Aesth Plast Surg
https://doi.org/10.1007/s00266-021-02236-0
ORIGINAL ARTICLE
Forehead Contouring as an Adjunct to Rhinoplasty: Evaluation
of the Effect on Facial Appearance, Personal Traits and Patient
Satisfaction
Oguzhan Demirel1
Received: 14 January 2021 / Accepted: 7 March 2021
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2021
Abstract
Background The nose has a great impact on facial beauty
and appearance. Therefore rhinoplasty is one of the most
performed procedures worldwide. However, considering
the varying degrees of cosmetic operations holistic
approach to face is essential to achieve more successful
results. In order to this, the forehead is noteworthy with its
gender-related features and important relation to the nose.
The purpose of this study is to assess the effect of forehead
contouring with fat grafting adjunct to rhinoplasty on
personal traits, facial appearance and patient satisfaction.
Methods A total of 15 patients who underwent rhinoplasty
and forehead contouring with fat grafting were enrolled in
this retrospective study. Facial appearance and personal
traits were evaluated via subject Global Aesthetic
Improvement Scale (S-GAIS), and patient satisfaction was
assessed with custom design Forehead Rhinoplasty Out-
come Evaluation Questionnaire (F/ROE-Q). Forehead
inclination was calculated as an objective indicator of fat
graft survival and contour improvement. Pre- and postop-
erative photographs were taken and used for evaluation.
Results According to the F/ROE-Q score, mean total pre-
operative score was 9,13 and the mean total postoperative
score was 24,86 (p \ 0,01). High postoperative satisfaction
scores were observed in all patients. Statistically significant
improvement was observed in attractiveness, femininity,
youthfulness, facial harmony, forehead contour, facial
profile view parameters based on S-GAIS assessment. The
& Oguzhan Demirel
mdoguzhandemirel@gmail.com
1 the mid-face and ethnicity-related anatomical differences
Denizli State Hospital Department of Plastic, Reconstructive,
and Aesthetic Surgery, Sırakapılar, Selcuk Caddesi,
Merkezefendi, 20100 Denizli, Turkey
RHINOPLASTY
mean forehead inclination angle was 19,04o preoperatively
and 16,74° postoperatively.
Conclusion With the important benefits such as higher
patient satisfaction and improvement on facial appearance
and personal traits, forehead contouring with fat grafting
was an efficient and applicable procedure adjunct to
rhinoplasty.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Forehead contouring
Forehead lipofilling

