**Acknowledgements**

re-insertion of free bone flaps. The direct approach will then require complex bone fixations using wires or plates and screws. More advanced modifications of these techniques to avoid free bone flaps have been discussed where the shortened and re-approximated bone tongues stay attached at their normal calvarial position at the base or the apex of the calvaria. For example, in the technique described by Wagner and Wiewrodt[113] in 2008, following sagittal suturectomy and parietalbarrel stave incisions, four or five lanceolate pieces of thefrontal bone are excised resulting in three or four vertical bone bridges. These osteotomies are designed to extend radially from thecranial base towards the fontanel. Small strips rectangular to the apicobasal axis are then cut out from these bridges, leaving basal and apical bone tongues. [113] The tabula externa at the base of the basal tongues is drilled off and the tongues are bent inward

Corresponding basal and apical bone tongues arethen re-approached and fixated with sutures. The gold standard procedure for correction of severe frontal bossing is still open approach with osteotomy of the anterior table of the frontal sinus which provides excellent outcome. Complications such as long coronal scars, alopecia, blood loss, forehead paresthesia, neuromas and traction palsy of the facial nerve makes this operation invasive, with increased chance of

Despite the widespread use of endoscopic frontal bone operations such as remodeling of bony defects and removal of osteomas of the frontal bone, only recently has "endoscopic frontal bossing correction" been introduced.[112] This emerging method seems to have rendered

Moreover, the introduction of the endoscope revolutionized the surgical approach to the forehead, as it allowed for smaller incisions, magnified visualization, decreased risk of bleeding, faster recovery, and decreased chance of neuropathy by preserving cutaneous nerves. Endoscopic contouring of the forehead was first described by Song et al. on a Korean woman with frontal bone deformities.[115] Since then, most published endoscopic manipu‐ lation of the frontal bone and supraorbital ridge has involved osteoma mass excision or frontal sinus fracture repair. Retrospective reviews of patients receiving endoscopic correction of frontal bossing have shown promising aesthetic results with minimal postoperative morbidity. This method of improving forehead contour, however, should be carried out on properly selected groups of patients. Mild deformities of frontal bossing and adequate bone thickness over the frontal sinus makes patients a great choice for endoscopic frontal bossing correction. [112] Some complications such as neurosensory damage, vascular injury, and extended operative time. [112]. Similarities like incision line and dissection planes for this technique with standard endoscopic forehead lift allows easy access to the frontal bone for contouring in

morbidity and less desirable for mild to moderate frontal bossing correction. [112]

frontal bossing correction much simpler, significantly safer, and minimally invasive.

patients with frontal bossing and undergoing concurrent forehead rejuvenation.[112]

The major architectural promontories of the facial skeleton, including the malar-midface region, nose, chin,angle of the mandible and frontal buttress provide the base upon which the

**6. Summary**

to correct the inferior aspect of the frontal bossing. [113]

180 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Special thanks to MS. Shahrzad Zojaji and Marjan Golpashafor illustrations.
