Pott puffy tumor (PPT) is defined as osteomyelitis of the frontal bone with a subperiosteal abscess, typically presenting as a localized swelling of the forehead [1-4]. First described in 1760 by British surgeon Sir Percivall Pott, PPT may result from infection of the anterior table of the frontal bone, commonly due to acute or chronic sinusitis, blunt or penetrating trauma, dental infections, or, more rarely, contamination from an insect bite [3-5]. Although PPT often presents acutely, there are reports of its occurrence even years after an initial insult, highlighting the risk for delayed sequelae [3]. The rarity of PPT in the context of facial feminization surgery justifies this report to enhance awareness among surgeons performing gender-affirming procedures.

A 30-year-old transgender female presented with a 1-day history of rapidly progressive, firm swelling over her forehead, occurring 1 year after upper third facial feminization surgery (including anterior table frontal sinus setback osteoplasty, bilateral superolateral orbital ostectomy, and bilateral frontal bone reduction osteoplasty). Her symptoms included clear rhinorrhea and nausea. Examination revealed a non-erythematous, firm, 5×5 cm swelling over the glabella and right forehead (Fig. 1). Laboratory studies showed a leukocytosis of 12.92×10³/μL, consistent with an active inflammatory process. Non-contrast enhanced computed tomography of the head demonstrated thickening of the frontal sinus mucosa, indicating a potential source of infection, as well as a peripherally enhancing subgaleal fluid collection measuring 3.5×0.8×2.3 cm (Fig. 2), consistent with a subperiosteal abscess.

Prompt intravenous amoxicillin and sulbactam were initiated, and the patient was taken to the operating room the following day for exploration and debridement. Intraoperatively, there was no gross purulence, necrotic tissue, or evidence of direct communication with the frontal sinus. The previously placed resorbable hardware from her frontal sinus setback osteoplasty was intact, with no signs of infection or bony defects in the surrounding area. Friable granulation tissue, suspicious for an infectious or inflammatory process, was sent for histological analysis and demonstrated fused acellular bone intermixed with blood clot. Final wound cultures grew Haemophilus influenzae, informing subsequent antibiotic management. She was discharged on postoperative day 3 and completed a 10-day course of amoxicillin-clavulanate, achieving complete resolution of symptoms at her first follow-up appointment (Fig. 3). Notably, the patient reported no change in the aesthetic results of her facial feminization surgery following PPT, with no soft tissue distortion or irregularity to diminish the feminizing effect. This positive outcome highlights the critical importance of timely and appropriate management for post-surgical complications.

PPT has been reported across a wide age spectrum, from infancy to the ninth decade of life, highlighting its potential to affect individuals of any age [3,5]. The increased incidence observed in adolescents is attributed to the unique anatomical development of the frontal sinus and its venous drainage during this period [1,5]. Its typical pathophysiology involves a progression from an initial sinus infection to osteomyelitis of the frontal bone, subsequently leading to the formation of a subperiosteal abscess through erosion of the anterior table [3-5].

Clinical presentation varies but often includes headache, fever, nausea, vomiting, and nasal discharge, which may be purulent or non-purulent. In more severe cases, neurological symptoms such as seizures can occur [1-7]. Infection may spread contiguously, resulting in periorbital complications. The relatively high rate of intracranial complications, particularly among pediatric patients, highlights the seriousness of this condition [2,5,7].

Cross-sectional imaging is critical for diagnosis, with magnetic resonance imaging providing superior soft tissue detail and facilitating detection of intracranial involvement [2,5]. While polymicrobial infections are frequently identified, isolation of a single pathogen, as in this case with H. influenzae, is also possible. The substantial proportion of culture-negative cases further illustrates the challenges of microbiological diagnosis [3-5].

The cornerstone of treatment involves a combination of broad-spectrum antibiotics and surgical drainage. The choice of surgical approach depends on the extent and location of the abscess and any associated sinus involvement [5,8]. Prolonged courses of intravenous antibiotics are often necessary, especially when osteomyelitis or intracranial spread is present, underscoring the need for careful and extended antimicrobial therapy [3,4,6,7,9].

When evaluating a postoperative collection, it is essential to consider conditions that may mimic the clinical picture of PPT. Cranial hematoma can present with forehead swelling but may lack infection-related signs such as fever or leukocytosis. Isolated osteomyelitis without abscess formation may cause localized pain and swelling, but typically does not produce a well-demarcated fluid collection on imaging. Uncomplicated sinusitis with soft tissue edema can result in forehead swelling due to inflammatory spread, but usually lacks the firm, fluctuant quality of an abscess. Benign or malignant skull tumors generally have a more gradual onset and may be associated with neurological deficits depending on their location.

PPT remains a rare but serious infectious complication that can arise following frontal sinusitis or other precipitating events. The occurrence of PPT in this patient after facial feminization surgery, specifically involving manipulation of the frontal bone and sinus, represents a novel clinical scenario. As the prevalence and accessibility of facial feminization procedures continue to increase, it is vital for surgeons performing these intricate osseous and soft tissue modifications to be aware of rare but serious postoperative complications such as PPT. Early recognition, coupled with timely and appropriate management, is essential to prevent significant morbidity and to ensure favorable aesthetic outcomes.

This unique case underscores the importance of considering even rare infectious complications in the postoperative period following facial feminization surgery. Surgical manipulation of the frontal bone and sinuses, while intended to achieve specific aesthetic outcomes, inherently carries a risk of infection, which may arise even after a delayed interval. The successful management in this instance, with complete infection resolution and preservation of aesthetic outcomes, highlights the importance of a multidisciplinary approach, including surgical intervention, targeted antibiotic therapy based on culture results, and vigilant postoperative monitoring. Further documentation of similar cases will help clarify the true incidence and risk factors for PPT in the context of gender-affirming facial surgery, ultimately enhancing patient care and outcomes as this field evolves.