Your Questions
Your Questions
Q: Dr. Eppley, I am a 21 year old girl, but I have a masculine forehead. I am interested in forehead augmentation and brow bone augmentation with bone cement. Could you tellI am a little girl, 5 feet tall, and I have a pretty small forehead. Also I was wondering, after the procedure will there be permanent metal or titanium in my forehead? Lastly, what is the general recovery time like? Thank you for your time!
A: Such forehead augmentation can be done using bone cement materials which are like putty and are shaped and allowed to harden during surgery. There are no metal materials that are used. The recovery from this type of surgery is largely just about the swelling that temporarily occurs around the eyes and forehead area. (the eyes do not swell shut) Most patients come in the day before the surgery, have surgery the next day and stay over night in a hotel the night and first day after. One can go home fairly quickly in a day our two after the surgery. It is not a procedure that is usually associated with much discomfort. In fact the forehead will be numb for awhile rather than painful.
Dr. Barry Eppley
Indianapolis, Indiana
Q:Dr. Eppley, I believe that many of the surgeries you perform are far more effective and life changing than traditional plastic surgery procedures.
I’m looking into having forehead, temporal/skull, and chin augmentation, and have found there are very few plastic surgeons are experienced in craniofacial surgery for cosmetic purposes.
I know that plastic surgery in Korea focuses very much on altering the bony structures of the face to achieve a prettier and more youthful appearance and for this reason I have been enquiring with some plastic surgeons in South Korea. Ideally I would prefer to travel to the US and have the above procedures performed by you.
I am interested in having forehead augmentation- preferably using bone cement as I understand that implant placement can be difficult, particularly when placed lower on the skull; I feel that my brows/superior orbital rim are quite flat and contribute to some minor eyelid sagging so would like the forehead augmentation to extend to this area, as well as smoothing out the temporal bone area, and reducing the backward slope towards my hairline.
I’d like head widening implants possibly extending to the temporal region to balance my lower face.
Lastly I’d like to get an “anatomical” or “extended” type chin implant which extends into the pre-jowl area which is quite hollow and shadow-y, and makes my lower cheeks look a little droopy.
A: My understanding of your email is that you seek the following procedures which are primarily Forehead Augmentation and Chin Augmentation. Let me provide some initial clarification on forehead augmentation because your assertion that implants are harder to get lower on the brow bone than bone cement is not accurate. Actually it is the exact opposite. Because foreheads/brow bone implants have a preformed shape they can more effectively positioned on the brow bone area through a smaller incision. Bone cements can achieve the same result but they take a full coronal scalp incision to really place as low as possible.
The biggest dilemma in forehead augmentation is management, if need be, of adding the temporal area in the overall augmentation. Bone cements can not be placed past the anterior temporal line onto the adding temporalis fascia as that often creates the potential for edge visibility and/or pain. Some slight blending of the upper temporal region can be done but it can not extend down too far.
The only really effective method for anterior temporal and posterior temporal head widening is with the use of subfascial implant placements which have to be semi-custom made and are designs of which I only have.
A chin implant that extends back more posteriorly would be the anatomical design which has long tapering wings back to the pre jowl area. That is a fairly standard facial implant request.
In conclusion, the most economic approach would be PMMA bone cement forehead and chin implant augmentation. The cost of the temporal implants would, by your own description, be prohibitive.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I am a male and I would like to know whether it is possible to increase the slope of the forehead given that the thickness of the frontal bone allows for it. I have high temples, so the roundness of my forehead is displeasing to me. While my forehead does slope backwards slightly it is quite round, whereas I would like a ‘sharper’ look. Thank you for your time.
A: Your forehead augmentation desire is possible and would be best done by a custom forehead implant made from a 3D CT scan of you. This is the best way to get the angularity and sharpness in the implant that would be needed to create the outward forehead effect. The limiting factor in any forehead augmentation procedure is not the thickness of the frontal bone but the stretch allowed by the overlying forehead skin and soft tissues. I have yet to see this potential soft tissue limitation, however, be an issue in any forehead augmentation procedure that I have ever done. Most forehead augmentation needs rarely exceed 10mms in thickness and are often less than that amount.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of forehead augmentation. I have a slight depression in the middle of my forehead which in certain lighting becomes obvious. I know it is not big but it still bothers me. I have attached a video of it so you can see what I mean. What is the best method of forehead augmentation for it?