Rhinoplasty
Facial appearance
Personal trait
Introduction
Facial appearance has an important impact on personal
characteristics, social status and interactions [1, 2].
Although beauty terms differ with ethnicity, culture, social
trends and time, the desire to achieve a more attractive
appearance is increasing remarkably [3, 4].
Facial beauty and attractiveness are mainly affected by
anatomical features of the face according to feminine or
masculine characteristics [5, 6]. Especially, variations in
nose and forehead anatomy and in their relations have an
important influence on the feminine perception [7, 8].
The nose is the most important facial unit that affects
facial appearance with the features like being centrally
located on the face, being the most prominent structure of
[9, 10]. With the sociological and physiological aspects, the
nose is an important determinant of femininity [2, 10, 11].
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In a study conducted by Schijndel, the effect of the nasal
deformities on personal traits and visual attention rate was
investigated. According to the comparison of the deformed
nose and computer-morphed nose, nasal deformities asso-
ciated with negative personal traits and higher visual fix-
ation duration [12]. In another study, the impact of
rhinoplasty on attractiveness, success and perceived health
status was assessed. According to study results, better
scores were observed in each parameter after rhinoplasty
[13].
The forehead is another important determinant of the
feminine appearance with remarkable gender-related dif-
ferences [5, 6]. Features such as high located hairline with
the temporal recession, prominent supraorbital ridge,
supraorbital bossing, flatter forehead and acute transition
between frontal and nasal compartment are associated with
the male gender, whereas low situated hairline, smoother
and sloping forehead, none or minimal protruding
supraorbital ridge and softer transition between frontal and
nasal compartments are associated with feminine and
attractive appearance [6, 7].
Based on these gender-related features, the forehead
constitutes an important part of facial feminization surg-
eries in transgender patients [14, 15]. Besides the femi-
nization surgeries that commonly include frontal bone
manipulations, less invasive forehead contouring proce-
dures with fat grafts [16], alloplastic materials [17] or fil-
lers [18] become popular recently among women to reach
more attractive, feminine and beautiful appearance.
In the literature, influence of nose and forehead on facial
appearance is well described solely [7, 8, 10, 14], whereas
despite anatomical proximity, information about the effect
of the combination of forehead contouring and rhinoplasty
procedures on facial appearance in the female population is
missing.
Considering the importance of the holistic approach to
facial units, the aim of this study to assess the effect of
forehead contouring with fat graft on facial appearance,
personal traits and patient satisfaction as an adjunct to
rhinoplasty.
Material and Methods
A total of 15 female patients who applied to our clinic
between February 2019 and August 2020 were enrolled in
this retrospective study. Inclusion criteria for forehead
contouring were existence of masculine forehead features
and contour abnormalities such as the prominent supraor-
bital ridge, supraorbital bossing, mid-frontal depression,
forehead flatness or any obvious contour abnormalities.
Also patients with high radix were enrolled in this study.
Patients with less than 3 months of follow-up and previous
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Aesth Plast Surg
nasal or forehead surgery were excluded from the study.
All patients underwent forehead contouring with fat
grafting and rhinoplasty in the same session. Standard pre-
and postoperative photographs of each patient were taken
in natural head position. The amount of injected fat was
recorded for each patient. Complications about forehead fat
grafting like infection, contour irregularities, cysts forma-
tion and fat emboli were noted. No additional forehead fat
grafting was applied during follow-up. Preoperative pho-
tographs and postoperative photographs which were taken
at the last appointment were used for evaluation.
Facial appearance and personal traits such as attrac-
tiveness, femininity, youthfulness and facial harmony and
improvement in forehead contour and facial profile view
were analyzed using 5-point Subject Global Aesthetic
Improvement Scale (S-GAIS) [19, 20]. Each parameter was
evaluated based on the following scale: 1 = worse, 2 = no
change, 3 = improved, 4 = much improved, 5 = very
much improved. The preoperative baseline score was
defined as 2 points for each parameter. Evaluation was
administered via Internet-based survey program (Sur-
veyMonkey) to provide comfortable environment for
patients. Detailed information about S-GAIS is given in
Table 1.
Patient satisfaction was assessed with forehead and
rhinoplasty outcomes evaluation questionnaire (F/ROE-Q)
which was designed based on the previously defined
‘‘Rhinoplasty Outcomes Evaluation Questionnaire (ROE-
Q)’’[21]. A 5-point Likert scale was used for assessment.
The questionnaire was conducted by a trained clinical
nurse.
Forehead inclination angle was measured on lateral view
photographs as an objective indicators of fat graft survival
and postoperative surgery outcome. Adobe Photoshop
digital imagining software program (Adobe Systems Inc,
San Jose, CA) was used to perform measurements and
calculations.
The study was conducted according to the declaration of
Helsinki for human participants and approved by the
Pamukkale University Hospital Local Ethical Committee.
Informed consent was obtained from all the patients for
enrollment and using photographs in this study .
Forehead Inclination Angle Measurement
Forehead inclination angle was calculated using three
anatomic landmarks and three measurement lines. Frank-
furt horizontal plane was used as reference line. Trichion
point (Tr), superion point (Sn), glabella point (G) and
forehead anterior point (FA) were used as anatomic land-
marks [22]. These anthropometric landmarks are detailed
in Table 2. Trichion point was selected in patients with flat
forehead contour. Superion point was selected in patients
Aesth Plast Surg

Table 1 Subject Global Aesthetic Improvement Scale (S-GAIS)

Degree Description

Worsened patient (1 point)
Unaltered patient (2 point)
Improved patient (3 point )
Very improved patient (4 point)
Exceptional improvement (5 point)
The appearance has worsened compared with the original condition
The appearance substantially remains the same compared with the original condition
Improvement of the appearance, better compared with the initial condition, but a touch-up is advised
Marked improvement of the appearance, but not completely optimal
Excellent corrective result

Table 2 Anthropometric landmarks and their definitions

Trichion point (Tr) Intersection between midline of forehead and hairline

Superion point (Sp) Most superior aspect of the forehead when the forehead is either rounded or angular in contour
Glabella point (G) Intersection between midline of forehead and most prominent point of inter-eyebrow plane
Forehead anterior point The midpoint between trichion and glabella for foreheads with flat contour or the midpoint between superion and
(FA) glabella for foreheads with rounded or angular contour.

