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Archive for the ‘browlift’ Category

Plastic Surgery Case Study – Temporal Browlifts with Lateral Canthopexies

Sunday, March 8th, 2015


Background: There are different types of browlifts that are done to help rejuvenate an aging eye area. The historic coronal browlift is done to lift up the entire brow arch through a long scalp incision way behind the hairline. An endoscopic browlift is performed using an endoscope through several small incisions just behind the hairline. A pretrichial  browlift is performed through incision that parallels the edge of the frontal hairline. in front of the hairline. All have their unique purpose and indication for forehead rejuvenation.

Temporal Browlift Dr Barry Eppley IndianapolisOne unique type of browlift is the temporal browlift. It is performed through an incision in the temporal scalp region at about 45 degrees upward from the tail of the outer brow. It is a limited browlift that just addresses the outer one third position or tail of the eyebrow. It is a very effective procedure for those patients, who are always women, that need only a lift in the outer one third of the brow.  By lifting the brow tail, it gives the eye a more open appearance without creating a surprise look.

Temporal browlifts are smaller incision procedures that lift the outside portion of the eyebrows which serves decrease the hooding that occurs with aging on the outer aspect of the upper eyelid. It can also improve wrinkles at the corners of the eye (crow’s feet) as lifting the temporal brow will flatten the wrinkles as the skin and muscle are placed on stretch with the elevation. When combined with an upper blepharoplasty (eyelid tuck) it can really have a substantial anti-aging effect of the upper eyes.

Case Study: This 62 year-old female wanted to improve the look of her eyes which became more tired looking as she was getting older. She previously had upper and lower blepharoplasties several years previously but had subsequently developed hooding of the outer upper eyelids. (inadequate temporal resection??)

Temporal Browlift results front view Dr Barry Eppley IndianapolisUnder general anesthesia, bilateral incisions were made of approximately 15 mms parallel to and 2 cms behind the hairline in the temple region. These were done along a line about 45 degrees outward from the tail of the brow. The incision was carried down to the deep temporal fascia. Using specially designed instruments dissection as carried down to the tail of the brow where the brow ligaments were released from the brow bone. The tail of the brow was lifted and secured with sutures to the fascia and the excess sin removed and closed. In addition hrough a 7mm skin incision in the outer eyelid skin crease, lateral canthopexies were performed. The outer corners of the eye were sutured up higher on the outer aspect of the lateral orbital rims with small permanent sutures. The skin incisions were closed with very small resorbable sutures.

Temporal Browlift results oblique view Dr Barry Eppley IndianapolisTemporal Browlift results side view Dr Barry Eppley IndianapolisHer one year after surgery pictures show sustained elevation of the tail of the eyebrow and an upward positioning of the outer corner of her eye. Lateral canthopexies add a degree of improvement to temporal browlifts by concomitantly lifting the corner of the eye as well. This is a subtle but complementary effect to the aging outer periorbital area.

Case Highlights:

1) Browlifts in females often focus on creating a higher outer tail of the brow or lateral brow sweep.

2) A lateral canthopexy lifts up the outer corner of the eye to fix a drooping eye or to create an upward tilt to the eye.

3) The combination of a temporal browlift and lateral canthopexies can provide a rejuvenated periorbital look in a female. or even a  ore exotic look if done more aggressively.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Direct Fixation Method for High Tail Browlifts

Wednesday, March 4th, 2015


Numerous browlift procedures exist to lift sagging brows and help rejuvenate an aging periorbital look. The success of most browlifts are based on a tissue release and a superior elevation of the sagging brows. Most techniques employ some form of fixation to the skull bone to hold the lifted forehead tissues as they heal. These have included a variety of metal and resorbable polymer devices that have taken the forms of pins, screws and platform style plates. They don’t have to hold the tissues very long as it has been shown that periosteal healing back to the bone in the new position takes about two weeks or less.