A:Thank you for sending the video which shows a circular dip/depression in the middle forehead. I have seen this before and it does represent a bit of forehead bone depression. While there are a variety of ways to do forehead augmentation, the most important consideration is to avoid any scar in doing so. This leaves us with an injection method of fat which is scarless, simple and can be reasonable effective if not overdone. The most important issue in your case is to make sure the downside of any procedure never makes the problem worse or trades off one aesthetic problem for another. The biggest downside of fat injections is the unpredictability of how well they will survive (although they usually do well in the forehead actually) and this a very ‘safe’ risk since it does not worsen the problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I spoke to you this last summer on Skype regarding forehead augmentation. I favor using bone cement as opposed to a silicone implant. Do you think burring of my supraorbital ridge will be necessary? If so, would the charge me extra? and is there a risk of damage to my sinus cavity?
A: When you have the severely sloped forehead that you have, it would be good to to do some modest burring of the supraorbital ridge. It would be complementary to the forehead augmentation in creating a better overall result. With burring the key is to stay out of the frontal sinus which requires experience in doing so. How much reduction can be obtained is a function of the thickness of your frontal sinus wall. If you need a frontal sinus setback that would be important to know up front because it will take some more surgical time to do and there will be some extra costs in doing so.
The choice of forehead augmentation material is a personal one. I have used both bone cements and custom implants successfully and each has their own advantages and disadvantages. I do not necessarily favor one over the other, I just try and educate the patient on the merits of each material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the sagittal region as a younger boy and I have always believed that I suffer from premature suture closure. The sagittal skull region is pointed and my skull height is reduced. I read your procedure articles about plastic implants in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar implants to widen and heighten the overall head shape. I am 69 years old and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: One is really never too old to address a physical problem that has bothered them all of their lifetime. From your pictures you have a very backward sloped forehead. This make your brow bones look bigger than they really are and also create the illusion that your forehead is too high. Forehead augmentation, using either a custom made implant or using bone cement, can provide a very effective solution to changing the slope of the forehead. In forehead augmentation the goal is to make the forehead inclination closer to 75 to 85 degrees if possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the saggital region as a younger boy, and I have always believed that I suffer from premature suture closure. The saggital region is pointed, and my skull height is reduced. I read your procedure articles about plastic inserts in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar inserts to widen and heighten the overall head shape. I am 68 years old, and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: Thank you for sending your pictures. I can clearly see your forehead concerns with a large flat area above your brow bones which slopes backward up into the skull. There is a relatively straightforward solution to our forehead deformity by building up the bone over the area of the depressed forehead region which is fairly well delineated. (forehead augmentation) This could be done using either a custom made silicone forehead implant from a 3D CT scan or using bone cement (PMMA) to do the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead and brow bone implants augmentation. I’m an Asian male, living in Korea, whose appearance is just like any other Asian’s. My eyes are very big for an Asian’s, but they are pretty much bulging. Besides, the prominence of my forehead and brow bone (I have heard that it’s called ‘supraorbital ridge’ or ‘supraorbital torus’) is very slight. It makes my eyes looked more bulging. And it also makes the distance between my eye and eyebrow look too far. All these all things make me look feminine. It’s really awful. Many people tell me that my eyes looked ‘faggy’.
So I’m considering the forehead and brow bone augmentation with intraoperatively applied bone cement. As you know, preformed custom implants easily makes
empty space between itself and forehead bone, and it can cause fatal side effects like dropsy. So I think bone cement will be better, but I want to know what
you think. I have wondered about this. For years, I have searched for a hospital who does forehead “including brow bone” augmentation surgery, but all hospitals in Korea told me it’s dangerous to use any implants on the brow bone, because there are much important nerve on brow bone region. So I had almost given up, and just at that time, I found your
website in google. So I wonder whether this surgery is really dangerous or not.
