Brow Augmentation & Forehead Reduction Surgery
Are you unsatisfied by the shape of your forehead or the appearance of a prominent brow bone? Dr. Barry Eppley, performs forehead reduction and brow contouring surgery. You can view results from Dr. Eppley’s previous Indianapolis forehead reshaping and brow lift patients by visiting our brow contouring before and after photo gallery.
AESTHETIC UNITS OF THE FOREHEAD
The forehead is a major part of the face and occupies up to one-third of its total surface area. It is a major contributor to facial aesthetics even though it has only one obvious feature: the eyebrows. However, the forehead actually has three features that create the visual impression of its overall size. The top of the forehead is marked by the variable position of the frontal hairline, which differs greatly between males and females. The bottom of the forehead is outlined by the eyebrows and the brow bones, which are the ridges of skull bone just above the eyes. The sides of the forehead are defined by the temporal ridges, the edges of the bony forehead where it meets with the large temporalis muscles.
MALE FOREHEAD SHAPE
The shape of the bony forehead (amount of convexity) and the prominence of the brow ridges help define the masculine or feminine appearance. A long forehead is more acceptable in a male because of the variability of the frontal hairline. The bone ridge running across the forehead above the eyes, known as brow bossing (supraorbital rims), is more pronounced in males. The degree of acceptable brow protrusion is not well-defined and can certainly become excessive, thereby causing an over-masculine or Neanderthal appearance. Male brow protrusion should be enough to create a noticeable break between the brow ridge and the forehead bone above it. It may also extend off to the side, tapering down onto the lateral orbital rims.
FEMALE FOREHEAD SHAPE
Females have almost no discernible brow bossing because their foreheads are more rounded with a fairly flat front. In profile, female foreheads are more vertical instead of backward sloping. This means that some brow bossing may be aesthetically acceptable when there is no break between the brow ridge and vertical forehead bone above it; it should flow smoothly without a noticeable transition. The amount of convexity in profile view, however, is important; it should not stick out further than the lowest edge of the brow ridge. The sides of the brow ridges are also more tapered towards the temples, unlike in males, in which the sides can be more boxy or square-shaped.
Forehead Contouring & Brow Bone Augmentation
Augmentation of the brows and forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic) and HA (hydroxyapatite cement). Each of these materials has its own advantages and disadvantages. These materials allow wide variability in adding to the brow ridges and increasing the amount of frontal bone convexity, width and smoothness. There is also the option of a custom made forehead and/or brow implants made off of a 3D CT scan of the patient.
FOREHEAD REDUCTION/BROW BONE REDUCTION
Conversely, decreasing the amount of forehead convexity (bossing) can be done by burring (shaving), but the amount is limited by the thickness of the outer cranial table. Reduction of the overly prominent brow bone can be done by burring alone, burring combined with infracture, or complete frontal table removal and remodeling. Which method is used is based on how thick the brow bone is and the location of the underlying frontal sinus. Almost all forehead and brow contouring procedures require a scalp incision for best results. Only reshaping of the tail or sides of the brow bone can be done through an upper eyelid incision.
FOREHEAD REDUCTION BY HAIRLINE ADVANCEMENT
The length of the forehead can also be reduced both in its bony bulging and in its forehead skin length. Through a frontal hairline (pretrichial) incision, the frontal hairline/scalp can be brought forward and excess vertical length of forehead skin removed. This shortens the long forehead and puts the scalp in a more aesthetic position. In rare cases, a staged approach with a tissue expander may be used when the hairline needs to come forward more than 1.5 to 2 cms. Through a hairline incision, forehead bulging can be shaved down to reduce a small amount of excessive convexity and forehead width. Often this is done at the same time as a hairline advancement/lowering.
Temporal augmentation can be done to build out the deficient or concave temporal region (muscle to the side of the bony forehead). These temporal hollows can occur from natural development, certain diseases (such as autoimmune diseases), severe weight loss, or neurosurgical operations. Through a small incision inside the temporal hairline, specially designed temporal implants are placed under the fascia on top of the muscle to create a permanent augmentation effect. Fat injections into the temporalis muscle can also be used although an implant creates more of an assured result. In larger temporal defects, bone cements or custom implants may be needed.
When the temporal area bulges out (has convexity) or the sides of the head (above the ears) are too wide, the temporalis muscle is usually the cause of it. Most people understandably think it is a bone problem and do not appreciate how large and thick the temporalis muscle is. Temporalis muscle reduction can be done very effectively with Botox injections but will take an indeterminate number of injection sessions and the amount of muscle shrinkage is not always predictable. Temporalis muscle reduction surgery is done by releasing much of the origin of the muscle attachments to the skull combined with some actual muscle removal.
Dr. Eppley performs a range of facial plastic and reconstructive procedures, including rhinoplasty, facelift surgery, and has helped many jawline enhancement surgery patients achieve a more attractive lower face.
Preparing for Forehead Reduction Surgery
The consideration of any form of forehead and brow changes requires a thorough pre-surgical analysis. While photographs and a physical examination are usually adequate for the forehead, brow reduction may require X-rays to visualize the location of the frontal sinus and the thickness of the outer table of the bone. The forehead and brow bones can be easily viewed through computer imaging software. Every prospective forehead / brow reshaping surgery patient must be assessed with predicted computer-morphed changes. Photographs are taken before surgery and computer images are provided to the patient for review. This is an essential step in any form of facial plastic surgery requiring changes to the structure of facial bones.
Forehead and Brow Contouring – The Operation
Forehead and brow reshaping procedures are always done under general anesthesia as outpatient procedures. They almost always need to be done through a scalp (coronal) incision for wide exposure and access. This will result in a scalp scar across the top of the head that ends above the ears. Endoscopic and injectable approaches are being developed, but they can only be used in a limited number of patients who are deemed good candidates. Forehead and brow bone augmentation is done by the careful placement and sculpting of various cranioplasty materials. Forehead and brow bone reductions are done by burring the outer cortex of these areas of the frontal skull. Large brow bones may require cutting off the bulging bone over the frontal sinus, reshaping it, and then putting it back into place with either resorbable sutures or very small plates and screws. For prominent or deficient lateral (tail) brow areas, the operation may be done by an incision in the upper eyelid in some cases. Forehead and brow reshaping procedures are often part of other facial structural surgeries such as rhinoplasty and jawline and chin enhancements.
Recovering from Brow and Forehead Contouring
A circumferential head dressing is used after surgery to control swelling of the forehead and help the overlying tissues stick down to the implanted material and bone. The forehead will have some swelling but rarely any bruising. More substantial swelling and bruising will occur around the eyes and on the eyelids. Surprisingly, forehead surgery is associated with minimal postoperative discomfort. Numbness of the forehead and the front part of the scalp is to be expected, and it will take months for the feeling to return to normal. Sutures in the scalp are dissolvable and do not need to be removed. Forehead and brow surgery is well tolerated and infection is very rare. All patients take antibiotics for one week after surgery and take pain medication as needed.