Forehead Feminization Surgery (FFS Forehead) – Los Angeles

Forehead feminization is performed to remove masculine features and soften the forehead. This surgery can be performed for cisgender, transgender (MTF), and gender non-binary or non-conforming individuals. Women often have rounder foreheads with less prominent brow bones. Forehead feminization aims to soften masculine features and enhance 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 forehead feminization surgery?

Forehead feminization surgery, also referred to as forehead FFS, forehead reduction surgery, brow bone reduction, brow bone shaving, or brow bone contouring, often involves a few different components. It commonly involves a hairline lowering procedure, setting back the brow bone, contouring the orbital rims, and performing a brow lift.

Hairline lowering, or forehead reduction, can be performed through a few different methods. The most commonly performed methods are through a scalp advancement or through hair transplantation.

A brow lift can be performed through a variety of techniques and most commonly involves lifting the eyebrows from where they are positioned on the forehead.

A brow bone reduction, brow setback, or brow bossing reduction can be performed through a variety of methods. The terms most commonly used originate from Dr. Ousterhout’s original work on the topic.¹

He noticed three types of foreheads during his procedures. He labeled these type 1, type 2, and type 3 foreheads. A type 1 forehead is one that can be set back with shaving alone. A type 2 forehead is one that is set back with shaving and then contoured with onlay of a material above the brow ridge to create a smooth contour. A type 3 forehead is one where cuts are made into the bone and the bone itself is moved backwards.

Brow bone shaving is commonly only performed for patients who have a “type 1 forehead.” This is a unique condition where the patient has frontal sinuses that are small enough and bone that is thick enough to achieve an adequate setback with shaving alone. See here for more information on a type 1 forehead reduction: What is a type 1 forehead reduction?

Orbital rim contouring involves shaving the bone located underneath the tails of the eyebrows or cutting the bone in this region. This opens the eyes allows more light to fall on them.

Why is forehead FFS performed?

FFS forehead surgery 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.

What are the benefits of forehead feminization?

Forehead feminization helps obtain a more feminine facial appearance and relieve symptoms of gender dysphoria.

Surgical Hairline Lowering

How is surgical hairline lowering performed?

A surgical hairline lowering or forehead reduction is performed by first creating an incision at the front of the hairline. The scalp behind the hairline is then separated from the underlying bone and advanced forward. A strip of skin is removed from the top section of the forehead where there is no hair. This allows the hair-bearing scalp to advance further down on the forehead. This form of hairline lowering does leave a scar at the hairline.

The scarring is minimized by using careful surgical technique during. the forehead reduction and can be reduced further by using a trichophytic incision. This type of incision involves creating an angled cut through the scalp so that hair will grow through a portion of the scar.

What are the risks of surgical hairline lowering or forehead reduction?

There are a few small nerves that provide sensation to the front of the scalp. The ends of these nerves are cut during the forehead reduction operation and the origin of the nerves are carefully protected. Even with careful protection, it is common for patients to have varying degrees of numbness of the forehead and scalp that can last up to 6-12 months and can sometimes be permanent.

Following surgical hairline lowering, there can be some degree of hair loss around the incision. The hairs will commonly grow back on their own, but some degree of hair loss around the forehead reduction incision can be permanent.

Hair Transplants

How are hair transplants performed?

There are a few methods for performing hair transplantation as a form of forehead reduction. Terms that are commonly used are FUT and FUE. FUT (Follicular Unit Transplantation) often involves removing a strip of hair-bearing scalp and cutting out individual hair follicle units. These units are then inserted, one-by-one into puncture wounds that are created in the scalp. FUE (Follicular Unit Extraction) is often performed with a machine that assists in removing individual follicular units directly from the scalp without removing a strip of the scalp first.

The hairs are then transplanted to the front of the scalp to lower and/or change the shape of the hairline. In general, men commonly have a high M-shaped hairline and women have a low rounded hairline. The goal for forehead feminization with hair transplantation is to convert a high M-shaped hairline to a low, rounded hairline.

What are the risks of hair transplantation?

Hair transplantation is a relatively safe procedure. There is a chance of infection, poor take of the follicular grafts, incomplete correction of the hairline, and the need for additional hair transplantation procedures.

Brow lift

How is a brow lift performed?

There are multiple methods by which a brow lift can be performed. During facial feminization surgery, the most common approach is through a coronal brow lift or pretrichial brow lift. This means that excess scalp is removed at the site of the incision used to perform the brow bone reduction. The brow itself is re-suspended and secured during the procedure to a lifted position.

There are other methods by which a brow lift can be performed. These minimally invasive brow lifts are frequently performed either through small incisions within the hair-bearing scalp or through incisions in the upper eyelids.

What are the risks of a brow lift?

