Q: What are the pros and cons of brow bone reduction?

Pros The procedure can permanently reduce a prominent brow bone, making it look less aggressive or more traditionally feminine. The incision can be hidden in the hair. Hairline incisions, if done well, heal almost invisibly, even with the hair pulled back, says Dr. Jumaily. Depending on a person’s goals, the procedure can be combined with hairline lowering surgery, a brow lift, or even a full facelift. Cons Recovery can take up to two weeks. The brow bone can be thinned only a certain amount without surgically altering it, so a complex procedure—with more cost and risk than burring alone—may be required to achieve a dramatic result. This is especially common with FFS, but it can be difficult to find a surgeon who has deep experience and skill with this type of procedure. Numerous small nerves can be damaged during surgery, causing scalp numbness that slowly resolves over the course of months or years. Brow bone reduction surgery can be expensive, and it’s an elective cosmetic procedure that’s typically not covered by health insurance.

Question 1

What is brow bone reduction?

Accepted Answer

Brow bone reduction (aka forehead contouring) is a surgical procedure that reshapes and softens a pronounced brow bone, the ridge of bone immediately above the eyes.

“When this bone is more prominent, it’s a very strong indicator of masculinity in a face,” says Dr. Bryan Rolfes, a facial plastic surgeon in Wayzata, Minnesota.

Reshaping this bony ridge can be a fairly straightforward surgical procedure, according to Dr. Jeffrey Spiegel, a facial plastic surgeon in Newton, Massachusetts. It’s typically performed via an incision placed along the hairline (or behind it) that allows access to the brow bone.

In cases where the patient needs a modest reduction, the surgeon uses a burr drill to file down the bone, reducing its prominence and making it more proportionate with other facial features.

For most transgender women undergoing facial feminization, it’s usually impossible to create a feminine appearance through burring alone, so the procedure often requires that the bone be cut and set back.

When it’s performed properly by a skilled provider, “the procedure can make really wonderful changes in the right patient,” says Dr. Richard Tholen, a plastic surgeon in Minneapolis.

RealSelf Tip: Brow bone reduction surgery minimizes the height of the forehead and can alter the overall look of the eyebrows, but it doesn’t always lift the eyebrows. If you want to raise eyebrows, remove sagging skin, or address asymmetry, ask your provider if you’re a good candidate for a brow lift.

If your goal is to reduce the area between your hairline and eyebrows, forehead reduction surgery (aka hairline lowering or scalp advancement) can create balanced facial features and make the hairline look much fuller.

Question 2

What are the pros and cons of brow bone reduction?

Accepted Answer

Pros

The procedure can permanently reduce a prominent brow bone, making it look less aggressive or more traditionally feminine.
The incision can be hidden in the hair. Hairline incisions, if done well, heal almost invisibly, even with the hair pulled back, says Dr. Jumaily.
Depending on a person’s goals, the procedure can be combined with hairline lowering surgery, a brow lift, or even a full facelift.

Cons

Recovery can take up to two weeks.
The brow bone can be thinned only a certain amount without surgically altering it, so a complex procedure—with more cost and risk than burring alone—may be required to achieve a dramatic result. This is especially common with FFS, but it can be difficult to find a surgeon who has deep experience and skill with this type of procedure.
Numerous small nerves can be damaged during surgery, causing scalp numbness that slowly resolves over the course of months or years. Brow bone reduction surgery can be expensive, and it’s an elective cosmetic procedure that’s typically not covered by health insurance.

Question 3

Who is a good candidate for a brow bone reduction?

Accepted Answer

Healthy adults who have a prominent brow bone are candidates for brow bone reduction surgery.

This is a cornerstone facial feminization surgery (FFS) procedure for transgender women.
Men with a very projected brow ridge (aka frontal brow bossing) “often want to maintain some prominence of the brow, but want it to be less extreme or aggressive looking,” says Dr. Jeff Jumaily, a facial plastic surgeon in Los Angeles.
Women with a traditionally masculine forehead shape “often want the upper face and brow area to be as feminine as possible, and the goal is to have a smooth, rounded forehead contour,” says Dr. Jumaily. Reducing this bone also helps brighten up the eye area.

Which type of brow bone reduction procedure is right for you will depend on your goals and anatomy.

Providers assess brow bone prominence based on projection: the elevation of the bone, compared to the level of the forehead above it and the radix (where the brow bone connects with the nasal bones) below.

“Like any facial procedure, we always look at the face as a whole,” says Dr. Jumaily. “If the radix is too deep or too high, then a rhinoplasty with radix adjustment may be needed.” Similarly, brow bone reduction often necessitates a brow lift (aka a forehead lift) to support the brows and avoid sagging.

The brow bone is the front wall of the frontal sinus, a hollow space in the bones around the nose. How significantly the brow bone can be filed down depends on its thickness—oftentimes, it’s no thicker than 2–3mms.

