Background: One of the key male distinguishing features of the upper third of the face are the brow bones. It is a very gender specific facial feature that truly separates a male vs a female facial appearance. One other aesthetic aspect of having some brow bone protrusion is that it also helps provide some coverage of the eyes and can make them look less protrusive or exposed.
To those men who have adequate brow bone protrusion they understandably take them for granted. But for the man who does not the concept of brow bone augmentation has appeal. Such brow bone augmentation, which is not a frequently performed facial augmentation procedure, has historically been done by a variety of materials and methods. But these typically consist of an open coronal incision for the application for bone cements or to modify other materials into a brow bone shape.
The contemporary brow bone augmentation approach is that of a custom implant method. Beyond the obvious benefits of preoperatively creating an implant design that is specifically made for the patient is that its placement can avoid the need for a coronal scalp incision and be done in as close to s scar-free manner as possible.
Case Study: This young male desired brow bone augmentation. He had no discernible external brow bone appearance even though there was a hint of brow bone prominence on his 3D CT scan. Using that scan a custom brow bone implant was designed that provided significant expansion of his natural brow bone contours down to the frontozygomatic suture on each side. His CT scan showed an existing silicone nasal implant from prior surgery.
Under general anesthesia an initial 1.5 cm scalp incision was made just behind his widow’s peak hairline. With endoscopic assistance, subperiosteal dissection was carried down and across the brow bones releasing the periorbital tissue attachments on the underside of the supraorbital rims but protection the supraorbital nerves and vessels. Effort was made to go as low on the lateral orbital rims as possible. Once the pocket was created the implant was passed through the scalp incision and slide downward into place.
While it is tempting to feel that the implant is in ideal position, one has to be assured that the tails of the implant are in perfect position along the lateral orbital rim. If these tails are not in the correct position the implant may be sitting slightly too high or there may be asymmetry between the two sides of the brow bones…which will be an aesthetic problem. Thus small lateral upper eyelid incisions are made (10mms in length) to find the implant tails, make sure they are in the correct place and then place a single small fixation screw through them. The endoscope is the used to check all edges of the implant across the brow ridges.
With the custom brow bone implant in place, the immediate brow bone augmentation effect could be seen.
Brow bone 
augmentation with a custom designed implant can now be done with an incisional technique that is favorable for the male patient regardless of their hairline location or density. Avoiding the need for a significant scalp scar, like a coronal incision or anything close to it, makes the operation a more viable aesthetic option for many men. Not to play a secondary role to the benefits of its surgical placement is the fact that a custom design assures a smooth augmentation effect that pushes the brows forward in a more powerful manner than intraoepratively shaped biomaterials.
Case Highlights:
1) Male brow bone augmentation is best done using a custom implant approach.
2) Custom brow bone implants are placed using an endoscopic-assisted triangulated incision technique.
3) Getting the implant down low enough on the existing brow bones from one frontozygomatic suture to another is the key in intraoperative placement.
Dr. Barry Eppley
Indianapolis, Indiana