with more angular, oval or convex forehead contours. FA Operative Technique

point corresponds to the midpoint between trichion and
glabella or superion and glabella according to forehead
shape [22]. Line 1 was defined as a vertical line passing
from the G point that is perpendicular to Frankfort hori-
zontal plane. Line 2 was defined as a vertical line passing
from the FA point that is perpendicular to Frankfort hori-
zontal plane. Line 3 was defined as a line passing from FA
point to glabella point. The angle between Lines 1 and 3 is
defined as forehead inclination angle. Anthropometric
landmarks and measurement lines are illustrated in Fig.1.
Adipose tissue was harvested from the inner thigh or the
abdomen. After application of the tumescent solution,
liposuction was performed using a 3mm blunt-tip cannula.
Low negative pressure was created using 10cc Luer-lock
syringes. Harvested lipoaspirates were purified using cen-
trifugation with 1200g/3 minutes centrifuge protocol. After
centrifugation, the middle adipose layer separated from oil
and fluid layers and transferred to the 2.5 ml Luer-lock
syringes.
One central and two lateral access points at the hairline
were created. Deep and superficial central and two lateral
fat compartments were augmented with both suprape-
riosteal and subcutaneous plane injections. Small fat ali-
quots were transferred using 1.2 mm and 1.6 mm blunt tip
cannulas where the cannula was withdrawn. A 2.5 ml Luer-
lock syringe was used for appropriate calculation of the
amount of the transferred volume. The injection was con-
tinued until the deformity was corrected and proper contour
was achieved. Minimum and maximum transferred fat
volume was 7.5 cc and 17.5 cc, respectively. Preoperative
and postoperative images of patient in the operation room
are presented in Fig 2.

Statistical Analysis

Fig. 1. Anthropometric landmarks and measurement lines
The data were analyzed using the SPSS version 25.0 (IBM,
NY, USA) statistical program. Normality of each data was
assessed with the Shapiro–Wilk test. Nonparametric Wil-
coxon signed ranks test or paired sample t test was used
based on normality test. The Wilcoxon signed ranks test
was used to measure whether there was a statistically sig-
nificant difference between the mean values of the

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Fig. 2. Preoperative and immediate postoperative result of forehead
contouring and rhinoplasty in the operation room
variables of S-GAIS and F/ROE-Q parameters . Also the
baseline score was defined as 2 (2 point = no change) for
S-GAIS evaluation. Descriptive statistics was applied for
S-GAIS and F/ROE-Q parameters. The results were con-
sidered significant when the p-value was \0.05.
Results
Mean follow-up time was 10.9 months and ranged from 3
to 14 months. The mean age of the participants was
23.2 years (18–32 years). All of the patients responded to
all questions. The mean volume of transferred fat graft was
13.16 cc . In 4 patients 17.5 cc, in 2 patients 15 cc, in 5
patients 12.5 cc, in 2 patients 10 cc and in 2 patients 7.5cc
fat was transferred. Midfrontal depression (n = 14), fore-
head flatness (n = 4) and prominent supraorbital ridge
(n = 2) were observed contour deformities. Also, accom-
panying high radix was observed in 4 patients. The acne
formation and oily skin were observed in 2 and 4 patients,
respectively. These complaints were passed during the
follow-up without the need for any treatment. No other
complications such as fat emboli, infection, contour irreg-
ularities and cysts formation were observed.
Subject Global Improvement Scale (S-GIAS)
Differences of the mean scores between pre- and postop-
erative results and frequency analysis of scores were
investigated. Preoperative photographs were scored as 2
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Aesth Plast Surg
points for each parameter and 2 points defined as mean
baseline score for statistical significance analysis. Consid-
ering the mean scores, the improvement was observed in
all study subjects. The highest improvement was observed
in facial profile view and forehead contour with the mean
score of 4.86 and 4.46, respectively (Table 3). The
improvement of the forehead contour on lateral pre- and
postoperative images is presented in Fig. 3. The worsening
compared to the original condition has not been observed
in none of the patients. No change compared to the original
appearance was obtained once for attractiveness, youth-
fulness and forehead contour parameters. The distribution
of scores for each parameter is illustrated in Fig. 4.
Moreover, a statistically significant difference was
observed in all parameters (Table 3).
Forehead and Rhinoplasty Outcomes Evaluation
questionnaire (F/ROE-Q)
All questions were responded by the participants. The
mean total preoperative score was 9,13 and the mean total
postoperative score was 24.86 (p \ 0.01)(Fig 5). Consid-
ering all the data, significant statistical differences were
observed between mean preoperative and postoperative
scores for each F/ROE-Q section (Table4.). However, after
comparison of common questions about nose (question 1
and 6) and forehead (question 7 and 8), there were statis-
tical differences in preoperative mean scores between
questions 1 and 7 and questions 6 and 8 ( p \ 0.001 and
p \ 0.013, respectively)(Fig 6). However, no statistical
differences were observed in postoperative scores between
these groups (p values were 0.083 and 0.102,
respectively)(Table 4).
Forehead Inclination Angle
Forehead inclination angle was calculated on preoperative
and postoperative lateral photographs. Mean preoperative
inclination angle was 19.04° (ranging between 11.6° and
31.1°), and mean postoperative inclination angle was
16.74° (ranging between 10.9° and 26.2°). Remarkably, the
mean preoperative inclination angle was 26.02° in patients
with the flat forehead. To evaluate statistical significance, a
paired-samples t-test was applied after normal distribution
of data was observed. According to the test results, statis-
tically significant differences were observed between pre-
and postoperative groups (p \ 0.001). The highest incli-
nation angle difference between pre- and postoperative
calculation was 6.7° and the lowest was 0.2°. The mean
decrease value was higher in patients with flat forehead
(4.47°). Descriptive statistics are given in Table 5.
Improvement in forehead inclination angle and contour is
Aesth Plast Surg

