Q: Dr. Eppley, I am interested in brow bone reduction surgery. I have very deep set eyes, protruding forehead with brow bossing. I look like I’m mad and my eyes are hooded by bone. My forehead slopes downward from orbital rim a little and brow is very low set. Also I have calcium deposits on the front and sides of my head. I wouldn’t mind something dramatic but just doing some shaving on forehead and brow in front, possible slight brow lift would do wonders. I want to open up my face. I want to project what I feel on the inside and when I go out side I don’t want to see my brow especially when I squint which I’m usually forced to do.
A: Than you for sending your pictures. You do have prominent brow bones and you are correct in what their effect is on your eyes/face. I would agree that a brow bone reduction and forehead shaving and a brow lift would be very beneficial. Like in any man, however, the key issue is the surgical access to do so. This is always problematic in men where the use of a coronal scalp incision creates its own aesthetic trade-off. Usually in men because of their hairline location and hair density, the better option may be a mid-forehead incision in a horizontal wrinkle line. This eliminates the ability to do an overall forehead bony reduction. But an endoscopic browlift can still be done through very limited scalp incisions at the same time.
Q: Dr. Eppley, I am interested in brow bone reduction. Since high school I’ve had a prominent forehead and found it hard to accept. Now ten years later I have decided to do something about it. I have read on your website and checked out the various methods and then decided that the only method that would work for me is directly through the forehead because my hairline is receding. I don’t really have any deep forehead wrinkles but it is the only option. I have attached pictures for your review.
A: Thank you for sending all of your pictures. In regards to the type of forehead reshaping you need the question is whether this is a brow bone reduction (to bring the brow bones back to the level of the upper forehead) or whether it is to build up the forehead above the brow bones to correct its slope. Just based on forehead aesthetics for a male, I am assuming it is the latter. A custom forehead implant is made from a 3D CT scan.
Conversely brow bone reduction can also be done. In your case the brow bone reduction may only be a burring of the most prominent portion of the outer table where it bulges tyhe most.
You are correct in that a limited horizontal forehead incision would be the only reasonable incisional approach. Fortunately custom silicone implants are very flexible (until they situ against bone) and thus can be inserted in a rolled fashion and then unfurled once inside. That at least will keep the horizontal forehead incision more limited, perhaps in the 4 to 5 cm length. The location of the incision would be determined by raising your eyebrows and seeing where the eventual deepest horizontal crease will eventually be. Placing it there will usually lead to a pretty good scar result. The exact same type of incision would be used for any form of brow bone reduction as well.
Q: Dr. Eppley, I am interested in brow bone reduction. I don’t need much so I think a burring technique could be fine.I read on your website that burring doesn’t actually weaken the bone. However I play football for my school and I just want to make sure that I wouldn’t break the bone if I got hit too hard. Is that a concern I should have?
A: What you undoubtably are referring on my website was that of the skull reduction in general. Removing some of the outer skull bone does not weaken it. But brow bone reduction of the frontal sinus is different because what lies under it is a large air space. Burring of the anterior wall of the frontal sinus probably does weaken it a bit from the perspective of being easier to fracture from direct trauma. But this is not a practical concern since that amount of trauma needed to break the bone would probably break it anyway if it occurred…whether it had been burred or not.
In a burring reduction technique in brow bone reduction, the anterior wall of the frontal sinus is thinned down as much as possible without actually entering the underlying air space.
Q: Dr. Eppley, I’ve had a brow bone reduction procedure before. It was a frontal sinus reduction. This procedure didn’t really solve my issue. I am unhappy with my forehead prominence and how especially at 45 degree angles it looks really abnormal. Is there a procedure to smooth this feature to get rid of the sticking out effect, but also not feminize my face. Obviously I am a male and not wanting a feminization look, i just want to smooth out my forehead protrusion.
