Background: Brow bone augmentation is requested for various aesthetic objectives. Besides the obvious reason to augment the lower forehead due to flatter and non-descript brow bones it may also be part of an overall periorbital or eye look. In men this is most commonly known as the Hunter eyes. This refers to a specific eye shape in which the eyes are deep set, has a narrow aperture and a positive lateral canthal tilt. Such an eye look in men is considered to create an attractive and masculine appearance.
There are numerous anatomic components to the Hunter eye look but the basic one is prominent brow bones. Good or strong brow bone projection sets the frame or shape of the eye. The only reliable and effective method of brow bone augmentation for those men who need it is with a custom implant design. The intricacies of brow bone shape are more complex and it is more than picking an amount of desired brow bone projection. The brow bone has numerous thicknesses that differ from the central glabellar are to the medial and lateral brow bone mounds. Then there is its surface area coverage such as does it need to cross the frontozygomatic suture onto the lateral orbital wall and how far up onto the forehead should it extend.
The eyelids also play an important role in achieving a Hunter eye look. In the upper eyelid increased supra tarsal fullness may be needed wh ich may or may not be created by the brow bone augmentation. A positive canthal tilt and a more elevated lash line are lower eyelid needs. Procedures such as upper eyelid fat grafting, lateral canthoplasties, spacer grafts and occasionally orbital decompression are all available to help change the eye shape.
Case Study: This male previously had custom jawline and midface implants (including the infraorbital rim) to correct lack of bony projection and contour irregularities after double jaw surgery. These worked well for him and he now looked to the upper third of the face to complete his facial reshaping efforts.
A custom brow bone implant was designed to augment the upper half of the orbits down past the frontozygomatic suture line to join with the previously placed custom infraornbital-malar implant. This creates the extended brow bone implant design.
Under general anesthesia initially through a small incision at the edge of the frontal hairline a subperiosteal pocket was developed using an endoscope. The brow bone tissues were released along the entire ridge preserving the supraorbital nerves. The implant was inserted through this incision in a turned longitudinal orientation.
Once inside it was turned into its horizontal orientation and the ‘legs’ of the implant brought down along the lateral orbital walls. This was aided by small upper eyelid incisions to get the orbital wall implant legs into proper position. To make sure the the entire brow bone part of the implant was positioned adequately low the orbital wall extensions (legs) are brought out of the eyelid incisions.
Once the larger horizontal part of the implant had good positioning the lateral orbital wall legs are put back into the tissue pocket and the implant secured with a small microscrew per side.
Endoscopic visualization confirmed flat and even placement of the horizontal part of the implant. The scalp incision was then closed with small resorbable sutures.
The lower eyelid incision from the prior custom infraorbital-malar implants was partially open so lateral canthoplasties could be performed. The lateral canthoplasty was done using a 5-0 permanent suture from the outer eye corner top through the implant at the frontozygomatic suture line engaging the microscrews for tying it down and lifting the eye corner. The upper eyelid incisions was then closed.
Lastly spacer grafts using 1.5mm thick Alloderm were applied in the lower eyelid to help elevate the lid level as the final method of lower eyelid reshaping.
Custom brow bone implants are often done as part of an upper facial masculinization effort. While this can be done as an isolated procedure it is not uncommon to have it requested as part of a total facial augmentation procedure. The brow bone and/or forehead is often the last facial level done after the lower to facial level of augmentations have been completed. In this patient the origin of those efforts was the original double jaw surgery which led to the pursuit of facial augmentation of all three levels.
Key Points:
1) One reason male patients consider custom brow bone implants to try and achieve the Hunter Eye look.
2) Extended custom brow bone implants are placed through a triad or triangle pattern of small incisions to ensure proper placement.
3) The lateral upper eyelid incisions provide the opportunity to perform lateral canthoplasties to raise up the outer corner of the eye..
4) With the use of a lower subciliary lid incisions spacer grafts can also be placed to help raise up the lash line of the lower eyelid.
Dr. Barry Eppley
World-Renowned Plastic Surgeon