Finally, I wonder how much my forehead can be protrude by surgery. You know I am Asian, and I want to make my forehead and brow bone protrude as much as a Caucasian, if it’s possible. I really want to know whether it’s possible or not.
A: I have done forehead and brow bone augmentation over my career by every conceivable method including PMMA and hydroxyapatite bone cements, prefrormed Medpor implants and, more recently, custom forehead and brow bone implants.
Each of these methods have their own distinct advantages and disadvantages…neither one is perfect. Bone cements are very good to use but they require a lot of intraoperative shaping, can be very expensive (HA cements) and can lead to frontal bossing/protrusions if the forehead and brow bones is brought too far forward. (as bone cements should not extend beyond the anterior temporal lines onto the tenporalis muscle fascia where they will not adhere and can lead to visible edging). To place them well, they require a long coronal incision to get adequate exposure way down to the suprarbital ridge. They are also associated with modestly high revision rates particularly when the amount of augmentation needed/desired is significant.
Custom forehead and brow bone implants have numerous advantages over bone cements. Computer designing the implants allows much greater precision and control over the amount and symmetry of augmentation. They can be designed with forehead widening in mind in large augmentations as the material can sit without complications on top of the temporalis fascia beyond the anterior temporal lines. The potential open space under the implant (which I have never seen to be a true problem) can be circumvenyed by screw fixation and the placement of numerous perforation holes in the implant to allows for tissue ingrowth through the implant and down to the bone. A custom implant also allows for a smaller scalp incision to be used to place it since it already has the desired size and shape through preoperative designing.
There is no truth at all that forehead and brow implants are dangerous. They are no more ‘dangerous’ than bone cements. They do not cause ‘dropsy’. They do not have a greater incident or risk to the supraorbital nerves than bone cments.They require the same amount of tissue dissection down onto the brow bones that bone cements do. Forehead and brow bone implants are just as safe as bone cements, they just are another implant option to consider for aesthetic augmentation in this area that has its own unique advantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am an otherwise very thin healthy 42 year old female searching for a forehead augmentation solution to my upper forehead contour defect. I had what would be considered minor trauma in 2010 (struck forehead on breakfast bar) with a resultant depressed skull fracture. To fix the resultant indentation I have had 2 fat grafts and several Radiesse injections with no resolution. Is there any hope of a repair with a closed procedure; something akin to Artefill w/o Bovine Collagen (allergic)? Bone graft? Stem cells? Can frontal bone be shaved down to create a smoother contour endoscopically?
A: I am not surprised that your frontal defect in the upper forehead could not be adequately contoured/restored with any of the injectable methods that you have had. They simply will not work for a bone contour defect nor is there are injectable material like fat or any other synthetic filler that will work.
There are a variety of minimally invasive procedures, however, that will work for your type of forehead augmentation. Through a small incision in the scalp (3 to 4 cms) done endoscopically, a variety of implant materials can be introduced to smooth out the upper frontal bone depression. These can include PMMS or HA bone cement or even a small semi-custom or custom implant. These are all procedures that can be done under local anesthesia/IV sedation. The most economical approach would be PMMA bone cement. I will have my assistant Camille pass along the cost of the procedure to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am two months out from my forehead augmentation procedure using hydroxyapatite cement. I believe I am happy with the outcome although I enjoyed it more when it was swollen but it is still big enough at present. I just wanted to know have your patients experienced longevity with the cement? Does it have the staying power of a implant or do cases like these need to be redone because of absorption.
A: Like all forms of bone cement, hydroxyapatite cement is non-resorbable. It will never resorb or change shape over your lifetime. It is just as stable and enduring as a forehead implant. It is very normal to maximally like the result when it is swollen in the first few weeks. But the vast majority of forehead augmentation patients are happy with their final size result even if they wish it were just a touch bigger. The biggest fear in forehead augmentation (at least my biggesty fear) is to make it too big as that will result in a revisional surgery 100% of the time. A forehead augmentation that is a bit too small, as long as it is not way too small, is very well tolerated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation but I am unsure what the ideal is so I want to ask you the expert. What in your opinion is the ideal forehead shape? I have two thoughts:
1) A strong straight vertical type forehead with no brow ridge, just straight up and down and no sloping,
Or
2) a straight forehead but with a visible supraorbital ridge which extends from side to side in a slight curve (long sunset stretched half oval shape) but still straight forehead?
