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Archive for the ‘brow bone reduction’ Category

OR Snapshots – Transpalpebral Brow Bone Reduction

Saturday, September 2nd, 2017

 

Brow bone reduction surgery reduces the prominence of the supraorbital ridges of the forehead and can be done in both men and women. Whether done for males to reduce the ‘Neanderthal’ brow or in male to female transgender facial feminization procedures, the main direction of reduction is in the horizontal dimension. Reducing the brow bone prominence generally means reducing its projection.

But horizontal brow bone reduction is not the only dimension of the brows that can be changed…or may need changed based on the patient’s aesthetic desires. Brow bones can also be reduced vertically to increase the orbital aperture and give the eyes a more open look or reduce a heavy appearance.

While both horizontal and vertical brow bone reduction can be done through a long coronal scalp incision, a purely vertical reduction of the bone does not need to be done so. It can be done through an upper eyelid incision (transpalpebral approach) which provides a direct and short route to the lower edge of the brow bone.Using a handpiece and burr the brow bone edge can be raised 5 to 7mms if desired from side to side. It also can be reduced horizontally if desired on the outer 2/3s of the brow bone.

The transpalpebral approach is an often overlooked method for brow bone reduction. While it does not provide enough access for the more significant osteoblastic flap reduction technique and is limited for central or glabellar reductions, it does provide direct visual access to the tail of the brow bone where burring reduction can be done. It is an excellent technique for secondary or revisional brow bone procedures and can be used for primary reductions that need changes in the outer half of the brow bone only.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Brow Bone Reduction

Friday, April 14th, 2017

 

Background: Males almost always have much more pronounced brow bones than females due to a greater pneumatization effect of the frontal sinuses. Numerous studies have shown that the male frontal sinus is bigger, usually asymmetric and has a bigger left side than that of the right. This is clinically evident in the external shape of the forehead with greater supraorbital protrusions than females.

Why some men get much bigger and disproportionately larger frontal sinuses and subsequent brow bone protrusions is not known. Whether this is due to hormonal influence, masticatory loading forces or an increased developmental effort to separate the brain from the eyes are theories that have all been espoused. Regardless of its cause, the enlarged male brow bone often produces a dramatic effect that can be enhanced by a backward sloping forehead.

The male brow bone is reduced with several basic tenets in mind. First, simple burring is inadequate for a major brow bone protrusion. The anterior table of bone is not thick enough to allow for a significant reduction and the maintenance of  a bony covering of the frontal sinus air cavity. Second, the male brow bone should be so reduced that the foreflat has a completely flat profile. Some degree of brow bone break into the upper forehead needs to be maintained.

Case Study: This 30 year-old male had been bothered for a long time by the shape of his forehead. He had a very strong brow bone with two very distinct paired brow protrusions with a midline glabellar groove. The size of the brow bones was magnified by a backward forehead inclination of almost 45 degrees.

Under general anesthesia and using a near complete coronal scalp incision, his forehead and brow bones were exposed. A reciprocating saw was used to remove the anterior table of the frontal sinuses at the level of the surrounding forehead. Osteotomes were used to make the final bone elevation to preserve as much of the underlying sinus mucosa as possible. Burring was then done all around the bone edges as well as down into the frontonasal angle.

The removed bone segments were thinned and reshaped and the put back into the frontal sinus. (setback) They were secured using small plates and screws to maintain bone contact as well as prevent any inward displacement.

The immediate change in the forehead profile was evident but not over flattened.

The osteoplastic setback technique for male brow bone reduction is the gold standard by which it is done. Whether it can be done by a single piece of bone across the frontal sinuses or whether it needs to be done by two separate bone pieces depends on the patient’s anatomy.

Highlights:

  1. Most brow bone reductions in men require an osteoplastic setback technique.
  2. Removing the anterior table of bone from the frontal sinus by osteotomy with surrounding burring produces the best brow bone reduction effect.
  3. Male brow bones should be only reduced to the point of leaving some brow bone break to avoid overfeminization of the forehead.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Transpalpebral Brow Bone Reduction

Friday, March 24th, 2017

 

Brow bone reduction surgery reduces the prominence of the lower forehead bone just above the eyes. It is most commonly done in men for large “Neanderthal’ like brow bone protrusions or in male to female transgender facial feminization surgery. Whether it is done using a bone burring method or a more complete osteoplastic bone flap setback technique depends on the thickness of the anterior wall of the frontal sinus and the amount of projection reduction needed.

