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Hi,  so I am new to these forums.  I am currently deciding on a surgeon for forehead brow bossing,  my choices have narrowed down to Zukowski and Facial Team.  I was only wanting partial ffs for the time being. I chose Zukowski cause I like his approach to foreheads, but facial team has such excellent reviews.  Was wanting to so my surgery in the states though,  since it is my first surgery.  Cost is also a factor so if anyone has cost comparisons for this surgery alone.  Also results of forehead work is beneficial as well thank you.

Welcome to Susan's Place. I am not knowledgable enough to provide you with information on FFS but I have moved this thread into the FFS (https://www.susans.org/forums/index.php/board,180.0.html) area of the board where you should be able to get more information on this topic. If there is anything I can help you with, let me know.

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Quote from: JazzyHeart on December 12, 2016, 09:25:27 PM
Hi,  so I am new to these forums.  I am currently deciding on a surgeon for forehead brow bossing,  my choices have narrowed down to Zukowski and Facial Team.  I was only wanting partial ffs for the time being. I chose Zukowski cause I like his approach to foreheads, but facial team has such excellent reviews.  Was wanting to so my surgery in the states though,  since it is my first surgery.  Cost is also a factor so if anyone has cost comparisons for this surgery alone.  Also results of forehead work is beneficial as well thank you.

Depends on the kind of forehead you have.  If it's Type I (thick bone, only discernible through X-ray, not the shape) then either will be a fine choice.  If the bone is thin, though, I think reconstruction is preferable, for which you'd want Facial Team. 

Who can realistically analyze such an X-Ray and how to get such an X-Ray? I have some CT scans - but the surgeons I contacted did not really want to look at them . It appears they have a preferred method and always use that one - Dr Z always does burring, no reconstruction, Facialteam always do reconstruction...

Quote from: anjaq on December 14, 2016, 09:15:55 AM
Who can realistically analyze such an X-Ray and how to get such an X-Ray? I have some CT scans - but the surgeons I contacted did not really want to look at them . It appears they have a preferred method and always use that one - Dr Z always does burring, no reconstruction, Facialteam always do reconstruction...

Any doctor can order an x-ray, but not sure what exact kind you would need. I am of the opinion that, unless you already have a very feminine forehead, burring alone is rarely enough to give you the result needed. I have seen people with quite prominent brow bossing who had a large sinus and were told that bone shaving would be just as good as having a reconstruction. It was not. They still had prominent central bossing, and the attempts made by the surgeon to hide this (by using bone paste or by yanking the eyebrows up to a very abnormal position) were not successful in my opinion. Several people I have talked to had holes punched into their sinus by aggressive burring without reconstruction, and one lady on here actually had her whole forehead collapse years later after the bone was shaved paper thin by a doctor who only does burring. I myself had serious complications after having surgery by a doctor who tried to cut corners, and I ended up needing a lot of reconstructive work. Choose wisely, and at the very least I do think an x-ray can be helpful to determine bone thickness and make the decision easier.

Well I was more thinking about which doctor would make an assessment based on the X-Ray - I mean, a independent one that does not reflect what he usually likes to do himself.

Here is my forehead
(https://www.susans.org/proxy.php?request=http%3A%2F%2Fi.imgur.com%2FdWHjwhN.jpg&hash=8c250c8f28d84cb74afbce54534187488cf6483b)
and the CT pictures I had
(https://www.susans.org/proxy.php?request=http%3A%2F%2Fi.imgur.com%2FWG6J9HY.jpg&hash=268454360940411a24890300fcbeaa879d43141c)

The surgeons did not seem to care about the CT pictures but basically seemed to recommend whatever they always do in FFS - I never know what is really needed or better - but I guess in the end it does not matter as the surgery is similar in repsect to trauma and healing - I think a reconstruction is probably not healing less quickly than burring alone - the big part after all is taking the skin from the bone and pullin it down and not creating too much damage there.

