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Everything You Need to Know About FFS Brow Bone Reduction

Medically reviewed by Jennifer Richman on December 16, 2024.

Understanding FFS Brow Reduction

What Is FFS Brow Reduction?

At the Gender Confirmation Center (GCC), our surgeons offer a series of cutting-edge techniques to feminize the shape of a patient’s forehead. Specifically, many of our patients experience dysphoria as a result of a protruding brow bone. This one of the many possible results of a first, testosterone-dominant puberty.  A FFS brow reduction flattens the brow bone, giving the forehead a flatter contour, creating the effect of more visible, rounded eyes in addition to lifted eyebrows. Learn more about the requirements to undergo this procedure, the surgical process, costs, recovery and more in this article.

Significance of Brow Reduction in Facial Feminization

While some cisgender women have prominent brow ridges, this facial feature is often a visual cue for masculinity. Given that the brow ridge is one of the most visible parts of the face, even when someone is wearing a mask, many patients are quick to notice and focus on its appearance.

The results of a brow bone reduction become visible a few days after the initial swelling from the procedure begins to reduce. This makes it one of the most gratifying procedures for patients who experience relief and gender euphoria from seeing a more contoured forehead in the mirror.

Many of our transfeminine patients report being misgendered less after undergoing a brow reduction. Still, no gender-affirming medical intervention can control the way others perceive you. While outside perceptions have an influence on our own self-esteem and self-perception, it is important that patients do not undergo surgery primarily to change the reactions of others.

Benefits of Brow Reduction in FFS

Several peer reviewed studies have shown that FFS has tremendously positive impacts on patients quality of life and self-esteem because of its ability to eliminate some causes of gender dysphoria. What often brings patients satisfaction, peace, confidence and euphoria after a frontal sinus setback is seeing a face that is more aligned with their internal sense of self.

Candidates for Brow Reduction Surgery

At the Gender Confirmation Center, both Dr. Ley (she/her/they) and Dr. Facque (he/him) use informed consent standards to determine patient eligibility for facial surgery. In practice, this means that adult patients can make the decision to undergo surgery once they have been educated on the advantages and risks involved in the procedures.

Though our practice does not require therapist support letters or hormone replacement therapy (HRT) as prerequisites for FFS, many insurance providers do. For more information on obtaining a support letter from a licensed mental health professional, click here.

If you are currently taking estrogen HRT, we recommend that you wait 1-1.5 years on treatment before considering facial surgery. This is merely a suggestion, not a requirement. Given that HRT alters the soft tissues and overall appearance of the face, patients’ goals for surgery may differ after they see these changes. Still, HRT will not affect bones, meaning that a protruding brow ridge will likely not lose prominence after HRT.

Complications, Risks and Candidacy

Like any surgery, FFS carries a small risk of complications. Undergoing surgery with a qualified board-certified surgeon with hospital privileges–can help ensure your safety and the integrity of your results. That said, one of the most common long-term effects of this procedure is that patients lose a small amount of sensitivity on the scalp behind where the incision is made.

Due to health and safety issues, you may not be a good candidate for surgery if you have any of the following conditions or may need to take some time to optimize your medical conditions before pursuing facial surgery:

• Heavy smoker, drinker, or drug user
• Uncontrolled diabetes
• Uncontrolled high blood pressure
• Bleeding or clotting disorders
• Significant lung or heart disease
• Active sinus infections
• Previous facial trauma, sinus surgeries, etc.

Please openly and honestly discuss your medical history with your surgeon so they can help make a plan that is safe for you.

The Brow Reduction Procedure Explained

Step-by-Step Overview

1. Consultation and Planning: The first step to undergoing FFS is requesting a surgical consultation. At the GCC, our consultations are free of charge. During this time, you can discuss your medical history, have any questions about surgery answered and create a surgical plan by going over your goals and expectations.
2. Pre-Operative Preparations: First, you will either receive a quote for your procedure or begin the process of soliciting pre-approval authorization from your insurance provider.
   Second, once a date for your surgery has been scheduled, you will be sent pre-operative instructions including medical exams to do before surgery such as a CT scan or X ray of your skull.
3. Anesthesia Options: A frontal sinus setback is always performed under general anesthesia. This means that you will be completely unconscious for the duration of the surgery. As a result, you will need to discontinue herbal supplements and blood thinning medications at least a week before surgery to prevent anesthesia-related complications.
4. Surgical Techniques: An FFS brow reduction is performed by first making an incision at the hairline or over the top of the scalp. The hairline incision leaves a small scar at the top of the forehead, but allows the surgeon to simultaneously perform a brow lift and hairline advancement. Since there is a sinus cavity behind the brow bone, it most often cannot be shaved down directly. Rather, it will be removed and contoured alongside the orbitals. It will then be set back in with titanium plates and screws, which will not set off metal detectors.
5. Duration: Performing this procedure typically takes 2–3 hours. That said, your FFS will likely last longer if you also undergo procedures like a rhinoplasty, jaw contour and/or Adam’s Apple reduction.

