Forehead contouring is probably the most noticeable and effective part of a Facial Feminization Surgery.

The forehead is one of the facial features that more clearly reveals whether a person is male or female. Male foreheads are markedly different from female ones, although most people don't realize it.

A female forehead is considered pleasant when it shows a smooth and even surface. They tend to draw a vertical line on the facial profile. Male foreheads are instead sloped with a pronounced brow bossing. This brow bossing (brow ridge) is solid bone on the orbital rims, but hollow over the frontal sinuses, right above the nose.
The male hairline tends to be shaped like an M, whereas in women it tends to be shaped like an arch and it's closer to the eyebrows.

Best Candidates for Forehead Recontouring

The ideal candidates for forehead contouring surgery are patients who have masculine, misshaped, sloping, indented, depressed, or irregular foreheads which cause an unaesthetic or a manly appearance. Results achieved through a forehead contouring surgery markedly improve the aesthetic appearance of the forehead which in turn enhances the entire facial appearance of the patient to look more feminine.

Preparing for Forehead Augmentation

The reconturing of a forehead bone can be done alone or as part of a facial feminization surgery. The most frequent incisions are the coronal incision, which runs from ear to ear on top of the head, and the hairline incision that is made along the hairline. The latter is mainly used when the patient has a receding hairline and needs a scalp advancement done along with the forehead contouring.

Through any of these two incisions the surgeon access the forehead bone and starts contouring. In some cases, shaving the brow ridge is enough. In other cases, a reconstruction of the external wall of the frontal sinuses becomes necessary.

In some cases, a surgical paste can be applied to smooth out the forehead surface and complement the feminization procedures mentioned before, but this is very rare.
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 feminine shape, which is called forehead lift or brow lift. If necessary, a feminization of a male hairline can be achieved by softening the vertexes of the M shape and/or advancing the scalp towards the forehead.

Forehead Reconstruction or Shaving

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 "shaving surgery" because going further would mean leaving the sinuses uncovered. This shell (called anterior wall of the frontal sinuses) 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 sinuses get uncovered, shaving the surrounding surface and the orbital rims to reduce their projection, and then putting the external wall back to cover the sinuses again (like it if it were a bony cap). This generates a new forehead surface that is placed more backwards than before. Titanium mesh and screws are used for the bone pieces to knit together properly.

By means of a "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 placed before surgery.

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).

Forehead Contouring Results

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.

Once the forehead is shaped to its desired position and balanced with the rest of the face the small fragment is held in place snug with the body’s natural tissues, in some cases with a tiny titanium screw, and a special “bone cement”.   This “cement” is the patient’s living bone ground down to a smooth paste and laid over the broken bones helping the bones heal rapidly in their new position.

Recovery After Forehead Contouring

The forehead recontouring (brow bossing reduction surgery) is perhaps the facial surgery that hurts the least during the recovery period (whether the recontouring procedure performed is shaving or reconstruction). It usually gets rid of swelling before other facial areas too (swelling is mostly liquid and slides down from top to bottom). It might be numb for some time after the recontouring, but during the following 6 months the sensation will gradually become normal again. Usually the eyebrows take several months to settle into a definitive position, which can limit facial expressions meanwhile. Bruises may appear and descend to lower facial areas before vanish.

If a scalp advance was done along with a forehead recontouring, you will have a scar along the hairline. You may be able to return to some of your social activities 10 days after the forehead contouring surgery. A head scarf will help conceal the scar. You will have to wait at least one month after the forehead contouring surgery prior to do any hard work or physical exercise. Sleeping with your head elevated and ice packs on the brow bossing area during the first days favor the healing process.

During the first weeks after forehead contouring some patients tend to suffer from depression. You may find it difficult to come to terms with the new look of your brow bossing and you may even feel that having a surgery was a big mistake. But don’t worry: most of people who today are happy and satisfied with the results of their forehead feminization surgery have also gone through that phase.

Forehead Contouring Post Operative Care

Because breast tissue is stretched and separated, and because implants are inserted through incisions, the breasts will be bruised, sore, and swollen after surgery. You can expect to wear a surgical bra for several days. There may be some moderate pain, but that can be treated by a prescription from your plastic surgeon. Your doctor may suggest that you wear an athletic or support bra until the swelling has subsided.

Heavy lifting or straining should be avoided after surgery because this can cause the breasts to swell and increase pressure. You can typically return to work within a week and to full activity within a few weeks. Sensation in your nipples may be reduced temporarily, but should return to normal as your breasts heal. Breast feeding usually is not hindered; however, it is important to ask the doctor about breast feeding during your initial consultation.

After healing, some permanent scarring will remain. Scars are typically small and inconspicuous. Your surgeon’s goal will be to make them as unnoticeable as possible. Inframammary and periareolar incision scars are on the breast. Transaxillary or TUBA incisions can be placed in a natural fold in the skin under the armpit, virtually unnoticeable after surgery.

Possible Forehead Recontouring Risks

Every surgery, no matter how simple it might be, has certain risks, and we should not rule them out. However, it is very unlikely for a forehead contouring by shaving or reconstruction to present any complications when performed by a qualified facial feminization surgeon.

Risks and Complications of Forehead Contouring:

• Adverse reactions to anesthesia. Asymmetry. Even though the surgeon marks very carefully the areas he is going to operate, there may be asymmetries.
• Infections, although they are very unusual if you take the right antibiotics.
• Uneven surface.
• Long lasting numbness on the scalp.
• Nerve damage.
• Hair loose by the scar line, due to excessive traction.
• Bad or hypertrophic scarring.
• Titanium or other implants rejection (extremelly unusual)
• Palpability. The heads of titanium screws or the edges of titanium mesh can become touchable. This is acceptable as long as they don't become visible.