Type 3 Forehead Reduction for Forehead Feminization
A type 3 forehead reduction (also referred to as a type 3 brow bone reduction or type 3 cranioplasty) is performed for people with excessive brow bossing who wish to undergo brow bone reduction surgery. This type of Brow Bone Reduction Surgery is commonly performed for transgender women, however it is also done for cisgender women and cisgender men who are dissatisfied with the appearance of their forehead. This is one of the few surgical procedures that are commonly used for Forehead Feminization as part of more general Facial Feminization Surgery.
The term “type 3” comes from the original research performed by Dr. Douglas Ousterhout.1 In his original research on the topic, he noticed there were three types of foreheads he encountered when performing modifications of frontal bossing with surgery. A type 1 forehead was one where the brow bossing can be addressed with burring alone. A type 2 forehead was one where the brow bossing was addressed by burring the bone low on the forehead and using the addition of an artificial material higher on the forehead to improve the transition. A type 3 forehead was one where the brow bossing needed to be addressed by making cuts in the bone and repositioning that bone. Type 3 brow bone reduction refers to this procedure.
Contouring the forehead can rarely involve simply burring the bone in that region. More commonly, cuts need to be made into the frontal sinus in order to move the bone backwards. If one were to simply shave down the bone at the forehead, holes would be produced into the frontal sinus and a large setback would be unobtainable.
These illustrations demonstrate the desired effect on a skull from reduction of forehead bossing. Notice the prominent frontal bone bossing above the root of the nose.
When there is a large frontal sinus, it can be necessary to make cuts into the frontal sinus in order to move the outer surface of the bone. This is more easily explained using a cross-section of the skull. The image below demonstrates a cross-sectional view down the center of the face. It shows brow bossing from a profile (sagittal) view. In this view, the frontal sinus is shown in black. It is bordered by bone on the front (anterior) and back (posterior) sides.
When there is a large frontal sinus, it can be necessary to make In order to reposition the outer piece of bone (the anterior table of the frontal sinus), cuts need to be made around the edges of the frontal sinus.
This allows the front part of bone to be removed and contoured to the appropriate forehead shape. After removing the bone from the patient, the piece is contoured to create a round forehead.
The anterior table of the frontal sinus is then replaced at a position behind (posterior to) to its original position. In this position, the brow bossing is removed and a more feminine facial profile is obtained.
Dr. Mittermiller is a plastic surgeon with specialty training in craniofacial surgery and facial feminization surgery. He is primarily located in Los Angeles, California and serves the broader Southern California area.
Contact us today to schedule a consultation.
Frequently asked questions
Am I a candidate for type 3 forehead reduction?
A question people often want to know is whether they can have a type 3 or a type 1 forehead reduction. The answer to this question should be primarily dependent on the patient’s anatomy. If they have no frontal sinus, then it is possible to do a large reduction with only a type 1 forehead reduction. However, if the patient has a large frontal sinus with thin bone, then a type 3 brow bone reduction will likely produce the best results.
What are the risks of a type 3 brow bone reduction?
A type 3 brow bone reduction has all the same risks as any brow bone reduction plus a few additional risks. Risks that occur with any type of brow bone reduction include injury to the nerves supplying sensation or motion to the forehead and wound healing difficulties. There will be a scar from exposure of the forehead.
In addition to the standard risks, a type 3 reduction has a few additional risks. These include problems with bone healing, infection of the bone graft, poor positioning of the bone graft, and problems related to the sinuses themselves such as mucocele formation (rare).2
Before and After Photos
Before and after photographs can be important for patients to see the degree of movement that can be obtained with type 3 brow bone reduction. These photographs can be seen in the Facial Feminization Photo Gallery.
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- Ousterhout DK (1987) Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 79 (5):701-713. doi:10.1097/00006534-198705000-00003. https://pubmed.ncbi.nlm.nih.gov/3575517/
- S. Khetpal, F. Dahoud, A. Elias, Justine Lee PC23. Feminization of the Forehead: A Systematic Literature Review and Cohort Study of Transfeminine Patients. In: AAPS 2023 Meeting, 2023.