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Orbital Rim Bossing

Please refer to the preceding description of endoscopic forehead feminization for an in-depth reference to this topic.  Much has been made about the specifics of forehead feminization, and quite frankly, there is a lot of misunderstanding and misinformation that has been propagated in a fashion to make it self-serving to the various surgeons who do this surgery.  Traditional open techniques for forehead approaches to the bone have been around for decades.  It typically is the standard incision used for any neurosurgical approach, and it goes from ear-to-ear across the top of the scalp.  This incision is carried down to bone and allows one to flip the hair-bearing scalp both forward and back.  This incision has been modified for cosmetic use in that, if this incision is placed in the standard post-hairline position, one actually elevates the scalp and increases the height of the forehead.  However, if this incision is placed along the edge of the forehead/front hairline interface, one can actually reduce the height of the forehead and advance the scalp forward.

It’s ironic how much is made of the thinness of the forehead sinus bone if you believe the self-serving banter on the Internet.  Many will try to convince you that this bone is only a few millimeters thick and, therefore, it is impossible to do a forehead procedure anyway other than an open technique that invades physically into the sinuses.  This is absolute and total baloney.  If you believe that, then you can join the list of people who have purchased the Brooklyn Bridge over the last century.  Specifically, if the forehead was that thin anywhere, then one would expect in their lifetime to hear about a number of forehead fractures.  I bet you never heard of one, and that’s because the orbital rim which sits below the eyebrows and encompasses the upper eye sockets is one of the thickest bones in the body.  Its purpose is to protect the brain.  If you think about it, almost every major athlete should have had a forehead fracture at least one time in their life if the sinus bone was so thin.  In fact, the simple act of diving into a swimming pool would most likely cause your forehead to break if indeed the bones were so thin.   You have probably walked into at least one door or one wall in your lifetime with no adverse effect.  One should understand that this type of misinformation serves only people who do this operation open.  The reality of the matter is that is doesn’t make a difference whether you go into the sinuses or stay outside of the sinuses because if you think that only modifying the bone over the sinus is going to make your forehead more feminine, look around – that’s not the case.  In fact, when you think of high school geometry, you understand the concept of 3-dimensionality in that an action on one side of a structure requires an opposite and equal reaction on the other side if one is trying to make a forehead into a semi-circle conceptually.  Quite frankly, to go into the sinus is a very old-fashioned technique.  It is akin to the proverbial 12-inch incision to take one’s gallbladder out which is how that operation was performed for our parents and grandparents.  Today, small incision, minimal scar, endoscopic techniques are the standard of care within the field of surgery, and that same gallbladder can be removed thru three one-inch incisions.  Over a decade ago, if you tore up your knee cartilages, you would require a 6- to 8-inch incision over the knee whereas now it is just a series of stab marks.  Typically, the bone over the sinus is thicker with less air space in males.

There are multiple ways to approach the forehead.  If you do not possess endoscopic skills to allow both the soft tissue as well as the hard bone changes, then you are left with only open procedures.  Open procedures are the standard procedures which is how we as board certified surgeons learn to do a particular operation.  It’s no magic to perform an open procedure, but unfortunately the complications are built in and these complications occur no matter who the surgeon is.  Built in you say?  Let me explain further.  Specifically, with an open technique when you completely cut through the sensory nerves to the scalp and forehead region, in over 80% of cases the sensitivity never returns to normal in the 6 inches behind the cut.  This will lead to the greater chance of permanent hair loss as well as sensory problems that lead to hair loss later in life.  Only 20% of patients will return to normal sensitivity with an open technique.  By comparison, an endoscopic technique preserves the nerves, and, therefore, one is able to get a return to normal sensitivity in over 95% of areas in the six inches behind the cut.  Also, when you cut into the sinus bone, you need to somehow fix that bone.  If you think about it conceptually, you have to drill a series of pilot holes.  You have to then free up the underlying mucosa or lining of the sinus.  You then take a modified jigsaw and cut the sinus out and manipulate the bone any way you choose.  You have to insure that there is not undue damage to the lining which would cause a sinus air leak.  You also need to hope that all the bones will grow together normally, and that there is not abnormal scarring to both the cuts as well as the metal hardware left behind that causes abnormal wrinkling when one elevates the eyebrows and forehead tissue.

Also of great concern is the misinformation that, if you do any contouring of the lateral or outside orbital rim in the area of the eyebrows, this is somehow dangerous.  This is the farthest thing from the truth and is almost laughable.  If you don’t contour the entire orbital rim at a minimum, you are not going to get a 3-dimensional smooth contour.  Having taken down the solid orbital rim, it’s imperative to back contour in 3-dimensional fashion taking down the entire frontal bone, the bone over the sinus as well as the bone in the area of the temporal ridges which is the interface between forehead bone and soft tissue of the temple region.  The worse thing that can happen with an endoscopic or burring technique is a microperforation of the sinus bone.  This is much more difficult with endoscopic techniques to have happen because the endoscope magnifies the operative site 20 times, and you can tell the thickness of the bone by its color change.  If one does microperforate, it’s just like cracking an egg that doesn’t break.  It’s very easy to fix with a number of bone paste materials.  It’s not the same concern you would have when you physically cut bone with the multiple number of things that can happen regardless of who you are as the surgeon.  Remember complications are built in with open techniques.  It’s the reason why things have shifted to endoscopic techniques.  Obviously people who don’t do endoscopic techniques will have a million reasons why you shouldn’t have endoscopic techniques.  Quite frankly, you have to ask the question, “If you don’t do endoscopic procedures, how are you even able to comment on those techniques?”  You will find that surgeons are very egotistical individuals who, if they can’t do something, will simply badmouth it hoping that you will not see the individual who can do a better job.  This is one of those “buyer beware” moments.  The real question is do you like playing Russian roulette.  If you like playing Russian roulette with a six chamber gun, you only have a one in six chance that you will blow your brains out.  It is the same thing with open techniques.  It doesn’t make a difference who does them, the complications from cutting the nerves and cutting the bone may occur no matter what.  It’s the reason why the focus of surgery has shifted over the last 20 years from open techniques to minimal scar techniques, and it is even shifting further into robotic computer operating systems.  You have to simply talk to our patients to see the beautiful foreheads that we achieve with this technique.

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