Brow bone augmentation can be done using a variety of techniques and materials. The most common approach has been an open scalp or hairline incision using bone cements to do the buildup of the brow bones. While effective it does necessitate a long incision that is fairly distant from the implantation site and the final shape of the result depends on the surgeon’s artistic shaping skill during surgery.
Another approach is to place a brow bone implant that is premade from a 3D CT scan. This has a lot of advantages in that the implant design is predetermined before surgery and its placement can be done through a much more limited incisional method. An endoscopic technique can be done using two small paired hairline (or just behind the hairline) incisions. The subperiosteal pocket is developed under endoscopic visualization and the brow bone implant is inserted through one of the incisions.
The implant is then positioned and secured, if needed, with small screws using a percutaneous technique. Even though the implant has a custom fit, keeping it from sliding upward is important since most brow bone implants need to sit as long as possible particularly in the male patient. This is a brow procedure that takes only about an hour to complete.
The hairline incisions offer a very direct approach to the brow bones. Some patients understandably may find these incisions and their resultant scars as potentially problematic. But it has been my experience that these hairline scars in the male patient do well and blend in inconspicuously. It is their irregular zigzag pattern that allows them to heal well as a straight line incision would be more noticeable.
Brow bone augmentation is often desired and requested by men for a more masculine appearance. While injectable fillers and fat can provide some temporary augmentative effects, a sustained and stronger brow bone effect requires placement of a non-resorbable material. While an implant would be such a permanent method, there is no preformed brow bone implants that are available. In addition, even if standard brow bone implants did exist, the approach of placing it through an open incision and the extensive scalp scar that would be created would make it a suspect aesthetic choice for most men.
The use of a custom brow bone implant is an ideal permanent brow bone augmentation method. Using a silicone biomaterial, the implant is fashioned from the patient’s 3D CT scan. The desired implant shape and dimensions are created beforehand with emphasis on the location of the brow bone prominence, its thickness across the length of the brow bones and the location of the supraorbital nerve locations.
Because it has a performed shape and the silicone implant has some flexibility, its placement can be done with an extensive scalp incision. To the contrary it can be placed using an endoscopic technique through small 2.5 cm incisions either at or behind the hairline. Such incisions typically heal with imperceptible scars. The endoscope allows the subperiosteal pocket to be developed and released along the brow ridge area with observation and preservation of the supraorbital neurovascular bundles.
Once the pocket is made the brow bone implant can be easily slide through one of the small incisions into place. Because it is a custom made implant its accurate placement is aided by its precision shape. Once in place the decision can be made about whether to secure it with a small titanium screw or not. I prefer to do so and it with an endoscopic method after passing the screwdriver down to the implant through a small central 3mm horizontal low forehead incision. The screws is passed with an instrument into position over the implant and the endoscope guides the screwdriver into place to drive it through the implant and into the underlying bone.
The custom brow bone implant offers a relatively simple and permanent method for brow bone augmentation. It is easily placed and secured through an endoscopic technique which causes minimal scarring to do so.
Background: One of the main characteristics of the male forehead are the brow bones. They usually are more pronounced than the projection of the forehead creating a brow bone break between the two structures. Brow bones occur in men due to the larger growth of the underlying frontal air sinuses, a result of a testosterone influence. Brow bone problems in men are more often the result of excessive overdevelopment rather than underdevelopment.
Building up a deficient or flat brow bones can be augmented by a variety of implanted materials. The simplest brow bone augmentation method is by fat injection. It can be placed without an incision and can be feathered the whole way down the lateral orbital rim. Its one disadvantage is that fat survival is unpredictable and often undergoes substantial resorption weeks to months after surgery.
A brow bone implant is a permanent augmentation method as its composition can not undergo any physical change. While there are a number of available materials the most versatile and easily made is that of silicone. Having worked with silicone brow bone implants over the years, a variety of ‘off the shelf’ implant designs have been used and can be applied to other patients as well. Ideally a custom made brow bone implant can be fabricated from the patient’s 3D CT scan and build out in shape and size to what the patient wants.
Case Study: This 32 year-old male was having a variety of facial reshaping procedures and brow bone augmentation was one of them. He had no brow bone prominence evident and a flatter forehead profile. He opted for a preformed brow bone implant placed through one of his low horizontal forehead wrinkles.
