Facial Feminization Surgery - Surgical Procedures - Forehead Recontouring

Forehead Recontouring

The forehead is the facial region most important for sex identification. Males tend to have a horizontal ridge of bone running across the forehead just above eyebrow level called the brow ridge or “brow bossing” while female foreheads tend to be smoother, flatter and have less bossing, or bossing that project just below eyebrow level. The outer segments of the bossing that the eyebrows sit on are called the “supraorbital rims”.

The supraorbital rims are usually solid bone and can simply be ground down. The section of bossing between the eyebrows (the glabella) sits over a hollow area called the frontal sinus. Because the frontal sinus is hollow it can be more difficult to remove bossing there. If the bone over the frontal sinus is thick enough the bossing can be removed by simply grinding down the bone, however if the wall of bone is too thin it may not be possible to grind the bossing away completely without breaking through the wall into the frontal sinus. FFS surgeons have taken 3 main approaches to resolving this problem:

1. Most FFS surgeons can perform a procedure called a forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled, in the new feminine position with small titanium wires or titanium microplates and screws.

2. Some surgeons grind down the wall of bone as far as possible without breaking through and then build up the area around any remaining bossing with hydroxyapatite bone cement if necessary. The hydroxyapatite bone cement, commercially available as BoneSource, can smooth out any visible step between remaining bossing and the rest of the forehead to provider a smoother, more feminine appearance. In these cases some additional reduction in the bossing can sometimes be achieved by thinning the soft tissues that sit over it.

There is a debate within FFS circles about whether it is best to remove the bossing with a reconstruction or to use the build-up method to disguise it. Some feel that a reconstruction is too invasive and that disguising the bossing is just as effective as removing it. Others feel that disguising the bossing is an unacceptable compromise and that it can sometimes leave the forehead with an unnatural bulge - these patients would rather have the bossing completely removed with the reconstruction technique.

3. Some FFS surgeons now offer a compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.

Male foreheads also often have various indented areas. For example, the centre of the forehead is often slightly indented. These areas can be filled with hydroxyapatite during surgery to smooth them.