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Posts Tagged ‘brow bone reduction’

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

Five Things You Did Not Know About Brow Bone Reduction

Friday, February 7th, 2014


Brow bone reduction is often aesthetically necessitated when the frontal sinus air cavities become too large. This is almost exclusively a male problem since the development of the frontal sinuses is highly related to levels of circulating testosterone and growth hormone during development. As a result, it is often associated with other strong facial bone features in men as well. Very strong brow bones due to frontal sinus pneumatization is almost never seen in women.

Brow Bone Reduction - Bone Flap Technique Dr Barry Eppley IndianapolisWhile brow bone reduction can occasionally be done by a burring technique, the thin cortex of the overlying brow bone does not allow for more than a few millimeters of reduction with that approach. More substantial brow bone reduction requires an osteoplastic flap technique whereby the bulging bone cover of the frontal sinus is removed, reshaped and then replaced. This can increase the amount of brow bone reduction by three or four times than of just burring the bone.

When it comes to brow bone reduction surgery, here are five things you may not have known about it.

Brow Bone Reduction and Browlift Surgery Are Related. The osteoplastic technique for making the brow bone less prominent requires an open incision and forehead flap turndown for exposure. Several types of browlifts also require an identical surgical approach through either a hairline or scalp incision. This also means that a browlift can be done with brow bone reduction if needed, which often is the case in Facial Feminization Surgery.

Brow Bone Reduction and Migraine Surgery Can Be Done At The Same Time. For those individuals that suffer from frontal migraines caused by supraorbital nerve compression, decompression of the nerve by stripping off the surrounding muscle and opening up the bony foramen can reduce symptom frequency and intensity. Working on the brow bones requires coincidental exposure of the supraorbital nerve, thus potentially solving an aesthetic and pain problem during the same operation.

Frontal Sinusitis Is Not Caused By Brow Bone Reduction. While the osteoplastic technique does expose the frontal sinus cavity, often not leaving the underlying mucosal lining completely intact. such exposure does not place one at increased for subsequent sinus infections. Almost every frontal sinus cavity that i have ever seen is completely healthy and no patient has ever reported a frontal sinusitis problem later.

Air Leaks Are Uncommon Sequelae from Brow Bone Reduction Surgery. By taking off the overlying bone and some mucosal lining with it, broad frontal sinus exposure does occur. But putting back the reshaped bone provides a near complete seal on most cases. When small openings around the replaced bone are seen, which is common, patching of them are done. This is accomplished by a variety of materials from temporalis fascia, bone cement or even bone wax. Despite these efforts, it is possible that extreme sinus air pressure (usually from blowing one’s nose) can open up a small hole (‘blow hole’) right after surgery. This is seen by the filling up of the forehead with air. Time and avoiding blowing one’s nose usually makes this a self resolving problem as the tissues eventually scar down.

Upper Forehead Augmentation May Be Needed When The Brow Bones Are Reduced. Some prominent brow bone patients have the opposite problem in the upper forehead. While the lower forehead may be too prominent, the upper forehead may be too recessed or sloped backwards. This can be simultaneously treated by building up the forehead above the brow bones with bone cement after the brows are reduced. The angulation of the forehead in profile should be assessed before surgery to avoid missing this aesthetic problem and the opportunity to simultaneously correct it. (the ying and yang of forehead reshaping)

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: One-Sided Brow Bone Reduction

Tuesday, November 12th, 2013


Background: Prominent brow bones are the direct result of the development of the underlying frontal sinus. While all of the frontal forehead bone above the brows is very solid and thick skull bone, the brows are made up of air with only thin bone in front and back of its thickness. The anterior or frontal part of the brow bone beneath the eyebrows is remarkably thin, often only being a few millimeters thick.

Brow bone reduction is done for two main reasons. Men who have large and very prominent brow bones often want them reduced to look less ‘Neanderthal-like’. Women  with larger brow bones or men to women transgender patients who want a softer and more feminine appearance may want their brows reduced and the tail of the brow bone reduced and flared upward. In some cases simple burring may be effective to achieve these goals but most of the time the outer table of the frontal sinus bone must be removed and reshaped to get a significant reduction. The thin outer bone of brow bone makes only a few millimeters reduction possible with burring.

