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Archive for the ‘brow bone reduction’ Category

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

 

Mid-Forehead Approach for Male Brow Bone Reduction

Tuesday, February 10th, 2015

 

Reduction of the prominent brow bones can be done by two basic techniques and is done for different reasons/patient populations. (e.g., prominent male brow, part of facial feminization surgeries) The type of patient and the degree of brow bossing will determine the best surgical technique. In some cases augmentation of the forehead above the brow bone can also help reduce its appearance, either done alone or in combination with actual brow bone reduction.

Brow Bone Reduction by Burring X-Ray Dr Barry Eppley IndianapolisThe thickness of the brow bones (technically the thickness of the anterior bony wall of the frontal sinus) will largely determine the surgical technique of choice. When combined with the degree of brow prominence needed, the choice of reduction technique will be clear. The best way to determine the thickness of the anterior bony wall is a CT scan. This will allow one to measure the thickness of the anterior wall the whole way across the width of the brow bossing. A side to side assessment is very important and can not be judged just based on a lateral plain skull film alone. (better than no x-ray at all however)

Brow Bone Rerduction by Burring Dr Barry Eppley Indianapolis Preoperative X-RayIf the anterior wall of the brow bone is thick enough (usually 5mms or greater), a burring technique for reduction can be used. This is the simplest brow bone reduction technique and allows for the best degree of reshaping with a low risk of frontal sinus exposure. It is a technique much more commonly used in women than men because the degree of brow  bone reduction needed is often less. But is some men with adequate bone thickness, burring alone may be adequate for the central and adjoining medial brow areas where men have the greatest protrusions.

Male Brow Bone Reduction Mid Forehead Approach Dr Barry Eppley IndianapolisThe problem with brow bone reduction in men is usually one of access. While a full coronal scalp or frontal hairline incision is typically used, such incisions in men often poses aesthetic challenges based on their hairline location, density and pattern. One incisional option for a few select men is a horizontal forehead wrinkle. (if they have a fairly prominent one.

Mid-Forehead Approach for Brow Bone Reduction by Burring Dr Barry Eppley IndianapolisDirect Brow Bone Reduction by Burring with Supraorbital Nerve Isolation Dr Barry Eppley IndianapolisThrough a central horizontal forehead wrinkle incision, the brow bones can be easily accessed. One important feature of this forehead incision is not to make it too far lateral to avoid transecting the supraorbital nerves and causing permanent forehead and anterior scalp numbness. This allows a burring reduction technique to be done under direct vision where the exit of the supraorbital nerves can be seen and protected. Reduction can be aggressively done in the glabellar and medial half of the supraorbital rims with relative ease.

The central forehead incision for male brow bone reduction requires a thick anterior frontal sinus wall, an evident horizontal forehead wrinkle and an aesthetic reduction amount that does not exceed the bone wall thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques and Outcomes in Forehead and Brow Feminization

Sunday, September 28th, 2014

 

Forehead feminization Surgery Dr Barry Eppley IndianapolisFacial feminization surgery is a relatively recent plastic surgery procedure that has only been done since the late 1980s. It has been developed to address the need to modify masculine facial features for those with gender dysphoria who need to change their facial identity. As a result it is a well known need for the transgender patient. Certain facial features can have very specific male and female characteristics. Specifically the forehead and the jawline are especially important in facial gender identification.

In the October 2014 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Facial Feminization Surgery: The Forehead. Surgical Technique and Analysis of Results’. Over a four year period, the authors performed 172 forehead reshaping procedures. The results were assessed by cephalometric x-rays and a six month after surgery survey. The specific techniques discussed were incisional access and how the bone areas are specifically reshaped. Incisional access was done through either a hairline (pretrichial) or modified coronal based on the vertical length of the forehead and whether hairline lowering was simultaneously needed. The bone was reshaped through sequencing of frontonasal-orbital reconstruction/recontouring with osteotomy and setback of the anterior wall of the frontal sinus.

No serious complications were observed in this forehead feminization patient series. No hematomas, seromas or infections occurred. There were no complications related to osteotomizing the anterior wall of the frontal sinus such as sinus dysfunction, sinusitis, mucoceles, or air leaks. One patient did develop a cerebrospinal fluid leak from the posterior wall of the frontal sinus that resolved spontaneously within days after surgery by posture measures. Most patients had some degree of forehead numbness with complete recovery starting three months after surgery. No permanent injury to the frontal branch of the facial nerve occurred although some patients  had some weakness which fully recovered weeks after surgery. The average level of patient satisfaction by the after surgery survey was between satisfied and completely satisfied.