Under general anesthesia, the brow bones were exposed through a central horizontal forehead incision. The supraorbital and supratrochlear nerves were identified and retracted downward. The brow bone implant was inserted, positioned and secured with a single midline small screw. The forehead incision was closed in layers.
When seen nine months after surgery he had a very noticeable brow bone ridge and brow bone break. The scar had healed nicely and it was not noticeable.
While brow bone augmentation is uncommon, its biggest issues are the implant’s design and how to get it onto the brow bones. (incision) The shape and thickness of the brow bone implant is best done through a custom manufacturing process. But I have done enough of these surgeries over the years that a number of different preformed brow bone implants are available. The real challenge is how to place it and the most common methid would be through an endoscopic approach from at the hairline or just behind it. In rare instances, like in this case, the patient will permit direct access through a horizontal skin incision just above the brow bone area.
1) Permanent brow bone augmentation can be done using a custom made brow bone implant.
2) Placement of a brow bone implant requires an open incision which can be done through a mid-forehead crease/wrinkle.
3) Brow bone implants are available in preformed shapes or can be custom made.
Background: The forehead occupies one-third of the face and has a significant role to play in overall facial aesthetics. One component of the forehead is the prominence of the supraorbital rims, also known as the brow bones. How prominent they are affects the shape of the forehead and the appearance of the eyes. The more prominent the brow bones, the more deep set one’s eyes will appear. The more prominent the brow bones, the more masculine one’s facial appearance will look..
For men who seek brow bone augmentation, the traditional treatment options have had their drawbacks. Access to the brow bone area has had to be done through a long open incision placed either at the hairline or further back in the scalp. This has some obvious limitations for many men given what their frontal hairline pattern and density may be. In addition, there are no preformed brow bone implant options available. As a result various types of bone cements have to be used, which can be done successfully, but still requires a wide open forehead exposure to do.
Case Study: This 23 year-old young man wanted to have a more prominent and masculine brow bone appearance. His forehead was not particularly recessed or retro-inclined but there was no distinct brow bone bulge or brow bone break up into the forehead. He was interested in a limited method of brow bone augmentation using implants rather than bone cement. A 3D CT scan was done from which a one-piece brow bone implant was designed.
Under general anesthesia, two small (2.5 cms) irregular incisions were made at the edge of the hairline. Under endoscopic visualization subperiosteal elevation was done down to the lower edge of the brow bones where the periosteum was released from one frontozygomatic suture to the other. The supraorbital neurovascular bundles were dissected out and made sure that they were not at risk form compression by the implant. The custom brow bone implant was soaked in antibiotics and then inserted through one of the incisions. It easily slide into position and had a virtual ‘snap fit’ into place. The position of the implant was confirmed through the endoscope. No fixation of the implant was needed due to its custom fit.
A custom implant offers a surgically straightforward and reliable method of brow bone augmentation. It avoids the historic need for a long open scalp incision, reducing morbidity and expediting recovery. Through a computer design process, thickness, symmetry and maximal point of projection of the implant can be assured.
The endoscopic approach provides good pocket dissection and visualization of the supraorbital nerves for implant insertion and placement. While this works extremely well for implants, it would equally so for preformed or standard sized brow bone implants if they were available.
1) Brow bone augmentation as an isolated procedure can be done through either preformed or custom implant designs.
2) An endoscopic approach through two small scalp incisions can be used for brow bone implant placement with very minimal scarring.
3) An endoscopic implant placement technique now makes it more feasible for men or women who seek a higher profile to their brow bones.
The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.
While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.
While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.
Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.
Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.
Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.
One of the reasons that fat grafting has become so popular in plastic surgery is its versatility. Because of small cannula delivery techniques, fat grafts can literally be placed just about anywhere in any amounts. This has led to fat grafting becoming a near universal method for soft tissue augmentation and, more selectively, bony augmentation. While there are issues with how well fat grafting works (how much fat survives), its ease and precision of placement makes it appealling nonetheless.
The role of aesthetic facial fat grafting is to add volume providing a rejuvenation effect. This can be done in all regions of the face, although it is more commonly done in the midfacial and perioral regions The upper face, consisting of the forehead and brow, is well known to be treated with it mostly being done for temporal hollowing in the lateral forehead. The flatter surfaces of the forehead are a far different challenge as providing a significant augmentative effect that is smooth is virtually impossible with injection fat grafting. Brow augmentation, however, is a much smaller area and creating an enhanced ridge is am easier shape to achieve and maintain.
