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Posts Tagged ‘brow bone reduction’

Five Things You Did Not Know About Brow Bone Reduction

Friday, February 7th, 2014

 

Brow bone reduction is often aesthetically necessitated when the frontal sinus air cavities become too large. This is almost exclusively a male problem since the development of the frontal sinuses is highly related to levels of circulating testosterone and growth hormone during development. As a result, it is often associated with other strong facial bone features in men as well. Very strong brow bones due to frontal sinus pneumatization is almost never seen in women.

Brow Bone Reduction - Bone Flap Technique Dr Barry Eppley IndianapolisWhile brow bone reduction can occasionally be done by a burring technique, the thin cortex of the overlying brow bone does not allow for more than a few millimeters of reduction with that approach. More substantial brow bone reduction requires an osteoplastic flap technique whereby the bulging bone cover of the frontal sinus is removed, reshaped and then replaced. This can increase the amount of brow bone reduction by three or four times than of just burring the bone.

When it comes to brow bone reduction surgery, here are five things you may not have known about it.

Brow Bone Reduction and Browlift Surgery Are Related. The osteoplastic technique for making the brow bone less prominent requires an open incision and forehead flap turndown for exposure. Several types of browlifts also require an identical surgical approach through either a hairline or scalp incision. This also means that a browlift can be done with brow bone reduction if needed, which often is the case in Facial Feminization Surgery.

Brow Bone Reduction and Migraine Surgery Can Be Done At The Same Time. For those individuals that suffer from frontal migraines caused by supraorbital nerve compression, decompression of the nerve by stripping off the surrounding muscle and opening up the bony foramen can reduce symptom frequency and intensity. Working on the brow bones requires coincidental exposure of the supraorbital nerve, thus potentially solving an aesthetic and pain problem during the same operation.

Frontal Sinusitis Is Not Caused By Brow Bone Reduction. While the osteoplastic technique does expose the frontal sinus cavity, often not leaving the underlying mucosal lining completely intact. such exposure does not place one at increased for subsequent sinus infections. Almost every frontal sinus cavity that i have ever seen is completely healthy and no patient has ever reported a frontal sinusitis problem later.

Air Leaks Are Uncommon Sequelae from Brow Bone Reduction Surgery. By taking off the overlying bone and some mucosal lining with it, broad frontal sinus exposure does occur. But putting back the reshaped bone provides a near complete seal on most cases. When small openings around the replaced bone are seen, which is common, patching of them are done. This is accomplished by a variety of materials from temporalis fascia, bone cement or even bone wax. Despite these efforts, it is possible that extreme sinus air pressure (usually from blowing one’s nose) can open up a small hole (‘blow hole’) right after surgery. This is seen by the filling up of the forehead with air. Time and avoiding blowing one’s nose usually makes this a self resolving problem as the tissues eventually scar down.

Upper Forehead Augmentation May Be Needed When The Brow Bones Are Reduced. Some prominent brow bone patients have the opposite problem in the upper forehead. While the lower forehead may be too prominent, the upper forehead may be too recessed or sloped backwards. This can be simultaneously treated by building up the forehead above the brow bones with bone cement after the brows are reduced. The angulation of the forehead in profile should be assessed before surgery to avoid missing this aesthetic problem and the opportunity to simultaneously correct it. (the ying and yang of forehead reshaping)

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: One-Sided Brow Bone Reduction

Tuesday, November 12th, 2013

 

Background: Prominent brow bones are the direct result of the development of the underlying frontal sinus. While all of the frontal forehead bone above the brows is very solid and thick skull bone, the brows are made up of air with only thin bone in front and back of its thickness. The anterior or frontal part of the brow bone beneath the eyebrows is remarkably thin, often only being a few millimeters thick.

Brow bone reduction is done for two main reasons. Men who have large and very prominent brow bones often want them reduced to look less ‘Neanderthal-like’. Women  with larger brow bones or men to women transgender patients who want a softer and more feminine appearance may want their brows reduced and the tail of the brow bone reduced and flared upward. In some cases simple burring may be effective to achieve these goals but most of the time the outer table of the frontal sinus bone must be removed and reshaped to get a significant reduction. The thin outer bone of brow bone makes only a few millimeters reduction possible with burring.

When the frontal sinus is enlarged, it most always involves both sides of the brow bones. This is because the frontal sinus in most people is paired and exists under both eyebrows. But the frontal sinuses are rarely symmetrical and the septum that exists between them frequently deviates to one or other side, allowing for one frontal sinus to become larger than the other. This can account for the rare occurrence of asymmetrical brow bone hypertrophy.

