Where Is The Scar Placed For Brow Bone Reduction Surgery?

Q: Dr. Eppley, I am interested in brow bone reduction surgery.  I am a 37 year old transgender. I started transition about eight years ago. I still need to have my browbone shaved and lifted a little. I’m just scared of side effects like big scars in the hairline and permanent numbness. Is the scar hidden in the hair ? Please advise. And how long before I can get back to my normal activities?

A: When it comes to brow bone reduction, there are two basic incisional approaches to it. The incision could be placed either at the frontal hairline or back further in the scalp. There are advantages and disadvantages to either incisional approach depending upon other features of the brow, forehead and frontal hairline. If one is happy with their current brow position, has a low to average forehead height (brow to hairline distance) and has any type of frontal hairline density, then the coronal (way back in the hairline) incision can be used to avoid any risk of frontal hairline scarring. But there will be a longer scar across the scalp and a greater risk of some reduced scalp sensation permanently. The frontal hairline (pretrichial) incision can be used when the brows need to lifted, there is an average to long forehead length (usually greater than 6 to 6.5 cms) and one wants to either maintain their existing forehead length or advance or lower the frontal hairline to to shorten their forehead height. The pretrichial incisional length would be shorter than the coronal incision (because it it closer to the brow) and there is less risk of any significant scalp numbness.

The scars from either the coronal or pretrichial incision usually heal well as evidenced on my experience of very few scalp/hairline scar revision ever requested. Quite surprisingly, even though the frontal hairline incision is more ‘exposed’, it actually heals very well as hair eventually grows through it. As a result, many brow bone reduction particularly in the transgender patients, use a pretrichial incision. This is also useful as hairline advancements, brow lifts and upper forehead augmentations (to create greater forehead convexity) are often aesthetically advantageous and simultaneously done.

Recovery from brow bone reductions is very similar to that of an open brow lift. It is all about how much swelling one gets around the eyes and how long it takes to go away until looks socially acceptable. That is usually about ten days.

Dr. Barry Eppley

Indianapolis, Indiana

Is The Scalp Scar For Brow Bone Reduction Surgery Worth it?

Q: Dr. Eppley, I am interested in brow bone reduction surgery. As you can probably tell from the pictures I have attached,  I suffer from Alopecia areata. I realize there will be a scar from the coronal incision, but I have no reference for how bad the scar will be. Would the trade off be worth it? I look forward to your assessment.

A: When it comes to brow bone reduction surgery, the degree of brow bone protrusion is important as that determines whether surgery is worth it and how it might be done. You do have a Grade IV brow bone protrusion which aesthetically is very severe so I can understand your pursuit of brow bone reduction surgery. A dramatic change in your forehead can be obtained through a combination of a brow bone reduction via an osteoplastic bone setback and a little forehead augmentation just above it. The very legitimate question is whether the scalp scar trade-off is worth it. I certainly have done a significant number of forehead and skull reshaping surgeries on men who shave their head or are otherwise bald but always do so with great trepidation. Since much of aesthetic surgery is always about trade-offs, one has to be sure that what one is trading off into is better than the initial problem. I can not make that decision for any patient as only they can place those type of values, all I can do is provide information that may help in making that decision. I will send you a picture of the scalp scar from a brow bone reduction patient who largely was bald across the top by tomorrow. This may help you in making that trade-off decision.

Dr. Barry Eppley

Indianapolis, Indiana

Can A Brow Bone Reduction Be Done That Just Reshapes Lateral Superior Orbital Rim?

Q: Dr. Eppley, I am interested in a unique form of brow bone reduction/reshaping. I am wondering if you can reshape the bone on the lateral superior side of my orbital rim through osteotomy. I was only able to find one instance of this procedure in medical journals. I have attached the article below and I have also attached photos of my current eyes and what I would like my eyes to look like after the procedure. I am also interested in forehead augmentation especially on the lateral sides but that is not something that is as important right now and can be discussed later. I am not concerned much about scars as long as I can hide them with fairly long hair. This is because without an eyelid crease, I get ptosis and the current eyelid crease is causing much discomfort.

A: You obviously have researched out the need/benefits of a lateral superior rim orbitectomy/reshaping procedure (variation of brow bone reduction) so the issue of whether it is of benefit to you I will bypass over.

I have performed this procedure several times and it is the ‘simplest’ form of brow bone reshaping/orbital rim modification that I know. This is because it is done through an upper eyelid incision (as opposed to most brow bone procedures which is done through a scalp or coronal incision) and the frontal sinus or intracranial contents are not close to this area so the bone is thick and can be aggressively reduced. So it can  be very successfully done just as you have shown in this ‘ancient’ Plastic and Reconstructive Surgery article.

