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Posts Tagged ‘forehead reshaping’

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

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

Commentary

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

Case Study: Reduction of Prominent Brow Bones in Men

Monday, January 30th, 2012

Background:One important aesthetic area of the forehead is the brow region situated at its lowest extent above the eyes. Men and women have different brow and forehead shapes that are considered desireable and gender specific. Females have non-protrusive brow bones that taper towards the temples on the sides and give a smooth rounded forehead appearance with no slope. In contrast, men have slightly more prominent brow bones that transition into a forehead that has more of a retroclined vertical slope. In essence, the masculine forehead is characterized by heavier more prominent eyebrows due to the greater growth of the brow bones.

The brow bones, while called a bone, is really not one at all. They are caused by the growth and size of the frontal sinus which lies beneath it. Surprisingly the outer layer of the brow bones, known as the outer table of the frontal sinus, is remarkably thin. While a big brow bone looks quite stout, it is usually only just a few millimeters thick. The bigger and more prominent the brow bones, the bigger is the air cavity of the frontal sinus.

While some brow bone prominence is desireable in a man, it can become too extreme. When the frontal sinus cavity grows too big, it causes a large amount of brow bone protrusion. Jutting out from the forehead in a very conspicuous manner, it gives the appearance often unflatteringly called the ‘Neanderthal’ or Cro-Magnon’ look. This can be reduced to a more aesthetic appearance but can not be done by a bone burring techniqiue.

Case Study: This 35 year-old male from Los Angeles California had been bothered by his large brows since he was a teenager. Even though he was successful at many levels from professional to personal, he still remained sensitive about his facial appearance, particularly in a profile view. He fully realized that reduction would require more than just bone burring and also understood that a scalp incision would be needed to do the procedure.

Under general anesthesia, a bicoronal scalp incision was made to expose the entire forehead and the large brow bones. The supraorbital neurovascular bundles were seen exiting the outer aspect of the brow bones and were dissected out and preserved.

The base of the brow bones was marked out where it joined the forehead bone. A burr was used to take down the bone at the base of the protrusion around its entirety with the exception of the lower edge. A reciprocating saw made an osteotomy at the base of the brow bossing and the entire anterior table of the frontal sinus was then removed.

The removed frontal bone flap was reshaped by multiple osteotomy cuts. This allowed the bone flap to be made straight by gentle pressure through microfractures. The bone flap was made completely flat from its natural convex shape.

The frontal sinus bone flaps were stabilized and then secured over the open sinus cavity with multiple microplates and screws. (1.0mm) The numerous small bone defects between the osteotomy cuts was filled in with a demineralized bone paste on top of a netting of resorbable collagen sheeting. The scalp flap was repositiond, 1 cm. of scalp skin and hair across the top removed for a coronal browlift and closed with resorbable sutures over drains.

The head dressing and drains were removed the next day. While there was some mild swelling, he had no periorbital bruising. Even being just one day after surgery and with brow swelling, his improvement was very visible. Further improvement would be expected over the next month as the swelling resolves and the tissues shrink down and adapt to the newly shaped brow bones.

Case Highlights:

1) Significant brow bone bossing or protrusion in men is a result of overgrowth or excessive pneumatization of the frontal sinus.

2) Reduction of large brow bones, brow bone reduction, can only be done by an osteoplastic bone flap technique with reshaping and repositioning with microplate stabilization.

3) Male brow bone reduction should not be overdone and some small amount of brow protrusion should remain.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions on Forehead Reshaping and Contouring

Monday, February 8th, 2010
  1. What influence does the forehead have on one’s appearance?

The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.

The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.

A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women. 

2. How is forehead reshaping done?

Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.

They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.

3. How is brow bone reduction done?

In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only has  thin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.

In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.

A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone. 

4. How is brow bone augmentation done?

Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.

PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.

Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.

5. Can other areas of the forehead be reshaped besides the brow bone?

The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.

6. What is the recovery after forehead reshaping? What complications can occur?

Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.

Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?

7. What can I do if my forehead is too long?

Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.

The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference. 

Dr. Barry Eppley

Indianapolis, Indiana

Brow Bone Forehead Augmentation

Thursday, October 8th, 2009

The forehead has a variety of shapes that do differ based on gender. Men will tend to have flatter fuller foreheads with more prominent brow bones (supraorbital ridges) while women’s foreheads will usually be softer, less full, and with flatter brow bones that tend to angle off into the temporal region. Whether it be by a congenital deformity (such as craniosynostosis), frontal tumor resection (craniotomy flap) or from prior contouring purposes (FFS, facial feminization surgery), there are rare instances when one desires to have a fuller or more prominent brow definition restored.

Brow bone augmentation (BBA) is one form of forehead reshaping that can be done. Using synthetic materials as a building material, the bone can be ‘thickened’ and recontoured to alter how the brow looks. Since the eyebrow and the upper part of the eyelid is affected by its underlying bony support, such changes can produce subtle to dramatic differences.

One of the key issues of brow bone augmentation is which material to use. Currently, hydroxyapatite (HA) and acrylic (PMMA) are the only two moldeable materials of choice. Your own bone is usually not a good option since you have to harvest it and how it survives as an onlay is unpredictable. Both HA and PMMA have their advocates but I have gotten good results with both. Either one can do the job. PMMA is much cheaper from a material cost standpoint and is very hard once it sets, being hard if not harder than natural bone. HA is much more expensive, a little harder to work with, and is more fragile to impact. But it is closer to the mineral of natural bone so it has greater compatibility and less risk of long-term body reaction concerns.

There is also the option of a synthetic implant carved out of silicone or polyethylene. (Medpor) This requires a greater degree of skill and time to get all the edges flat and flush with the surrounding bone. It is easy to see how an edge step-off can be felt through the skin unless it is done perfectly. Feathering edges and blending into the surrounding bone is much more assured with the moldable materials. 

The other important consideration of BBA is access. For the most part, an open scalp approach provides the best vision and control of the shape. But this is understandably problematic for most men unless they have a pre-existing scalp scar to use. For most women, this is not a significant issue as a hairline (pretrichial) approach can be done and that scar can really be quite fine and unnoticeable. I know this from a lot of experience with pretrichial (hairline) browlift procedures done for cosmetic purposes.

A non-open scalp approach (endoscopic) can be used in select cases of forehead augmentation. When it is the central or more upper parts of the forehead that are being augmented, the endoscopic approach using PMMA as an injectable material can be done. PMMA can be injected and pushed around as a congealed putty and shaped by external molding through the forehead skin. HA is a quite different material and its handling properties do not permit anything but an open approach scalp approach. But working down at the brow area, which is a very low point for endoscopic visualization, is even difficult with PMMA. Therefore, I would advocate an open approach for any amount of brow bone augmentation.

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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