Case Study: This 33 year-old male had one enlarged brow bone that had bothered him for years. He had no specific history of trauma to the area. It had just developed naturally that way. It created the appearance of a large knot or ball on his brow that also pushed down into the eye socket, giving it a swollen appearance. He had no pain or numbness over the brow area.

Under general anesthesia, a coronal scalp incision was made way behind his hairline. A full-thickness scalp flap was raised down to the underside of the brows exposing the enlarged brow bone. The supraorbital nerve was identified and preserved. A reciprocating saw was used to remove the brow bone prominence. Internal osteotomies were made to infracture the part of the brow bone that had expanded into the orbit. Burring was done around the osteotomy site to remove additional protruding areas. The removed brow bone was reduced, reshaped and placed back as a cover with resorbable sutures over the exposed frontal sinus. The scalp incision was then closed with a total operative time of less than two hours. He was discharged later in the day as an outpatient.

Immediately during surgery the change in the brow bone was apparent with improved symmetry between the two sides of the brow bones. He went on to heal uneventfully with a satisfied symmetrical brow bone result.

Case Highlights:

1) Brow bone hypertrophy most commonly occurs on both sides and rarely on just one side.

2) Brow bone reduction is done through an open coronal (scalp) approach by removal and reshaping of the bone overlying the enlarged frontal sinus.

3) Brow bone reduction has no adverse effect on the frontal sinus.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Testimonials: Brow Bone Reduction/Forehead Reshaping

Sunday, August 25th, 2013

Brow Bone Reduction and Forehead Reshaping

‘Had brow bone and forehead bone reshaping done recently by Dr. Eppley. The results are amazing. I had a really big protruding brow bone that made me look like a Neanderthal man. The whole process was very smooth and transparent. A large amount of bone was removed, some of it was reshaped and put back. This way not only sinus size was reduced, but also brow bone on the sides and along orbits was made smoother. Recovery was very quick, I was able to return to work two weeks after the procedure. 

If you have this kind of forehead problem I would recommend this surgery. I would get a 3D CT scan, as Dr. Eppley suggested to me, to make the consultation more productive and results more predictable.

Victor Z.

Durham, North Carolina

Commentary

For brow bones that are really prominent, particularly in men, the only really effective reduction method is going to be the osteoplastic bone flap technique. The anterior wall of the frontal sinus (visible brow bone ridge) is very thin, often less than 3 or 4mms, so to expect a significant change from burring is not going to happen. The entire brow bones must be removed, reshaped and then put back in place. By so doing up to 10mms of brow bone setback can be achieved. But no matter how brow bone reduction is done it requires a scalp incision to do it. Whether it is way back in the hairline or along the edge of the frontal hairline (women only) a turn down scalp flap is needed.

While all of this sounds quite ghastly the procedure actually is fairly easy to go though and has a quick recovery. Most patients have little pain after surgery and the biggest issue is some eyelid swelling and occasional bruising. By a week after surgery most people look good enough to walk around in public or even be at work without detectable signs of  having had surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization with Combined Brow Bone Reduction, Browlift and Hairline Lowering

Sunday, April 21st, 2013

 

There are numerous surgical procedures to feminize a masculine facial appearance. They include jawline reshaping (chin and mandibular angle reduction), rhinoplasty, cheek reduction, tracheal shave and forehead reduction/reshaping. While every transgender patient’s face is different and may need just a few or all of these facial feminization procedures, the forehead is one of the top considerations for most patients. The female forehead has a very distinct shape with a rounded contour from the brows up to the hairline with no obvious bone break.

Forehead reshaping incorporates reduction of the prominence of the central glabellar region as well as the projection of the brow bones. The brow bones must not only be deprojected but should also have the tail of them near the lateral orbit reshaped to have more of a sweeping effect up and towards the temples. Since this procedure requires an open scalp approach, this creates the oportunity to lower the frontal hairline as well. Together this type of foreheadplasty has a significant impact on the gender identification of the face.

The prominent glabella and brow bones are always due to the pneumatization of the front sinus. In cases of minor protrusion, the outer table of the frontal sinus can be simply burred down. Unfortunately this rarely can be successfully done due to the thin bone thickness overlying the frontal sinus. A few millimeters of change is rarely enough to make a noticeable external change. Most patients require the anterior wall of the bone to be removed, reshaped and repositioned back into place with resorbable sutures or metal microplates and screws. This method sets back the bulging bony prominence while preserving sinus function. The outer brow bone areas that lie outside of the sinuses can be reshaped as desired by burring.