One aspect of brow bone reduction surgery that can be overlooked is that of the tail of the brow bone. This is uniquely different from the inner half of the brow bone because it is solid bone with no underlying frontal sinus. Whether it needs to be reduced depends on what gender look one is trying to achieve. A more straight brow bone from one side to the other is more consistent with a male with an outward sweep or upwards arch to the tail of the brow bone is perceived as more feminine in appearance.

Trtanspalpebrfal Brow Bone Reduction intraop Dr Barry Eppley IndianapolisWhile the tail of the brow bone should be reduced, if needed, at the time of an open forehead approach from above, it can also be done from ‘below’. Through an upper eyelid incision the outer half of the brow bone can be surgically accessed. Whether this is done for forward projection reduction or inferior bone border elevation depends on the aesthetic goals.

Elevating the lower border of the tail of the brow bone is done to help open up the eyes. By making the vertical distance between the superior and inferior orbital rims longer, the subsequent retraction of the soft tissue back down to the bone can potentially make the eyes look more open. If the forward projection of the elevated brow is also reduced an upward sweep to the tail of the brow can also be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Brow Bone Reduction by Burring

Sunday, December 18th, 2016

 

Brow bone reduction is useful for both men and women who have frontal sinus development that creates an unaesthetic appearance. It is far more commonly done in men whether it be for reduction of very prominent brow bone protrusions or as part of an overall facial feminization surgery for male to female transgender patients.

In most of these types of brow bone reductions a significant change is needed and this requires an osteoplastic setback technique. This is where the complete outer table of bone over the frontal sinus air cavity is removed, reshaped and put back in a more recessed position.

But brow bone reduction can also be done by a burring technique albeit for a more limited result. This is where a hand piece and rotary burr are used to shave down the bone as much as possible but without actually going through the bone into the sinus. The amount of reduction possible is controlled by the thickness of the outer table of bone overlying the sinus. This is relevant over the inner half of the brow bones as this is where the frontal sinus lies. Over the outer half or tail of the brow bones one can burr away as it is solid bone.

brow-bone-reduction-burring-techniquie-dr-barry-eppley-indianapolisBrow brow reduction by burring has the advantage that it can be done through more limited access. An incisional approach such as a pretrichial or hairline browlift provides good linear access for the instrumentation to reach the brow bones from side to side. It also allows adequate visualization of the supraorbital nerves so they are not injured during the bone reduction.

Brow bone reduction by burring works best in those men that just want a little taken off the brow bones or for women who have developed a small brow bone prominence and want it reduced.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Male Direct Brow Bone Reduction

Thursday, November 26th, 2015

 

Brow bone reduction can be done by two basic techniques. A burring reduction of the outer table of the frontal sinus wall is one option. The amount of reduction achieved will be limited by the thickness of the outer table bone which can be anywhere from 2 to 5mms. The other method of brow bone reduction is removal of the entire outer table of the frontal sinus, reshaping it and putting it back in place. This method of brow bone reduction produces a more dramatic result with further setback than what can be achieved  by more simple burring methods.

But regardless of the method of brow bone reduction used, an open approach is always needed for the best result. While more limited incision approaches using an endocope have been described, they produce a very minimal reduction in brow bone prominence at best. While this open incisional access is less of an issue for women it is of major consideration in men…who coincidentally make up more than half of patients seeking brow bone reduction.

Male Direct Brow Bone Reduction markings Dr Barry Eppley IndianapolisOne option for male brow bone reduction is the mid-forehead incision. Using a prominent  horizontal wrinkle line identified by raising of the eyebrows preoperatively, a central forehead incision can be used. It is important to keep the location of the incision limited to the central third of the forehead between lines drawn up vertically between the pupils. By so doing the major branch of the supraorbital nerve is preserved so much of forehead sensation is saved.

Male Direct Brow Bone Exposure and Bone Flap Removal intraop Dr Barry Eppley IndianapolisMale Direct Brow Bone Reduction Bone Flap Fixation Dr Barry Eppley IndianapolisThrough this limited incision, the anterior table of the frontal sinus can be successfully removed by a combination of a reciprocating saw and osteotome technique. The frontal bone flap can be removed, reshaped and replaced by small plate and screw fixation. Once the incision is closed in layers with small resorbable skin sutures, an imperceptible scar results.