What in your view is the best forehead shape for a man? Because I want to come get implant with you soon.
A: When it comes to the ideal male forehead shape it is largely a personal preference. In my extensive experience performing male forehead augmentation the most common desire is to have a slight slope to the forehead (almost straight) and a visible brow bone break. I would view the straight vertical nature of the male forehead as more important than the brow bone break. But either type of forehead shape can be designed into a custom implant if one chooses that type of forehead augmentation or applied with that shape if bone cements are intraoperatively applied.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making my forehead wider and more squarer to balance out the width of my new custom jaw implants that will be placed in about a months time. I have booked in for temporal implants at this stage but not forehead as I don’t think my doctor or any doctors here are quite familiar with the procedure. I wanted to know if it is ok to request to my doctor to use Medpor temporal implants? This is because I had a look at the Medpor catalogue and have found that the Medpor brand offered a significantly BIGGER size compared to the silicone ones offered my Implantech (which my doctor will use). Medpor ones go up to 20mm in augmentation. I’ve read your resource millions of times (very helpful) and want to know do temple implants sit only on top of the soft tissue or can the implant itself be placed higher if the implant overlaps onto the bone? Or is that something a custom made forehead implant would fix? If so are there any off the shelf forehead implants available on the market to widen the forehead?
I also wanted to know if I was certain that I need a forehead augmentation in future are temporal implants necessary? Or are they needed along WITH forehead augmentation. I just don’t want to waste my money on temple implants if a custom made forehead implant will fix both areas.
A: I would never use Medpor temporal implants myself. They are too big, are very difficult to modify and are very difficult to remove should that ever be desired. (and there should be a high probability that they would) No one ever needs a temporal augmentation that requires a 20mm thick implant. They are simply too big for most cases and were initially designed for patients that suffered significant temporal muscle atrophy from neurosurgical procedures not for patients that want a pure aesthetic augmentation with a normal tenporalis muscle.
If you are seeking a temporal augmentation that reaches the high temporal region to make the forehead wider as well, only a custom designed temporal-forehead implant can achieve that aesthetic change. No current implant style, Medpor or silicone, are made to create that look as a ‘catalog’ item.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 20 year old male and am interested in forehead augmentation. I have a protruding occipital bone and a slightly sloped forehead. I would like to get my occipital bone reduced, and then have the bone transferred to my forehead to make it more vertical. I reckon my own bone would be a better and safer material for forehead augmentation than a foreign substance like methylmethacrylate. Is this possible? I have heard wonderful things about your expertise, and I am willing to fly all the way to the United States from Australia to get the procedure done.
A: In regards to forehead augmentation, your concept of transferring bone from the back of your head to the forehead seems logical but unfortunately will not work for many different reasons. There would not be enough bone, it would have the wrong shape and part or all of it would be resorted. The safer, easier and highly predictable option are a variety of synthetic materials that maintain their shape, can be precisely shaped, and will not ever change shape after surgery. Options include PMMA, HA or a custom silicone implant, each either own unique advantages and disadvantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been perusing through your blog and I’m curious about forehead augmentation. I would like a more masculine brow bone and forehead. I feel like mine is flat. I’ve attached a profile view. Do you think it would be beneficial to my appearance. What I don’t like is my forehead starts to slope back starting from the brows. I would like it to be more square as if a stick was held against the forehead, more of the forehead would touch the stick instead of only the brow bone. From what I gather, the most economical option is using PMMA bone cement, correct?
A: Forehead augmentation can be done by using either intraoperatively applied PMMA bone cement or a custom forehead implant. The cost differences between PMMA and a custom implant are not really that different. While PMMA bone cement cost less (the material) than a custom implant, most of that material cost savings is offset by the increased time too place and shape the material. A custom implant costs more than the PMMA material to fabricate but is done in half the operative time, with smaller incision and a lower risk of potential revision due to shape. In the end, both forehead augmentation techniques cost about the same.