Male vs Female Eyebrow ShapeHow much to elevate sagging brows and how to shape them as they are lifted is as much an art form as it is a science. How the brow arch gets shaped as it is lifted is affected by numerous factors such as incision and tissue fixation location as well as the amount of upward pull. What is known is that the shape of the shape of the brows and the amount they can be aesthetically lifted does differ significantly between women and men. Women can tolerate higher amounts of browlifting with an arch shape that is often preferred to be higher at the outer aspect than the inner brow area. Conversely, men can tolerate only a modest amount of browlifting and the arch shape should stay relatively flat. (unarched)

A few women do prefer a  more dramatic browlift result which usually refers to a very high tail of the brow. This is often accompanied with a high outer corner of the eye lift as well. Such high tail of the brow positions can be difficult to achieve as they require a significant upward tissue lift and are almost always done best through a pretrichial or hairline incision to avoid backward displacement of the frontal hairline.

Direct Tail of the Brow Pexy technique Dr Barry Eppley IndianapolisDirect Tail of the Brow Pexy technique 2 Dr Barry Eppley IndianapolisOne simple method of brow fixation that I have found useful in these more extreme browlift procedutes is a direct browpexy method. Once the maximum amount of lift of the tail of the brow is achieved, a 3mm stab incision is made inside the hairline of the outer brow. Using a self-tapping 1.5mm screw, the deeper brow tissue are grasped lifted and secured to the underlying bone. The screw can be used to either hold the existing brow position or to even lift it up higher before placing the screw into the bone. If the tail of the brow is lifted up even higher, a skin bunching around the tail will occur. Thus will need to be released right under the skin with small sharp scissors. It is important to make sure the screw is turned down flush to the bone since it is not paplpable. A small resorbable sutures is then placed to close the tiny incision.

Tail of the Brow Lift intraop result Dr Barry Eppley IndianapolisThis direct brow fixation method is a useful adjunct to securing the outer tail of the brow in select cases. A direct browpexy may be necessary when a very high arch shape is desired amongst female patients.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Visual Obstruction Treated By Browlift And Blepharoplasties

Monday, December 8th, 2014


Background: Changes around the eyes are the earliest signs of facial aging. As a result, the ongoing aging effects often creates severe changes around the eyes as one enters their sixties. Besides the excess skin of the upper eyelids and the lower eyelid bags, the eyebrows often sag downward magnifying the hooding effect on the upper eyelids.

Visual Field testing Indianapolis Dr Barry EppleyHooding of upper eyelid skin and brow sagging do have functional effects. By weighing down the upper eyelids there is a loss of a portion of one’s visual fields. A portion or all of the upper visual field may be lost as the position of the upper eyelid acts like a blind over a window. Partial closure of the blind results in loss of one’s ability to see what lies above as one is looking straight forward. This is often confirmed by an historic test known as Goldman’s visual field examination which evaluates the entire range of peripheral vision. But automated perimetry testing today has replaced the traditional Goldman method in many ophthalmology/optometry practices.

To correct these severe eye aging effects and to improve one’s upper peripheral vision, multiple procedures need to be done. With brow sagging, an upper blepharoplasty alone (while helpful) may induce one to remove too much upper eyelid skin and severely shorten the distance between the eyebrow and the lashline. (in essence even pulling the eyebrow down further) A browlift combined with an upper blepharoplasty is needed to not only lift up the low brows but to also reduce the amount of upper eyelid skin that really needs to be removed. Together they create a periorbital effect that is better than a browlift or an upper blepharoplasty alone.

Case Study: This 62 year-old female was bothered by the way her eyes looked and how ‘old’ her appearance. She had such severe hooding that her upper eyelid skin hung below her lashlines. The weight of her upper eyelids, combined with some brow sagging, created a pseudo ptosis look as the level of her upper eyelids enchroached on the iros of the eye.

Visual Field Obstruction Blepharoplasties result front viewVisual Field Obstruction Browlift Blepharoplasties result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, an initial browlift was performed using a pretrichial incisional approach. An irregular zigzag incision was used along her frontal hairline. A total of 8mms of vertical upper forehead skin was removed for a moderate browlift effect. An upper blepharoplasty was then done using marks done before surgery based on pulling the brows upward. Lastly, lower blepharoplasties were performed with skin and fat removal, orbicularis muscle resuspension and lateral canthopexies.

