Can A Forehead and Back of the Head Skull Augmentation Be Done At The Same Time?

Q: Dr. Eppley, I’m 28 years old and transgender (MtF) and have previously had two rounds of facial feminization surgery elsewhere. The specific procedures were brow bone reduction and trachea shave initially and chin/jaw reduction later. This has made a significant improvement to my face, but there are some points that still bother me:

1. My forehead has what I feel is a kind of masculine backwards slope, and I’m interested in the possibility of improving this with a custom implant. I’m also somewhat bothered by my flatter back of the head (around the indent that’s visible on the CT pictures). Would it be possible to address both of these issues in a single procedure, or would that put too much tension on the scalp? Also, how would the position of the hairline be affected by a forehead implant?

2. I’m also bothered by my undereye area, which I feel lacks projection and gives my face a gaunt and tired look. My eyes also have some scleral show and the upper eyelid sits lower on my right side. The right upper eyelid crease has also been asymmetric since my previous forehead surgery. I understand that infraorbital rim augmentation can improve scleral show, but would that be sufficient on its own? And would it be possible to improve the eye asymmetry issues?

3. Unfortunately my chin was reduced more than I expected, and I’m struggling to adjust to the new appearance which just feels too small and pointed. Comparing the pre- and post-op CT scans I think I also lost a few millimetres of height, which I specifically didn’t want; and there’s a bit of ptosis as well. The jaw reduction also wasn’t quite symmetric, so my jawline is now higher on the right, and on the left it’s uneven. I guess a custom implant would be my best option to address these issues?

4. I was initially scheduled to have a rhinoplasty during my original surgery, but the surgeon talked me out of it because I wanted to feminize my nose while retaining a bit of the convexity, which he said would be difficult to achieve. I’m just wondering if you have the same or a different assessment of that.

I have attached some photos, along with some views from my most recent CT scan in case those might be useful.

Any advice would be much appreciated.

Kind regards,

A:Thank you for your inquiry and sending your pictures to which I can say the following:

1) The combination of forehead and back of head augmentations can be done concurrently. The volumetric needs of both do not seem excessive. (see attached)

2) While infraorbital rim augmentation will provide needed volume the eyelid issues need their own concurrent attention for optimal improvement. The right upper eyelid has ptosis which needs a direct ptosis repair. The lower eyelids need a combination of lateral canthoplasties and spacer grafts to eliminate the scleral show.

3) As for the jawline it depends on how far you want to go with it.The chin by itself can be addressed with a standard small vertical lengthening chin implant (and leave the rest of the jawline alone) or make a custom jawline implant and address all of its issues.

4) i see no reason why our rhinoplasty couldn’t be done without leaving some slight convexity to the dorsal profile. That is simply a matter of doing what you see as best as opposed to some ideal standard. (see attached)

Dr. Barry Eppley

Indianapolis, Indiana