Background: The shape of the male forehead is dominated by three physical features. The presence of brow bone protrusions, a slight backward slope to the forehead and an overall more square shape are the main characteristics of the masculine forehead. In profile view the amount of brow bone projection and the slope of the forehead have a distinct relationship by which when the diametric differences become them become out of balance an undesired aesthetic appearance results.
While an exact measurable relationship between brow bone projection and the slope of the forehead does not exist (or as yet to be specifically measured and normative values established) there is a clear impact of one on the other. The more the brow bones project the more the slope of the forehead looks recessive. Conversely the greater the backward forehead slope that exists the more projection the brow bones appear to have. Thus when a male patient presents for brow bone reduction due to excessive projection the slope of the forehead must be considered in the treatment plan.
When both the slope of the forehead and the amount of brow bone projection are at fault for the aesthetic imbalance, this os where the role of computer imaging is invaluable. Imaging is used to preoperatively evaluate and plan for how both are to be treated. When the slope of the forehead is the dominant problem a custom forehead implant combined with limited or no brow bone reduction is the effective aesthetic approach.
Case Study: This male presented for forehead reshaping due to the perception of prominent brow bones. He also knew that his forehead was a bit inclined backward but his low hairline and long hair hid that forehead feature. His 3D CT scan showed a forehead slope of almost 45 degrees and a brow bone projection of 6mms with 3.5mms thickness of the anterior table of the frontal sinus.
The severe inclination of the forehead is what made the brow bones look too projected. As a result, the treatment plan consisted of a dual approach of a custom forehead implant and brow bone reduction. The brow bone reduction needed only to be a minor amount so a burring reduction was planned as opposed to a more aggressive bone flap setback procedure.
Under general anesthesia a limited scalp incision was made 3 cms behind his frontal hairline. Through this incision the anterior table of the frontal sinus was reduced on both sides by a burring technique…but without going through the bone and creating a sinus communication.
Once the brow bone reduction was done the custom forehead implant was placed through the same scalp incision, secured with two microscrews and a two layer closure done with resorbable sutures after the placement of a drain. A scalp nevus next to the incision was also removed.
His intraoperative results showed the degree of improvement in his forehead shape both in projection of the upper forehead as well as in the reduced brow bone projection.
When seen the next day for head dressing removal the degree of improvement remained evident despite the onset of some swelling. (which will get worse by day 2 after surgery)
In profile the difference in the male vs female forehead slope has been shown to be around the 80 degree inclination. Women generally are above 80 degrees while are below it. At near 45 degrees of forehead inclination this patient’s forehead slope was the fear greater problem than the apparent excessive brow bone projection. Some brow bone projection reduction was helpful but avoiding any exposure of the frontal sinus, which would have occurred from a more aggressive bone flap setback procedure, was important when placing an implant or even using bone cement above it.
Case Highlights:
1) The appearance of brow bone protrusion can be exacerbated by how much the forehead slopes backward.
2) When both excessive brow bone protrusion and an excessively backward sloped forehead exists the ratio of correction between the two adjoining brow bone reduction and forehead augmentation must be preoperatively determined.
3) When the backward slope of the forehead is the dominant profile problem the combination of minor brow bone reduction by burring and a custom forehead implant is the most effective approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon