Supraorbital Rim Shaving: Opening Up Deep-Set Eyes | Dr. MFO

Deep-set eyes, characterized by eyes that sit further back in the orbital socket, can create a shadowed, intense, or sometimes tired appearance. While some find this look mysterious and alluring, others seek a more open, feminine, and awake aesthetic. The anatomical culprit behind deep-set eyes is often a prominent supraorbital rim—the bony ridge above the eye socket. In Gezichtsfeminisatiechirurgie (FFS), reshaping this bony structure is a pivotal procedure for softening the upper third of the face and achieving a harmonious, feminine gaze. Supraorbital rim shaving, also known as forehead contouring or type III forehead reconstruction, is the surgical technique used to reduce the projection of this bony ridge, thereby “opening up” the eyes and creating a more youthful, accessible appearance.

The decision to undergo supraorbital rim shaving is deeply personal and rooted in the desire for facial harmony. For transgender vrouwen and non-binary individuals undergoing FFS, a prominent brow ridge is a significant masculine marker. Reducing this prominence is not merely about aesthetics; it is about aligning one’s physical appearance with their gender identity. For cisgender individuals, the procedure can correct genetic predispositions or age-related changes that have made the eyes appear heavy or hooded. Understanding the surgical nuances, the recovery process, and the potential outcomes is essential for anyone considering this transformative procedure.

Vanuit het genuanceerde standpunt van een chirurg gespecialiseerd in Gezichtsfeminisering Surgery (FFS), the periorbital region – encompassing the eyes and their surrounding structures – presents a critical frontier in achieving optimal aesthetic harmony and feminization.

— Klinisch perspectief van dr. MFO

Anatomy of the Supraorbital Rim and Deep-Set Eyes

To appreciate the impact of supraorbital rim shaving, one must first understand the complex anatomy of the forehead and eye region. The supraorbital rim is the thick, curved bone that forms the upper boundary of the eye socket (orbit). It serves as the attachment point for the corrugator supercilii muscles (which furrow the brow) and the frontalis muscle (which elevates the eyebrows). In many individuals with deep-set eyes, this rim is naturally prominent and projects forward, creating a “brow bossing” effect. This projection casts a shadow over the upper eyelid and the eye itself, making the eyes appear smaller and the gaze more intense.

The depth of the eye is also influenced by the position of the orbital septum and the fat pads within the orbit. When the bony rim is prominent, the soft tissue envelope is pushed forward, often resulting in a heavy brow and a hooded upper eyelid. This is distinct from simple skin laxity; it is a skeletal issue that cannot be fully corrected with soft tissue procedures alone. Supraorbital rim shaving addresses the root cause by reducing the bony volume, allowing the soft tissues to settle in a more natural, forward position relative to the eye.

The Surgical Procedure: Type III Forehead Reconstruction

The gold standard for correcting a prominent supraorbital rim in FFS is the Type III forehead reconstruction. This is an invasive surgical procedure that involves accessing the forehead bone through an incision. There are two primary approaches: the coronal approach (incision across the scalp) and the hairline approach (incision along the hairline). The choice depends on the patient’s hairline, scalp elasticity, and desired outcome. The coronal approach offers excellent visibility but raises the hairline, while the hairline approach preserves the hairline but offers slightly more limited access.

Once the forehead flap is elevated, the surgeon visualizes the frontal bone and the supraorbital rims. The goal is to reduce the projection of the bony ridge without compromising the structural integrity of the skull. This is achieved using specialized surgical tools. As noted in surgical literature, “The supraorbital rim is reshaped with a burr.” This burring technique allows for precise, controlled reduction of the bone, smoothing out the prominent bossing to create a gentle, continuous curve from the forehead to the nasal bridge. The procedure often extends to the lateral orbital rims to ensure a seamless transition and to widen the eyes horizontally.

The supraorbital rim is reshaped with a burr.

— AO Surgery Reference

The Role of Osteotomies and Bone Grafting

In some cases, particularly where the forehead is significantly recessed or the brow bossing is extreme, simple burring may not be sufficient. The surgeon may need to perform an osteotomy—a controlled fracture of the bone. This involves cutting the supraorbital rim and moving it backward to reduce projection. When bone is removed or significantly reduced, the structural integrity must be maintained. In Type III reconstruction, the entire forehead bone segment is often removed, reshaped, and then reattached using titanium plates and screws. This allows for the most dramatic reduction in prominence and the creation of a smooth, feminine forehead contour.

Bone grafting is sometimes utilized to fill defects or to smooth out irregularities after burring. The harvested bone from the forehead itself can be ground into a paste (bone dust) and reapplied to the area. This technique ensures a seamless transition and prevents the “over-burred” look, where the bone becomes too thin. The surgeon’s artistry lies in creating a natural curve that complements the patient’s other facial features, such as the nose and chin.

Isolated anterior wall fractures with displaced fragments require surgical correction to restore normal forehead contour.

— PMC Article

Impact on Eye Aesthetics: Opening Up the Gaze

The primary aesthetic goal of supraorbital rim shaving is to “open up” the eyes. By reducing the bony prominence above the eyes, several positive changes occur simultaneously. First, the shadow cast by the brow ridge is eliminated. This allows light to hit the upper eyelid and the eye itself more directly, making the eyes appear brighter and more prominent. Second, the reduction in bony volume allows the soft tissues (skin, fat, and muscle) to settle forward. This can reduce the hooding of the upper eyelid, revealing more of the eyelid crease and the iris.