When the frontal sinus is enlarged, it most always involves both sides of the brow bones. This is because the frontal sinus in most people is paired and exists under both eyebrows. But the frontal sinuses are rarely symmetrical and the septum that exists between them frequently deviates to one or other side, allowing for one frontal sinus to become larger than the other. This can account for the rare occurrence of asymmetrical brow bone hypertrophy.

Case Study: This 33 year-old male had one enlarged brow bone that had bothered him for years. He had no specific history of trauma to the area. It had just developed naturally that way. It created the appearance of a large knot or ball on his brow that also pushed down into the eye socket, giving it a swollen appearance. He had no pain or numbness over the brow area.

Under general anesthesia, a coronal scalp incision was made way behind his hairline. A full-thickness scalp flap was raised down to the underside of the brows exposing the enlarged brow bone. The supraorbital nerve was identified and preserved. A reciprocating saw was used to remove the brow bone prominence. Internal osteotomies were made to infracture the part of the brow bone that had expanded into the orbit. Burring was done around the osteotomy site to remove additional protruding areas. The removed brow bone was reduced, reshaped and placed back as a cover with resorbable sutures over the exposed frontal sinus. The scalp incision was then closed with a total operative time of less than two hours. He was discharged later in the day as an outpatient.

Immediately during surgery the change in the brow bone was apparent with improved symmetry between the two sides of the brow bones. He went on to heal uneventfully with a satisfied symmetrical brow bone result.

Case Highlights:

1) Brow bone hypertrophy most commonly occurs on both sides and rarely on just one side.

2) Brow bone reduction is done through an open coronal (scalp) approach by removal and reshaping of the bone overlying the enlarged frontal sinus.

3) Brow bone reduction has no adverse effect on the frontal sinus.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Testimonials: Brow Bone Reduction/Forehead Reshaping

Sunday, August 25th, 2013

Brow Bone Reduction and Forehead Reshaping

‘Had brow bone and forehead bone reshaping done recently by Dr. Eppley. The results are amazing. I had a really big protruding brow bone that made me look like a Neanderthal man. The whole process was very smooth and transparent. A large amount of bone was removed, some of it was reshaped and put back. This way not only sinus size was reduced, but also brow bone on the sides and along orbits was made smoother. Recovery was very quick, I was able to return to work two weeks after the procedure. 

If you have this kind of forehead problem I would recommend this surgery. I would get a 3D CT scan, as Dr. Eppley suggested to me, to make the consultation more productive and results more predictable.

Victor Z.

Durham, North Carolina


For brow bones that are really prominent, particularly in men, the only really effective reduction method is going to be the osteoplastic bone flap technique. The anterior wall of the frontal sinus (visible brow bone ridge) is very thin, often less than 3 or 4mms, so to expect a significant change from burring is not going to happen. The entire brow bones must be removed, reshaped and then put back in place. By so doing up to 10mms of brow bone setback can be achieved. But no matter how brow bone reduction is done it requires a scalp incision to do it. Whether it is way back in the hairline or along the edge of the frontal hairline (women only) a turn down scalp flap is needed.

While all of this sounds quite ghastly the procedure actually is fairly easy to go though and has a quick recovery. Most patients have little pain after surgery and the biggest issue is some eyelid swelling and occasional bruising. By a week after surgery most people look good enough to walk around in public or even be at work without detectable signs of  having had surgery.

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

Postoperative Instructions for Brow Bone Reduction Surgery

Tuesday, April 9th, 2013

Most brow bone reductions need to be done through an open scalp incision. Unless the amount of brow bone reduction is very minimal (a few millimeters) the underlying frontal sinus must be factored into the operative technique. Brow bone reductioin can be done by burring, burring and infracture and removal of the brow bone with reshaping and replacement.

The following are the typical instructions for brow bone reduction:

1. Brow bone reduction is associated with a only a very moderate amount of pain in the first few days after surgery.  Narcotic pain medications are prescribed and use them if you need them. In a few days, you may switch to Tylenol or Ibuprofen or alternate between doses with the narcotic medication.

2.  There will be a circumferential head wrap placed right after surgery. This is in place to control extreme swelling and does not play a role in maintaining the new position/shape of the brow bones. You may take it on the next day after surgery. If it should get loose or come off during the night, just leave it off. It is not a critical part of brow bone reduction surgery.

3.  The sutures in the scalp incision are dissolveable and do not need to be removed. There is no need to apply antibiotic ointment to the incisions as all it will do is make your hair greasy and be hard to shampoo out.