Table 3 Descriptive statistics

Descriptive statistics Wilcoxon signed ranked test
and p-value for S-GAIS
Mean Std. Deviation Minimum Maximum Asymp. Sig. (2-tailed)

Attractiveness 4.0667 .96115 2.00 5.00 0.001*

Femininity 3.9333 .70373 3.00 5.00 0.001*
Youthfulness 4.4000 .91026 2.00 5.00 0.001*
Facial harmony 4.2667 .70373 3.00 5.00 0.001*
Forehead contour 4.4667 .91548 2.00 5.00 0.001*
Facial profile view 4.8667 .35187 4.00 5.00 0.000*
*
p-value \ 0.05 considered statistically significant

Fig. 3. A 22-year-old patient with severe midfrontal depression, mild forehead flatness and prominent supraorbital ridge. Preoperative and
postoperative front, oblique, lateral and basilar view photographs at 12 months after 15 cc fat injection for forehead contouring.

Fig. 4. Score frequency of

S-GAIS parameters

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presented in pre- and postoperative lateral view images in
Figs. 7 and 8.
Discussion
The perception of facial beauty is an important issue in the
past and today [23, 24]. With the significant increase in
social media usage, enthusiasm for better facial appearance
is common among women [25].
To achieve a more attractive and beautiful appearance,
rhinoplasty is one of the most important and efficient
aesthetic procedures. Besides improvement in facial beauty
and attractiveness, rhinoplasty is associated with increased
Fig. 5. Mean preoperative and postoperative scores of F/ROE-Q
personality characteristics like self-esteem, self-confidence
and sociability [26–28].
In a study by Lu et al. [29], the effect of rhinoplasty on
various parameters such as symmetry, youthfulness, facial
harmony, likeability, trustworthiness, confidence, femi-
ninity, attractiveness, approachability, and intelligence was
investigated. Better outcomes in all parameters were
observed in the postoperative group. Similarly, more
straightened nose was associated with more attractive
appearance [30].
Besides the important impacts of the nose on attrac-
tiveness and personal traits, patient satisfaction is varying
remarkably among individuals after rhinoplasty [31].
Especially, missing of the other facial deformities may
affect surgical outcome. Therefore, the assessment of facial
units with a holistic approach is essential to achieve more
favorable and harmonic facial appearance [8, 9, 32].
Based on these holistic approach, the forehead, as the
main structure of the upper third of face, is one of the most
important regions that affects facial appearance [6, 17].
With the interaction to the nasal compartment and the
gender-specific characteristics, forehead plays important
role in facial contouring, balancing and feminization pro-
cedures. Also, forehead fullness is also associated with
intelligence, beauty, youth, leadership and popularity in
different studies [33–35].

Table 4 Descriptive statistics and p-values of F/ROE-Q

Rhinoplasty and Forehead Outcomes Evaluation questionnaire (RFOE-Q) Descriptive statistics Wilcoxon signed
ranks test
Operation Mean Std. Asymp. Sig. (2-
status scores Deviation tailed)

(1)How well do you like the appearance of your nose? Not at all(0) / Somewhat(1) / Pre .4667 .51640 .001*
Moderately (2) / Very much (3) /Completely (4) Post 3.5333 .51640
(2)How well are you able to breathe through your nose? Pre 2.0667 .88372 .002*
Not at all(0) / Somewhat(1) /Moderately (2) / Very much (3) /Completely (4) Post 3.0667 .59362
(3)How much do you feel your friends and loved ones like your nose ? Pre .8667 .83381 .001*
Not at all(0) / Somewhat(1) /Moderately (2) / Very much (3) /Completely (4) Post 3.4667 .51640
(4)Do you think your current nasal appearance limits your social or professional Pre 1.8667 .91548 .003*
activities? Post .5333 .74322
Always(0) / Usually (1)/Sometimes(2)/Rarely (3)/ Never (4)
(5)How you confident you that your nasal appearance is the best that it can be? Pre .6000 .50709 .001*
Not at all(0) / Somewhat(1) /Moderately (2) / Very much (3) /Completely (4) Post 3.4667 .51640
(6)Would you like to surgically alter the appearance or function of your nose? Pre .4000 .50709 .000*
Definitely(0)/ Most likely(1)/ Possibly(2) Probably not(3) No(4) Post 3.8667 .35187
(7)How well do you like the appearance of your forehead? Pre 1.7333 .45774 .001*
Not at all(0) / Somewhat(1) /Moderately (2) / Very much (3) /Completely (4) Post 3.3333 .72375
(8)Would you like to surgically alter the appearance of your forehead? Pre 1.1333 .74322 .001*
Definitely(0)/ Most likely(1)/ Possibly(2) Probably not(3) No(4) Post 3.6000 .50709
*
p-value \0.05 considered statistically significant

