Brow bone reduction is a forehead reshaping procedure that is done on both men and women. But the end goals for each gender are a bit different as females have a bit of a different look for their lower forehead shape than men. In men a prominent brow bone most commonly occurs more centrally due to over pneumatization of the frontal sinus. Have a persistent tail or temporal portion of the brow bone is a desirable male feature and is usually left unchanged. In women and in particular transgender male to female brow bone reduction changing both the central and sides of the brow bone is important for a more feminine appearance.
Very often I see female patients that have undergone brow bone reduction but the temporal brow bone was unchanged. This can leave a prominent bulge of bone above the eye corner as well as a flat or low tail of the eyebrow the lies over it. Reopening a hairline or scalp incision to secondarily reduce the temporal brow bone area is not very appealing…and is also unnecessary.
The transpalpebral approach to the temporal brow bone is a direct one that provides the ability to reduce both its horizontal projection as well as vertically raising the lower level of the bone. This is done by making a skin incision in the lateral half of the upper eyelid crease. It is important to choose the lower eyelid crease for the incision and not any of the skin folds that may lie above it. The temporal brow bone is accessed through suborbicularis muscle dissection and exposed by wide subperiosteal undermining. Besides providing access this releases the entire tail of the eyebrow.
Using a small high speed burr the temporal brow bone can be reduced with horizontally and vertically. Typically a 5mm horizontal bone reduction is done . Given that there is no frontal sinus in this area and the intracranial cavity is fairly deep, this is a safe area for significant bone reduction. The lateral eyelid is closed by muscle and skin sutures only.
The transpalpebral approach provides direct access to the bony temporal brow bone area. This is an excellent procedure to complete a previous forehead feminizing procedure as well as in conjunction with a temporal browlift. The wide subperiosteal undermining and release of the eyebrow maximizes its ability to be lifted. The eyelid incision heals as well as ay other upper blepharoplasty incision.
Dr. Barry Eppley