The only caveat in an Asian patient like yourself is that I would have some potential concerns about using an eyelid incision due to adverse scarring and in the face of pre-sexisting ptosis. In addition, if you have an interest/need for forehead augmentation, this would be another reason to consider coming from above, addressing two problems simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Cost Of Brow Bone Reduction?

Q: Dr. Eppley, I have some questions about brow bone reduction. I read your case study “Reduction of Prominent Brow Bones in Men” and was wondering what the cost would be to have a surgery done like this? I have a prominent brow bone and would like to have this feature removed from my face. How long is the surgery? What are the long-term effects of the surgery? Are there any medical conditions that could occur as a result of the surgery? 

A: Brow bone reduction is usually about a 2 to 2.5 hr surgery. It needs to be done through a scalp incision way back from the edge of the frontal hairline. The outer portion of the brow bones is removed and reshaped and put back so it is flat. It is a highly successful procedure that is associated with no known medical conditions or problems. Its only potential issues are aesthetic in nature…smoothness and symmetry of the bones and the risk of some persistent forehead numbness. (these are uncommon). The total cost of the procedure is in the range of $8,000 to $9,000. I would be happy to review any pictures you could send me to see how this procedure may be of benefit to you.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Frontal Sinus Be Reconstructed After Brow Bone Reduction?

Q: Dr. Eppley, years ago I had a brow-bone reduction surgery for facial feminization. Unfortunately, the surgeon I chose tried some novel procedure that ended up leaving me with a missing anterior sinus wall and bone chips lodged in my frontal sinus. Another surgeon, an ENT, then obliterated my frontal sinus with hydroxyapatite. This fixed the air leaks and replaced the missing bone, but left obvious irregularities in my forehead. I recently had a CT scan done and discovered that he also failed to completely obliterate the sinus; there is still a cavity on the left side. I came across your page while doing research and discovered that you had a lot of experience in forehead work as well as craniofacial experience, and I was wondering if this was something you think you could fix. I’m hoping to have the last of the sinus obliterated with hydroxyapatite or similar and to have the defects in my frontal bone filled. 

A: In doing brow bone reduction surgery, removing the anterior table of the frontal sinus and putting it back as morselized bone chips is not going to be a successful strategy. (as you have discovered) This will leave one with significant indentations and irregularities over the brow bones. Repairing this problem with frontal sinus obliteration by mucosal lining removal, obliterating the frontal sinus ducts with bone grafts and then filling it with hydroxyapatite cement up to the level of the desired brow bone shape is the correct treatment. However if one fails to get out all the lining or does not obliterate the frontonasal ducts, a residual frontal sinus cavity will remains which could be a source of infection.

I am going to assume that this residual sinus cavity is located near the frontonasal ducts underneath the hydroxyapatite cement. If this asymptomatic and the cavity is clear, then I would just fill in the outer brow bone contour and leave it alone. However, if it is a source of pain or frontal sinus infections, then it should be removed and obliterated with cement along with the brow bone/forehead contouring.

Dr. Barry Eppley

Indianapolis, Indiana

Will Forehead Reduction Make Me More Attractive?

Q: Dr. Eppley, I am interested in some type of forehead reduction. I am a young woman and I’m not happy about my face at all. The biggest problems I have are with my jawline and my frontal bone. I also have really deep insetted eyes. I’m kinda chubby but I used to be skinny and I had to exact same problem. I have big cheeks , something like squirrel cheeks and jowls on the side of my face. I really want a nice tight jawline. When I tighten the skin together and pull it through my ears I see it the way I would want it to be. I was wondering if that is possible for me without having a jawline surgery.

I have a very big frontal bone and I would love to have a nice flat forehead like most women have. I was wondering if that is possible for me to get it flattened. Maybe there is also someting you could do for my deep insetted eyes. I want to send you some picture’s and I’m wondering if you could look at them yourself and if you have any tips for me to make me as beautiful as possible.

A: Thank you for your inquiry and sending your pictures. The most effective procedure that you could do for your face would be a combined orbital/forehead reduction and hairline scalp advancement. This would reduce the depth of your eyes, lessen the brow ridge prominence, and make the forehead look smaller.

Only a jowl lift can create the desired look you are after along the jawline and you are too young for that procedure. There are no non-surgical methods that can create the same effect.

Dr. Barry Eppley

Indianapolis, Indiana

Can Brow Bone Reduction Be Done For Big Brow Bones?

Q: Dr. Eppley, I am interested in brow bone reduction surgery. In the past few months my brows have started to be protrude. Is there anything that I can do to stop it or how much would it cost to have it remove or is their payment options? Its really affecting my way of life.