Visual Field Obstruction Blepharoplasties result side viewHer results at six weeks after surgery showed a significant improvement in the appearance of her eyes but without an overdone look. Her lower eyelids had good contact with the globe and the position of the outer corner of her eyes was maintained. She did have some mild dry eye symptoms during the first month after surgery even though she had no ectropion or eyelid malpositioning problems. This is not rare when upper and lower blepharoplasties are combined with a browlift as this will slow the blink reflex for a period of time after surgery.

Case Highlights:

1) Severe aging around the eyes results in brow sagging and upper eyelid hooding which does impact one’s superior visual fields.

2) Optimal correction of visual field obstruction requires a combined brow lift and upper blepharoplasties.

3) Lower blepharoplasties are often done at the same time to enhance the overall periorbital aesthetic effect but do not provide an improvement in peripheral vision.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Eyebrow Fat Injections

Friday, August 29th, 2014

Eyebrow Arch ShapeEyebrows are an important component of facial shape as they provide some  visible structure to it.  One of the important components of eyebrow shape for women is whether they have an eyebrow arch. A small arch in the middle of the eyebrow helps create a nice frame for the eye. But not everyone is fortunate enough to have an arch in their eyebrow. This has led to numerous ways to create it, most commonly done by plucking/threading/shaving but also can be created by pencil liner or even hair transplants.

An alternative surgical approach is to add or change the arch shape by structural enhancement using fat grafts. Through small cannulas, concentrated fat can be linearly placed along the eyebrows in an arched fashion. This very straightforward fat grafting method only requires about 2ccs of fat per brow which is placed through a small needle puncture in the middle of the brow.

Brow Fat Injections Dr Barry Eppley IndianapolisFat Injections Brows Dr Barry Eppley IndianapolisThe entrance site should be placed in the height of the arch of the brow. Finding where to place the arch of the eyebrow is well known. The peak of an eyebrow arch is not necessarily in the direct middle of it but usually just a bit more towards the tail of the brow.  It usually is just a bit more lateral than a vertical line drawn up from the iris. Thus, a good eyebrow arch shape does not have a perfectly symmetric rainbow shape.

Eyebrow Arch Fat Injections Dr Barry Eppley IndianapolisBeside helping with eyebrow shape with good placement, fat injections can also have a lifting effect. By adding volume directly beneath the eyebrows, an outward and upward push of the eyebrows can occur.

Small volume fat injections to the eyebrows done with a microdroplet (small aliquot) technique is associated with good survival. (volume retention rate) Given the small volume needed, a large number of donor site options are available for harvest.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: The Pretrichial Browlift for Forehead Rejuvenation

Wednesday, June 11th, 2014


Browlift Surgery Indianapolis Dr Barry EppleyBackground: Aging of the face affects all structures but none are more noticeable, both early and late in the process, than that of what occurs around the eyes. One of those changes is a sag or lowering of the eyebrows. Due to frequent motion of the muscles which often pulls them down and the long-term effects of gravity, the eyebrows can lower from their original position on the brow bones. A lower than normal eyebrow position not only affects how we look but can make redundancy of upper eyelid worse.

The treatment of brow ptosis (brow sagging) can be done by a variety of techniques, most of which are based on some type of superior scalp incisional approach. The traditional full coronal incision of yesterday has been largely replaced by a much more limited endoscopic technique. With smaller incisions and a quicker recovery, the endoscopic browlift can be applied even to younger patients with smaller amounts of brow sagging.

But the endoscopic browlift is not perfect and the benefits of the smaller incisions are offset by the limits of what the procedure can do. Besides restrictions on how much of the forehead muscles can be manipulated, its lifting effect is based on an epicranial shift concept. Because no tissue is removed, the browlift effect is created because the scalp is moved backwards. As the scalp tissues a removed back, the forehead is pulled upward with the brows at the lower end being pulled with it. While the brows may be lifted, the forehead also lengthens. This may be aesthetically disadvantageous for the patient who already has a long forehead.

