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Archive for the ‘brow bone reduction’ Category

OR Snapshots – Tail of the Brow Bone Reduction

Sunday, November 5th, 2017


Brow bone reduction is a well known aesthetic procedure for reducing the horizontal projection of the lower forehead. Done by either burring for minor changes or an osteoplastic bone flap setback technique for more major setbacks, the horizontal position of the brow and/or its convex shape can be reduced. But no matter what brow bone reduction method is used, it almost always requires an open approach through a hairline or coronal scalp incision.

But the horizontal reshaping of the brow bones is not the only dimension in which it can be changed. Vertical brow bone reduction can also be done. This may be performed when the brow bone is sitting too low into the orbit, particularly the tail of the brow bone. This may be indicated in reducing the exposed or skeletonize brow bone after a browlift, for a congenitally short orbital height, in vertical orbital dystopia to even out the superior orbital rims or to try and increase the vertical opening of the eye.

Unlike traditional brow bone reduction surgery, vertical brow bone reduction is done through an upper eyelid incision. This provides direct access to the lower edge of the brow bone which is to be reduced by a burring technique. Because the outer half of the brow bone does not contain the frontal sinus, significant reduction of it can be done. The outer half of the lower edge of the brow bone can be removed to create an increased vertical distance between the superior and inferior orbital rims. Excessive projection of the tail of the brow bone can also be done to reduce its prominence through a combined vertical and horizontal bone removal.

Transpalpebral brow bone reduction is largely about reshaping the outer half or tail of the brow bone. The upper eyelid offers both direct and good aesthetic access to perform it.

Dr. Barry Eppley

Indianapolis, Indiana

The Osteoplastic Bone Flap Technique in Brow Bone Reduction Surgery

Saturday, November 4th, 2017


Brow bone reduction is done for a variety of reasons in both men and women. While the primary objective is to reduce an overlying prominent brow protrusion, there are differences in why it is done and the technique used to achieve it. In men reduction of the brow bone is done to get rid of the Neanderthal’ look. In women a softening effect is needed to make the forehead more vertical from the brow upward. In the male to female transgender patient, the brow bone must be brought back and reshaped from the frontonasal junction out to the tail of the brow for a complete change in the periorbital appearance.

Brow brow reduction can be done by either a burring technique or actually cutting off the outer cortical bone and reshaping and moving it backwards. (osteoplastic bone flap setback) The differences between these two brow reshaping methods is more than just technique alone but in the amount of brow bone reduction achieved. Because a prominent brow is the reflection of how big the underlying front sinus is, burring can only reduce it by a subtotal thickness of the thin anterior table bone. This is usually less than 5mms and can often be only a few millimeters. Cutting out the bone and moving it back into the frontal sinus air space creates a far greater amount of brow protrusion reduction.

The osteoblastic bone flap setback technique must be done through either a hairline or coronal scalp incision. In some men with little to no hair coverage, a forehead horizontal wrinkle line can be used. But regardless of how one gets there the prominent outline of the frontal sinus can be seen and marked as the brow bone protrudes out prominently from the surrounding central forehead above the eyes.

A reciprocating saw is used to remove the anterior table of the frontal sinus at the level of the surrounding frontal bone from side to side. There will almost always be a vertical septum of bone that separates the two sides of the frontal sinus encountered underneath the bone flap that must be cut. The bone flap is then removed and the large frontal sinus cavity will be revealed underneath. The opening that goes down into the nose can easily seen which allows drainage of the sinus cavity. Unless there is chronic inflammation or mucocoeles in the frontal sinus there is no reason to remove it lining.

The bone flap is thinned out on both its under and outer sides to try and work out its convex shape. The bone is too thin to cut and reshape it unless one wants to use a lot of plates and screws to out it back together. Prior to its replacement back into the frontal sinus, the surround rim of bone of the frontal sinus is reduced particular across the inferior orbital rim and the frontonasal junction. This step is of critical importance as it is what allows the bone flap to be recessed back into the sinus without palpable step offs

The bone flap is placed back into position which should be further back into the frontal sinus cavity. It can be appreciated that the amount of brow bone reduction is a combination of the bone flap reset into the frontal sinus and the thinning of the bone flap by burring. The former is more important for the actual setback, the latter is more to make for a flatter outer brow bone shape. A single central low-profile bone plate is all that is needed for fixation. This should be for assured immobility and not to hold it out in space over the frontal sinus. The fit of the bone flap should primarily be against the midline bony septum with resting on much of surrounding bone edges. There will always be some open areas along the seams which can be covered by Surgical mesh or bone wax.

With an understanding of how the osteoblastic bone flap technique of brow bone reduction works, it is easy to see how it is far more effective than a burring reduction method. But if a complete brow bone reduction technique is needed, such as in facial feminization surgery, burring reduction is also needed to reshape the tail of the brow bone.

Dr. Barry Eppley

Indianapolis, Indiana

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.


  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.


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

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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