When significant brow bone reduction is done (flattening of the bone), there is the potential for an excess of overlying skin. Loose skin on the brows can result in sagging or overlying brow ptosis. This can be easily addressed at the time of the brow bone reduction by a comcomitant browlift using the transcoronal or hairline incision made for access to the brow bones. An alternative approach is a direct browpexy from the galea below the eyebrows to underlying bone holes or the fixation plates (if used) above the reshaped brow bones.

A final component of the feminizing foreheadplasty procedure is the potential to simultaneously lower the frontal hairline. A long forehead (> than 6.5 to 7 cms between the brow and hairline) is unaesthetic for any gender but is particularly so in the male to female transgender patient. If a hairline approach (trichophytic) is used, a simultaneous scalp advancement can be done by securing the galea of the advanced scalp by sutures to bone holes in the outer table of the skull. By bringing the scalp forward, the lifted forehead skin will need to be trimmed creating a combined forehead skin reduction and browlift.

Ultimate feminization of the forehead can be done by simultaneous brow bone reduction, browlift and hairline lowering.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Brow Bone Reduction Surgery

Tuesday, April 9th, 2013

Most brow bone reductions need to be done through an open scalp incision. Unless the amount of brow bone reduction is very minimal (a few millimeters) the underlying frontal sinus must be factored into the operative technique. Brow bone reductioin can be done by burring, burring and infracture and removal of the brow bone with reshaping and replacement.

The following are the typical instructions for brow bone reduction:

1. Brow bone reduction is associated with a only a very moderate amount of pain in the first few days after surgery.  Narcotic pain medications are prescribed and use them if you need them. In a few days, you may switch to Tylenol or Ibuprofen or alternate between doses with the narcotic medication.

2.  There will be a circumferential head wrap placed right after surgery. This is in place to control extreme swelling and does not play a role in maintaining the new position/shape of the brow bones. You may take it on the next day after surgery. If it should get loose or come off during the night, just leave it off. It is not a critical part of brow bone reduction surgery.

3.  The sutures in the scalp incision are dissolveable and do not need to be removed. There is no need to apply antibiotic ointment to the incisions as all it will do is make your hair greasy and be hard to shampoo out.

4. Bruising and swelling will develop around the eyes after surgery which is perfectly normal. In some patients the eyes may almost swell shut by the second day after surgery.

5. You may shower and wash your hair 48 hours after surgery. There is no harm in getting your sutures wet with soap and water.

6. Your forehead will feel stiff and may not move normally for up to a month after surgery. It will also feel numb for even longer. This is all normal and as the feeling comes back in the forehead you will experience strange sensations such as shooting pains or itching as the nerves recover.

7. You may wear any type of hat around your forehead whenever you feel comfortable doing so.

8. There are no restrictions on normal daily activities after the surgery. You may do light exercise anytime afterwards that you feel comfortable. But no strenuous exercise that involves bending over for three weeks after surgery.

9.   You may drive within several days after the procedure, provided you are off pain medication and can react normally to driving conditions.

10.  If any redness, tenderness, or increased swelling develops on the forehead or around the eyes after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery – Brow Bone Reduction

Monday, April 8th, 2013

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the brow bone reduction procedure. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all, of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

There are no alternatives to surgical reduction of he prominent brow bones. One potential alternative is to build up the forehead above it to make the whole forehead smooth.

GOALS

The goal of brow bone reduction is to reduce the brow bulging and bring the brow bones back into a smooth contour with the forehead that lies above it, if possible.

LIMITATIONS

The limitations of brow bone reduction is the thickness of the overlying anterior table of the frontal sinus and the size of the frontal sinus that lies beneath the bone. (inner half of the brow) The outer half of the brow bone is limited is reduction only the thickness of the skull bone.

EXPECTED OUTCOME

Expected outcomes include the following: temporary swelling and bruising of the forehead and eyes, a temporary or permanent numbness of the forehead and scalp, temporary weakness of the forehead muscles, and permanent scalp scars. It may take four to six weeks before the final shape and appearance of the brow bones is seen.

RISKS

Complications may include bleeding, infection (wound or frontal sinusitis),  poor scalp scarring, bone fixation palpability,  undercorrection of the brow prominences and brow asymmetry.