An intermediate browlift technique between a coronal and endoscopic method is the pretrichial or hairline method. This less frequently used browlifting method has many of the advantages of other browlift techniques with the only disadvantage of how well the hairline scar appears.

Case Study: This 62 year-old female was undergoing a variety of facial rejuvenation procedures. One of them was her desire to give her eyes a less tired look. She already received Botox injections in the glabellar region and felt that if her brows were lifted, particularly the middle and outer areas (which Botox did not lift very much) then she would have a less tired and worn appearance.

JR Browlift results front viewUnder general anesthesia, a beveled frontal hairline incision was made which went behind the hairline as it was extended into the high temporal area. The forehead tissues were elevated off the bone and the brow ridge periosteum separated and lifted, exposing the supraorbital neurovascular bundles on each side. Portions of the corrugator and procerus muscles were removed centrally and around the nerves. Horizontal strips of frontalis muscle were also removed in two separate rows. The forehead skin was lifted to create the desired browlifting effect as well as temporal scalp skin out laterally. The overlapping forehead skin and scalp tissues were trimmed, the deeper tissues secured to the galea and deep temporal fascia and the incisions closed.

Pretrichial Browlift result side view Dr Barry Eppley IndianapolisRecovery from a pretrichial browlift is about whatever bruising and swelling occurs around the eyelids. That will be significantly influenced by whether any blepharoplasty surgery is done at the same time. When done without accompanying blepharoplasties, one can look pretty good in one week after surgery. When done with blepharoplasties, that recovery of acceptable appearance will be extended to 10 to 14 days.

Pretrichial Hairline Scar Dr Barry Eppley IndianapolisThe pretrichial browlift does carry two distinct disadvantages, one of which is obvious and the other not visibly apparent. There will be a fine line scar along the frontal hairline which usually heals very well. In patients with more pigment in their skin, a mild line of hypopigmentation may result. The unseen disadvantage is the transection of the sensory nerve branches as they cross into the scalp. This will cause some temporary numbness of the frontal scalp which patients often described as a ‘dead woody’ feeling in that area for  few months after surgery. That numbness feeling is usually more profound than the more traditional coronal incision because it cuts across the nerves closer to their origin.

Case Highlights:

1) Brow lifts can be done by a variety of techniques of which the hairline or pretrichial approach offers a balance between a relatively hidden scar and a powerful brow lifting effect.

2) The amount of skin removed along the frontal hairline correlates closely with the amount that the brows are actually elevated.

3) The scar along the frontal hairline can have some hair that grows through it with a small amount of hypopigmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Long-Term Hairline Stability in Pretrichial Browlifts

Saturday, January 11th, 2014


When it comes to forehead rejuvenation a variety of browlifting strategies exist. Three of the browlifting methods use a superior or scalp incisional access to do the procedure. The most popular of these is the endoscopic technique which uses a few small scalp incisions and an epicranial tissue shift to create its brow elevation effect. It is popular because of a lack of significant incisional lengths even though it does also result in some forehead lengthening.

Pretrichial Open Browlift Scar Dr Barry Eppley IndianapolisA very effective but less popular browlift method is the pretrichial or hairline technique. Making an irregular incision along the frontal hairline, the brows are lifted but without elongating the forehead. While this does place a scar along the frontal hairline, in the properly selected patient with good frontal hairline density, the scar can heal remarkably well and has rarely been a concern in my experience. There is always the understandable concern, however, if whether this incision negatively affects hair growth after healing and in the long-term. (does hair loss occur along the incision)

In the January 2013 issue of Plastic and Reconstructive Surgery, an article was printed entitled ‘Cessation of Hairline Recession following Open Forehead Rejuvenation’. Over a 15 year period, 31 patients had browlifts done using either the endoscopic (17) or open pretrichial incision (14) approaches. Measured photographs of eyebrow to hairline distances were done at 1 and greater than 8 years after surgery and compared to other cosmetic surgery patients who did not have forehead rejuvenation. Their results showed that over the long-term only the pretrichial group had a stable or improved hairline position without any signs of recession. No separation was seen between the scar and the hairline in the pretrichial incision patients.

