The need to change the shape of the forehead or brow bone is very rare. It is possible to reshape the forehead or brow bone (the bone under the eyebrows), but there are different procedures that can be performed depending on the shape of the forehead and brow bone.

The shape of the skull between a man and a woman is usually quite different. The male forehead often has fullness above the brow bone known as a supraorbital bump or a supraorbital bulge with a flatter forehead over this area. The female forehead, by contrast, has a more convex or curved forehead shape and little to no significant supraorbital bulge. Such forehead shapes give a masculine or feminine look.

The degree of brow enhancement and the shape of the forehead help determine what type of surgical reshaping should be performed. With the exception of one other important consideration… the frontal sinus. The frontal sinus, an air-filled bony cavity, lies just below the brow bone and its development will affect surgical options. For this reason, any forehead/brow modification surgical effort should have a plain skull radiograph (lateral view) prior to surgery.

In those patients with mild to moderate protrusion of the forehead and thick skull bone over the frontal sinus (or who are missing a frontal sinus), reduction of the bone by reaming can be performed with good result. When brow bulge exists but the bone thickness over the frontal sinus is thin, simple bone reduction contouring is impossible without entering the frontal sinus. Many attempt only a small bone reduction, without going into the sinus, but this does not make enough of a difference to justify the effort. Removing just 1 or 2 mm of bone is not enough to make a difference. In this situation, one option is to open the frontal sinus, ream the edges of the bone, and reposition the ‘outer eyelid’ in a more inward contour, thus preserving the frontal sinus. The other option is to obliterate and fill the sinus with a bone substitute material, flattening the brow contour with the paste or bone cement. (and not reattach the outer bone table) I’ve done both and both will work. If I can get a good brow contour and still leave the frontal sinus present and functioning, that is my preferred option.

Any forehead and brow contouring requires an open approach through a scalp or hairline incision. The skin on the forehead should be ‘peeled back’ for good access for surgery. An endoscopic approach or a more limited approach is not adequate to do a good job. In most women, the hairline patterns and hair density make an open approach possible. When this procedure is considered in men, the hair problem makes an open scalp approach potentially more problematic.

In my experience, the most common patient for brow bone reduction is female feminization surgery (FFS), where reduction of brow bone prominence aids in overall facial conversion from masculine to feminine appearance. In a select few men with very prominent brow bones, this procedure can make a big difference in softening the more ‘Neanderthal’ facial appearance.