Male Direct Brow Bone Reduction Skin Closure Dr Barry Eppley IndianapolisMale brow bone reduction can be successfully done through a limited forehead incision. The result achieved is comparable to what can be done through a longer pretrichial or full coronal scalp incision. Given the state of many men’s hairlines and their potential regression with aging, a well healed mid-forehead incision can be considered a good option for brow bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Brow Bone Fixation with Microplates and Screws

Saturday, September 26th, 2015

 

Brow bone reduction surgery is often done either for men with extreme prominences or as part of facial feminization surgery. The brow bones can be reduced by two basic methods, bone burring or an osteotomized bone flap. The thickness of the anterior frontal sinus wall and how much brow bone reduction is needed will determine what is the best technique for the patient.

Brow Bone Thockness X-Ray Dr Barry Eppley IndianapolisBut for very prominent brow bones a frontal sinus wall setback technique is needed. Known as an osteoplastic bone flap method, it is done by removing the entire frontal sinus wall by sawing it off flush with the surrounding forehead bone. This exposes some or all of the underlying frontal sinus cavities. Sometimes the mucosal lining can be kept intact if it is carefully peeled off the cut bone segment. The removed bone segments are rehaping, usually thinning them out so a flat piece is obtained, and then put back.

Putting the frontal sinus bone flap back requires that it be fixed to the underlying and surrounding bone. A stable bone segment will permit a good seal over the frontal sinuses (to prevent a postoperative air leak) and will allow for bone consolidation/healing. Multiple methods of brow bone fixation have been used from resorbable sutures, wire ligature and various sizes of metal plates and screws. Depending on the shape of the repositioned bone segment and how it fits into the surrounding bone, any of these bone fixation methods can work. The most stable method is always going to be plate and screw fixation as it is anywhere else on the craniomaxillofacial skeleton. But the plates and screws need ti be fairly small so that their profile does not eventually show through the forehead skin.

Microplate Fixation Brow Bone Reduction Dr Barry Eppley IndianapolisMicroplate Fixation Brow Bone Reduction Indianapolis Dr Barry EppleyMicroplate and screw fixation is ideal for the brow bones. With screws that are just 1mm in size and plate profiles that also sit no higher than 1mm, they provide firm fixation with negligible prominence. They can be used to piece together small bone fragments to securely cover the exposed frontal sinus. The length of the screws need to be no longer than 4mms to just enter the outer cortex of the forehead bone.

Brow bone fixation with microplates and screws works well but has only one minor drawback…cost. Such fixation will always be more expensive than that of sutures or even large plates and screws.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Tail of Brow Bone Reduction

Wednesday, September 23rd, 2015

 

Background: Reduction or augmentation of the brow bones is typically thought of as a horizontal change in their prominence. Such movements create more or less of a brow bone prominence most easily seen and appreciated in a lateral or side view. Such degrees of horizontal brow bone prominence is very gender-specific and is the motivation for much of aesthetic brow bone surgery.

brow bone orbital rim anatomyOne dimension of the brow bone or supraorbital rims that is rarely discussed is that of its lower edge. This dimension of the tail of the brow bone has an influence on eye shape affecting the position of the eyebrow and the fullness of the supratarsal fold. Eye asymmetry can result from differences in the position of the lateral brow bone edge. Low bony rims can also close down the eye and make contribute to upper eyelid heaviness/fullness.

The anatomy of the lateral brow bone is very simple. In this area of the brow bone there is no frontal sinus and the bone is very thick before entering the intracranial space. The only piece of relevant anatomy is that of the lacrimal gland. It is just under the tail of the brow bone in the lacrimal fossa.

Case Study: This 56 year old female had lifelong eye asymmetry. Her right upper eyelid was fuller than that of the left and she felt that the bone was pressing down on the eyelid. By feel the tail of the brow bone on the right side was lower.

Transpalpebral Brow Bone Reduction Technique Burring Reduction Dr Barry Eppley IndianapolisUnder general anesthesia, an upper blepharoplasty incision was made and dissection done under the orbicularis muscle up to the outer brow bone. The soft tissues were elevated and 5mms of the lower edge of the tail of the brow bone was removed with a handpiece and burr in a 9 to 1:00 o’clock span. The superolateral orbital soft tissues were suspended back up to the periosteum on the anterior face of the brow bone.