The risks of brow lifts include many of the same risks listed above such as bleeding, damage to the nerves of the forehead (sensation and motion), asymmetric postoperative brow position, or gradual loss of the effect.

Brow Bone Reduction for Brow Bossing

How is a brow bone setback for brow bossing performed?

As mentioned previously, there are a few methods for performing a brow bone setback for brow bossing. Broadly speaking, this involves either shaving the forehead or moving back the bone of the forehead by repositioning of the bone. Please read the articles below to learn more about a type 3 forehead setback and a type 1 forehead reduction.

What is a type 3 forehead setback?
What is a type 1 forehead reduction?

What are the risks of a brow bone setback for frontal bossing?

Frontal bossing reductions are generally safe procedures. The greatest concern with this procedure is the possible risk of injury to the brain or the covering of the brain. The cosmetic risks include the possibility of acquiring asymmetries or bony irregularities.

As with all operations, additional risks include bleeding, infection, and scarring. There are also the usual risks associated with general anesthesia.

There is a chance of injuring the nerves that provide sensation to the forehead and the nerves that provide motion to the forehead.

Before proceeding with your operation, you should find a surgeon with experience in this type of procedure and make sure they are the best forehead ffs surgeon for you, whether that be in Los Angeles or another city.

Orbital rim contouring

How is orbital rim contouring performed?

Orbital rim contouring is almost always performed at the same time as a forehead bone setback. Many surgeons consider orbital rim contouring to be a necessary part of any forehead setback.

The orbital rims are accessed the same way as a brow bone reduction. An incision is made either within the hairline or behind the hairline. The skin of the forehead is lifted off the bone to expose the orbital rims. The orbital rims are then reduced using either a shaving technique or creating cuts in the bone at the upper, outer part of the orbital rims.

Frequently Asked Questions

Prior to Consultation

Am I a candidate for forehead feminization surgery?

Forehead feminization surgery (forehead FFS) 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 masculine features and enhance feminine features.

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 cisgender women get forehead feminization surgery?

Yes, cisgender women can get forehead FFS. The same procedures performed for transgender women (MTF FFS Forehead) can be performed for cisgender women to reduce masculine features and enhance their feminine features.

How much does it cost to have forehead feminization surgery near me in Los Angeles, California?

The cost of forehead feminization surgery is extremely variable and depends on multiple factors. Some of these factors are included below:

Is insurance covering a portion or all of the operation?
How many procedures are being performed during the operation?
How long is the operation?
Where is the operation being performed (surgery center or hospital)?
How expensive is the specific surgeon’s pricing?

The best way to get an estimate for the cost of forehead feminization surgery is to contact a surgeon who specializes in forehead feminization to discuss your specific situation. Costs will vary between LA and other cities or states.

According to a 2022 article by RealSelf, the average cost of a surgical hairline lowering, or forehead reduction, is $8,500 and ranges from $4,000 to $13,500.²

According to a 2022 article by Realself, the average cost of hair transplants is $7,300 and can go as high as $25,000. ³ These costs are especially variable because each individual requires a different number of hair transplants, which often drives the cost. The cost is also dependent on whether the transplants are being performed at the same time as the other forehead feminization procedures, or at a later date in the clinic.

According to a 2022 article by RealSelf, the average cost of a brow lift is $7,200 and can be as high as $15,000.⁴

There are no great references discussing average cost of brow bone reduction surgery. The range of the cost for this procedure usually ranges between $7,000 and $20,000 based on anecdotal evidence.

Of note, it is difficult to know how much of cost listed above is driven by insurance-based or out-of-pocket procedures. The final cost to the patient will likely be much lower if the cost is shared between the patient and the insurance company.

There are multiple insurance companies that cover forehead feminization surgery in California and Los Angeles. Dr. Mittermiller and his office have experience working with patients and their insurance companies to help them afford these procedures.

It sometimes happens that a patient’s insurance does not cover forehead feminization or a patient does not want to wait for the insurance approval process. In this scenarios, self-pay options are permitted.

Click here for more information on Dr. Mittermiller’s financing options: Financing Surgery

Click here for additional information on whether specific insurance companies cover facial feminization surgery (FFS): Insurance Coverage of FFS

What happens during a consultation for forehead feminization surgery?

During your consultation, many items will be discussed. Your surgeon will first want to know whether there any facial features that are particularly concerning to you. Your health and any medical issues will be reviewed. The possible surgical options will be discussed with you and the advantages and disadvantages of these procedures will be explained.

During the consultation, the surgical process and the recovery period will be discussed. If it is indicated, a CT scan may be performed to better evaluate the anatomy of the frontal bossing. Photo simulations of the surgical results may also be performed to help discuss the procedures.

Can I travel to Los Angeles for forehead FFS consultation and surgery?

