is fixated with screws.

  • As with scalp advancement, the skin is fixed to the bone using Endotines to prevent it from pulling back.

Recovery

  • Hospital—You will spend one night at the hospital following surgery.
  • Pain—Pain may occur for a few days, and is manageable with normal painkillers.
  • Work—Many patients can go back to work within two weeks following this surgery (as a stand-alone procedure).
  • Sport—Avoid physical activity that causes sweating or a rise in blood pressure for eight days.
  • Sutures—Sutures are self-dissolving. They dissolve in about a week’s time.
  • Forehead Numbness—Expect your forehead to be numb for about 3 months.
  • Blurred Vision (seldom, 5%)—Because of swelling around the eyes, some patients have noticed some degree of blurriness for 1 to 4 months.

Complications

  • Changed feeling of the scalp—Because the skin is detached from the bone during the forehead recontouring it is possible the feeling in the scalp changes. In most of the patients, sensation returns to normal within the year, but some patients report the feeling doesn’t return to normal 100%. Most don’t report this as a problem, but rather something they noticed.
  • Infection
  • Asymmetry
  • Non-satisfying aesthetic result
  • Double vision in certain directions (temporary frequent, permanently rare)
  • Reduced sensation of the forehead skin (temporary always, permanently rare)
  • Changes to the shape of the frontal sinus could change the 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 which creates a ’surprised look’