Transpalpebral Orbital Rim Contouring Right Eye result front view Dr Barry Eppley IndianapolisTranspalpebral Orbital Rim Contouring Right Eye result side view Dr Barry Eppley IndianapolisHer results show improved eye symmetry with a more open upper outer area of the right eye. She has no numbness or motion difficulties with the eyelid during blinking. The blepharoplasty incision healed imperceptibly.

The lower edge of the outer brow bone can be contoured/vertically reduced to create a more open eye or correct eye asymmetry. It is safe, causes no orbicularis muscle motion problems and can be done through the well known upper blepharoplasty incision.

Highlights:

1) Brow bone reduction can be done on the inferior outer edge for brow asymmetry or to open up the outer aspect of the upper eye.

2) Inferior brow bone reduction can be done through an upper blepharoplasty incision.

3) Resuspension of the stripped soft tissues is important when reducing the lower edge of the supraorbital rim.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization Surgical Techniques

Tuesday, September 15th, 2015

 

Forehead feminization Surgery Dr Barry Eppley IndianapolisOne of the many important areas to change in facial feminization surgery (FFS) is that of the forehead. The typical male forehead has a prominent brow bone, a visible brow bone break into the upper forehead and a central forehead area that is often flat or even slopes backward to some degree. This is a major phenotypic difference from that of a female forehead who has or desires a rounder smoother and more vertically oriented forehead.

The cornerstone of a male to female forehead shape change begins at the brow bones. While the brow bones can have variable thicknesses before entering the underlying frontal sinus, simple burring down of the brow bones is minimally effective and inadequate for many patients. It may be useful when there is little brow bone protrusion or the outer table of the frontal sinus is very thick. (thus the importance of preoperative x-rays)

Transgender Brow Bone Reduction technique intraop 2 Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction technique intraop 3 Dr Barry Eppley IndianapolisBut the most consistent and effective technique for brow bone reduction is that of the osteoplastic bone flap. Also known as the frontal sinus setback procedure the outer table of the frontal sinus (brow bone) is removed and reshaped. When the bone is replaced, which is necessary to cover the exposed frontal sinus cavity, it is put back so the brow bone contour is flatter. The much smaller segments of bone are usually best secured by small titanium microplates and screws. (1mm is thickness) The tail of the brow bones also needs to be reduced to create more of a lateral reduction and upward swoop. This can be done by bone burring since there is no underlying frontal sinus in this portion of the brow bone.

Transgender Brow Bone Reduction Forehead Augmentation intraop 1 Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction Forehead Augmentation intraop 2 Dr Barry Eppley IndianapolisBut reduction of the brow bones alone is often insufficient to create a more optimal female forehead shape. The central portion of the forehead also needs to be augmented to create a more vertical forehead inclination and a rounder shape from side to side between the temporal lines. Various bone cements can be used and both PMMA and hydroxyapatite compositions are effective. The optimal choice is, however, hydroxyapatite cement due to direct bonding to the bone without a scar interface due to its calcium phosphate composition.

Combining flattening of the inner half of the prominent brow bones, reduction of the outer or tail of the brow bones and increasing the convexity and vertical slop of the forehead are all important forehead feminization techniques. In some cases a hairline advancement to shorten a vertically long forehead can also be done at the same time tio provide the most complete forehead shape change.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Transpalpebral Brow Bone Reduction

Sunday, July 12th, 2015

 

Brow Bones and Orbital RimsBrow bone reduction is one of numerous types of facial bone reshaping procedures. In its most traditional sense it is done to reduce the horizontal or forward projection of the brow bones. In essence this is to reduce the bulge or outward prominence of them. This is usually done either in men with very large and overgrown frontal sinuses or in male to female transgender surgery to create a perfectly flat brow bone arch. Depending upon the degree of brow bone protrusion and the thickness of the anterior wall of the frontal sinus burring reduction or an osteoplastic bone flap setback procedure can be done.

But excessive brow bone growth or shape can occur in other dimensions as well. Brow bones that are too vertically low or high can cause undesired orbital/eye issues. Brow bones that are too high (increased vertical orbital height) may make the eye look too open and the brows retracted. Brow bones whose edges are too vertically low may make the eye look too closed or push down on the eyelid tissues causing an appearance of eyelid hooding or pseudoptosis.