With one exception, which was why I considered Dr Z - if one really can work very well with burring alone, Dr Z can do that endoscopic approach and claims have been made that this results in less nerve damage as the nerves leading from face to the scalp do not have to be cut. I am not sure if this is true, but if it is, it would be worth finding out if burring or reconstruction makes sense and then maybe choose Dr Z over Facialteam (or others, but those were the ones mentioned in the starter post). So it would be good to find out who can make such a judgement without bias...

Quote from: anjaq on December 14, 2016, 01:01:54 PM
Well I was more thinking about which doctor would make an assessment based on the X-Ray - I mean, a independent one that does not reflect what he usually likes to do himself.

Here is my forehead
(https://www.susans.org/proxy.php?request=http%3A%2F%2Fi.imgur.com%2FdWHjwhN.jpg&hash=8c250c8f28d84cb74afbce54534187488cf6483b)
and the CT pictures I had
(https://www.susans.org/proxy.php?request=http%3A%2F%2Fi.imgur.com%2FWG6J9HY.jpg&hash=268454360940411a24890300fcbeaa879d43141c)

The surgeons did not seem to care about the CT pictures but basically seemed to recommend whatever they always do in FFS - I never know what is really needed or better - but I guess in the end it does not matter as the surgery is similar in repsect to trauma and healing - I think a reconstruction is probably not healing less quickly than burring alone - the big part after all is taking the skin from the bone and pullin it down and not creating too much damage there.

With one exception, which was why I considered Dr Z - if one really can work very well with burring alone, Dr Z can do that endoscopic approach and claims have been made that this results in less nerve damage as the nerves leading from face to the scalp do not have to be cut. I am not sure if this is true, but if it is, it would be worth finding out if burring or reconstruction makes sense and then maybe choose Dr Z over Facialteam (or others, but those were the ones mentioned in the starter post). So it would be good to find out who can make such a judgement without bias...

The frontal sinus is on the large side.   The bone thickness is pretty thin on the anterior (forward) sinus wall.

Rather clearly NOT an Ousterout type I forehead bone configuration.   It is almost a classic  Type III.

A  Type I  is the only configuration for which Dr. Z can legitimately do brow bossing.  In order for brow bossing to work, the frontal wall of the sinus has to be really thick so that you then burr it down and end up having visible results.

If he was to try to grind off  2 to 3mm of your frontal sinus, that would probably end up with a hole in your frontal sinus.  In that case,  you would likely end up where another poster here on Susans was many years ago when she went to Dr. Z for brow burring.   

You are rightly concerned that some surgeons tend to always do the "same" regardless of what the patients' bone structures would otherwise dictate.  That is much more likely in the situation where a surgeon only has one trick in their bag of forehead bone surgery skills. 

On the other hand, I would suggest, based on the imaging in your message,  that this evaluation (Ousterhout Type III forehead)  is not likely something about which any well qualified surgeon would honestly disagree. 

I agree with oneoftwo. 

The bulge at the upper left of each image is your brow.  The white portion is bone. The black portion is the sinus cavity.  The grey portion far left is your flesh.  The first image is the center of your forehead, and it progresses through to the edge of your nostril. 

To have any significant change to your brow, the bone will need to be removed and replaced with a new shape -- the "new" line you'd want to see would bisect the current position of your sinuses, and that extends all the way over to your eye -- so this would likely go for your orbits as well. 

Quote from: anjaq on December 14, 2016, 09:15:55 AM
Who can realistically analyze such an X-Ray and how to get such an X-Ray? I have some CT scans - but the surgeons I contacted did not really want to look at them . It appears they have a preferred method and always use that one - Dr Z always does burring, no reconstruction, Facialteam always do reconstruction...