This study is very relevant to not only pretrichial browlifts but other procedures that use incisions along the hairline such as a hairline lowering/advancement surgery for forehead reduction. Whether it is a woman or a man (but particularly in men), there is always the concern that hair loss may occur along the incision from surgical trauma or that long-term hairline recession may occur. These findings in this paper allay those concerns and suggest that the incision may have some protective effect in the long-term for follicular preservation…and intriguing but as of yet unexplainable biologic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Upper and Lower Blepharoplasties with Endoscopic Browlift

Sunday, July 7th, 2013


Background:  Changes around the eyes is the first part of the face that shows signs of aging. The development of excess skin on the eyelids and protruding eyelid fat makes the eyelids heavy and tired looking. But the eyes do not age in isolation, above them sits the eyebrows which are not immune to the effects of time. Aging of the eyebrows is primarily seen as they fall lower, often off of the bony brow ridges.

When considering corrective eyelid surgery, the standard and very effective approach are blepharoplasties. (eyelid lifts) While effective, the best result may not be obtained if the consideration of the brow position is overlooked. Whether a browlift is also beneficial can be tested before surgery by lifting the eyebrows and seeing if it also makes the eyes and the forehead look better. If a browlift is going to be performed with the blepharoplasties, this necessitates a smaller amount of skin removed from the upper eyelids. (a browlift recruits eyelid skin upward)

Browlifts have many different options than blepharoplasty surgery. They can be done from behind the scalp through a long open incision (coronal type), small incision scalp approach (endoscopic type), at the hairline (pretrichial type) and through the upper eyelid. (transpalpebral) Which technique is used depends on how much browlifting is needed, the vertical length of the forehead skin and how much muscle deanimation of the forehead is needed. The endoscopic browlift is one of the most common methods due to its smaller incisions but still having a powerful upward lifting effect.

Case Study: This 52 year-old female was tired of people telling her she looked tired or mad. Her eyes had a lot of excessive skin and herniated fat. But her brows were also heavy, low hanging and were asymmetrically positioned. She had very thick and heavy skin throughout her face.

Under general anesthesia, the first procedure done was an endoscopic browlift. Through four small incisions in the central and temporal scalp, the periosteum over the brows and across the nose was released through an endoscope. Muscle was removed from the supraorbital and supratrochlear neurovascular bundles and the brows lifts and secured to the outer cortex of the cranial bone by resorbable Lactosorb screws and sutures. The upper eyelids were done next, removing less skin than originally marked to prevent any potential risk of incomplete eyelid closure. The lower eyelids had skin and fat removed and the orbicularis muscle resuspended during closure.

The time required for all swelling and bruising around the eyes to completely go away after surgery was three weeks. By one month after surgery she showed a significant improvement with more open and refreshed eye look…no longer having a mad or angry appearance.

Combining a browlift with blepharoplasties creates the most complete amount of periorbital rejuvenation. While the change can be dramatic, the patient should anticipate a significant period of time for a complete recovery as the eyes are visible to all and even small amounts of swelling or bruising may be noticeable.

Case Highlights:

1) Aging of the eye area must not only consider the eyelids but the position of the eyebrows as well. Some of the excess skin on the upper eyelids can be due to yhe downward push of the eyebrows as well.

2) Total periorbital rejuvenation consists of upper and lower blepharoplasties as well as a browlift.

3) If the forehead is not vertically long, an endoscopic browlift can raise the eyebrows without making the forehead too long.

Dr. Barry Eppley

Indianapolis, Indiana

The Uniqueness of Male Plastic Surgery – Facial Procedures

Saturday, June 15th, 2013


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.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Satisfaction and Long-term Stablity of the Endoscopic Browlift

Saturday, May 18th, 2013


Elevation of low or aging brows can be done by a variety of browlift procedures. But since its introduction in the mid-1990s, the endoscopic browlift has remained a popular method. Its appeal is in the much smaller incisions and the lack of scalp morbidity, such as scar widening and alopecia and persistent numbness that occurs from a transverse scalp incision regardless of whether it is at or way back in the hairline.