Pre-Operative Instructions

• As a FFS brow reduction patient, you will need to complete an x-ray or CT scan of your cranial bones before surgery. This will allow your surgeon to have a more precise idea of the kind of contour and bone excision that needs to be made for the procedure. Our team can help GCC patients order and complete this test.
• Second, please note that you will need to stop consuming alcohol at least a week before and after surgery. Tobacco consumption and smoking of any kind should be suspended at least four weeks before and after facial surgery. Likewise, you may be asked to temporarily stop taking estradiol (estrogen hormone therapy) two weeks before FFS to reduce the risk of blood clots. You may receive other specific instructions from your surgeon.
• Third, it is important that you set up a care plan for the first week of recovery before you go under anesthesia. Please note that you will only be discharged from the hospital once you have a support person present to pick you up, since you will not be able to operate a vehicle. Likewise, you will need 24/7 care for the first 72 hours after surgery to help you ice your wounds, take medications on time and thereby manage pain and swelling.

Surgical Techniques

To support patients who experience dysphoria related to a protruding brow bone, in some individuals, the front wall of the frontal sinus can be removed and then secured back in place in a way that the forehead appears flatter. In medical terms, this is called a setback, alluding to the procedure name “frontal sinus setback.”

In a small number of people, about 4-5% of the population, the front wall of the frontal sinus is thick enough that it can be shaped to achieve the desired effect without being removed. This is called frontal bone contouring. Before surgery, your surgeon will order a CT scan of the patient’s facial bones to help determine which type of surgery is needed for any given individual.

Our surgeons often combine this procedure with reshaping the orbital bones (the bones of the eye socket) to help feminize the eye shape as well. This can help make the eyes appear more open and rounded, which is more typical of the eye shape created during a first, estrogen-dominant puberty. Reshaping the orbital bones also allows for greater lifting of the brows for patients who want that done as well.

Post-Operative Care

Recovery Timeline

If your job does not require heavy lifting, you will likely be able to return to work two to three weeks after surgery. The most difficult phase of the recovery process lasts two weeks, although patients should not lift heavy weights or engage in rigorous exercise until at least six weeks have passed. Likewise, any impact sports may need to be avoided for longer.

Please note that while the majority (around 80%) of swelling should revolve in the first 3 months after surgery, you may not see your final FFS results until 12 months after surgery. We encourage you to practice patience and self-compassion as your body works hard to heal over time. It may take a while for your face to settle after such an invasive procedure. That said, unlike other procedures such as mandible contouring, its results are often visible during the first week of recovery, making it one of the more immediately gratifying procedures for our patients.

Aftercare Tips

• Keep the surgical site clean and follow wound care instructions. This involves placing antibiotic ointment over incisions and using cotton swabs with either hydrogen peroxide or saline water to break up any crusting here.
• You will be taking prescription pain medications during the first few days after surgery to manage pain. You cannot operate a vehicle or consume alcohol at this time.
• During the first 72 hours post-op, you will need to place ice over the surgical sites for 20 minutes every hour. Use a towel over the ice packs or frozen vegetables to prevent ice burns. Your surgical sites will be temporarily numb while nerves regenerate, so you may not be able to feel an ice burn when it comes on. After the 72 hour period, you should continue icing your face around 4 times a day for two weeks.
• You will be on sinus precautions for the first 6 weeks after surgery. During this time, you should avoid sneezing whenever possible, blowing your nose, or adding any other pressure to your sinuses. You can resolve nasal dripping by wiping your nose, not blowing it.
• You will need plenty of rest during the first two weeks and should avoid household chores or activities. Elevating your head while you rest will help manage inflammation.

The Cost of Brow Reduction Surgery

Typical Costs

It is uncommon for this procedure to be performed alone. A brow bone reduction is typically accompanied by a brow lift and/or a hairline advancement. Cash-pay patients, meaning those who are paying for surgery without insurance, can expect a quote for the upper-third of the face to come out to $10,000-$50,000. This cost estimate may not include anesthesiology or facility fees and will vary from patient-to-patient. Likewise, the costs of post-operative medications and some supplies will not be included in your surgery quote.

Financing Options

Many patients who are not able to get insurance to cover the surgery look into grants and trusted medical creditors to help them finance the procedure. We have compiled trusted resources on this page. At the GCC, all patients must pay their financial contribution in-full no later than six weeks before surgery or they risk getting their procedure cancelled.

Frequently Asked Questions About Brow Reduction

How painful is the recovery?

A frontal sinus setback is one of the more painful procedures to recover from because it involves removing bone, contorting it, and setting it back into the skull with titanium plates and screws. Swelling in the face can be distressing, especially if swelling around the eyes causes a harder time opening and closing the eyes. Patients will be given prescription pain medications to manage pain for the first few days, before switching to over-the-counter medications. Most pain should subside after the first two weeks so long as the patient does not overexert themself.

Are the results permanent?

Yes, the results of this surgery are life-long.

Will there be visible scars?

This depends. If your surgeon creates the incision for this procedure along the hairline, there will be a faint scar at the top of the forehead. Patients that are worried about visible scarring and do not want a hairline advancement can opt for the incision to be made entirely through the scalp. This way, the patient’s hair will cover the scar. Small amounts of hair loss can be expected along incision lines.

How long before I can resume work or exercise?

If your job does not require heavy lifting or other taxing physical exertion, you can return 2-4 weeks after surgery. Otherwise, you will need to wait 6 weeks to take up strenuous activities again.

Is brow reduction covered by insurance?

Yes, many insurance providers we work with will cover a brow bone reduction surgery for trans women and trans feminine non-binary patients. The patient will need to provide a support letter from a licensed mental health professional and be on feminizing HRT for at least a year to qualify for coverage. For more information, click here.

In Summary…

In the following video, Dr. Facque (he/him) gives a summary of the hairline advancement and a frontal sinus setback procedures: