Brow Bone Reduction Surgery – Los Angeles

Brow bone reduction surgery is a key component of forehead feminization and facial feminization that seeks to further remove masculine features and feminize the forehead. This surgery can be performed for cisgender, transgender (MTF), and gender non-binary or non-conforming individuals.

The term brow bone refers to the portion of the frontal bone above the eyes. Brow bossing is when there is a prominence of the brow bone above the eyes. Brow bossing is often associated with a masculine appearance. Reducing the degree of brow bossing is a critical component of facial feminization surgery. In men, this bone is typically more prominent. In women, the brow bone is rounder and further back. Brow bone reduction or brow bone setback is performed to soften this masculine feature and enhance one’s feminine features.

Dr. Mittermiller is one of only a few surgeons in California and the states with specialty training in craniofacial surgery and facial feminization surgery.

Introduction

What is brow bone reduction surgery for FFS?

Brow bone reduction surgery is typically performed as part of forehead feminization, which is a subset of facial feminization. Men typically have a more prominent brow bone, resulting in excess brow bossing or brow prominence. A brow bone reduction is performed to reduce the brow bone prominence.

Brow bone reduction for FFS (Facial Feminization Surgery) is typically referred to as three types based on the original paper by Douglas Ousterhout.¹ 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.

There are multiple terms used to describe a brow bone reduction. These include the following:
Forehead reduction
Brow bossing reduction
Brow bossing surgery
Frontal bossing reduction
Forehead cranioplasty
Frontal bone cranioplasty

Why is an FFS brow bone reduction performed?

A brow bone reduction is performed for cisgender women to increase feminine appearance and for transgender women, gender non-binary individuals, and gender non-conforming individuals to relieve symptoms of gender dysphoria. The procedure reduces the masculine appearance of the face by softening appearance of the forehead and reducing brow bone protrusion.

Surgery

What are the forehead bone reduction techniques used for FFS?

Forehead bone reduction is performed using a variety of techniques. As mentioned previously, when considering a patient for forehead bone reduction, there are three types of foreheads as described by Douglas Ousterhout. These types (1, 2, and 3) are described below.

Type 1 brow bone reduction

A type 1 brow bone reduction is performed by burring the forehead bone at the area of the planned reduction. This technique does not create any cuts into the bone. Depending on the presence and size of the frontal sinus, there may be limitations to how much of a reduction can be achieved with this technique. Additional details about this type of procedure can be found here: type 1 brow bone reduction.

Type 2 brow bone reduction

A type 2 brow bone reduction is performed through a combination of making the lower forehead less prominent and adding material to the upper forehead to move it forward. This allows for creation of a rounded forehead. In general, this type of forehead bone reduction is performed least commonly. This type of forehead bone reduction can be helpful for patients who have a visible brow ridge, but do not have a very prominent forehead bone in relation to their eyes.

Type 3 brow bone reduction

A type 3 brow bone reduction is performed by making cuts in the bone of the forehead and moving the bone backwards. This type of forehead bone reduction is the one most commonly performed by facial feminization surgeons. Additional details can be found here: type 3 brow bone reduction.

What type of incision is used for a brow bone reductions?

In general, the approach to the forehead bone is the same for all these types of foreheads. The most common approaches involve creating an incision either across the top of the head (coronal incision) or through a hairline incision. Both of these incisions for a forehead bone reduction extend from above the ear on one side to above the ear on the other side.

A coronal incision is placed within the hair over the top of the head. It usually heals well and produces a barely visible scar since it is covered easily by hair. A hairline incision is placed within the hair on the sides of the head and at the border of the hair and non-hair bearing forehead skin in the front of the forehead.

A hairline incision is used for patients who are undergoing a hairline lowering (aka scalp advancement) procedure at the same time as the forehead bone reduction. The coronal incision is used when there are no incisional modifications being done to the hairline.

What are the risks of brow bone reduction?

There are multiple nerves that provide sensation and motion to the forehead. The nerves that provide sensation to the forehead and the front part of the scalp are often encountered when performing the brow bossing surgery. It is possible for these nerves to be injured during forehead bone reduction, resulting in numbness on one or both sides of the forehead. Most patients will have some degree of numbness immediately following the operation that recovers over the following weeks to months. In some patients, the numbness can be permanent.

The nerves that supply sensation to the forehead pass through either notches or foramina (holes) in the frontal bone. Brow bossing surgery can often be performed with minimal manipulation of the nerves. In some cases, additional manipulation of the nerves is necessary based on a patient’s unique anatomy.

Frequently Asked Questions

Prior to Consultation

Am I a candidate for brow bone reduction?

FFS brow bone reduction is offered for cisgender, transgender (MTF), and and gender nonbinary or nonconforming individuals who are seeking to feminize their face. It can be the correct choice for people who are hoping to soften the masculine features around the eyes and enhance one’s natural feminine features.

In some cases, patients may have minimal brow bossing and a brow bone reduction may not be necessary for that patient.

Candidacy for surgery depends on multiple variables. One may not be an ideal candidate if they have medical problems that can result in significant complications from anesthesia.

Insurance companies sometimes cover facial feminization for the treatment of gender dysphoria, which results when there is an incongruence between one’s physical traits and one’s gender identity.

Can a cisgender woman or cisgender man undergo brow bone reduction?

Yes, cisgender women and cisgender men can get orbital rim contouring. Cisgender women often undergo the procedure to obtain a more feminine forehead. Cisgender men request brow bone reduction for excessive brow bone prominences.

How much does a brow bone reduction cost?

The cost of a brow bone reduction depends on multiple factors. The primary factor likely revolves around insurance coverage. When insurance covers brow bone reduction, the patient is responsible for covering the charges that are passed on to the patient. This varies from patient to patient depending on their individual insurance plan. The best way to determine cost of a brow bone reduction through insurance is to contact the office of the surgeon to discuss your insurance plan or to contact the insurance company directly.

When considering self pay for brow bone reduction there are additional factors affecting the cost.
Surgeon experience – More experienced surgeons generally charge higher rates than less experienced surgeons.
Hospital or surgery center – Undergoing the procedure at a hospital is generally more expensive than undergoing the procedure at a surgery center.
Anesthesia – Anesthesia costs depend on the experience of the anesthesia provider and duration of the operation.

Recovery

Are there scars after brow bone reduction surgery?

The scars associated with FFS brow bone reduction is related to the location of the incisions. A coronal incision (an incision that goes over the top of the head) is usually very well hidden within the hair. A hairline incision does leave a visible scar that can be slightly hidden with the adjacent hair.

How is recovery from brow bone reduction surgery? Is it painful?

Reduction of brow bone protrusion is usually not very painful. When performed with other facial feminization procedures, it is usually not a source of primary concern. When a scalp incision is used to access the orbital rims, there will be swelling of the forehead that can persist for a few months postoperatively. The major effects from surgery to reduce brow bone protrusion are usually obvious immediately following surgery. There can sometimes be significant swelling or bruising of the eyelids that takes a few days to resolve.

Can I see before and after photos of a brow bone reduction?

Dr. Mittermiller is continuing to update the before and after photos that are being shared publicly. In addition to the photographs shared publicly, he has photographs of postoperative patients that he can share privately during a consultation. The publicly-available photographs can be reviewed in the website gallery through the link below:

Facial Feminization Photo Gallery

References

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/