Dr Deschamps-Braly analyzes and based on the type does the appropriate procedure

Well, I do not see much benefit in doing different procedures unless one can be saved the trouble of having that large scar. I guess the only thing that would make sense is to see if one has a type I and if so one can choose one of the few surgeons doing endoscopic surgery to avoid the large scar. If one has to open the face completely , I guess the difference between Type I and Type III is merely one of time, work and money. Of course if one has a type I one still would have the benefit of having less invasive surgery if one can avoid a type III surgery, but I think the best benefit would be to avoid having to have that procedure where they have to remove all the scin from the upper face and put it back on ...

Quote from: anjaq on December 23, 2016, 05:28:41 PM
Well, I do not see much benefit in doing different procedures unless one can be saved the trouble of having that large scar. I guess the only thing that would make sense is to see if one has a type I and if so one can choose one of the few surgeons doing endoscopic surgery to avoid the large scar. If one has to open the face completely , I guess the difference between Type I and Type III is merely one of time, work and money. Of course if one has a type I one still would have the benefit of having less invasive surgery if one can avoid a type III surgery, but I think the best benefit would be to avoid having to have that procedure where they have to remove all the scin from the upper face and put it back on ...

From my understanding, and it IS limited, admittedly, they're gonna have to peel down your forehead for any brow work, be that type one (only bossing) type 2, (bossing and putty) and type three, (complete reconstruction) From what I hear, the huge scar usually comes from scalp advancement, which often goes along with the forehead contouring as a freebie if requested, or needed as it causes a lot of tension and pulling stretching the scalp that far. (often an inch or more?) the normal forehead word incision is more often than not angled to minimize scaring and hidden in the hairline.

Quote from: anjaq on December 23, 2016, 05:28:41 PMWell, I do not see much benefit in doing different procedures unless one can be saved the trouble of having that large scar. I guess the only thing that would make sense is to see if one has a type I and if so one can choose one of the few surgeons doing endoscopic surgery to avoid the large scar. If one has to open the face completely , I guess the difference between Type I and Type III is merely one of time, work and money. Of course if one has a type I one still would have the benefit of having less invasive surgery if one can avoid a type III surgery, but I think the best benefit would be to avoid having to have that procedure where they have to remove all the scin from the upper face and put it back on ...

You can always have a coronal incision, so it's set back behind the hairline. Or, if you're going to have hair transplants anyways, you can have it at the hairline and then camouflage it with new hair. 

The best benefit is not having to have the surgery in the first place.  :)

Quote from: Sophia Sage on December 23, 2016, 10:47:47 PM
You can always have a coronal incision, so it's set back behind the hairline. Or, if you're going to have hair transplants anyways, you can have it at the hairline and then camouflage it with new hair. 

The best benefit is not having to have the surgery in the first place.  :)

The problem with coronal incision as I understand it is that it can actually make your forehead look larger? It can push back your hair which for most of us is not desirable? I think that's right?

Peeling back the forehead scalp for the orbital rim shave does contribute to a lot of short-term swelling of course, but it does go down ;)

Dr Sutin achieved a 2cm forehead hair advance with me. The scar is tucked into my hairline but I was lucky to have a fair bit of hair. There's definitely numbness on top of my head as a result but at the moment I think that's a relatively small price to pay.

Well - yes - coronal incision is probably a good way concerning the visibility of the scar - getting hair transplants in a hairline scar is just as good in that sense. And of course there is a benefit from getting a hairline advance when having that incision anyways...

What I was thinking of was more the idea that with a type I forehead one could avoid the long incision and do the burring endoscopically (like Dr Z does it). This would not only cause less scarring (just 2 incisions behind the hairline - hairline correction can be done with transplants anyways) but also possibly less nerve damage. I guess for most that seems not to be a concern though, I am the odd one out in that respect that I was kinf of hoping to have a type I in order to avoid that big scar and the numbness that comes with it - but apparently no luck.

Quote from: Sophia Sage on December 15, 2016, 12:29:29 AM
I agree with oneoftwo. 

The bulge at the upper left of each image is your brow.  The white portion is bone. The black portion is the sinus cavity.  The grey portion far left is your flesh.  The first image is the center of your forehead, and it progresses through to the edge of your nostril. 

