type 1 forehead reduction

What is a type 1 forehead reduction in facial feminization surgery (FFS)?

Type 1 forehead reduction describes a specific technique to reduce brow bossing (brow protrusion). This type of procedure 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.

History of forehead reductions for FFS

The term “type 1” comes from research performed by Dr. Douglas Ousterhout.[1] In his research, he noticed there were three types of foreheads he encountered when performing modifications of frontal bossing. A type 1 forehead is one where the brow bossing can be addressed with burring alone. A type 2 forehead is one where the brow bossing was addressed by burring the bone low on the forehead and augmenting the upper forehead using artificial material to improve the transition. A type 3 forehead is one where the brow bossing needs to be addressed by making cuts in the forehead bone and repositioning that bone.

Contouring the forehead can occasionally involve only burring of the bone in that region (type 1 forehead reduction). Contouring alone is only possible when a patient’s anatomy is appropriate for that procedure. If the frontal sinuses are large, then burring the forehead bone would either produce an inadequate setback or result in the creation of a large hole into the frontal sinus before an appropriate degree of forehead setback is reached. The presence and size of frontal sinuses are commonly evaluated preoperatively using x-ray imaging or a CT scan.

type 3 forehead
This illustration demonstrates a type 3 forehead that requires a type 3 cranioplasty (cutting and shifting the brow bone) for adequate correction of the forehead.
burring a type 3 forehead
If only burring is performed on a type 3 forehead and the surgeon stops before creating a hole in the frontal sinus, there is frequently incomplete correction of the brow bossing.
burring a type 3 forehead creates a hole in the frontal sinus
If the surgeon continues to bur the frontal bone in order to achieve a greater forehead setback, then a large hole can be created in the frontal sinus.

The illustrations below demonstrate a type 1 forehead reduction on a type 1 forehead. This type of forehead reduction requires that the frontal sinus be small or located behind the desired setback location. With a frontal bone (forehead bone) of this anatomy, one can simply bur the bone in this region to obtain the desired degree of setback.

type 1 forehead
A type 1 forehead has a small frontal sinus or only requires a minimal amount of setback. There is no need for a type 3 cranioplasty (cutting and moving the brow bone) with this type of anatomy.
burring a type 1 forehead
A type 1 forehead can be set back with burring alone. In this scenario, it is not necessary to perform a type 3 cranioplasty (cutting and moving the brow bone) in order to achieve the desired result.

How much does a type 1 forehead reduction cost?

The cost of a type 1 cranioplasty depends on a few factors. The primary factor is whether insurance will cover the procedure. It may also vary depending on whether additional procedures are being performed during the same operation. There are also variations between surgeons.

You may contact our office to gain a better idea of the cost for your specific scenario.

How is the recovery after a type 1 forehead reduction?

Recovery from a type 1 cranioplasty is relatively easy. There will be an incision in the scalp, which is performed to provide surgical access to the forehead bone. There will be swelling of the forehead that will significantly reduce over the first few weeks but may take a few months to reach its final state.

What is the best location for a scalp incision in facial feminization surgery?

 

How painful is the recovery?

This portion of a facial feminization operation produces relatively little pain. There will be swelling around the eyes, which produces discomfort, and there will be some degree of a headache. Pain is easily managed with oral pain medications.

 

How much time do I need off work after a type 1 forehead reduction?

Taking at least one week off work is ideal. This allows the swelling to subside and for the incisions to become less noticeable. Depending on the extent of surgery and the desire for privacy, some people opt to take a few weeks off work to allow the incisions to heal more completely and for the swelling to subside more significantly.

 

What are the risks of a type 1 cranioplasty?

A type 1 cranioplasty is safer than a type 3 cranioplasty. It is less likely to result in contour irregularities and there are fewer concerns about instability of the frontal bone. As with any forehead reduction technique, there is a chance of nerve damage to the nerves that move the forehead and eyebrows and the nerves that supply sensation to the forehead. There is a possibility of having asymmetries and contour irregularities.

It is uncommon that someone will be a candidate for a type 1 cranioplasty since it requires the presence of very small frontal sinuses. More commonly, one’s individual anatomy will require performing a type 3 cranioplasty (cutting and moving the brow bone).

 

How long will the results last from a type 1 forehead reduction?

This is a permanent procedure. The bone does not grow back in this region to an extent that would produce brow bossing later in life.

 

What can be done if a type 1 forehead reduction was performed and there is inadequate reduction of brow bossing?

Some patients with a type 3 forehead undergo a type 1 cranioplasty. In these scenarios, they may have an inadequate reduction of their frontal bossing or holes into their frontal sinuses. A surgical revision is required in these cases in order to correct the issue. This may require performing a type 3 cranioplasty.

What is a type 3 cranioplasty?

 

Am I a candidate for a type 1 forehead reduction?

It is important to discuss facial feminization surgery with your surgeon to determine your candidacy. It is uncommon for a type 1 cranioplasty to provide a sufficient amount of setback for most patients. Most patients have a large frontal sinus that prevents sufficient setback with burring alone.

A consultation with us commonly includes a CT scan of the facial bones to determine which type of forehead setback is best for you.

Contact us here to make a consultation with Dr. Mittermiller to see what type of forehead reduction is best for you and whether you are a candidate for a type 1 forehead reduction in Los Angeles.

Citations

  1. 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/

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