The glabellar area, the part of the brow bone between the eyebrows, often will have no frontal sinus cavity underneath, so it may be able to be reduced much more. To avoid burring into the sinus cavities, an X-ray or CT scan will be taken prior to surgery to determine the location of the sinuses and the thickness of the bone.

RealSelf Tip: There’s really no way to “try out” the outcome of a brow bone reduction in real life, but photo simulations can be a good tool to help get an idea of the results, says Dr. Jumaily.

Question 4

What happens during brow bone reduction surgery?

Accepted Answer

Brow bone reduction is typically performed under general anesthesia on an outpatient basis, so you’ll go home a few hours after the surgery. You’ll be groggy from the anesthesia, so plan to have someone take you home safely and stay with you for at least the first 24 hours after surgery.

The procedure can be accomplished through a variety of techniques, and your surgeon may use one of two types of incisions are used to reach the brow bone: one at the hairline (known as a trichophytic incision), or one that spans from ear to ear over the top of the scalp (aka a coronal incision).

The position of the incision will be determined by your forehead anatomy, hairline, and whether or not you’re having complementary plastic surgery procedures at the same time.

Hair loss is an important consideration with the incision placement. “For women or trans women on hormone therapy, it’s rare to have a significant hairline recession,” says Dr. Rolfes. “However, since most men will have at least a little hair loss with time, you can’t make the incision for a man in the same place as you would for a woman, or you risk having it be very visible in 10 or 20 years.”

A hairline incision is more visible initially, but it allows the surgeon to advance the hairline, a plus if one of the patient’s goals is to lower the hairline. “The incision is angled, so hairs grow through it and camouflage the incision,” says Dr. Rolfes.

Once the incision is made, the brow ridge can be reduced.

If the bone is dense or has minimal “brow bossing,” it can be simply shaved or burred down (a technique known as a type 1 cranioplasty).
If the bone is thin, or significant brow reduction is desired, the bone must be removed, reshaped (possibly with bone cement, to create the contour and help reduce the risk of bone erosion over time), and secured back into place with tiny titanium screws (a type 3 cranioplasty).

To create your desired result, the lateral orbital rims (the bones around the outside of the eyes) may need to be reduced as well. These bones are very thick, so they can usually be reduced significantly with shaving or burring. Reducing the orbital rims helps open up the eyes and allows light from above to illuminate them—making them appear brighter, softer, younger, and more feminine.

Question 5

What is brow bone reduction recovery like?

Accepted Answer

Recovery after brow bone contouring can take up to two weeks, though how long you’ll need will depend on the extent of your procedure and how your body heals.

“Typical recovery is 1–2 weeks before returning to work,” says Dr. Jumaily. “Patients look great in three months and are fully healed after a year.”

If your surgeon didn’t use dissolvable sutures, those will be removed during a follow-up visit after 5–7 days.

RealSelf member lindanm, who traveled to have a type 3 reduction, reported that by the fifth day of recovery he looked and felt well enough to go sightseeing.

This procedure isn’t associated with a high level of pain. Any discomfort is usually controlled with over-the-counter pain medication.

You can expect mild to moderate bruising and swelling around the temples and eyes, especially during the first week. Most of the swelling resolves within two weeks.

Some patients also experience blurred vision for a few months afterward.

In most cases, incisions heal very well over time. An incision along the hairline can be visible on close inspection for at least a couple of months, until hair grows through it, but it will be difficult to detect after a few months and fully healed after 12 months.

Question 6

Is brow bone reduction surgery safe?

Accepted Answer

Brow bone contouring procedures are considered safe when they’re performed by a well-trained, experienced surgeon. “We almost never see complications with the procedure,” says Dr. Rolfes.

Still, there are risks and possible complications that should be discussed prior to the surgery, including:

bleeding
infection
chronic pain
hair loss at the incision site
temporary or permanent injury to the frontal branch of the facial nerve, which may result in numbness or reduced sensation in the forehead skin
visible scarring
front sinus disease
cosmetic imperfections and asymmetries
double vision (usually just temporary, but occasionally permanent)
changes in vocal resonance, due to altering the shape of the frontal sinus

RealSelf member Ciceroesq also reported an “emotionally distressing” bone void near his eye following his brow bone reduction, which will require correction with an implant or bone cement. This type of complication can occur if the bone is shaved so thin that it loses some of its blood supply and dissolves over time.

During your consultation, your surgeon should discuss all of these potential complications, their own complication rate, and how their technique reduces these risks.

Question 7

Are there any alternatives to brow bone reduction surgery?

Accepted Answer

No other procedure can produce results on par with this surgical procedure.

Adding fillers above the brow bone prominence to smooth it out works in some patients with minimal prominence. In most cases, this can create an overfilled forehead appearance, sometimes referred to as “dolphin head.”

Botox won’t change the brow bone at all. “It can shrink the overlying muscles slightly, with minimal results,” says Dr. Jumaily.

BROW BONE REDUCTION

Karyn Repinski

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Karyn Repinski

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