Our office in Los Angeles is familiar with helping patients who travel from outside Los Angeles with determining whether Dr. Mittermiller is the best forehead feminization surgeon for them.

There are multiple options for housing and hotels in Los Angeles that are located near the clinic and operating suites.

Los Angeles has wonderful, pleasant weather all year. This allows patients to easily travel to Los Angeles and make their way around the city of Los Angeles.

Oftentimes, patients who travel to LA for surgery will take advantage of their trip by adding experiences. Arriving early or staying late offers opportunities to enjoy the many sites in Los Angeles and California.

Recovery

Are there scars after forehead feminization?

The primary issue determining scarring after forehead feminization is whether an incision was created and where the incision is located. Brow bone setback or brow bone contouring often requires either a pretrichial (in front of the hair) or coronal (over the top of the head) incision. The pretrichial incision is more visible than the coronal incision because it is locate at the border of the hair-bearing scalp and the non-hair-bearing forehead. Care is taken to limit scarring, but the scar will never be invisible. If performed postoperatively, hair transplants can be used after a pretrichial incision to further hide the hairline scar.

The coronal incision is often hidden will within the hair and with long hair can be extremely difficult to see.

How is recovery from forehead feminization? Is it painful?

Forehead FFS is often not very painful compared to the other components commonly performed during facial feminization surgery. Patients can expect to have some pain, bruising, swelling, and numbness. The areas around the eyes often become very swollen and sometimes the eye itself can have small broken blood vessels that heal on their own without nay long term complications.

It is usually recommended that patients take at least 1 week off work to recover from in the immediate postoperative period. It can sometimes be beneficial to take a second week for additional recovery.

The swelling of the upper face is usually worst around the eyes. Most patients are asked to ice their face for 48 hours following the procedure. A compression garment or compression dressing can help to further reduce the swelling. It is recommended that patients sleep with head elevation on multiple pillows to decrease the pain and swelling following the procedure. The swelling of the upper face improves significantly during the first month but can take 6 months to 1 year to completely resolve.

If a type 3 forehead reduction was performed, do not blow your nose strongly for at least the first month following the operation. You may gently blow your nose with both nostrils open if necessary. If you need to sneeze, this should be done with an open mouth. Dramatically increasing the pressure in the frontal sinuses can theoretically disrupt the healing or cause air to exit through the cuts in the bone in the forehead.

Pain following the procedure is often well managed with only oral medications. The surgeon will discuss a postoperative pain medication regimen prior to the operation.

What should I look out for after surgery?

You should contact your surgeon if you notice anything that seems abnormal.

The primary issues for which you will want to contact your surgeon are bleeding and infection. If you develop bleeding that does not stop or a significant increase in swelling on one side of your face, you should contact your surgeon immediately. If you develop fevers, chills, or unusual sweating after the operation, these can be signs of infection and you should contact your surgeon. Other signs of infection include worsening pain or discharge of fluid that tastes bad or has a foul smell.

How long do the results of FFS forehead surgery last?

Forehead feminization surgery produces permanent changes. The bones of the face will not regrow or expand back to a masculine shape. The face continues to age, so with time, the brows will continue to drop. If one is prone to balding, the hairline may continue to recede.

Preparation for Surgery

How do I prepare for forehead ffs?

Prior to having the procedure, you will need to arrange time off work. Allowing for at least 1 week off work gives enough time for the pain to be better managed and for the swelling to improve to a point where you feel more comfortable interacting with other people in public.

Please be prepared to answer personal questions during your consultation. You will be asked about your health, prior operations, the medications you take, and any allergies to medications. You will also be asked about habits such as smoking or the use of recreational substances. 

A CT scan of the face is necessary prior to a brow bone reduction so the surgeon can adequately counsel you on the operation and plan for the procedure. 

How do I find the best forehead feminization surgeon near me in Los Angeles, California?

It is important to find a surgeon who you trust who has experience with feminizing operations of the face.

These procedures are generally performed by plastic surgeons with specialty training in craniofacial surgery or ENT surgeons with specialty training in facial feminization surgery. It is important to do your research on the potential surgeons to ensure you feel comfortable with your surgeon.

Dr. Mittermiller is a fellowship-trained craniofacial surgeon with experience in facial feminization surgery. He can be seen at the practice’s offices in Los Angeles.

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://www.ncbi.nlm.nih.gov/pubmed/3575517
2. How Much Does Forehead Reduction Surgery Cost? (2022). https://www.realself.com/surgical/forehead-reduction/cost. Accessed 09/11/2022 2022
3. How Much Does a Brow Lift Cost? (2022). https://www.realself.com/surgical/brow-lift/cost. Accessed 09/11/2022 2022
4. How Much Does a Brow Lift Cost? (2022). https://www.realself.com/surgical/brow-lift/cost. Accessed 09/11/2022 2022