4. Bruising and swelling will develop around the eyes after surgery which is perfectly normal. In some patients the eyes may almost swell shut by the second day after surgery.

5. You may shower and wash your hair 48 hours after surgery. There is no harm in getting your sutures wet with soap and water.

6. Your forehead will feel stiff and may not move normally for up to a month after surgery. It will also feel numb for even longer. This is all normal and as the feeling comes back in the forehead you will experience strange sensations such as shooting pains or itching as the nerves recover.

7. You may wear any type of hat around your forehead whenever you feel comfortable doing so.

8. There are no restrictions on normal daily activities after the surgery. You may do light exercise anytime afterwards that you feel comfortable. But no strenuous exercise that involves bending over for three weeks after surgery.

9.   You may drive within several days after the procedure, provided you are off pain medication and can react normally to driving conditions.

10.  If any redness, tenderness, or increased swelling develops on the forehead or around the eyes after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery – Brow Bone Reduction

Monday, April 8th, 2013

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the brow bone reduction procedure. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all, of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.


There are no alternatives to surgical reduction of he prominent brow bones. One potential alternative is to build up the forehead above it to make the whole forehead smooth.


The goal of brow bone reduction is to reduce the brow bulging and bring the brow bones back into a smooth contour with the forehead that lies above it, if possible.


The limitations of brow bone reduction is the thickness of the overlying anterior table of the frontal sinus and the size of the frontal sinus that lies beneath the bone. (inner half of the brow) The outer half of the brow bone is limited is reduction only the thickness of the skull bone.


Expected outcomes include the following: temporary swelling and bruising of the forehead and eyes, a temporary or permanent numbness of the forehead and scalp, temporary weakness of the forehead muscles, and permanent scalp scars. It may take four to six weeks before the final shape and appearance of the brow bones is seen.


Complications may include bleeding, infection (wound or frontal sinusitis),  poor scalp scarring, bone fixation palpability,  undercorrection of the brow prominences and brow asymmetry.


How the foerhead heals and the occurrence of complications can influence the final shape and appearance of the brows. Should complications or the desire to enhance the result further by additional surgery be needed, this will generate additional costs.

Endosopic Reduction of Prominent Brow Bones

Wednesday, March 13th, 2013


A prominent supraorbital or brow bone is known as bossing. While some degree of bossing is acceptable in men, it rarely is so in women. The shape of the lower forehead in men can have a brow bone prominence as evidenced by a brow bone break into the mid-forehead area. In contrast, women desire a smooth transition from the brow area into the forehead which requires no bossing.

While the brow bone looks and feels like solid bone, it is not. The brow bone and its outer shape is determined by the size or aeration of the underlying frontal sinus cavity. This creates a comparatively thin layer of bone over an underlying air space. Reducing frontal bossing, therefore, requires a knowledge of the thickness of the outer bone comprising it to determine how much it can be reduced and what is the best technique to do it.

The most common method of brow bone reduction is an open approach using either a burring reduction, an infracture technique or osteotomies and reshaping. Simple burring can be effective if the outer table of the brow bone is thick enough. This then raises the question of whether a burring procedure can be done short of using an actual open scalp method.

In the March 2012 issue of the Plastic and Reconstructive Surgery journal, an article was published entitled ‘Endoscopic Correction of Frontal Bossing’. In this paper, the authors performed a retrospective review of 10 patients who had the endoscopic procedure done over a seven year period. The degree of frontal bossing correction was rated as moderate improvement. No violation of the frontal sinus occurred in any patient. The limiting factor in achieving better outcomes was the thickness of the outer table of the brow bone.

Endoscopic reduction of the prominent brow bone requires two things; proper endoscopic instrumentation and frontal bossing that has thick enough bone. Adequate bone thickness has to be at least 5mms in thickness as determined by a lateral skull x-ray. A 1 or 2mm reduction is not going to make a noticeable difference. But a 3 to 4mm reduction will make a discernible reduction in the amount of frontal bossing. This determination can be done beforehand by tracing out the frontal bossing outline and seeing how the soft tissue profile changes as the bone is thinned.

Endoscopic reduction of the prominent brow bone is a safe and effective procedure. Its use, however, is restricted to a very few patients whose brow bone thickness allows visible improvement with a burring technique.

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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