In the past, PMMA bone cement was the only forehead augmentation option available. But computer design technology is now making custom implant designs not only possible but affordable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am considering having a cranioplasty and/or temporal shell implant. I recently had a cranial CT done, and was wondering if you would be able to recreate that into a 3D CT scan in order to make the temporal shell implant, or at least to get a better idea of which areas are deficient in the cranium in order to better place the PMMA cement. Could you please let me know the costs associated with translating the CT scan into a 3D format, and if this would help you even with a PMMA cranioplasty without temporal shell implant?
A: Unless the original CT was taken in high resolution cuts (1mm or less), you can not get it converted into 3D CT images.
When it comes to what you are calling a temporal shell implant, I need to know exactly the temporal area to which you refer in terms of augmenting. There is skin only area between the temporal hairline and the eye which is where preformed temporal shell implants are used to augment. I am going to assume this is the temporal area to which you refer. A regular or 3D CT scan is not helpful in addressing the volume needs of this area since this is a muscular augmentation area and not bone. A CT scan, particularly a 3D one, only shows bone.
The only reason to get a 3D CT scan for the forehead is if one is getting a custom temporal implant made. If one is using PMMA bone cement, the scan is not really helpful as this is artistically applied and shaped during surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Just about ten days ago I had forehead augmentation through a hairline incision. Everything appears to have gone well and I have suffered no complications of which I am aware. The swelling has gone down considerably but I doubt if it is all gone. The scar across the hairline is still pretty noticeable. How long does it take for the swelling to go away and when will the scar become less noticeable.
A: I am glad hear that everything so far has gone well after your forehead augmentation and it looks very acceptable at this early point after surgery. At three weeks after surgery, I would say about 85% to 90% of the swelling will be gone. Over the next two months the very final remnants of swelling will subside and the absolute final shape will be seen. In my experience it takes a full three months before one should judge the final result of any craniofacial reshaping procedure. As for the hairline scalp incision, It usually takes several months, and sometimes up to six months, to judge the final outcome of the frontal hairline scar. Usually the frontal hairline scar does really well even in patients of significant pigment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few question regarding forehead augmentation and back of the head augmentation. I would appreciate your kind answers to each of them one by one.
1. Which procedure is more durable, bone cement or implant?
2. Can you please tell the advantages and disadvantages of each?
3. Is it possible that bone cement is filled without cutting the scalp, so we fill the scalp by injection three to four time(interval of ten days) and it may increase the whole head size?Because i fear of cutting scalp and tissue expander.
4. Is bone cement strong enough like skull bone?
5. Which procedure do you recommend?
A: For forehead and occipital (back of the head) augmentation, there are two basic materials that be used…bone cement and preformed implants. In answer to your questions:
- Both material are equally durable. Neither can degrade, be broken down or will ever need to be replaced because they ‘wear out’.
- Each material type has its own unique advantages and disadvantages. Bone cements must be mixed, applied and shaped during surgery thus taking more operative time to do. Preformed implants are made before surgery off of a 3-D CT scan of the patient’s skull. By computer design they provide the best and most symmetrical augmentation with the least risk of any irregularities at the implant-bone transition areas. They can also be done with less operative time. From a cost standpoint, they are roughly equal.
- With either approach, a scalp incision is needed. There is not injectable cranioplasty technique for this size of skull augmentation areas. There is no need for a tissue expander with your dual augmentation.
- The resistance to fracture is roughly equal between PMMA bone cements and skull bone.
- I find both procedures can make for successful skull augmentations. The choice between the two is a matter of personal preference and which one sounds better for each patient. Both type of forehead and skull implants can be done very successfully.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping surgery. My head shape is not normal. It is flat from the back side and inclined backward at the forehead making it smaller on the top as a whole. My face is not much wider as well resulting in a small head. I want to increase head size especially from my back side and forehead areas. Please tell me which procedure I need whether it is an implant or bone cement filling.
