Your Questions
Your Questions
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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.
Dr. Barry Eppley
Indianapolis, Indiana
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)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a lot of orbital bossing of the skull which may be pinching the supraorbital nerves causing daily migraine pain. I guess this surgery would be called forehead reconturing/orbital bony contouring/brow bone reduction of that region. I was hoping to get a surgery that could take care of the functional as well as the aesthetic. I have a 3D Ct scan of that region and was wondering what a rough estimate might be for that surgery. Would insurance cover this procedure? I know that the same incision is made across the hairline for both the migraine surgery and the recontouring of the orbital bony area of the forehead. Listed below are descriptions of the surgery I have in mind. Thanks!
1. Forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled with small titanium wires or titanium microplates and screws.
2. Or the compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.
A: Certainly orbital rim recontouring by brow bone reduction and decompression of the supraorbital nerves can be done at the same time. Only brow bone reduction uses an open scalp incision. Isolated supraorbital nerve decompression for frontal migraines is usually done by an endoscopic limited incision technique. But the open approach does afford great access to the nerves for the best decompression possible.
Most brow bone reductions are best done by an osteoplastic flap technique where the outer table of the frontal sinus is removed, reshaped and then put back in its reshaped form by either resorbables sutures or very plates and screws.
Neither is aesthetic brow bone reshaping or supraorbital nerve decompression for migraines covered by insurance. Prominent brow bones are not a recognized craniofacial deformity by insurance companies. Nerve decompression for migraines is currently viewed as ‘experimental’ surgery without long-term clinical studies to be currently viewed as an approved medical procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, It has been determined that I suffer from brow ptosis by my general doctor, he had recommended orbital rim contouring and a browlift to alleviate the issue and prevent it from happening in the future. I have also checked with my insurance company and they have stated that both procedures would be covered if deemed medically needed by the surgeon of my choice. I would love to be able to submit pictures if needed to assist you in diagnosing brow tosis on your own and would love to hear feedback. I was hoping it would be possible to request that the brow bone can be shaven to a more feminine contour. Please let me know if you are interested in helping me pursue treatment and are able to accept insurance or if we need to make an exception!
A: While there is no question that brow contouring can be done to create a more feminine appearance with or without a browlift, the issue of potential insurance coverage for it is almost certainly not. It is important to understand that when a patient calls up their insurance company, the standard unqualified answer is always ‘if your doctor says there is a medical reason for it, it will be covered’. Unfortunately that person and the section of the insurance company that they work for has nothing to with the department that actually approves the surgery and issues payment for it. That is the Predetermination section and they are tasked with determining whether there is any medical reason for the surgery. The only medical reason for a browlift is upper visual field obstruction and this must be substantiated with a visual field test. This must accompany a predetermination letter on which they will pass judgment about medical coverage. If they deem it is medically necessary based on the evidence, a browlift may be approved as a medical procedure. Any orbital rim/brow bone reduction/shaving never has a medical reason for it being done and is always deemed a cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping and brow bone reduction surgery. I know you probably get these comments a lot, but I have always been very self conscious about my head shape and eyes. First my head is I guess a triangle oval shape but from a straight view it makes my head look very square and the top of my head is sort of flat. I absolutely hate it, it bothers me everyday. I wake up because even when I wear hats my head still looks square. I want the top of my head to look more smooth and oval shaped like a normal head but my head just looks fat. Also on top of that my eyes are really really puffy and close set which bothers me a lot also. I hate the boney parts at the end of my eyebrows. I feel they make the close set eyes look worse and how the bottom of my eyes are so pockety. This is destroying my self confidence day by day. I need to know if there is anything possible I can do so I will be happy in the end and not disappointing nor satisfied with a procedure. I have attached a couple pics for you to see my troubles. I love my hair but this head shape hurts my self-image. Also when I have short haircut it is embarrassing to me.
A: Based on your description of your concerns, it appears that a skull reshaping procedure with augmentation and lateral brow bone reduction is what is needed for improvement. Because you head is flat across the top, it can be built up between the two temporal lines to more of an oval shape by applying a bone cement material. There is a limit as to how thick it can be based on the scalp stretches but I would imagine that about 1 cm thickness in the very middle can be added. The tail of your brow bones (boney parts at the ends of the eyebrows) can also be reduced. All of this can be done through either a scalp incision or a smaller scalp incision combined wth upper eyelid incisions.
