What is the best management approach for a patient with an osteoma (bone tumor) on the forehead?

Management of Forehead Osteoma

For a forehead osteoma, surgical excision is indicated only when the lesion causes aesthetic concerns or functional problems; asymptomatic lesions can be observed, and when surgery is needed, endoscopic or minimally invasive approaches through anterior hairline incision are preferred over traditional bicoronal approaches to optimize cosmetic outcomes and preserve nerve function.

When to Treat vs. Observe

Observation is appropriate for asymptomatic forehead osteomas, as these are benign lesions with very slow continuous growth 1. Surgical treatment should be reserved specifically for:

• Symptomatic lesions causing aesthetic deformity that bothers the patient 1
• Functional problems such as visual disturbance from orbital displacement 2
• Complications from sinus involvement if the osteoma extends into frontal sinus 2

The key distinction here is that unlike osteosarcoma (which requires aggressive multimodal treatment with chemotherapy and wide surgical margins 3), a benign forehead osteoma requires no treatment unless it causes problems for the patient.

Diagnostic Workup

CT scan is the gold standard imaging modality to confirm the diagnosis and plan surgery 1. The imaging will show:

• Radiopaque lesion similar to bone cortex 1
• Relationship to adjacent structures including sinuses and orbit 1
• Extent of bone expansion 1

Cone beam CT provides optimal assessment for surgical planning when intervention is needed 1. Biopsy is not routinely required when imaging findings are characteristic 4.

Surgical Approach Selection

When surgery is indicated, choose the approach based on lesion size and location:

For Most Forehead Osteomas: Endoscopic Approach

Endoscopic resection is the preferred technique for accessible forehead osteomas because it offers 5:

• No visible scarring (incisions hidden in hairline)
• Operating time of 20-40 minutes
• Same-day discharge
• Excellent cosmetic outcomes with high patient satisfaction
• Magnification of anatomical structures
• Preservation of supraorbital nerve function

This approach has been validated in both adults and adolescents with no recurrences at one-year follow-up 6, 5.

For Large Osteomas: Anterior Hairline Incision with Subcutaneous Dissection

When osteomas are too large for endoscopic removal, use an anterior hairline incision with subcutaneous dissection 7. This technique:

• Provides broad visualization for complete resection 7
• Hides the scar in the hairline 7
• Preserves scalp sensation by dissecting in the subcutaneous plane and dividing frontalis muscle and periosteum parallel to the supraorbital nerve course 7
• Avoids inadvertent injury to deep nerve branches 7
• Shows no recurrence at 12-month follow-up 7

Avoid Traditional Bicoronal Approach

The bicoronal approach should generally be avoided because it can result in damage to the supraorbital nerve with resultant permanent forehead numbness 7. Reserve this only for giant lesions with extensive sinus involvement requiring fat obliteration 2.

Surgical Technique Principles

The goal is radical surgical resection with optimal cosmetic result 1:

• Complete removal of the osteoma 2
• Recontouring of any resulting bony defect (can use Medpor® or similar material) 7
• Minimally invasive approach prioritized 1
• If frontal sinus is opened, consider fat obliteration 2

Postoperative Management

Patients typically recover quickly with:

• Same-day or next-day discharge for endoscopic cases 5
• Resolution of edema as early as postoperative day 9 6
• Vision improvement within 2 months if there was orbital involvement 2
• No routine need for antibiotics in uncomplicated cases 7, 5

Follow-Up and Recurrence Risk

Monitor for recurrence at 6-12 months postoperatively 7, 2. Recurrence is rare with complete excision 7, 5. Unlike osteosarcoma which requires intensive surveillance with chest imaging every 2-3 months 3, benign osteomas need only clinical follow-up to assess cosmetic result and detect any rare recurrence.

Critical Pitfalls to Avoid

• Do not confuse osteoma with osteosarcoma: Osteomas are benign and require only local excision when symptomatic, whereas craniofacial osteosarcomas require referral to bone sarcoma MDT before surgery and consideration of chemotherapy 3
• Do not use bicoronal incision routinely: This causes unnecessary nerve damage and visible scarring 7
• Do not operate on asymptomatic lesions: Observation is appropriate for benign osteomas causing no problems 1
• Do not attempt endoscopic removal of very large lesions: Use anterior hairline approach instead for adequate visualization 7