The reconturing of a forehead bone can be done alone or as part of a facial feminization surgery. The most frequent incision is made along the hairline, just in front of it, but in some cases it can be done across the hair bearing scalp as well, in order to better conceal the resulting scar. The hairline incision is the preferred one when the patient has a receding hairline and wants to correct it along with the forehead contouring. It also allows doing a brow lift without lifting the hairline at the same time.
In some cases, grinding down (“shaving”) the brow ridge is enough to obtain a forehead feminization, but in about 95% of the cases, a reconstruction of the external wall of the frontal sinuses is necessary (see below Forehead Reconstruction or shaving? What type of forehead contouring surgery suits my forehead best?)
Then, using the same incision, the surgeon lifts the soft tissues of the forehead to adapt the eyebrows to the new skull outline and to give them a more feminine shape, which is called forehead lift or brow lift. If necessary, a feminization of a male hairline can be achieved by softening the corners of the M shape and/or advancing the scalp up to 2cm towards the forehead.
What makes this facial area look feminine is not only the brow-ridge shape but also the amount of projection the whole forehead bone has over the eyes (even if doesn't show a brow ridge at all) . These pictures show examples of the forehead reconstruction procedure and belong to 4 different patients with different degrees of brow bossing. Shaving the forehead bone wouldn't have been enough to achieve a good extent of feminization, and thus the reconstruction procedure was chosen for all of them. The photos were taken at different stages of recovery, so some of them still show some swelling. The yellow lines indicate how much the distance between the forehead surface and the eyes surface was reduced and how much this reduction of the brow bossing changed the perception of the forehead from male into female. Female eyes look female not because of any difference in the eyes themselves, but due to differences in the surrounding facial bones.
In order to set back the projection of a male forehead to a female range, several procedures can be used, being reconstruction and shaving the most common. Shaving is also called burring or grinding.
What is the difference between reconstruction and just shaving? The brow bossing is a kind of external shell that covers two empty cavities called frontal sinuses, which are within the frontal bone. These facial x-rays show them.
This external shell of the forehead bone can be shaved up to the point where the frontal sinuses are reached. That is the limit for "forehead shaving " because going further would mean getting through the wall and leaving the sinus uncovered. This shell (called anterior wall of the frontal sinus) can be thin or thick, depending on the patient's facial skeleton. When it is thinner than the amount of reduction needed (the vast majority of cases) a “reconstruction surgery” of the frontal bone surface becomes the technique of choice for the recontouring to result in a real feminization. "Reconstruction" (popularly known as type 3 procedure) means removing the external wall of the forehead bone in a way that the sinus gets uncovered, shaving the surrounding surface and the orbital rims to reduce their projection, and then putting the external wall back to cover the sinus again (like it if it were a bony cap). This generates a new forehead surface that is placed more backwards than before.
Dr. Di Maggio puts small pieces of bone (bone chips) into the sinus before covering them again. They are remains of the forehead reduction and are meant to give support to the anterior wall when it is put back in place. This way the grafted wall gets propped from inside by these pieces of bone and he doesn’t need to use titanium screws, plates or mesh to keep it stable. He uses some bone dust mixed with the patient’s own blood to fill the gaps between the grafted piece of wall and the solid frame. This bone dust is produced during the process of sawing and grinding the forehead bones and has the function of a “finishing plaster” on the outside.
The mucosa into the sinus is removed and the sinus defunctionalized, so the probabilities of getting infections are very low. According to Dr. Di Maggio, this is the kind of treatment that a frontal sinus is given after a car accident, in order to reduce the risk of infections to the minimum possible.
By means of a "forehead reconstruction surgery" the forehead projection can be set back as close to the ideal female range as needed. Some of our patients got about half inch of projection removed. Many times the nose must be operated along with the forehead contouring because the surface of the forehead is moved more backwards than where the top of the nose is.
It is important to point out that although forehead recontouring is agressive surgery, it is just facial plastic surgery and in no cases will the brain be exposed, since all the work is done on the external surface of the skull, no matter which contouring technique is used (shaving or reconstruction).
With Dr. Di Maggio’s reconstruction technique the anterior wall of the frontal sinus isn’t left any less strong than before, unlike what happens with the shaving technique that makes the anterior wall of the frontal sinus thinner and more fragile. There is an area of the forehead that is left thinner and thus less strong than before, though, with both reconstruction and shaving: the orbital rims.
If your forehead contouring for facial feminization (brow bossing reduction surgery) is combined with a scalp advance, the scar will be on the top of the forehead, along the hair line. It will gradually fade to light pink during the first 6 months and finally, after about a year, it should acquire the same color as the rest of the skin and get barely visible. If a scalp advance is not needed and the forehead contouring is then made through a coronal incision, then the scar will be on the top of the head, from ear to ear, concealed by the hair.
See our results. This page gathers before and after photo examples of our facial surgeries.