Background: Like most other facial features the shape of the forehead is gender specific. There are numerous parts of the forehead that differ between women from men but the most obvious is that of the brow bones. In men due to the influence of testosterone the frontal sinuses develop more fully, creating prominent brow bone mounds in the central lower forehead. With the brow bone mounds comes a supra brow bone break as it transitions into the forehead above it.
In women such brow bone prominences do not usually exist…or if they do they are very small. With lack of enlarged brow bones there is no brow bone break with a smooth transition between the forehead and the brow bones. This is one reason women have a more vertically inclined forehead with a more ‘retracted’ base. The other reason is that women have a greater overall forehead convexity or roundness.
While men dominate those seeking aesthetic brow bone augmentation, there are indications for females to seek that aesthetic change as well. One indication is in females that have a very flat brow bone area that makes the forehead look too protrusive and even the eyes a bit too prominent.
Case Study: This young female desired a brow bone augmentation due to her brow bones being very flat (superior negative orbital vector) and the forehead above it being ‘protrusive’. A custom brow bone implant was designed to have maximal projection at the frontonasal junction. (unlike that in male brow bone implant designs)
Under general anesthesia a small 3cm scalp incision was made through which the forehead was dissected in the subperiosteal plane with endoscopic visualization. This required protection of the supraorbital neuromuscular bundles at the lower end of the brow bones.The dissection was completed by making bilateral small incisions in the lateral upper eyelid creases to ensure that a complete pocket was created down to the frontozygomatic suture line on each side.
The custom brow bone implant was inserted through the scalp incision and rotated down into position. Once the ends of the implant were identified and positioned along the tail of the brow bone, a single screw was placed into each visible end of the implant. Endoscopic inspection after placement confirmed that the thinner tail of the implant was laying flat and into the tail of the brow bone properly.
Her immediate intraoperative before and afters shows the effect of the custom brow bone implant on the profile of the forehead.
The three incision triangulation placement technique is usually what is needed to ensure that a custom brow bone implant sits in the correct position. If it is not sitting low enough, even by a few millimeters, it will create an unnaturally high brow bone protrusion. Besides getting it low enough for proper positioning there also needs to be assurance that it will stay in the proper position as it heals. It is important to recognize that there is soft tissue pushback over the brow bone area even though it has been released as this is the tightest area of the forehead. Screw fixation is this essential to know that the implant stays where it is intended to be.
Case Highlights:
1) The objectives of female brow bone augmentation are different than men and are to create fullness on the lower forehead that merges with the forehead above it.
2) The design and shape of a female brow bone is different than in men with lack of defined brow bone prominences.
3) The three incisional triangulation technique is the most assured method of custom brow bone implant placement with minimal scarring.
Dr. Barry Eppley
Indianapolis, Indiana