A: In looking at your pictures it is unclear as to what type of brow bone reduction procedure you had. By your description of ‘frontal sinus reduction’ that would imply that you had a setback of the anterior wall of the frontal sinus. But with your current brow bone protrusion that is hard to believe. May be it was just burring a few millimeters of the anterior sinus wall. But the degree of brow bone protrusion aside, your forehead appears to be at a 45 degree angle. (although that is hard to tell based on your hairstyle) Such forehead inclinations can make the brow bones appear to stick out further than they really do. (pseudo brow prominence) This may have partially contributed to the ineffectiveness of your prior brow bone reduction surgery. It may be that forehead augmentation to change the slope of the forehead may be more beneficial. By so doing this will also maintain a masculine appearance. To make that determination I need to do some computer imaging from the side view and will need a picture that shows your forehead without hair hanging over it.
Q: Dr. Eppley, I am interested in brow bone reduction. I have a prominent brow ridge and orbital region. The orbital region is particularly prominent. I am not a candidate for coronal incision as I have a receding hairline. I have been told by a couple of surgeons that it is possible to do an eyelid incision to shave down the orbital bone region. Would this be something that is possible at your clinic? Thanks for any help.
A: The transpalpebral (through the eyelid) approach be used if the outer half of the brow bone needs reduced. (tail of the brow bone) But it can not be used for the inner half of the brow and glabellar region due to the location of the supraorbital and supratrochlear nerves, They directly exit the lower end of the brow bone in this area and block access to any type of brow bone reduction. If one was willing to sever these nerves and live with permanent numbness of the forehead and frontal scalp then this approach could be used. But I know few patients who would consider this a good tradeoff. The other option would be to do the procedure through a horizontal forehead wrinkle if you have a prominent one.
Q: Dr. Eppley, I think my eyes are slightly uneven but I doubt anything can be done about that and that’s okay. I would like to change the prominent eyebrow structure from the center of my face extending to the outside supraorbital ridges. (brow bone reeduction) They are also slightly uneven. People often ask me if mosquitoes bit my eyebrows. The other thing that bothers me is my weak jaw line. I push my lower jaw out so its less obvious. (chin augmentation)
I know I will never look like a super model, its not even something that I want. I would just like a more symmetrical, angled, softer looking face. Thank you so much for your time and effort, Dr. Eppley. I hope it’s what you need in order to assess for possible procedures.
A: Thank you for sending your pictures. What they should is considerable brow bone protrusion from the glabella to the outer orbital rim. Even without x-rays I can tell that is due to significant frontal sinus hypertrophy and will require an osteoplastic bone flap setback technique for your brow bone reduction and not just burring alone to get a significant reduction. The brow bone protrusion you have is very similar to what I see in men with two distinct medial brow bone mounds. The slope of your forehead is also fairly retroclined and it would be ideal to augment the upper forehead at the same time to really change the entire shape of your forehead.
From a chin standpoint, it is both horizontal and vertically deficient in regards to being in balance to the rest of your face. While a sliding genioplasty would be the historic solution (due to the need for increased vertical chin height), my newer vertical lengthening chin implant (small size in your case) would work well as it brings the chin both forward and down. (at 45 degrees) This would a very good solution for you that is more cost effective than a sliding genioplasty with a much quick recovery as well.
Now that I know exactly what need to be done, I will have my assistant pass along the combined costs of the procedures to you on Monday.
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I hate my nasofrontal angle, it is very deep. I am not sure if I need to build up the bridge, reduce the projection of the tip, or both… I would value very much your learned opinion and recommendations.
A: A deep nasofrontal angle is often cased by a combination of factors including a low nasal bone height, an overprojecting nasal tip and low dorsum and, of equal importance, brow bone bossing/protrusion. In doing some computer imaging (which is attached) you can see that the effects of a rhinoplasty (radix/dorsal augmentation and tip deprojection/rotation) lessen the depth of your deep nasofrontal angle by about half. When you add in a brow bone reduction with the rhinoplasty (see attached imaging) the deep nasofrontal angle problem is completely solved. So you see in your case, which is not rare, that it is really a combination of low nasal bones (45% of the problem), brow bone bossing (45% of the problem) and very minimally impacted by nasal tip changes (10% of the problem). For a female you have fairly prominent brow bones and that is most certainly a big part of the problem. There is nothing wrong with a rhinoplasty alone you just have to realize its limitations…it will make it better but is not the complete cure for it.