ADDITIONAL SURGERY

How the foerhead heals and the occurrence of complications can influence the final shape and appearance of the brows. Should complications or the desire to enhance the result further by additional surgery be needed, this will generate additional costs.

Endosopic Reduction of Prominent Brow Bones

Wednesday, March 13th, 2013

 

A prominent supraorbital or brow bone is known as bossing. While some degree of bossing is acceptable in men, it rarely is so in women. The shape of the lower forehead in men can have a brow bone prominence as evidenced by a brow bone break into the mid-forehead area. In contrast, women desire a smooth transition from the brow area into the forehead which requires no bossing.

While the brow bone looks and feels like solid bone, it is not. The brow bone and its outer shape is determined by the size or aeration of the underlying frontal sinus cavity. This creates a comparatively thin layer of bone over an underlying air space. Reducing frontal bossing, therefore, requires a knowledge of the thickness of the outer bone comprising it to determine how much it can be reduced and what is the best technique to do it.

The most common method of brow bone reduction is an open approach using either a burring reduction, an infracture technique or osteotomies and reshaping. Simple burring can be effective if the outer table of the brow bone is thick enough. This then raises the question of whether a burring procedure can be done short of using an actual open scalp method.

In the March 2012 issue of the Plastic and Reconstructive Surgery journal, an article was published entitled ‘Endoscopic Correction of Frontal Bossing’. In this paper, the authors performed a retrospective review of 10 patients who had the endoscopic procedure done over a seven year period. The degree of frontal bossing correction was rated as moderate improvement. No violation of the frontal sinus occurred in any patient. The limiting factor in achieving better outcomes was the thickness of the outer table of the brow bone.

Endoscopic reduction of the prominent brow bone requires two things; proper endoscopic instrumentation and frontal bossing that has thick enough bone. Adequate bone thickness has to be at least 5mms in thickness as determined by a lateral skull x-ray. A 1 or 2mm reduction is not going to make a noticeable difference. But a 3 to 4mm reduction will make a discernible reduction in the amount of frontal bossing. This determination can be done beforehand by tracing out the frontal bossing outline and seeing how the soft tissue profile changes as the bone is thinned.

Endoscopic reduction of the prominent brow bone is a safe and effective procedure. Its use, however, is restricted to a very few patients whose brow bone thickness allows visible improvement with a burring technique.

Dr. Barry Eppley

Indianapolis, Indiana

The Psychological Aspects of Facial Structural Surgery

Wednesday, March 21st, 2012

There are many reasons that patients request surgical changes to their face. With over twenty different facial regions that can be altered, there are seemingly endless options and combinations. But when you break it down, there are two main reasons for making cosmetic changes to the face. I divide these into either facial anti-aging surgery and facial structural surgery. For the most part, this is the difference between soft vs hard tissue facial surgery.

Anti-aging facial surgery includes many of the most recognizeable procedures such as a facelift, blepharoplasty (eyelid tucks) and skin resurfacing. These are done to counteract the effects caused by time, age and sun exposure. Changes are made to the soft tissues of the face, largely the outer skin layer. Facial structural surgery goes much deeper and makes changes to the bone and cartilage. The most common structural procedure historically is rhinoplasty but today includes everything from forehead augmentation and brow reduction down the face to chin and jaw angle augmentation.

Besides the tissue levels which these two types of cosmetic facial surgeries affect, there are also very significant psychological differences between them. Anti-aging facial surgery is more psychologically comfortable for patients because the goal is to take them back to once how they looked, a place in which there is familiarity. The surgery and recovery may be scary but the end result is a look that the patient can recognize and has known in the past. In contrast, structural facial surgery is very different. The end result is one that is not familiar. It is a new look, an alteration of a face that one has known their whole life.

Having done many facial structural procedures in my practice from rhinoplasty to jawline enhancement, I have made several observations about these types of plastic surgery. Some of these are not new and have been known in plastic surgery for a long time. But new technologies and biomaterials have changed what is possible today and with that comes new psychological ramifications for patients.

Changing the structure of one’s face obviously requires an understanding as to what the patient’s goals are. Patients provide that information by descriptions of their concerns and often provide visual aids such as drawings, self-photographs and photographs of other people. These are all really helpful and collectively important. But one concerning issue is the overuse of model or celebrity facial photos. Seeing too many of these or having a patient show a whole notebook of other people’s or famous face may be a sign of unrealistic expectations after surgery. While everyone willingly acknowledges that they can not look like someone else, whether they believe that or not may be another story.

