We strive to perform Type 3 Forehead contouring and setback on every FFS patient.  The only reason to not perform a Type 3 Forehead is because the patient does not desire maximal set back of the frontal forehead bossing or the patient has an absent frontal sinus.  Upwards of 10-15% of patients in the general population never develop a frontal sinus which limits the amount the forehead can be setback because the posterior border is the brain. 

We perform pre-surgery CT Imaging of the Face and Skull for every patient during the in office consultation to determine with the highest accuracy how much the forehead can be set back and reduced.  This allows us to see the frontal sinus and thickness of the forehead bone.  This CT Imaging is used during surgery for realtime Stereotactic Imaging Navigation to help us plan with pinpoint accuracy the bone cuts to temporarily remove the anterior table of the frontal sinus bone and set back the skull.   This stereotactic imaging navigation is the same technology to assist neurosurgeons and ENT surgeons to pinpoint the exact location of critical areas of the brain and skullbase.

The vast majority of patients, we perform a pretrichial incision at the hairline as most FFS patients need hairline lowering and scalp advancement.  For the ones that do not need hairline lowering, the incision is placed in the hair bearing scalp.  The forehead is elevated down to the level of the bone until the forehead and orbital rims are exposed.   Then using stereotactic imaging navigation with real time CT Imaging, we can pinpoint exactly the borders of the frontal sinus to make the bone cuts.  An osteoplastic bone flap is created with the frontal sinus bone and the forehead and orbital rims are maximally drilled and contoured down.  The frontal sinus bone is replaced back and contoured.  You do not want to thin the frontal sinus bone too much as it will effect the strength and integrity of the forehead.  This is why the forehead bone is removed first then the bone beneath is drilled to setback the forehead. 

For patients who have no prior frontal sinus disease of sinusitis, we do not advocate removing the frontal sinus mucosa or obliterating the frontal sinus.  This just delays and prolongs healing time and sets up the possibility of developing a fontal sinus mucocele 10-15 years down the road.  If a surgeon obliterates the frontal sinus, 100% of the sinus mucosa has to be removed and inner sinus cavity drilled to remove all remnants of mucosa otherwise a mucocele can development.  Most patients do NOT need any manipulation of the frontal sinus cavity besides setting back the bone.

For the vast majority of patients, the frontal sinus bone is simply placed back over the forehead without need for plates or screws.  The bone flap is accurately contoured to exactly fit in place.  The forehead bone is not a dynamic area that bears weight so the the bone heals fine.  Areas that are subject to dynamic forces such as the jawbone if fractured or cut should be stabilized with screws as movement occurs.  There is no advantage to using titanium miniplates versus wires.  They work the same.  If needed, we prefer to use titanium miniplates.

Please feel free to contact us for any FFS related questions.  We provide complimentary Skype consultations.
Additional information can be found in https://www.susans.org/links/link/Healthcare/Plastic_surgery/facial-feminization-surgery--los-angeles--dr-keojampa-36   

Do you have any before and after photos?

Due to the private nature of these surgeries, we do not share patient photos online.  Before and afters can be viewed in person during the in office consultation.  In addition to CT Imaging of the Face and Skull, we also perform Virtual FFS computer image simulation to accurately communicate the changes desired during the office consultation.

You wrote that with your technique the frontal sinus bone is simply placed back over the forehead without need for plates or screws because the forehead bone is not subject to dynamic forces. But what happens if the person blows their nose or sneezes before the bone flap heals? Isn't the air pressure from underneath a big dynamic force? Wouldn't it expel the piece of wall or at least move it out of its place?

At the conclusion of the forehead contouring and forehead setback, the bone flap is replaced back into its form-fitted window without the need for fixation.    If there are any significant gaps, bone paste saved from the forehead bone shaving is used to fill the gaps.  If the bone does not fit back perfectly, then 1 titanium miniplate with two screws are used.  We additionally burr down the edges of the miniplate and screws so they are not palpable.  A forehead compression dressing is used for at least 2 weeks after surgery.  At 2 weeks the forehead bone is fairly rigid and at 4 weeks healed.   If would be VERY difficult to displace the bone by blowing one's nose or sneezing.  This is similar to rhinoplasty when we perform osteotomies to break and contour the nose.  The nasal bone is immobilized with a cast to allow healing and no fixation plates or screws are needed because again the area does not bear weight or subject to mobile forces like the jaw or arm.  There are several scientific studies describing this technique without using plates.  After the bone heals, plates or wires serves no purpose.  The only reason why they aren't removed is that it would require another surgery to remove them.

Has anyone on Susan's had FFS with Dr Keojampa?