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Aesth Plast Surg

Besides the being important part of facial feminization

Fig. 6. Comparison of the p values of common questions about the
nose and forehead.
surgery in transgender patients [36, 37], forehead con-
touring is widely administrated among female populations
[16, 33, 34, 38, 39]. In a study conducted by Li et al., long-
term results of forehead fat injection were assessed based
on postoperative photographs. After mean 8.1-month fol-
low-up, 87.5% of the patients were satisfied with the
results. Also, forehead projection was increased signifi-
cantly (p=0.01)[33]. Similarly, in a study performed by
Chou et al., micro-autologous fat transplantation (MAFT)
was used for forehead augmentation and contouring.
According to study data, efficient results were obtained in
83.1% of the patients after mean 10.2 ml fat transfer to the
forehead [34].
Despite knowledge about the importance of nose and
forehead on facial attractiveness existing in the literature,
data about the effect of the combination surgeries of nose

Table 5 Descriptive statistics

Descriptive statistics
for forehead inclination angle
Range Minimum Maximum Mean Std. Deviation

Preoperative inclination angle 19.50 11.60 31.10 19.0467 6.05060

Postoperative inclination angle 15.30 10.90 26.20 16.7467 4.47132
Pre- and postoperative differences 6.50 .20 6.70 2.3000 2.00107

Fig. 7. A 22-year-old patient with mild midfrontal depression and forehead flatness. Preoperative and postoperative front, oblique, lateral and
basilar view photographs at 10 months after 12.5 cc fat injection for forehead contouring.

