Forehead lumps can be caused by a variety of issues including osteomas, lipomas and unevenness of the skull caused by facial fracture. Hard knots on the forehead can often be attributed to benign bony growths known as osteomas. Osteomas are uncommon, but these benign tumors in the bone of the skull can have an unpleasing appearance which could also lead to pain and sight issues. Typically, they are rather slow growing in nature. Other bone tumors are possible and include osteoid osteomas, which can sometimes be distinguished radiologically.
The classic approach to the removal of forehead osteomas is using an incision along the face. Dr. Shah’s preference is to recontour the bone of the forehead with the use of an endoscope. By making the incision in the scalp, no scar is visible on the face, making scarring virtually invisible. The instruments Dr. Shah uses to reshape the forehead create an improved appearance and smoother to the touch.
Endoscopic forehead osteoma removal is done on an outpatient basis. Due to Dr. Shah’s technique of selectively blocking nerves with local anesthesia, most patients only need minimal anesthetic, allowing for a relatively pain free experience. Many patients are able to return to work either the next day or in a few days.
Patient before osteoma removal (left) and after removal by Dr. Shah (right)
Traditionally speaking, the removal of osteomas utilizes a coronal scar. As you can see in Figure A., the path of incision is just behind the hairline. There are two main issues with a coronal scar. First of all, the scar can be seen rather easily in some patients and with some hairstyles, particularly shorter hair. In addition, there is a nerve from the patient called the supraorbital nerve which will be cut when performing a coronal incision. This nerve provides sensation to the scalp which can be disconcerting to the patient as they cannot feel their hair when brushing it or combing it.
The other approach to removing osteomas has involved direct incision of the lesion over the skin (Figure B.). This can create a visible scar in the forehead and can result in a trade off of removal of the osteoma with a visible scar.
Dr. Shah has pioneered a technique to remove the lesions by concealing the scar in the scalp. By hiding the small incision within the scalp (as highlighted in Figure C.), the patient can have an incision which is difficult to see.
While it is technically more difficult to remove the osteoma from this approach, it does allow for a more pleasing aesthetic outcome. Dr. Shah has perfected this procedure and his removal process uses a minimal evasive path of dissection (as represented by the yellow cone in Figure D.) that allows for limited visible swelling and cuts down on the recovery time that a patient would have with a coronal or direct incision. Patients are ready to go back to their daily lives in no time at all.
One of the greatest parts of being a facial plastic surgeon is that there are a number of ways of performing one procedure. I think anyone who does things “by the book” loses out on the creative element necessary to be a successful plastic surgeon.
before removal by Dr. Shah (left) and after removal (right)
For example, this patient had a forehead osteoma, which is a hard lump on her forehead. (See photographs with blue outline). She has a history of keloids, or forming large thick scars. Rather than place a large scar on her forehead, I used an endoscope (an instrument the size of a drinking straw) and specially designed narrow instruments. From a small incision, I was able to contour the forehead so that she did not have a large bump on it and continue to wear her hair short and with confidence, avoiding a visible scar and any disruption of her hairline.
Dan is a patient of Dr. Shah’s who received this forehead bump procedure to remove his osteoma. This is his journey to help better understand what to expect from this procedure.
Frequently Asked Questions
Do I need general anesthesia for removal of a forehead bump?
Most patients do extraordinarily well in an office setting with small amounts of local anesthesia. The benefit of this technique is that patients have decreased downtime and less risk from an anesthetic standpoint. Dr. Shah is able to do this due to the large amount of forehead bumps he has removed making his approach both efficient and effective.
Is it painful to have an osteoma removed?
Most patients have been able to return to work in one day. Rarely does the patient require pain medications.
How intense is my post procedure care and recovery process?
Swelling is typically limited but can include the lower eye area and bruising can occur. Ice is recommended for the first 72 hours. Many patients fly in and out the same day as the procedure and many return to work within 24 hours.
How can Dr. Shah’s approach be so much quicker and have a fast recuperation period?
Dr. Shah limits the amount of dissection around the bump which can help reduce swelling. In addition, patients with local anesthesia often have less vasodilation and subsequent swelling.
Can the forehead osteoma return?
It is unlikely for the osteoma to return with the approach that is utilized.
Do I need a CT scan prior to the procedure?
For bony lesions of the skull, Dr. Shah does require imaging prior to the procedure. Our office can help to arrange this.
Does Dr. Shah treat forehead lipomas?
Yes, he utilizes a similar approach for forehead lipomas. With this approach he will go from underneath the galea and muscle and remove the lipoma directly. This avoids a noticeable scar.
Can I have general anesthesia or a deeper type of anesthesia?
The office has several options available. Most patients prefer local anesthesia however, other options are available, if desired, for patients.