To aid presurgical discussions and goals, I consider computer imaging essential to any facial structural surgery. For the psychological reasons previously mentioned, I rarely do it for anti-aging facial surgery but consider it essential for structural changes. But computer imaging can be misinterpreted and often is. It is not a guarantee of results and such imaged results may never actually be achieved. It is a communication tool about surgical goals and what a patient wants changed and the degree of those changes. It is only as good as the person doing it and is really an integration of surgical experience and how well one knows computer imaging technology. This is why a plastic surgeon should be doing the imaging, for only they know what can really be achieved by different types of facial surgery. But even in the best of hands, a patient should not assume that is exactly the way they will look after surgery. It is an estimate or prediction but human tissues induce more variables than pixels on a computer screen.

When going through structural facial surgery, the recovery is going to be longer and more psychologically difficult that most patients envision. The swelling and bruising on the face can be quite shocking and no patient is ever really prepared for it. When the dressings, splints or sutures come out days or a week later, it is not a moment of celebration or expectation. It is just the first step in the recovery process. One is not looking at the final result and, depending upon the procedure(s) being done, full recovery is not just a few weeks away.

Facial areas will be puffy, swollen and distorted and usually far more than one anticipates. It may be significant or not all that bad, but this is not the time to judge the results. More importantly, and I have seen this many times, one should not assume that the changes are too big and need an immediate revisional surgery. What appears too big at two or three weeks after surgery may be just perfect at two or three months. My minimal time for judgment of facial structural surgery results is three months and I will not consider any revision before then unless they are compelling medical reasons. (e.g., infection) One should not attempt aesthetic revision on a moving target.

When three or more structural facial procedures are done at the same time, the appearance of the face the first few weeks after surgery can be very disturbing. Patients will often feel that they have made a mistake and even wish to return to how they looked before even though they obviously did not care for that appearance. Such after surgery appearances disrupt work and social interactions but are part of the process. If one thinks they will go back to work in two or three weeks after such surgery and will look perfectly normal…this is not realistic. Plan accordingly and I mean this from a psychological perspective. Living through the process of facial swelling resolution and tissue adapation around the bone or implant shape requires tolerance, explanations and even an openness about what has been done if necessary.

One of the most important considerations about structural facial surgery is an appreciation that the risk of needing revisional surgery is significant. At the least, it is much higher than that of a facelift or eyelid surgery. On the most simplistic level, let’s compare the risk of complications/revisional surgery of eyelid surgery (1 % to 2%) vs a chin implant (5% to 7%) in my experience. Both are fairly straightforward and relatively simple procedures. But the use of an implant introduces issues of infection, malposition and size and shape issues that do not exist as much in manipulating one’s natural skin. Now multiple that times the number of facial structure procedures being done, each with their own percent of risk, and it is easy to see why the risk of revisional surgery in facial structural surgery is significant.

For example, take a patient who is having rhinoplasty (5% revision risk), a chin implant (5% revision risk) and jaw angle implants (10% revision risk) done as a single procedure. On an additive risk basis, the real risk of revisional surgery in this case is 20% or higher, If you take more extreme cases of five or more facial structural procedures being done at the same time (a not uncommon collection of procedures in my practice), the potential risk of revisional surgery could be as high as 50%. This doesn’t mean that the complications are devastating or severe but are almost always about symmetry and the size of the changes done in the various areas. It is hard aesthetically to make so many facial changes and have them all look perfect afterwards…particularly when one is not precisely sure how they will interpret the changes.

Facial structural surgery can make significant aesthetic changes to either give the face a better shape, more definition and improved balance or to improve asymmetries between the two sides. But it is harder surgery to undergo both in planning and during recovery and has a higher risk of the need for revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions on Forehead Reshaping and Contouring

Monday, February 8th, 2010
  1. What influence does the forehead have on one’s appearance?

The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.

The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.

A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women. 

2. How is forehead reshaping done?

Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.

They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.

3. How is brow bone reduction done?

In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only has  thin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.

In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.

A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone. 

4. How is brow bone augmentation done?

Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.

PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.

Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.

5. Can other areas of the forehead be reshaped besides the brow bone?

The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.

6. What is the recovery after forehead reshaping? What complications can occur?

Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.

Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?

7. What can I do if my forehead is too long?

Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.

The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference. 

Dr. Barry Eppley

Indianapolis, Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)

Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone.  There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.

Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.

Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.

Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.

Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.

Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.

Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.     

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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