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Fig. 8. An 18-year-old patient with mild midfrontal depression. Preoperative and postoperative lateral view photographs at 12 months after 10 cc
fat injection for forehead contouring.
and forehead are limited. There are only two studies that
mentioned forehead contouring with autologous fat graft-
ing adjunct to rhinoplasty [39–41]
In a study conducted by Kornstein et al. [39], naso-
frontal and nasolabial angles were investigated in patients
who underwent fat grafting on forehead/glabella/nasal
radix complex and pyriform aperture alone and in combi-
nation with rhinoplasty. Study results showed a 2.0-degree
reduction in nasofrontal angle in both groups. The author
stated that fat grafting was a reliable method to control the
transition of the nose with other facial units. Although the
effects of fat grafting on radix control were evaluated with
nasofrontal measurements, no evaluation method was used
to assess the effect of forehead contouring on facial
appearance, personal traits and patient satisfaction.
In 2012, Işık et al. [40] assessed the effect of the new
injection technique for forehead contouring with fat graft in
nine patients who underwent rhinoplasty. In their tech-
nique, fat grafts were transferred in a space that created
with a sharp epidural needle between the skin and under-
lying muscle. The main objective of the study was defining
a novel injection technique.
In our study, statistically significant improvement was
observed in all patients based on S-GAIS and F/ROE-Q
assessments. These data were consistent with the literature
and reveal the efficiency of forehead contouring with fat
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Aesth Plast Surg
grafting adjunct to rhinoplasty by means of facial appear-
ance, personal traits and patient satisfaction.
Importantly, when the preoperative responses of F/ROE-
Q were analyzed, it has been observed that patients are
more disturbed with the appearance of their noses in
comparison with forehead. These differences may be due to
the low awareness of patients about the forehead defor-
mities comparison with the nose deformities. However,
high and similar satisfaction rates were observed in post-
operative evaluation for both surgeries.
As a secondary objective of our study, forehead incli-
nation was investigated as an objective indicator for
assessment of fat graft survival in forehead fat grafting
procedure. In all patients, forehead inclination was
decreased. This objective measurement supports the higher
scores obtained from F/ROE-Q and S-GAIS surveys.
Results from forehead inclination assessment were also
compatible with the literature [42–44].
In a study conducted by Guerrero-Apolo et al. [42], the
association between impulsiveness and slant of the fore-
head was investigated. The increasing angle of the slant of
the forehead was correlated with higher self-impulsiveness
rates. In a study performed by Farkas et al. in 1985, the
inclination of five profile segments was analyzed. The
significantly higher backward inclination of forehead was
observed in males (p \ 0.001)[43]. Also in another study, a
Aesth Plast Surg
greater degree of frontal slope angle was associated with
more masculine facial features [44].
As another surgical benefit of this combination surgery,
the decrease in forehead inclination angle and an increase
in midforehead/glabellar projection after forehead fat
injection may create smoother forehead nasal transition and
balance in facial profile, especially in patients with high
radix. In our study, significant improvement was observed
in four patients with high radix.
Also, this holistic approach may be to raise awareness in
the patient about existing facial deformities that may affect
the surgical outcome and patient satisfaction. Conse-
quently, it may help the patient and the surgeon’s expec-
tations meet at a common point [45].
Lastly, autologous fat grafting comes forward with its
features like ease of application, low application cost, low
risk of infection and allergic reaction, and long-term effi-
ciency comparison to frontal bone surgeries, alloplastic
materials, or filler for forehead contouring. Besides these
advantages, fat graft resorption and deleterious vascular
complications are the main drawbacks of this technique. To
overcome these problems deep understanding of the anat-
