Forehead recontouring

The forehead is the largest part of the face. Douglas Ousterhout's "Feminization of the Transsexual" illustrates the primary differences between male and female foreheads.

Generally, male foreheads have a relatively flat slope from the hairline to the brow, where women's foreheads have a convex curve both vertically and horizontally.

Male foreheads often have a heavy bony ridge just above the eyes, in a line beneath the eyebrows. This is called brow bossing.

In my own case, this was something I'd never thought about until I started researching. It turned out to be the most important thing in my case. Having forehead recontouring took me from not passing to passing in about 10 days.

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Surgical options

A brow lift is a soft tissue procedure which tightens skin on the forehead and raises the eyebrows. This is usually done with an incision at the hairline, or endoscopically from smaller incisions within the scalp hair. This has the effect of opening up the face and making you look less stern and tired. However, it has no effect on the underlying bone, so its effects are not as dramatic as bony work. A brow lift is often done at the same time as bony forehead work.

Sometimes an implant or fill is enough to round out a flat forehead and give it a feminine appearance. There are several materials used for this. Some are porous and try to emulate bone, while others are types of acrylate fill.

A forehead recontouring or brow shave is the most dramatic option available. This involves making an incision at the hairline and surgically altering the bone. In severe cases, the bone is taken out, reshaped, and placed back in the skull. In some cases, this requires small titanium wires or screws that hold the bone in place while it heals.

Some women get silicone injections directly beneath the skin in their forehead. This procedure is banned by FDA and is illegal in the US. It's done on the black market, usually by unlicensed or non-medical personnel. It is known to be dangerous and lethal, but its low cost entices some, especially the younger and poorer members of our community, to opt for a quick and cheap but potentially dangerous option. For more on the dangers of this procedure, please read: Dangerous curves ahead

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Recovery

Bruising and swelling are common and vary greatly by individual. Swelling usually subsides fairly quickly over 2 to 14 days. Bruising is generally light on the forehead, but drainage from the site can cause bruising to show up below the eyes and on the neck and chest. Usually this resolves in one to three weeks.

Hair loss at the incision sometimes happens. Apparently the shock to those hair follicles causes them to stop their growth mid-cycle and shed. This is almost always temporary, and hairs begin their growth cycle again. Some suggest using minoxidil for a few months prior to surgery and immediately after to lessen the possibility, although there's no definitive proof that this helps.

Usually there is temporary tightness in the skin, especially after a brow lift, and women usually experience limited range of motion. Both can last two weeks to six months.

Most women experience temporary numbness and tightness in the soft tissue, lasting two weeks to six months.

Often the brow position looks too high at first, but they tend to settle into a more natural position over one to four weeks.

Some women have reported visual problems due to tightened tissue and swelling. Those who have had double vision or distortion in one or both eyes usually see it resolve in a few days to a month, as swelling subsides/

You will have stitches at the hairline, often supplemented by staples if the incision extends into the hair. These usually come out in one to two weeks. Stitches must be kept dry, and staples often stay in longer than stitches.

You may have temporary dimpling of the skin along the incision. This smoothes out over one to four weeks.

You will have a scar at the incision. How noticeable it is depends on the surgeon's skill, your amount of hair, and your body's formation of scar tissue. Some women get hair transplants to hide the incision. Severe cases might require surgical scar revision.

Complications

Some have a permanent change in sensation-- not necessarily numbness, but things just feel different. This might include itchiness, increased or reduced sensitivity, pain or tenderness.

A reader writes:

I had what you could call a complication of FFS, that some people might want to know about (and you may put on the Roadmap). Dr. O.-type forehead surgery includes actually removing the frontal bone and wiring it back in place, and altering the sinuses as well. This can make it uncomfortable for your face to hold as much pressure as it did before, for example when you’re playing a brass or reed-type wind instrument; I used to play the Great Highland bagpipes, and found it too uncomfortable afterwards. I had FFS seventeen months ago, and if I close my mouth and bring it up to that much pressure, the area between my eyes starts to feel strange, and I know that in a few moments it would start to hurt a lot. I wasn’t heartbroken to have to switch to a lower-pressure (and quieter!) variety of pipes, but if someone’s life and livelihood depended on playing the saxophone, for example, they might be in trouble. There’s still no question; I’d have my face done again in a heartbeat. It’s made so much difference in my life; I can walk into a crowded ladies’ room wearing my old pre-transition shapeless jeans and sweatshirt and get nothing more than a smile and a hello, when before FFS, I had to be in a dress and makeup to pass. Since my partner and I spend so much of our time hiking, biking, skiing, etc., that just wasn’t acceptable, so off to SF I went, and gladly.

Poor cosmetic outcomes include too much or too little revision, uneven revision. An excessive brow lift might leave the eyebrows too high, giving you a constant "surprised" look. You may have excessive scarring. Remember, no surgery will guarantee you will pass. There are many other factors involved.

More serious complications include rejection of or reaction to implants or fill, hematoma, infection, permanent change in muscle range of motion, permanent forehead muscle paralysis, permanent visual changes up to and including blindness, and death.

See my general complications page for more.