Isolated brow augmentation is done for different reasons that a total forehead augmentation. It is almost exclusively done in men who want a stronger and more masculine appearance through the creation of a more prominent brow ridge and visible brow break into the forehead. It may also be attempted because of the desire to have a bit of a browlift or to camouflage skeletonization of the orbital rims. To determine if fat grafting is a good option, one should first have a trial of an inexpensive injectable filler to ensure that any injection approach can create the desired brow look.
In fat grafting to the brow, there are two main considerations. First the typical volume needed is around 2 to 5cc per brow. Although the fat harvest must usally be twice this amount to get a good concentrate, such low volumes makes it possible for even thin patients. Second, like in all fat grafting, a even linear distribution of the fat is needed throughout the brow. Small microcannula delivery through a small entrance nick inside the midportion of the eyebrow allows access to the entire brow. It is important to avoid traumatizing the supraorbital neurovascular bundle whose location can be felt as a notch on the lower end of the brow bone.
While there are more precise and completely predictable methods of brow augmentation using bone cements, these require an open scalp approach and a resultant scar. This hardly seems justified when the amount of brow augmentation needed is relatively minor or isolated just to the brow ridge. Despite the unpredictability of fat injection survival, its simplicity makes it an appealing option for brow enhancement.
Fat grafting to the face, done by injection, has become incredibly popular in the past decade. The recognition that most faces lose fat volume as they age has led to fat grafting done alone or in conjunction with other facial lifting procedures. One such area of volume addition in the aging face is that of the eyebrows. Adding fat not only fills them out but can create a lifting effect as well.
In the January 2012 issue of Aesthetic Surgery Journal, a study is reported that looks at this issue of volume loss in the eyebrow as one ages.With the underlying tenet that the eye brows and the eyebrow fat pads are vulnerable to age-related changes, this study looked at the eyebrow region through 3D volumetric analysis. Over a five year period at an Eye Institute, patients that had undergone orbital CTs for medical purposes were evaluated. This included 52 CT scans that were fairly equally divided between men and women. 3D reconstruction techniques were used to calculate volumes of the retroorbicularis oculi fat (ROOF), galeal fat (ROOF and subcutaneous fat), and soft tissue muscles.
The study showed that overall eyebrow volume does not change appreciably with age. However, the contribution of fat and soft tissue to total eyebrow volume does seem to change. This pattern differs between males and females. As women age, the fat volume increases and the soft tissue volume decreases. In men, the shift from soft tissue volume to fat volume is less pronounced.
While fat volume deflation is a key component in facial aging, this study does not support this aging phenomenon in the eyebrow fat pad. This may be due to the reality that this is true or could be a reflection of how the study was done. After all, these were not serial CT scans done on the same patient over many years (which would be a near impossibility) but were random points of information on different patients at one point in time. They were all then collectively compared which could be misleading.
Does this mean that fat injections into and around the eyebrows is a flawed aesthetic approach? My answer would be no. I have seen too many patients who were quite pleased with their fat injection results even if research does not indicate that they were really down in fat volume to begin with. Whether it is an eyebrow lifting effect, creating a better skin tone by expansion, or even some purported effect of skin rejuvenation by fat or stem cells, judicious placement of fat into the eyebrow can produce a rejuvenative effect in their appearance.
What influence does the forehead have on one’s appearance?
The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.
The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.
A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women.
2. How is forehead reshaping done?
Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.
They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.
3. How is brow bone reduction done?
In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only hasthin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.
In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.
A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone.
4. How is brow bone augmentation done?
Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.
PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.
Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.
5. Can other areas of the forehead be reshaped besides the brow bone?
The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.
Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.
Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?
7. What can I do if my forehead is too long?
Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.
The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference.
The forehead has a variety of shapes that do differ based on gender. Men will tend to have flatter fuller foreheads with more prominent brow bones (supraorbital ridges) while women’s foreheads will usually be softer, less full, and with flatter brow bones that tend to angle off into the temporal region. Whether it be by a congenital deformity (such as craniosynostosis), frontal tumor resection (craniotomy flap) or from prior contouring purposes (FFS, facial feminization surgery), there are rare instances when one desires to have a fuller or more prominent brow definition restored.
