Facial Feminization Surgery - Forehead Reduction Cranioplasty Type III (3) - Dr Keojampa

http://www.drkeojampa.com/facial-feminization-surgery-los-angeles-california/

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. Type 3 Forehead Cranioplasty is an extremely safe procedure when performed by an experienced surgeon. It is much more complex, technically challenging to perform, and only a handful of surgeons in the world perform it. Surgeons who advocate for only burring provide limited results and typically have little to no experience in Type 3 Forehead surgery. There is simply no increase in the rate of frontal sinus infections after. We have actually found the opposite with Type 3 patients having fewer sinus infections than the general population. Additionally, adjunctive procedures can be performed to improve sinus drainage during Type 3 Forehead surgery.

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, craniofacial and ENT surgeons to pinpoint the exact location of critical areas of the brain and skullbase.

If hairline contouring or lowering is needed, we perform a pretrichial incision at the hairline. For patients who do not need hairline lowering, the incision is placed in the hair bearing scalp (bicoronal incision) so it is completely hidden. 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.

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 frontal sinus mucocele 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 develop. Most patients do NOT need any manipulation of the frontal sinus mucosa beside setting back the bone. Patients who have undergone a Type 3 Forehead are actually less likely to have any frontal sinus issues since the partition or wall between the right and left frontal sinus is taken down so the sinus can drain from both the right and left side.

For the majority of patients, the frontal sinus bone is simply placed back over the forehead without the need for plates or screws. The area is sealed with autologous bone paste created from the forehead shaving. 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. If needed, we prefer to use titanium microplates which are nonpalpable or visible due to the extremely small size.

Dr. Keojampa is one of the few surgeons with extensive experience in facial feminization surgery with forehead reduction Cranioplasty Type 3, jaw contouring, and facial implants. He trained with Dr. Jeffrey Spiegel (www.drspiegel.com), an internationally renowned facial plastic surgeon and the foremost expert in facial feminization surgery in the world. During his training with Dr. Spiegel, he completed over 200 cases of facial feminization surgery. Based in the Greater Los Angeles region, we provide in office facial feminization consultations and skype consultation. Requests for in office or skype consultations can be made by calling our office (415) 666-2525 or using the consult request form. https://forms.gle/x3NhkrZ3KwPq6xnb9

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