Background:One important aesthetic area of the forehead is the brow region situated at its lowest extent above the eyes. Men and women have different brow and forehead shapes that are considered desireable and gender specific. Females have non-protrusive brow bones that taper towards the temples on the sides and give a smooth rounded forehead appearance with no slope. In contrast, men have slightly more prominent brow bones that transition into a forehead that has more of a retroclined vertical slope. In essence, the masculine forehead is characterized by heavier more prominent eyebrows due to the greater growth of the brow bones.
The brow bones, while called a bone, is really not one at all. They are caused by the growth and size of the frontal sinus which lies beneath it. Surprisingly the outer layer of the brow bones, known as the outer table of the frontal sinus, is remarkably thin. While a big brow bone looks quite stout, it is usually only just a few millimeters thick. The bigger and more prominent the brow bones, the bigger is the air cavity of the frontal sinus.
While some brow bone prominence is desireable in a man, it can become too extreme. When the frontal sinus cavity grows too big, it causes a large amount of brow bone protrusion. Jutting out from the forehead in a very conspicuous manner, it gives the appearance often unflatteringly called the ‘Neanderthal’ or Cro-Magnon’ look. This can be reduced to a more aesthetic appearance but can not be done by a bone burring techniqiue.
Case Study: This 35 year-old male from Los Angeles California had been bothered by his large brows since he was a teenager. Even though he was successful at many levels from professional to personal, he still remained sensitive about his facial appearance, particularly in a profile view. He fully realized that reduction would require more than just bone burring and also understood that a scalp incision would be needed to do the procedure.
Under general anesthesia, a bicoronal scalp incision was made to expose the entire forehead and the large brow bones. The supraorbital neurovascular bundles were seen exiting the outer aspect of the brow bones and were dissected out and preserved.
The base of the brow bones was marked out where it joined the forehead bone. A burr was used to take down the bone at the base of the protrusion around its entirety with the exception of the lower edge. A reciprocating saw made an osteotomy at the base of the brow bossing and the entire anterior table of the frontal sinus was then removed.
The removed frontal bone flap was reshaped by multiple osteotomy cuts. This allowed the bone flap to be made straight by gentle pressure through microfractures. The bone flap was made completely flat from its natural convex shape.
The frontal sinus bone flaps were stabilized and then secured over the open sinus cavity with multiple microplates and screws. (1.0mm) The numerous small bone defects between the osteotomy cuts was filled in with a demineralized bone paste on top of a netting of resorbable collagen sheeting. The scalp flap was repositiond, 1 cm. of scalp skin and hair across the top removed for a coronal browlift and closed with resorbable sutures over drains.
The head dressing and drains were removed the next day. While there was some mild swelling, he had no periorbital bruising. Even being just one day after surgery and with brow swelling, his improvement was very visible. Further improvement would be expected over the next month as the swelling resolves and the tissues shrink down and adapt to the newly shaped brow bones.
Case Highlights:
1) Significant brow bone bossing or protrusion in men is a result of overgrowth or excessive pneumatization of the frontal sinus.
2) Reduction of large brow bones, brow bone reduction, can only be done by an osteoplastic bone flap technique with reshaping and repositioning with microplate stabilization.
3) Male brow bone reduction should not be overdone and some small amount of brow protrusion should remain.
Dr. Barry Eppley
Indianapolis, Indiana