Dr. Barry Eppley
Indianapolis, Indiana
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
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
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
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 surgery is typically a 2 to 2.5-hour procedure. The surgery is performed through a scalp incision way back from the frontal edge of the hairline. The outer portion of the prominent brow bone is removed and reshaped to create a flatter appearance. The procedure is highly successful with no known medical conditions or problems associated with the surgery. The only potential issues are aesthetic in nature, with the risk of asymmetry of the bones and some persistent forehead numbness (though both are uncommon). The cost of a brow bone reduction procedure falls 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
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
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
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
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
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
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
Q: Dr. Eppley, I am a 35 year-old male born with a significant facial asymmetry. I have a prominent left sided zygomatic prominence, a left ptosis and a slightly recessed left sided forehead. I also have prominent inverted-U shaped supra-orbital bossing, which divides my forehead into two, and cast unaesthetic shadows especially when I stand under light. I do understand that there are limitations to what could be corrected but I will like to explore what can be corrected. My surgical objectives would be; 1) repair of left ptosis, 2) reduction/shaving of the zygomatic prominence, 3) zygoma fossa augmentation and 4)
forehead contouring with burring/infracture of supra-orbital bossing +/- forehead augmentation. I have attached images for your review. I have also used a plastic surgery simulator to put my desire in a picture form. I would appreciate your review and consult.
A: I have taken a careful look at your pictures, including the simulations, as well as your goals and can make the following comments.
- The width of the zygomatic body/arch can be narrowed by an anterior and posterior osteotomies. (infracture method)
- The prominent brow bones could be reduced by osteotomy/infracture method. (brow bone reduction)
- #1 and #2 could be done through a coronal incisional approach. Since #2 mandates that this be used, #1 would take advantage of that approach also.
- You are showing a high temporal augmentation in the superior temporal zone. I believe you are incorrectly calling this area the zygoma fossa which I think you mean temporal fossa. This area could be augmented through the same incisional approach as #1 and #2. This would require an onlay augmentation using PMMA given the quantity of material needed as well as the size of the surface area.
- To optimally smooth out the forehead above the brow bones, some augmentation would need to be done as well above the brow bone infractured area.
- Your left upper eyelid ptosis appears to be in the 1mm to 2mm range which could be treated by an internal Mueller’s muscle resection.
- I also noticed that you have performed rhinoplasty for narrowing of your nose and lower lip reduction as well.
As you can see in the above description, the key to most of your desired changes is the need for a scalp or coronal incision to do them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 years old male and am interested in the orbital reshaping/brow bone reduction process. I had a procedure done a year ago, it was a frontal sinus reduction. This procedure didn’t really accomplish much. I didn’t stress to the doctor the type of results I was after. I guess looking back, I have myself to blame. I have attached pictures which show most of what I’m unhappy with… the somewhat uneven/large orbital rim. I would like to smooth that down to create a simple and more attractive looking eye area.
A: Thank you for sending your pictures. Knowing that you went through a major frontal sinus reduction procedure, there must have been some miscommunication as to your outcomes. While I don’t know what you looked like before, my assumption is that what was achieved was some high frontal sinus/brow setback. But you were as much interested in the lower frontal and lateral setback as well. In your previous procedure, do you know how it was done? Was the bone taken off and put back with small plates and screws, wires etc?? That may have an impact on how well further reduction can be by hardware being in the way, scar tissue, etc. There is also the issue of how much bone along the orbital rim can be reduced without entering the frontal sinus. This is the value of the frontal sinus osteotomy technique which overcomes this limitation. Orbital rim reshaping/brow bone reduction is more of a burring technique although some features of an osteotomy technique can be incorporated into it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was interested in getting my hairline lowered as well as brow and frontal bone reduction. However I have a very thin hairline due to constant damage to my hair follicles. Any suggestions and how long after would I have to wait to get a separate surgery.
A: If I understand your question correctly, you would like hairline lowering/scalp advancement combined with frontal/brow bone reduction. The concern, which is both understandable and appropriate, is whether with a fine and thin hairline that you should have the procedure. The answer to that question would be based on what your frontal hairline looks like now (please send me a picture), how much scalp laxity you have and whether you were eventually planning on any hair transplantation along the hairline after the procedure. (as some people do for scar camouflage) The quality (hair density and pattern) of your frontal hairline determines how well the scar would do and its potential visibility. Your existing vertical forehead skin length and your natural scalp laxity determines how much scalp advancement/hairline lowering is possible and whether the result justifies the effort. Knowing that one may be considering the potential for hair transplantation later gives one more freedom to perform the procedure is someone with less than an ideal frontal hairline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I understand that recontouring of the frontal bone is a procedure that is not often done in male patients due to the scalp scar. The problem that I have is that the upper portion of my frontal bone protrudes over the supraorbital ridge. In addition to this, I have an evident asymmetry in the area of the superior temporal line on the left side of my skull. My question is would these two issues be capable of being addressing by burr and synthetic materials as appropriate, and as for the required incision, as an alternative to a coronal flap incision, would an incision on the back of the head be used so as to conceal the scar given the possibility of male pattern baldness?