omy of forehead fat compartments [46] in conjunction with
the vascular network [47] and parameters affecting fat graft
survival in fat graft harvest, purification and transfer steps
are crucial.
Besides these valuable aspects of this study, there are
two main study limitations. Firstly, in the fat graft prepa-
ration step, cell-enriched lipotransfer strategies such as
adipose/bone marrow-derived stem cells or platelet-rich
plasma were not used. Despite consideration of every step
that affects fat graft survival, the use of the cell-enriched
lipotransfer technique may improve surgery effectiveness.
Secondly, enrollment larger patient sample may provide
more strength and valuable data.
Conclusion
Forehead contouring with fat grafting was an efficient and
powerful surgery that improves facial appearance, personal
traits and patients satisfaction in rhinoplasty patients. With
the strong interaction with the nasal compartment, forehead
contouring provides an additive and synergistic effect on
facial balancing and harmony. Also, cost-effectiveness and
low complication rates of fat grafting increase the clinical
applicability of this method.
Declarations
Conflict of interest All of the authors declare that they have no
conflicts of interest. The study was financed by the corresponding
author.
Ethical Approval This study was approved by the Pamukkale
University Hospital Local Ethical Committee. All procedures per-
formed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki Declaration and its later
amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all the
patients for enrollment and using photographs in this study.
References
1. Little AC, Jones BC, DeBruine LM (2011) Facial attractiveness:
evolutionary based research. Philos Trans R Soc Lond B Biol Sci
366(1571):1638–1659. https://doi.org/10.1098/rstb.2010.0404
2. Todorov A, Olivola CY, Dotsch R, Mende-Siedlecki P (2015)
Social attributions from faces: determinants, consequences,
accuracy, and functional significance. Annu Rev Psychol
66:519–545. https://doi.org/10.1146/annurev-psych-113011-
143831
3. Liew S, Wu WTL, Chan HH et al (2020) Consensus on changing
trends, attitudes, and concepts of Asian beauty. Aesthetic Plast
Surg 44(4):1186–1194. https://doi.org/10.1007/s00266-020-
01808-w
4. Internatıonal survey on aesthetıc/cosmetıc procedures performed
ın 2019. https://www.isaps.org/wp-content/uploads/2020/12/
Global-Survey-2019.pdf. Accessed 3 Jan 2020
5. Ascha M, Swanson MA, Massie JP, Evans MW, Chambers C,
Ginsberg BA, Gatherwright J, Satterwhite T, Morrison SD,
Gougoutas AJ (2019) Nonsurgical management of facial mas-
culinization and feminization. Aesthet Surg J 39(5):NP123–
NP137. https://doi.org/10.1093/asj/sjy253
6. Somenek M (2018) Gender-related facial surgical goals. Facial
Plast Surg 34(5):474–479. https://doi.org/10.1055/s-0038-
1670648
7. Spiegel JH (2011) Facial determinants of female gender and
feminizing forehead cranioplasty. Laryngoscope 121:250–261
8. Przylipiak M, Przylipiak J, Terlikowski R, Lubowicka E,
Chrostek L, Przylipiak A (2018) Impact of face proportions on
face attractiveness. J Cosmet Dermatol 17(6):954–959. https://
doi.org/10.1111/jocd.12783
9. Park J, Suhk J, Nguyen AH (2015) Nasal analysis and anatomy:
anthropometric proportional assessment in asians-aesthetic bal-
ance from forehead to chin part II. Semin Plast Surg.
29(4):226–231. https://doi.org/10.1055/s-0035-1564818
10. Andretto AC (2007) The central role of the nose in the face and
the psyche: review of the nose and the psyche. Aesthet Plast Surg.
31(4):406–410. https://doi.org/10.1007/s00266-006-0241-2
11. Khansa I, Khansa L, Pearson GD (2016) Patient satisfaction after
rhinoplasty: a social media analysis. Aesthet Surg J 36(1):1–5.
https://doi.org/10.1093/asj/sjv095
12. Van Schijndel O, Tasman AJ, Litschel R (2015) The nose
influences visual and personality perception. Facial Plast Surg
31(5):439–445. https://doi.org/10.1055/s-0035-1565009
13. Nellis JC, Ishii M, Bater KL et al (2018) Association of rhino-
plasty with perceived attractiveness, success, and overall health.
JAMA Facial Plast Surg 20(2):97–102. https://doi.org/10.1001/
jamafacial.2017.1453
14. Morrison SD, Vyas KS, Motakef S, Gast KM, Chung MT,
Rashidi V, Satterwhite T, Kuzon W, Cederna PS (2016) Facial
feminization: systematic review of the literature. Plast Reconstr
Surg. 137(6):1759–1770. https://doi.org/10.1097/PRS.
0000000000002171
123

