Male foreheads differ from female foreheads by having a bony prominence (supra-orbital ridge or brow bone) over the eyebrows. In other words, the bone over the eye sockets projects farther forward than the bone in female foreheads. Additionally, the forehead above this prominence is usually flatter or occasionally tilted backwards compared to the female forehead, which is usually more vertical or even slightly rounded or convex. Located behind these ridges are the frontal sinuses. However, they are absent in 5% of the population and only on one side in 15%. To reduce the brow bossing, an incision is made in the scalp which allows the forehead skin to be elevated for access to this area. It is then burred down with an electric drill. In patients with very flat or posteriorly directed foreheads, a synthetic material (methyl methacrylate) is occasionally used to produce the more feminine, rounded contour. And, finally, if the frontal sinuses are very enlarged, the anterior wall may, at times, have to be set back.
Drilling down brow bone
Drilling down brow bone with methyl methacrylate augmentation
Browlift in the MtF TS patient
The female eyebrow is arched compared to the flat eyebrow in the male. The ends of the eyebrow (the club and the tail) are at the same level, and the highpoint of the arch is between the outside of the iris and the corner of the eye. Since many MtF TS patients have their supra-orbital ridges reduced, the eyebrows can be elevated at the same time by pulling the forehead skin upward in this open approach. On the other hand, if brow bossing is not an issue, endoscopic (closed) browlifting or even brow elevation through an upper eyelid incision can be performed. This latter technique would be a good approach if upper eyelid surgery were also being performed and most of the elevation that was needed was on the outside or lateral aspect of the eyebrow without significant drooping of the inside or medial aspect of the eyebrow.
Browlift (before & after)