Q: Dr. Eppley, my forehead bone has grown from from normal to abnormal. Because when I was young almost 10 years old I had fibrous dysplasia. I had an operation in 1999 and it started growing up at the age of 19 but then stopped at the age of 22. It is not growing anymore. I want to know now that it is not growing anymore if it is possible to make it normal? MANY THANKS
A: Thank you for your inquiry and sending your pictures. I can see that your brow bone has grown disproportionately compared to the rest of your forehead. Because the origin is fibrous dysplasia, your brow bone may well be completely ossified as opposed to be a large air-filled bone cavity. That could be determined by a CT scan. But regardless of what constitutes the brow bone protrusion, the surgical technique to reduce it is basically the same. I assume because you have had a prior operation that you already have an existing scalp incision/scar. This makes brow bone reduction ‘easy’ because there is not a concern about the method of access to do the surgery. Dramatic reduction can be done on your brow bones to get their appearance much more normal looking.
Q: Dr. Eppley, I would like a shorter, fuller face with softer, more feminine features. I am wondering if I need corrective jaw surgery or could a chin reduction and facial fillers alone achieve the look I want. If there isn’t a great difference in the results of corrective jaw surgery and chin reduction surgery, then I would be more inclined to just get chin surgery because it is less invasive and costly. I do not like the large space between my nostrils and my upper lip. Could rhinoplasty help to shorten that distance? You might not be able to tell from these pictures but as far as my nose. I do not like the hump and I do not like my nasal tip. It is very bulbous and when I smile I feel the span of my nostrils becomes very wide. Finally I feel that I have a very prominent brow bone and feel it makes me look even more masculine. I am wondering if I am a good candidate for brow bone reduction surgery and also hairline lowering in order to decrease the length of my face. Thank you in advance for your help. I look forward to communicating with you soon and seeing the computer facial images.
A: All of the facial fershaping procedures you have mentioned would be helpful in shortening the appearance of your face from hairline lowering, rhinoplasty, subnasal lip lift and vertical chin reduction. It is impossible to comment on whether corrective jaw surgery or chin reduction would be better since that decision requires knowing the state of your bite. (occlusion) If your bite is good, then chin reduction would absolutely be the better procedure.
Brow bone reduction would be helpful to feminize your forehead and would be needed with your rhinoplasty to help bring back the glabellar (central) area of the brow. Otherwise the hump reduction with your rhinoplasty will make a deep nasofrontal angle which is more of a masculine facial feature.
While a subnasal lip lift would be helpful, it can not be performed at the same time as a rhinoplasty due to blood supply concerns to the intervening columellar skin between it and the open rhinoplasty incision.
To properly do computer imaging, I need more than just a lateral or side view. Additional views from the front and even a three-quarter (oblique) view make for a complete imaging assessment of the aforementioned facial changes.
Q: Dr. Eppley, I wanted to know if during brow bone reduction will the top of my eye socket orbit be addressed as well to better define and make my eyes pop a little more? Could the protrusion of my forehead upper and mid section be burred down also as the bulging extends beyond the sinus region. Lastly could the chin bone be chiseled down horizontally using the inner incision approach and a slight bit of vertically?
A: During brow bone reduction surgery, it is possible to also reduce the horizontal projection of the brow bones. This is not a standard part of the operation but can be done at the same time. This does involve freeing up the supraorbital and supratrochlear nerves from the lower edge of the brow bone so that it may be reduced. That does create the increased risk of some permanent numbness of the forehead with the stretching or manipulation of these nerves. Simultaneous forehead bone reduction through a burring techniques can also be done with no increased risk.
While the chin bone can be reduced both vertically and horizontally through an intraoral approach, this is usually not a good idea as it will likely create chin ptosis due to the soft tissue excess. (the tissues do not shrink down so where does the excess go?) These types of chin reduction are best done from a submental approach as the excess soft tissues can then be managed (reduced) as well. (submental tuck)