Transpalpebral Brow Bone Reduction Technique Surgical Exposure Dr Barry Eppley IndianapolisLike horizontal reduction of the brow bones, vertical reduction of them can also be done. This is often combined with horizontal reduction particularly in transgender brow/orbital bone reshaping through a coronal scalp incision. But there are cases when only a vertical brow bone reduction is needed which is usually when it is causing a more ‘closed eye’ appearance or eyelid asymmetry. Rather than using a scalp incision, isolated vertical or tail of the brow bone reduction can be done through an upper eyelid or transpalpebral incisional approach. This direct access allows for a limited dissection technique that more easily isolates the desired brow bone location.

Transpalpebral Brow Bone Reduction Technique Burring Reduction Dr Barry Eppley IndianapolisTranspalpebral brow bone reduction is limited in that it can not reach the more medial part of the brow bone due to the location of the supraorbital nerves. But for tail of the brow bone reshaping or pure vertical reduction of the supraorbital rim, an eyelid incision is more appealing than the ‘far away’ and more extensive coronal incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Brow Bone Reduction with Mid Forehead Nerve Sparing Technique

Wednesday, May 13th, 2015

 

Excessive brow bone protrusion, known as brow bone hypertrophy, is a well recognized phenomenon that is due to over pneumatization of the frontal sinus. While many people think that it is due to excessive bone growth, it is actually due to an over enlargement of the frontal sinus air cavity. This pushes out the air cells making the brow bone and lower forehead look like a ‘bubble’ is sticking out from the bone. It can occur in different patterns from a large horizontally protruding brow bone across the top of the eyes to extensions up further up and out from the brow bone. It is a forehead growth pattern that is seen almost exclusively in men.

Male Brow Bone Reduction Dr Barry Eppley IndianapolisThe approaches to brow bone reduction are fundamentally two-fold, either burr the brow bone down or remove the outer cortex of the brow bone and completely reshape and re-insert it. In men with any significant amount of brow bone protrusion, the bone removal/reshaping approach (osteoplastic flap method) is the one that is most effective and will make the greatest difference. The success of bone burring is limited by the thickness of the outer bony cortex of the frontal sinus which is usually only a few  millimeters.

The real issue in male brow bone reduction surgery is not the method to do it but the surgical access. Because any form of effective brow bone reduction requires open exposure an incisional access is needed. Typically this is done from a coronal or scalp incision and if one has a good hair density this would be the preferred placement of the incision. But for men with thin hair or who shave their head a coronal incision may not be aesthetically acceptable. This leaves the alternative option of a forehead incision through an existing horizontal wrinkle line.

Supraorbital NerveA mid-forehead approach provides direct access to the brow bones and involves far less tissue dissection than that of the more traditional coronal scalp incision. It requires one to have an existing horizontal wrinkle line which is preferable to get the best scar outcome. But besides the scar the other aesthetic trade-off would be a high likelihood of permanent forehead and anterior scalp numbness. The mid-forehead horizontal incision will directly transect the branches of the supraorbital and supratrochelar nerves that run vertically up the forehead from their exit from the bony foramen usually located on the bottom of the brow bones. While this does not affect movement of the forehead since these are sensory nerves, permanent numbness could be a bothersome long-term issue.

Nerve Sparing Brow Bone Reduction Dr Barry Eppley IndianapolisBone Flap Removal in Nerve Sparing Brow Reduction Technique Dr Barry Eppley IndianapolisBone Flap Fixation Nerve Sparing Brow Bone Reduction Technique Dr Barry Eppley IndianapolisA nerve sparing technique can be used with the horizontal forehead incisional approach to the brow bones. After the skin incisions the vertical nerve branches are dissected out and spared. The brow bone surgery is then done by working underneath them. The brow bone flap is removed, reshaped, resinserted and then rigidly fixed, all while working in and around the spared nerve fibers. The incision is closed in layers with care taken to not inadvertently entrap the nerve branches in the sutures.

Mid-Forehead Brow Bone Rerduction result intraop Dr Barry Eppley IndianapolisA nerve sparing forehead incision brow bone reduction technique can produce a very successful setback of the brow bones.  While the spared nerve branches do get stretched a little during the procedure they are more likely to allow a return of forehead feeling that if they were completely transected.

Dr. Barry Eppley

Indianapolis, Indiana

 


Dr. Barry EppleyDr. Barry Eppley

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.

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