American Association of Plastic Surgeons

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Three-dimensional Evaluation Of The Frontal Sinus And Implications For Forehead Feminization
Ying C. Ku, BS, Filippo Perozzo, MD, Mazen Al-Malak, MD, Jacob Lammers, DO, Abigail Meyers, MD, Mychajlo Kosyk, MD, MPH, Raymond Isakov, MD, Cecile Ferrando, MD, Antonio Rampazzo, MD, PhD, Bahar Bassiri Gharb, MD, PhD;
Cleveland Clinic Foundation, Cleveland, OH, USA

PURPOSE: Forehead feminization surgery reduces supraorbital prominence. However, the current Ousterhout-based approach overlooks frontal sinus heterogeneity and asymmetry. This study aimed to investigate frontal sinus contribution to supraorbital prominence and the implications for forehead feminization.
METHODS: An IRB-approved retrospective review of maxillofacial CT scans was conducted on genetically male patients (2003-2022). Three-dimensional reconstruction of the skull and frontal sinus was performed. Data collected included patient age, frontal sinus dimensions and symmetry index, surface area of the frontal sinus and supraorbital prominence, degree of supraorbital protrusion and nasofrontal angle, and frontal sinus anterior wall thickness.
RESULTS: One hundred and six patients (51.520.4 years) were included. Bilateral frontal sinus absence occurred in 2 patients (1.9%), unilateral absence in 8 patients (7.5%), and 39 patients (36.8%) exhibited moderate/severe asymmetry. The average areas of the frontal sinus and supraorbital prominence were 1279.8 591.7 and 1251.9 393.3 mm2, respectively. Supraorbital prominence area aligned with frontal sinus in 22% of patients, while 38% exhibited larger frontal sinus area and 40% larger supraorbital prominence area. The degree of supraorbital protrusion (3.61.5 mm) positively correlated with supraorbital prominence area (r=0.4, p<0.0001), frontal sinus volume (r=0.24, p=0.02), and depth (r=0.35, p=0.0002), and negatively correlated with nasofrontal angle (r= -0.31, p=0.001) and anterior wall thickness (r= -0.21, p=0.03).
CONCLUSION: Modifications to Ousterhout's classification are warranted to account for frontal sinus asymmetry. Anterior wall osteotomy should be tailored to the protrusion area. A combination of limited anterior wall setback and bone remodeling should be used for asymmetric cases.
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