For deep-set eyes, this procedure can be transformative. A patient who previously felt their eyes were hidden or overshadowed often reports that their eyes look larger and more expressive after surgery. The procedure also facilitates other eye-enhancing surgeries. For instance, an bovenste blefaroplastie (ooglidcorrectie) is often performed in conjunction with forehead contouring. With the bony obstruction removed, the blepharoplasty can achieve a more defined double eyelid crease, further enhancing the eye shape. The result is a harmonious balance between the forehead, brow, and eyes.

Combining Supraorbital Rim Shaving with Other Procedures

Supraorbital rim shaving is rarely performed in isolation. It is a cornerstone of comprehensive Facial Feminization Surgery, often combined with other procedures to maximize aesthetic impact. The most common combination is with a brow lift. While rim shaving reduces the bony prominence, a brow lift addresses the position of the eyebrows. In many masculine faces, the brows sit low and heavy. A brow lift elevates the brow tail, creating a more arched, feminine shape that complements the newly contoured forehead.

Other common combinations include neuscorrectie (nose job) and hairline advancement. The forehead contouring sets the stage for a balanced profile; a rhinoplasty can refine the nose to match the new forehead angle, while hairline advancement lowers the hairline to reduce the vertical height of the forehead. For patients seeking a complete transformation, these procedures are often staged or performed simultaneously to minimize overall recovery time.

The Synergy with Lateral Orbital Rim Shaving

While the central supraorbital rim is the primary focus, the lateral orbital rims (the outer edges of the eye sockets) also play a crucial role in eye appearance. Prominent lateral rims can make the eyes look sunken and narrow. Lateral orbital rim shaving, often performed alongside central rim reduction, widens the eye socket horizontally. This creates a more open, almond-shaped eye appearance, which is highly desirable in FFS. The combination of central and lateral reduction creates a smooth, continuous orbital contour that frames the eyes beautifully.

This comprehensive approach ensures that the eyes are not only opened vertically (by reducing the brow ridge) but also horizontally (by reducing the lateral rims). This dual action is particularly effective for deep-set eyes, as it addresses the confinement from all angles. The result is a gaze that is open, bright, and harmoniously integrated with the rest of the facial features.

Herstel en postoperatieve zorg

Supraorbital rim shaving is a major surgical procedure requiring a significant recovery period. The surgery is typically performed under general anesthesia and requires an overnight hospital stay. Immediately after surgery, patients will experience swelling, bruising, and numbness in the forehead and scalp. The head is kept elevated to reduce swelling, and cold compresses are applied around the eyes (not directly on the incision). Pain is usually manageable with prescribed medication, though the sensation of tightness and pressure is common.

Managing Swelling and Numbness

Swelling peaks around day 2-3 and gradually subsides over the following weeks. However, residual swelling can persist for several months as the tissues settle. Numbness in the forehead and scalp is a temporary side effect of the dissection required to access the bone. Sensation typically returns within 3 to 6 months, though it can take up to a year for full recovery. Patients must avoid strenuous activity, bending over, and heavy lifting for at least 4-6 weeks to prevent increased blood pressure and bleeding.

Scarring is a primary concern for many patients. With a coronal incision, the scar is hidden deep within the hairline and is virtually invisible once healed. With a hairline incision, the scar is placed along the front edge of the hairline. Surgeons use meticulous closure technieken to ensure the scar is fine and well-hidden among the hair follicles. Sun protection is critical during the healing phase to prevent hyperpigmentation of the scar.

Resultaten op lange termijn en onderhoud

The results of supraorbital rim shaving are permanent. Once the bone is reshaped, it does not grow back. However, the aging process continues. The skin will eventually lose elasticity, and gravity will act on the soft tissues. While the bony structure remains feminine, patients may eventually require non-surgical maintenance, such as Botox to relax the brow muscles or fillers to restore volume loss in the temples. The goal of the surgery is to create a youthful, feminine foundation that ages gracefully.

It is crucial for patients to have realistic expectations. While supraorbital rim shaving can dramatically open up deep-set eyes, it cannot change the fundamental shape or color of the eyes. It is a structural procedure that enhances the natural beauty of the eyes by removing the bony obstruction. The final aesthetic outcome is a result of the surgeon’s skill, the patient’s anatomy, and the healing process.

Bibliografie

• AO Surgery Reference. (n.d.). Contouring of the Frontobasal Supraorbital Ridge. Opgehaald van https://surgeryreference.aofoundation.org/cmf/sequela/skull-base-and-cranial-vault/frontobasal-supraorbital-ridge-orbital-roof-malposition/contouring
• Dokter MFO. (nd). Reshaping Supraorbital & Lateral Orbital Rims in FFS. Opgehaald van https://www.dr-mfo.com/reshaping-supraorbital-lateral-orbital-rims-ffs/
• Spiegel, JH, en DeRosa, J. (2005). The Aesthetic Forehead: Anatomical Considerations in Forehead Rejuvenation. Facial Plastic Surgery Clinics of North America, 13(2), 233-242.
• Deschamps-Braly, J. (2017). Facial Feminization Surgery: The Forehead and Hairline. In Facial Feminization Surgery (pp. 45-68). Thieme.
• PubMed Central. (2011). Management of Frontobasal Trauma. Opgehaald van https://pmc.ncbi.nlm.nih.gov/articles/PMC3208335/
• Capitán, L., & Simon, D. (2014). Gezichtsfeminisatiechirurgie: een uitgebreide gids. Aesthetic Surgery Journal, 34(6), 789-802.