A: In answer to your question about what type of incision may be possible in a male for brow bone and/or forehead surgery, the picture of a potential incision you have shown (the wrap-around occipital incision) is not one that can be used. While anything can be done on a drawing or on paper, it is impractical to use for brow bone or forehead surgery. To really reach this area and work on it adequately, the scalp and forehead tissues must be 'flipped' down to see the area. That incision is so far back that it would be difficult if not completely impossible to work under so much scalp tissue from so far away. This is more than just theory for me as I have tried such incisional approaches and can testify to the difficulties that they pose. The problem is not that you can not access as low as the brow bone area with am occipital coronal incision, it is that any bone modifications or material additions that one does becomes very hard to get them smooth or even at such a distance. And if you don't have some assurance that a good aesthetic improvement can be obtained then that defeats the purpose of doing the operation in the first place. That being said, if the back end of the incision is moved up by 5 to 6 cms in the high occipital area, then it can be used for brow bone or forehead modifications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a variety if procedures including brown bone reduction, rhinoplasty, chin augmentation and correction of my chest which I think is a pectus excavatum deformity. I have attached a variety of pictures so you can see all of the problems. I would like to know what you think.
A: I have taken a careful look at your pictures and can make the following comments.
1) Your chest deformity is very slight and not a true form of pectus excavatum. Regardless of what it may be called, I see no surgical procedure that would be worthwhile. Given the mild nature of the sternal groove/depression, the only option would be to build up the sternum with an injection technique to avoid any significant visible scarring. The problem is that it would be virtually impossible to get a smooth result. Without such a result, you would end up with an equally distracting aesthetic problem.
2) Forehead/brow bone reduction is not an option for you due to the mild nature of the bossing and the need to have a scalp scar to do it. That is always a challenging problem in a male. The trade-off of a scalp scar is not a worthy exchange.
3) Your chin shows both a significant horizontal and vertical deficiency. Its amount of deficiency makes your nose look bigger than it really is. It is the one feature on your face that would make the most dramatic change. Because of these three-dimensional chin deficiences, a chin implant is not a good option as it only brings it forward. Only a sliding genioplasty can bring the chin forward and down which are the changes that you ideally need.
4) The only beneficial changes that I see in your nose is the tip. It could be made thinner. But I would not change the height nor the smoothness of the dorsal line. I would also not change the tip position by making it any shorter or have anymore upward rotation. In essence, a tip rhinoplasty is all that you need.
I have attached some computer imaging based on the chin and nose changes.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I feel my brow is too prominent/large. I had one surgeon tell me only a full “sinus setback/type III” will be the only way to fix it. However, can the bones be modified/burred enough to make a difference? I want the side/profile to be more flat and less prominent. I feel my forehead profile is the only element that makes people look at me strangely sometimes and it makes me very uncomfortable. I read that the supraorbital rims can easily be reduced even with just brow remodeling. Is this true? I appreciate any feedback you can give me, even if it is that I am likely to only benefit from the aggressive sinus setback type of surgery. I just need to know if there is an adequate amount of change that can be achieved with some mild bone shaping and with soft tissue modification to effect a real improvement (not perfection, but more feminine appearance, in profile as well) or if I’ll have to do the full reconstruction. I know an x-ray is the only way to know for certain.
A: In looking at your photos, the brow bulge does appear to be from the frontal sinus. But whether that needs to be burred or setback by osteotomies will require a lateral skull film to best answer that question. In some cases in women, I have done a little burring of the brow bone prominence and building up of the forehead above it to create a smoother more convex forehead. That can be a very good alternative to setback osteotomies for mild amounts of brow bone bulging like yours.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you ever do a forehead burring/scalp advance/brow lifts without the sinus setback? I am a woman and my brow bones are not that big so I don’t think I need the frontal sinus setback.
A: Most forehead reductions in women are actually done by burring and not osteotomies/sinus setbacks. That is more of a male procedure in most cases. In women it is common to do a brow bone reduction by burring and/or forehead reshaping with a hairline advancement (scalp advancement) or a browlift. Seeing some photos of you would be helpful in determining which are the desired procedures.
Dr. Barry Eppley
Indianapolis, Indiana