To have any significant change to your brow, the bone will need to be removed and replaced with a new shape -- the "new" line you'd want to see would bisect the current position of your sinuses, and that extends all the way over to your eye -- so this would likely go for your orbits as well.

Look at anjaq's picture again.  Her glabella, the anterior sinus bone, does not need resection and repositioning.  Reshaping of the orbital rims would be quite sufficient to give a feminine profile.  That is a type I procedure. Then again, neither of us are Board Certified plastic surgeons or maxillofacial surgeons, so our opinions mean nothing.

With kindness,

Terri

Edit:  All I can tell you anjaq, is that if you go to my post about my FFS experience with Dr. Zukowski, and look at my pre-op photo, my forehead bossing and orbital rims looked very similar to yours. I had a type I procedure, and the results were very good.

Well as I said, different surgeons, different opinions. So far most seem to want to make a type III reconstruction if I ask for an opinion. Only one suggested a type I. I guess it depends on how dramatic a change one wants to produce with a surgery - in my case the results probably would be subtle anyways, so maybe they wanted to give a bit more visible change by adding a type III procedure.

Whats your opinion on the risk of numbness and nerve damage with Dr Z? Is it really less than with the other procedures that need a coronal or hairline incision?

Quote from: Maybebaby56 on December 24, 2016, 06:56:54 PM
Look at anjaq's picture again.  Her glabella, the anterior sinus bone, does not need resection and repositioning.  Reshaping of the orbital rims would be quite sufficient to give a feminine profile.  That is a type I procedure.

I'm actually of the opinion that she doesn't need anything other than, perhaps, to address her hairline. Especially given her concerns of scarring and potential numbness. She already has a feminine profile.

But if she wants the most dramatic results (and if you're going to do this, I think you should want dramatic results) she should go for the whole deal -- Type III resection, including the orbital rims; rhinoplasty; genioplasty and mandibular recontouring; lip lift; scalp advancement, followed by hair transplants.

While the Type I burring of just the orbital rims would provide some mild improvement and thereby avoid the glabella altogether (well within Z's typical scope of work), that would in turn make her admittedly very slight brow bossing slightly more prominent. But there's just not enough bone there to do anything with that particular feature other than to resect and reposition.   

Quote from: Sophia Sage on December 24, 2016, 08:44:06 PM
I'm actually of the opinion that she doesn't need anything other than, perhaps, to address her hairline. Especially given her concerns of scarring and potential numbness. She already has a feminine profile.

But if she wants the most dramatic results (and if you're going to do this, I think you should want dramatic results) she should go for the whole deal -- Type III resection, including the orbital rims; rhinoplasty; genioplasty and mandibular recontouring; lip lift; scalp advancement, followed by hair transplants.

While the Type I burring of just the orbital rims would provide some mild improvement and thereby avoid the glabella altogether (well within Z's typical scope of work), that would in turn make her admittedly very slight brow bossing slightly more prominent. But there's just not enough bone there to do anything with that particular feature other than to resect and reposition.   

I can agree with that.  Sometimes less is more, though.

Anjaq, I'm sorry I didn't respond to your question, but I can't address it though personal experience because I had a hairline advance, and therefore have a hairline incision, with the attendant forehead numbness. That said, the incision is about 8-10 inches shorter than a coronal incision. Dr. Z's endoscopic approach involves four one-inch incisions, I believe. 

~Terri

Quote from: Sophia Sage on December 24, 2016, 08:44:06 PM
I'm actually of the opinion that she doesn't need anything other than, perhaps, to address her hairline. Especially given her concerns of scarring and potential numbness. She already has a feminine profile.

Maybe even "striking" - crossreferencing the other thread ;)
I considered recently to just do hairline, lip lift and maybe some minor reshaping of the chin, since it has that horizontal scar/fold... I am not sure how well the chin can be adressed though, if it requires more than adjusting some soft tissue, I could as well do the whole chin reshaping thing, but then again I would probably have to adress all the other parts as well again as you say:

Quote
But if she wants the most dramatic results (and if you're going to do this, I think you should want dramatic results) she should go for the whole deal -- Type III resection, including the orbital rims; rhinoplasty; genioplasty and mandibular recontouring; lip lift; scalp advancement, followed by hair transplants.