A: Brow bone reduction surgery is always an option for brow ridges that have excessively overgrown. Your brow protrusion, as long as it is symmetric (and it appears so in your pictures) is the result of a pneumatization process. (development and expansion of an underlying air cavity) While not present at birth, the frontal sinuses have a fair degree of development by 7 or 8 years of age but continue to grow (expand) until well after puberty. Why some people develop bigger frontal sinuses than others is not clear other than due to hormonal influences. (men develop bigger frontal sinuses than women hence the development of the stronger male brow ridge) Spontaneous frontal sinus growth after puberty could be the result of a late pubertal spurt, medications such as steroids or a more conscious awareness of its size.

While brow bone reduction surgery can be done (usually an osteoplastic flap setback is the most effective technique), this requires a scalp or coronal incision way back in the hairline. While this can certainly be done, men always have to think very carefully about this scar trade-off. Given that you shave your head this consideration is of high significance. Initially this is a far more important hurdle to cross than that of the cost of surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Does My Hairline Lowering Need A First Stage Tissue Expander?

Q: Dr. Eppley, I was curious if it is possible to receive these exact results from forehead reduction if I decided to go with the sinus removal and reshape instead of the tool to burr them down. Also I have what I feel to be extra bone above and on the sides of my eyes that are pretty prominent, thus making my eyes look a little sunk in. Can that be reduced as well? Lastly how far down do you think my hairline have to be reduced and does it look as though I need a tissue expander to achieve the results I’m aiming for or just a stage one?

A: Maximal brow bone reduction is always achieved with brow bone removal and reshaping. It is a far more effective procedure than just burring alone. By doing so I would be also be able to burr down the bone outside of the frontal sinuses (above the brow bone and on the side of the eyes) This bone is thick enough that burring alone would suffice. This would help open up the eyes.

In looking at where you are now and where you would like our hairline to be, that appears to be about a 3cm movement lower. That would require a first stage tissue expander for about three weeks prior to the second stage at which time the hairline can be advanced and the brow bones and eyes reshaped at the asme time.

Dr. Barry Eppley

Indianapolis, Indiana

Is A Browlift Needed When A Brow Bone Reduction Is Done?

Q: Dr. Eppley, I want to get my forehead reduced so it can be the flattest it can be. However I’m not sure of which approach to take. I heard that with the burring its only a limit to how far you can take it but with the set back you can accomplish more with greater results. However from what I’m told the set back can’t be hidden well and you’ll be able to tell where your bone was broken removed and repaired with screws cements or whatever you guys use to hold it into its new position Is it an additional price from the average burring technique and do you also lift the bones of the eyebrows into a new place to heighten them or you just simply lift the muscle and skin around the bones to raise the brows.

A: Everything that you are saying or have heard about brow bone reduction is relatively true. It would be very rare that a burring technique alone can significantly reduce prominent brow bones or make them as flat as possible. Thus, the formal brow bone setback is the better procedure to do for maximal change.It is true that in the thinner-skinned forehead patient it may be possible to potentially see the outline of the brow bone work. But I have learned to lessen the likelihood of this problem by either avoiding or minimizing the use of any plates and screws (use mainly resorbable sutures if possible) , use only very miniature plates and screws (1mm profile) if they are used, be meticulous about contouring the surrounding bone into and around the setback area and using a thin film or overlay of hydroxyapatite cement over the setback area for smoothness. Whether a simultaneous internal browlift is done depends on the patient’s current eyebrow positions, the degree of brow bone reduction and the patient’s desires. The internal browlift is done by suturing the underside of the eyebrow area onto the bone of the osteotomized brow bone edges or to any fixation hardware used in the brow bone setback.

Dr. Barry Eppley

Indianapolis, Indiana

Is A Large Brow Bone From A Medical Condition?

Q: Dr. Eppley, I have noticed that my son who has just turned 21 years old has quite a prominent protruding brow. In fact, I noticed it a few years ago and I am quite positive that it has become larger in the past 12 months. He is 6ft 5in (195cm) tall – a very slim built person; a sports man. Other body features, such as face and head, are all normal in size and do not have the ‘giant syndrome’ disease – which I recall most people with a large protruding brows have. I am wondering – will the brow bone stop growing or could it become larger? Should we be concerned? Should he see a physician? Is this a particular condition or syndrome which needs investigation? Look forward to your early response. With sincere thanks.

A: In theory, frontal sinus development is almost always complete by the later teen or early 20s. Your son is a large man so his frontal sinus development may be normal for his size…or it could represent an underlying endocrinologic disorder of the pituitary gland or excessive growth hormone. I would  recommend that he be initially seen by an endocrinologist to rule out this potential medical condition even though it may be unlikely. X-rays of his frontal sinus would also be helpful to determine its size. If there is not an endocrinologic basis for his frontal sinus development and it is an aesthetic concern, brow bone reduction/reshaping is a surgical option

Dr. Barry Eppley

Indianapolis, Indiana