Brow Bone Reduction - Bone Flap Technique Dr Barry Eppley IndianapolisThis article highlights several technical aspects of the procedure that one learns by doing this type of surgery over the years. Where to place the incision and how to access the brow area must be initially considered. Whether to place the incision at or behind the hairline depends on how long the forehead is and the natural shape of the frontal hairline. Brow bone reshaping almost always requires removing the anterior wall of the frontal sinus, reshaping it and repositioning it further back into the frontal sinus. (burring reduction is inadequate and the anterior wall of the frontal sinus permits little reduction to be achieved) With the anterior wall of the frontal sinus removed, the nasal root and glabellar region must be reduced to create a more feminine frontnasal junction. Reduction/rehaping of the superolateral brow bone down along the lateral orbital wall must not be forgotten as a more comprehensive approach to the fronto-orbital recontouring.

Despite the rather invasive nature of this type of forehead surgery, complications are remarkably few and significant improvement is always seen. There can be issues that may require secondary revision such as the smoothness of the brow region. This article does not address whether any revisions were required but some low percent can be expected. (3% to 5%)

Brow bone reshaping and associated hairline modifications can effectively alter masculine facial features in the transgender patient with a very low incidence of negative side effects. To really change the forehead/brow area a comprehensive bone and soft tissue approach is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Transgender Brow Bone Reduction/Reshaping

Tuesday, July 15th, 2014

 

Background: The shape of the forehead is very gender specific and these differences are well known. The male forehead has prominent brow ridges, a brow bone break and a forehead that has a slight backward slope. The female forehead has no visible brow ridging or break and a more convex shape as it extends upward into the frontal hairline. These forehead shape differences are driven largely by the influence of testosterone on the development of the frontal sinuses and the frontal bone.

Forehead feminization Surgery Dr Barry Eppley IndianapolisIn facial feminization surgery (FFS), forehead recontouring is an important one-third of the facial changes needed. This is usually perceived as ‘burring of the brow bone’ but this is an overly simplistic understanding of how to reshape the entire superior orbital rim. Because of the thinness of the outer cortex of the brow bone with a large underlying frontal sinus air space, simple burring of the frontal bone can only make a limited change. Most brow bone reductions of any significance require an osteoplastic bone flap technique in which the entire outer cortex is removed, reshaped and replaced.

But the brow bone reduction is often not enough to get a definitive gender change in the FFS patient. As part of the brow recontouring, the lateral or tail of the brow bone must be reduced to allow a more upward sweep to the tail of the eyebrow. In some cases, the orbital rim reduction may need to be carried around to the side to help with greater orbital exposure. (opening of the eye) Also, the frontal hairline may benefit from being advanced or lowered. If access to the brow bone reduction is done through a hairline or pretrichial approach, then vertical forehead reduction/hairline repositioning can be done at the same time as the brow bone reduction.

Case Study: This 35 year-old patient was undergoing a variety of facial feminization surgeries from the forehead down to the adam’s apple. The concerns on the forehead was that the brow bones were too strong but the upper forehead was adequately shaped/projected. The hairline was also in good place (not too high) with reasonable hair density.

Osteoplastic Brow Bone Reduction Technique front view Dr Barry Eppley IndianapolisOsteoplastic Brow Bone Reduction Technique side view Dr Barry Eppley IndianapolisUnder general anesthesia, a pretrichial or frontal hairline incision was made in an irregular fashion paralleling the direction of the hair shafts. The forehead flap was turned down and the brow bones exposed, protecting the supraorbital nerves. A reciprocating saw was used to take off the outer brow bones at the levels of the surrounding forehead. The two pieces were reshaped and put back with resorbable sutures. The tail of the brow bones were the frontal sinus cavities did not exist was burred done to reduce its prominence. The forehead flap was put back in a two layer closure with small sutures for the skin.

Transgender Brow Bone Reduction result side view Dr Barry Eppley IndianapolisTransgender Brow Bone Reduction result oblique view Dr Barry Eppley IndianapolisBrow bone reduction is usually more than just simple burring, particularly with the goal of changing a prominent masculine brow shape to a flatter more feminine one.  The osteoplastic bone flap technique is needed with the potential for additional procedures of lateral orbital rim contouring, forehead augmentation and hairline advancement done at the same time.

Case Highlights:

1) Brow reduction is an important part of many facial feminization surgeries.

2) Brow reduction can be done by burring but usually needs a more aggressive approach with an osteoplastic bone flap to create a more feminine brow shape.

3) Many FFS brow bone reductions can be done through a hairline or pretrichial incision which allows for a simultaneous hairline advancement if desired.

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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