15. Facque AR, Atencio D, Schechter LS (2019) Anatomical basis
and surgical techniques employed in facial feminization and
masculinization. J Craniofac Surg 30(5):1406–1408. https://doi.
org/10.1097/SCS.0000000000005535
16. Marten T, Elyassnia D (2018) Facial fat grafting: why, where,
how, and how much. Aesthetic Plast Surg 42(5):1278–1297.
https://doi.org/10.1007/s00266-018-1179-x
17. Eppley BL (2019) Forehead/brow reduction or augmentation with
custom implants for enhanced facial profileplasty. Facial Plast
Surg 35(5):430–445. https://doi.org/10.1055/s-0039-1697962
18. Bae B, Lee G, Oh S, Hong K (2016) Safety and long-term effi-
cacy of forehead contouring with a polycaprolactone-based der-
mal filler. Dermatol Surg 42(11):1256–1260. https://doi.org/10.
1097/DSS.0000000000000913
19. Alegre-Sánchez A, Bernárdez C (2020) A new nonhydrophilic
agarose gel as subdermal filler for facial rejuvenation: aesthetic
results and patient satisfaction. J Cosmet Dermatol
19(8):1900–1906. https://doi.org/10.1111/jocd.13529
20. Park YJ, Cha JH, Han SE (2020) Maximizing thread usage for
facial rejuvenation: a preliminary patient study. Aesthet Plast
Surg. https://doi.org/10.1007/s00266-020-01919-4
21. Alsarraf R (2000) Outcomes research in facial plastic surgery: a
review and new directions. Aesthet Plast Surg 24(3):192–197.
https://doi.org/10.1007/s002660010031
22. Andrews WA (2008) AP relationship of the maxillary central
incisors to the forehead in adult white females. Angle Orthod
78(4):662–669. https://doi.org/10.2319/0003-
3219(2008)078[0662:AROTMC]2.0.CO;2
23. Romm S (1989) The changing face of beauty. Aesthet Plast Surg
13(2):91–98. https://doi.org/10.1007/BF01571475
24. Harrar H, Myers S, Ghanem AM (2018) Art or science? An
evidence-based approach to human facial beauty a quantitative
analysis towards an informed clinical aesthetic practice. Aesthet
Plast Surg 42(1):137–146. https://doi.org/10.1007/s00266-017-
1032-7
25. Arab K, Barasain O, Altaweel A et al (2019) Influence of social
media on the decision to undergo a cosmetic procedure. Plast
Reconstr Surg Glob Open 7(8):e2333. https://doi.org/10.1097/
GOX.0000000000002333
26. Zojaji R, Sobhani E, Keshavarzmanesh M, Dehghan P, Meshkat
M (2019) The association between facial proportions and patient
satisfaction after rhinoplasty: a prospective study. Plast Surg
(Oakv). 27(2):167–172. https://doi.org/10.1177/
2292550319826097
27. Parsa KM, Charipova K, Coerdt K, Clark CM, Wang H, Chu E,
Reilly MJ (2020) The role of age and gender on perception of
women after cosmetic rhinoplasty. Aesthet Plast Surg. https://doi.
org/10.1007/s00266-020-02030-4
28. Nuyen B, Kandathil CK, Saltychev M, Most SP (2019) Social
perception of the nasal dorsal contour in male rhinoplasty. JAMA
Facial Plast Surg. 21(5):419–425. https://doi.org/10.1001/
jamafacial.2019.0321
29. Lu SM, Hsu DT, Perry AD et al (2018) The public face of
rhinoplasty: impact on perceived attractiveness and personality.
Plast Reconstr Surg 142(4):881–887. https://doi.org/10.1097/
PRS.0000000000004731
30. Roxbury C, Ishii M, Godoy A et al (2012) Impact of crooked nose
rhinoplasty on observer perceptions of attractiveness. Laryngo-
scope 122(4):773–778. https://doi.org/10.1002/lary.23191
31. Khansa I, Khansa L, Pearson GD (2016) Patient satisfaction after
rhinoplasty: a social media analysis. Aesthet Surg J. 36(1):NP1-5.
https://doi.org/10.1093/asj/sjv095
32. Li D, Xu H, Xu L, Huang X, Yuan J, Wei M (2015) The aesthetic
proportion index of facial contour surgery [published correction
appears in J Craniofac Surg 2015 Jul; 26(5):e466]. J Craniofac
123
Aesth Plast Surg
Surg 26(2):586–589. https://doi.org/10.1097/SCS.
0000000000001475
33. Li X, Kubiak CA, Yang X, Kemp SWP, Cederna PS, Ma J (2019)
Forehead fat grafting: Asian facial contouring and augmentation.
Plast Reconstr Surg 144(5):1057–1065. https://doi.org/10.1097/
PRS.0000000000006122
34. Chou CK, Lee SS, Lin TY et al (2017) Micro-autologous Fat
Transplantation (MAFT) for forehead volumizing and contour-
ing. Aesthetic Plast Surg 41(4):845–855. https://doi.org/10.1007/
s00266-017-0883-2
35. Kang GC, Hsiao YC, Huang JJ et al (2019) Aesthetic durable
forehead contouring in Asians with fat grafting and botulinum
toxin. Ann Plast Surg 82(1S Suppl 1):59–65. https://doi.org/10.
1097/SAP.0000000000001704
36. Ousterhout DK (1987) Feminization of the forehead: contour
changing to improve female aesthetics. Plast Reconstr Surg
79(5):701–713. https://doi.org/10.1097/00006534-198705000-
00003
37. Spiegel JH (2019) Facial feminization for the transgender patient.
J Craniofac Surg 30(5):1399–1402. https://doi.org/10.1097/SCS.
0000000000005645
38. Buckingham ED, Glasgold R, Kontis T et al (2015) Volume
rejuvenation of the facial upper third. Facial Plast Surg
31(1):43–54. https://doi.org/10.1055/s-0035-1544943
39. Kornstein AN, Nikfarjam JS (2015) Fat grafting to the forehead/
glabella/radix complex and pyriform aperture: aesthetic and anti-
aging ımplications. Plast Reconstr Surg Glob Open 3(8):e500.
https://doi.org/10.1097/GOX.0000000000000470 (Published
2015 Aug 27)
40. Isik S, Sahin I (2012) Contour restoration of the forehead by
lipofilling: our experience. Aesthet Plast Surg 36(4):761–766.
https://doi.org/10.1007/s00266-011-9800-2
41. Peleman JR, Chung MT, Johnson J et al (2020) Surgical adjuncts
to rhinoplasty: an algorithmic approach. Aesthet Plast Surg
44(5):1694–1704. https://doi.org/10.1007/s00266-020-01744-9
42. Guerrero-Apolo JD, Navarro-Pastor JB, Bulbena-Vilarrasa A,
Gabarre-Mir J (2018) The slant of the forehead as a craniofacial
feature of impulsiveness. Braz J Psychiatry 40(3):270–276.
https://doi.org/10.1590/1516-4446-2017-2339
43. Farkas LG, Sohm P, Kolar JC, Katic MJ, Munro IR (1985)
Inclinations of the facial profile: art versus reality. Plast Reconstr
Surg 75(4):509–519. https://doi.org/10.1097/00006534-
198504000-00011
44. Han DS, Park JH (2014) Aesthetic correction of a protrusive
forehead through repositioning of the anterior wall of the frontal
sinus. Arch Craniofac Surg 15(3):129–132. https://doi.org/10.
7181/acfs.2014.15.3.129
45. Sözen T, Dizdar D, Göksel A (2020) Awareness of facial
asymmetry and its impact on postoperative satisfaction of
rhinoplasty patient. Aesthetic Plast Surg. https://doi.org/10.1007/
s00266-020-01968-9
46. Cotofana S, Mian A, Sykes JM et al (2017) An update on the
anatomy of the forehead compartments. Plast Reconstr Surg
139(4):864e–872e. https://doi.org/10.1097/PRS.
0000000000003174
47. Cong LY, Phothong W, Lee SH et al (2017) Topographic analysis
of the supratrochlear artery and the supraorbital artery: implica-
tion for improving the safety of forehead augmentation. Plast
Reconstr Surg 139(3):620e–627e. https://doi.org/10.1097/PRS.
0000000000003060
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