I am also planning to do forehead work late this year in thailand but im torn between dr sutin (PAI) and dr charan. I want to do the forehead work together with cheekbone reduction but Dr Sutin said he does not do it as it can injure my cheekbone in future (confused with this one).

My only option is go to Thailand so Im looking for good doctors in Thailand. I heard Dr Sutin frequently here in this forum but I am wondering why Dr Charan Mahatumarat has never been popular in most facial bone work here in Susan.

Tried googling him but then most of feedbacks I got was from long time ago like around 2013. I also googled his credentials and it seems very promising. On the other hand I also heard about Dr Nond but its so hard to get a response from him.

Ladies, can you help me decide which of them would recommend?

- Dr Sutin (PAI)
- Dr Charan Mahatumarat
- Dr Nond

Quote from: AutumnLeaves on December 14, 2016, 11:15:49 AM
Any doctor can order an x-ray, but not sure what exact kind you would need. I am of the opinion that, unless you already have a very feminine forehead, burring alone is rarely enough to give you the result needed. I have seen people with quite prominent brow bossing who had a large sinus and were told that bone shaving would be just as good as having a reconstruction. It was not. They still had prominent central bossing, and the attempts made by the surgeon to hide this (by using bone paste or by yanking the eyebrows up to a very abnormal position) were not successful in my opinion. Several people I have talked to had holes punched into their sinus by aggressive burring without reconstruction, and one lady on here actually had her whole forehead collapse years later after the bone was shaved paper thin by a doctor who only does burring. I myself had serious complications after having surgery by a doctor who tried to cut corners, and I ended up needing a lot of reconstructive work. Choose wisely, and at the very least I do think an x-ray can be helpful to determine bone thickness and make the decision easier.

Wow, I have searched relentlessly on FFS and the difference between type i and iii. I have not come across any situations where type i was done and the done was left too thin that led to collapse. Where is this? I notice doctors and patients tend to bash the procedure that they do not perform/have done. I have also seen many, many before and afters where type i did a fine job for women with a pronounced brow, especially on Dr Mayers website.

Also which procedure did you have done that came with complications?

Thanks!

I think its a bit of a misconception that type 1 means to burr down the bone in front of the sinus and risk a hole. This is not a type 1 forehead then. A type 1 forehead has no sinus cavity and thus can be burred down. What these surgeons do is to apply the technique for a type 1 forehead to a type B3 forehead that has a sinus cavity - which is basically not worth it and risky. Better leave the forehead alone then and just do the orbitals

How much did it cost to have those x-rays made?

I think this is highly variable. The best is to have a 3D CT scan done. This probably will cost about $200-400? Facialteam does one for free at the consultations, but I guess you can also make one elsewhere and have the advantage to show it to all the surgeons you like. A good FFS surgeon should always ask for one or do one at the clinic anyways to plan the surgery, otherwise he is sort of starting the surgery without a plan on what is going to be in there - this is important for sinus cavity as well as position of some nerves of the eyes and lip/chin/jaw

Quote from: anjaq on August 13, 2017, 05:51:51 AM
I think this is highly variable. The best is to have a 3D CT scan done. This probably will cost about $200-400? Facialteam does one for free at the consultations, but I guess you can also make one elsewhere and have the advantage to show it to all the surgeons you like. A good FFS surgeon should always ask for one or do one at the clinic anyways to plan the surgery, otherwise he is sort of starting the surgery without a plan on what is going to be in there - this is important for sinus cavity as well as position of some nerves of the eyes and lip/chin/jaw

Im not a radiologist, but I think for nerves a CT will no being sufficient... That's why my surgeon for example anted a Orthopantogram which is much more precise that a CT scan.