The advantages of the endoscopic browlift has never been an issue of debate, the reduction or elimination of complications. What is not as clear is whether it offers similar aesthetic benefits as more open traditional browlift operations…is it effective and does it have lasting effects? Given how long the endoscopic browlift has been around, one would assume that the clarity of its aesthetic effectiveness is well established and documented. While plastic surgeons, including myself, find it to be very effective in the properly selected patient its longer-term stability is less clear.

In the May 2013 issue of the journal Facial Plastic and Reconstructive Surgery, a published study shows that the majority of patients who had endoscopic browlift procedures were satisfied with its long-lasting results. The study reviewed 143 patients over a 13 year period based on questionnaires of satisfaction and postoperative complaints as well as before and after pictures of eyebrow-to-eye measurements.

The study showed that the vast majority of patients were women (96%) who had an average age of 60 years and was rated successful by 93% of patients with 96% saying they would recommend the bprocedure. Three-fourths( 64%) said they looked younger and less tired. Some scalp numbness and itching persisted 3 to 6 months after surgery. Photographic analysis found that brow elevation was maintined to at least 2 years after surgery with an average elevation of over 5mms.

The endoscopic browlift significantly reduces the mobidity of scalp scars with a high patient acceptance rate. This study shows that there is long-term stability of the brow elevation. Thus scalp mobilization (epicranial shift) does work in lieu of forehead or scalp tissue excision. This study did not assess what happens to the frontal hairline, however, which I know moves back (lengthens) as the brows are lifted. For those patients that already have a long forehead, the open hairline browlift will need to be used instead.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization with Combined Brow Bone Reduction, Browlift and Hairline Lowering

Sunday, April 21st, 2013


There are numerous surgical procedures to feminize a masculine facial appearance. They include jawline reshaping (chin and mandibular angle reduction), rhinoplasty, cheek reduction, tracheal shave and forehead reduction/reshaping. While every transgender patient’s face is different and may need just a few or all of these facial feminization procedures, the forehead is one of the top considerations for most patients. The female forehead has a very distinct shape with a rounded contour from the brows up to the hairline with no obvious bone break.

Forehead reshaping incorporates reduction of the prominence of the central glabellar region as well as the projection of the brow bones. The brow bones must not only be deprojected but should also have the tail of them near the lateral orbit reshaped to have more of a sweeping effect up and towards the temples. Since this procedure requires an open scalp approach, this creates the oportunity to lower the frontal hairline as well. Together this type of foreheadplasty has a significant impact on the gender identification of the face.

The prominent glabella and brow bones are always due to the pneumatization of the front sinus. In cases of minor protrusion, the outer table of the frontal sinus can be simply burred down. Unfortunately this rarely can be successfully done due to the thin bone thickness overlying the frontal sinus. A few millimeters of change is rarely enough to make a noticeable external change. Most patients require the anterior wall of the bone to be removed, reshaped and repositioned back into place with resorbable sutures or metal microplates and screws. This method sets back the bulging bony prominence while preserving sinus function. The outer brow bone areas that lie outside of the sinuses can be reshaped as desired by burring.

When significant brow bone reduction is done (flattening of the bone), there is the potential for an excess of overlying skin. Loose skin on the brows can result in sagging or overlying brow ptosis. This can be easily addressed at the time of the brow bone reduction by a comcomitant browlift using the transcoronal or hairline incision made for access to the brow bones. An alternative approach is a direct browpexy from the galea below the eyebrows to underlying bone holes or the fixation plates (if used) above the reshaped brow bones.

A final component of the feminizing foreheadplasty procedure is the potential to simultaneously lower the frontal hairline. A long forehead (> than 6.5 to 7 cms between the brow and hairline) is unaesthetic for any gender but is particularly so in the male to female transgender patient. If a hairline approach (trichophytic) is used, a simultaneous scalp advancement can be done by securing the galea of the advanced scalp by sutures to bone holes in the outer table of the skull. By bringing the scalp forward, the lifted forehead skin will need to be trimmed creating a combined forehead skin reduction and browlift.

Ultimate feminization of the forehead can be done by simultaneous brow bone reduction, browlift and hairline lowering.

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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