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Augmentation of the upper third of the face has been less commonly done than the lower two-thirds of the face. Besides it being less frequently requested there is historically no standard implants to do so. The lack of available standard implants is a testament to the low frequency of demand for this area of facial augmentation. As a result any area of forehead augmentation has to be done by custom designed implants. Having done many custom forehead, brow bone and combined forehead-brow bone implants I can testify that the concept for a standard implant in the forehead would be challenging. The  variable anatomy amongst patient’s foreheads, particularly if the brow bone is involved, would make a uniform implant fit difficult.

Custom implants for the forehead work remarkably well and have the proper fit from side to side (temporal line to temporal line) which is a key element of their success. Besides the obvious reason for why they are placed a not uncommon question I get from younger male patients is whether a brow bone implant will lower their brows. The spirit of that question is will it help get them a ‘Hunter’ eye look. And the answer is maybe…depending upon what type of forehead implant is used.

The Hunter eye look is defined as having a short brow to upper eyelid distance with the brow being positioned on the lower end of the brow bone. Some may say it makes the eyes look like they are squinting but it is a static brow-upper eyelid appearance. It is logical to assume that brow bone augmentation may lower the brow position, and help achieve the Hunter eye look, and this may be true IF the implant design (style and shape) is made to do so.

The two forehead implant design concepts that can help lower the eyebrow are implant brow bone coverage and whether it is an isolated brow bone or a combined forehead-brow bone implant. If if is a limited brow bone implant the implant design must have the lower edge of the implant below the inferior rim of the brow bone and must have lateral coverage out to the frontozygomatic suture line. But even with the best brow bone implant design it is difficult to get the eyebrows to lower significantly due to the soft tissue recoil of the brow soft tissues and the limited ability of ms vertically short implant to create much push.

The combined custom forehead-brow bone implant provides the best downward push on the eyebrows and, as a result, provides the best brow lowering effect. Part of it is due to the long vertical implant which can be pushed lower on the brow bones from above and secured with screws behind the hairline. But another reason is that the soft tissue release is greater across the entire forehead than needed for just a brow bone implant alone. The mobilization of the entire forehead and anterior scalp recruits tissue down over the brow bone, enhancing the brow lower effect. (Somewhat like a browlift in reverse)

If one of the goals with brow bone augmentation is to lower the eyebrows I would encourage an implant design that has a forehead extension. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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