Brow bone augmentation (BBA) is one form of forehead reshaping that can be done. Using synthetic materials as a building material, the bone can be ‘thickened’ and recontoured to alter how the brow looks. Since the eyebrow and the upper part of the eyelid is affected by its underlying bony support, such changes can produce subtle to dramatic differences.
One of the key issues of brow bone augmentation is which material to use. Currently, hydroxyapatite (HA) and acrylic (PMMA) are the only two moldeable materials of choice. Your own bone is usually not a good option since you have to harvest it and how it survives as an onlay is unpredictable. Both HA and PMMA have their advocates but I have gotten good results with both. Either one can do the job. PMMA is much cheaper from a material cost standpoint and is very hard once it sets, being hard if not harder than natural bone. HA is much more expensive, a little harder to work with, and is more fragile to impact. But it is closer to the mineral of natural bone so it has greater compatibility and less risk of long-term body reaction concerns.
There is also the option of a synthetic implant carved out of silicone or polyethylene. (Medpor) This requires a greater degree of skill and time to get all the edges flat and flush with the surrounding bone. It is easy to see how an edge step-off can be felt through the skin unless it is done perfectly. Feathering edges and blending into the surrounding bone is much more assured with the moldable materials.
The other important consideration of BBA is access. For the most part, an open scalp approach provides the best vision and control of the shape. But this is understandably problematic for most men unless they have a pre-existing scalp scar to use. For most women, this is not a significant issue as a hairline (pretrichial) approach can be done and that scar can really be quite fine and unnoticeable. I know this from a lot of experience with pretrichial (hairline) browlift procedures done for cosmetic purposes.
A non-open scalp approach (endoscopic) can be used in select cases of forehead augmentation. When it is the central or more upper parts of the forehead that are being augmented, the endoscopic approach using PMMA as an injectable material can be done. PMMA can be injected and pushed around as a congealed putty and shaped by external molding through the forehead skin. HA is a quite different material and its handling properties do not permit anything but an open approach scalp approach. But working down at the brow area, which is a very low point for endoscopic visualization, is even difficult with PMMA. Therefore, I would advocate an open approach for any amount of brow bone augmentation.
Expanding or enlarging the forehead to a more desireable contour is most commonly considered in adults or teenagers who have had a congenital skull deformity. Most of these had some form of craniosyostosis, with or without early craniofacial surgery, and are now left with forehead irregularities, depressions, or a forehead that severely slopes to the temple area making it look too narrow. Other needs for forehead augmentation are from previous trauma cases with frontal bone fractures, neurosurgery patients with craniotomy defects, and rarely a female to male facial conversion patient.
All forehead augmentations use some form of synthetic material to add on top of the bone. The use of acrylic or PMMA, a liquid plastic that hardens after being mixed, has been around for many decades and consistently works well. The more recent uses of bone cements or HA (hydroxyapatite), which similarly harden after mixing, are of more recent use. I have used a lot of each and either PMMA or HA has its own set of advantages and disadvantages. PMMA is less expensive, sets up more reliably in surgery, and can be injected through an endoscopic technique (for small areas) if one wants to avoid a large scalp scar. It also sets up very firmly and gets as hard as any thick plastic material. Its biggest disadvantage is that it is truly a non-natural synthetic material and its long-term implantation may have higher risks of rejection or infection. HA is a more natural material that is similar to bone in structure but it sets up slower and can be more difficult to work with through small incisions. It usually is best placed through a more open scalp incision. Once set, HA is softer than PMMA and if exposed to a large impacting force, it will potentially shatter like a ceramic dinner plate. My decision as to what material to use for any particular forehead depends on the operative technique. For open forehead approaches, I will use HA. For endoscopic techniques, I will use PMMA.
Building up the forehead is similar to sculpting with clay. The forehead bone is exposed and the chosen material is applied and molded into the shape one desires. Whether it is done through an open approach when one uses the fingers to mold and shape or done through an endoscopic technique where the fingers mold it through the forehead skin, the procedure is not difficult and provides an immediate result that should not change over time. The most difficult decision for the patient is whether a larger scalp incision is acceptable or whether the endoscopic ( a few small scalp incisions) approach is preferred. Smaller or spot forehead augmentations can be done endoscopically. Larger or more complex forehead augmentations are best done with an open scalp approach.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.