The bony structure of the forehead is made of the frontal bone and is given its appearance due to the size and shape of the frontal sinus and soft tissues of the brow. Together these are often called the brow bone and brow respectively. During puberty influenced by testosterone, the frontal sinus enlarges and creates prominence just above the eyes in the middle of the forehead.
In order to support patients who experience dysphoria related to a protrusive brow bone, in some individuals the front wall of the frontal sinus can be removed and then secured back in place in a way that the forehead appears more flat. In medical terms, this is called a setback, alluding to the procedure name “frontal sinus setback.” In a small number of people, about 4-5% of the population, the front wall of the frontal sinus is thick enough that it can be shaped to achieve the desired effect without being removed. This is called frontal bone contouring. Before surgery, Dr. Facque will order a CT scan of the patient’s facial bones to help determine which type of surgery is needed for any given individual.
Dr. Facque often combines this procedure with reshaping the orbital bones (the bones of the eye socket) to help feminize the eye shape as well. This can help make the eyes appear more open and rounded, which is more typical of the eye shape created during an estrogen-influenced puberty. Reshaping the orbital bones also allows for greater lifting of the brows for patients who want that done as well.
Typically, in order to contour the brow bone and perform a frontal sinus setback, a “coronal” incision is made. This refers to an incision that goes up and over the head on the scalp, following the hairline. The coronal incision allows the surgeon to perform the frontal sinus setback (brow bone contouring), brow lift, and hairline advancement/reshaping. If the patient would also like to decrease the length of the forehead (a procedure called scalp advancement/hairline lowering), the incision is made just in front of the existing hairline, called a “pretrichial coronal incision”. Only by placing the scar there is Dr. Facque able to make the forehead shorter and also change the shape of the hairline.
It is important to understand that while this scar typically heals very well, it will be visible at conversational distances. Some patients choose to cover the scar with makeup or with hair pieces if they choose. For some patients with hair loss, this is a good option to feminize the hairline and remove areas of hair loss at the temples (also called temporal alopecia). For some patients, other procedures such as hair transplants may also be necessary in order to fully achieve the desired result.
If a patient does not want to have a visible scar along their hairline or does not want to have changes made to their hairline or forehead length, they can decide to move the incision back a couple of centimeters where it will be hidden within the hair. Unfortunately with this option, hairline advancement or reshaping won’t be possible.
Dr. Facque recommends that patients use narcotic pain medication for the first 7-10 days after surgery, or until their pain levels can be managed by over-the-counter pain medication. On the third day after surgery, patients can shower and gently wash their hair. For the first 2-3 weeks patients should apply Bacitracin ointment to the incision twice daily to help ward off infection. Patients may see some scabs form along the incision line during this time. All sutures will be dissolvable and will be under the skin, although from time to time, one or two might pop out and can be snipped with fine scissors at home. Scabs will usually resolve in 2-3 weeks, at which point patients can switch to silicone scar gel and can start performing scar massage to help soften and flatten the scar. Patients can resume light activity at three weeks, and at 6 weeks patients can resume full activity.
The swelling and bruising for this part of the procedure lasts for significantly less time than the other parts of facial feminization, and patients usually see the result of the surgery immediately. Therefore, this is often one of the most gratifying procedures for the patient. However, Dr. Facque notes that there is usually significant swelling on days 2-3 after surgery. Some patients have difficulty opening their eyes. Swelling comes on rapidly and resolves rapidly, and again most of the swelling is resolved in the first week.