A: When it comes to skull reshaping and the aesthetics of your skull, you are talking about a sagittal (front to back) deficiency. Your forehead is slanted backward (retroclined) and the back of the head is flat. (or has a reverse retroclination compared to the front. This is treated by two different methods of dual forehead and occipital augmentation. It can be done with either a bone cement filling material (usually takes 150 grams) or custom forehead and occipital implants made from 3D CT scan. There are advantages and disadvantages of either approach but the end results of either one are the same with a potentially dramatic difference in the volume of your skull from front to back.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to have a forehead augmentation. I am a female and have a small feminine-type forehead and would like a bigger more masculine forehead, one that is much more convex in shape. It is very clear to me now that the women I find the most beautiful almost all have a large forehead. Prior to the operation I will get permanent hair removal on the hairline. I think this hairline makes me look like an angry man from the sides. Thank you very much.
A: Forehead augmentation can be done to create a variety of aesthetic forehead changes. For many women that seek forehead augmentation, they are interested in a rounder or more convex forehead shape. This is one where there is no distinct brow break and a forehead shape that extends upward from the brow area in varying amounts of projection before heading back into the hairline. The degree of convexity, so to speak, is a matter of patient preference. The only issue in larger amounts of forehead augmentation is to make sure that it tapers gradually into the temporal line area on each side. Lack of a more gradual side transition can create a boxy forehead shape when the central augmentation amounts start to exceed more than 10 to 15mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a cranioplasty. I have a depression in my forehead for the past twelve years. I am twenty-two years of age and this depression started showing around age ten and has just been there ever since. It makes me feel alien, I don’t like taking pictures, I only comb my hair in one style to cover it kind of and I really think that I would be a more confident person had I have a normal forehead. I desire a “normal” forehead, without a sink in it :(. I have attached pictures of what it looks like.
A: In looking at your pictures, what you have is a classic case of what is known as linear scleroderma which creates a deformity known as the ‘coup de saber’ (cut of the saber) effect when it appears on the forehead. It is a condition that usually develops as a child and causes a loss of fat and an indentation in the bone. It is progressive and the tissue atrophy effect eventually burns itself out by the time one is a young adult in most cases. Its causes is not really understood and is currently felt to be related somehow to the nerves. When it appears on the forehead, it usually follows along the line of the first division of the trigeminal nerve. (supraorbital nerve which comes out of the brow bone and extends vertically upward into the forehead) This is why you have a very groove going upward from your brow bone, hence the description ‘cut of the saber’.
I can not tell completely from the pictures about the quality of the overlying skin, which usually is thinned and mottled in color although your skin along the groove does not appear so. (but the pictures are fuzzy) Treatment could consist of fat injections, a minimal incision endoscopic cranioplasty for bone augmentation or a combination of both. I would know exactly what to do by feeling it but I suspect it ail requires a combined fat and bone augmentation technique for optimal forehead augmentation contour improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation as well as temporal and back of the head augmentation. I like the way I look when I have hair, but sadly my hairline has began to recede. My forehead slopes back and I feel my head lacks the mass to balance my face (forehead and all) out. I’m interested both widening my temporal region (starting at about the ear back) with custom formed implants AND correcting relatively flat back. Can one incision be used for all three adjustments (left and right temporal and the back of the head)? And if so how large of incision would be needed and where would it be located?
A: I commonly have performed combined forehead augmentation and occipital augmentation. Dual access to both the back of the head, temporal and forehead regions can be done through a single scalp incision. It is known as a coronal scalp incision and runs across the top of the head from ear to ear. It effectively allows a ‘clamshell’ approach to be taken to skull rehabbing surgery and provides a 360 degree access and view of the entire head above the eye and ears. While it sounds and looks dramatic, it heals very well and quickly When looking at the patient the very next day when the dressing comes off, it is hard to image that type of surgical exposure that was done just the day previously. Patients also have a surprisingly minimal amount of discomfort afterward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I am wondering what all can be done to make my forehead go more up and down rather than how it slants severely back starting immediately above my eyes. After looking up pictures and seeing people with different types of foreheads I think I have found the answer to my problem, or rather, what I would desire to have for myself. I just don’t know how much can actually be done in the present time and how realistic my ideal results are. I would like to add quite a bit to my forehead to make it more vertical instead of so severely slanted and I was wondering if I am desiring something beyond the limits that are currently set? I gave a picture of myself from the side with wet hair to give an accurate shape of my skull as a whole, especially the slanting forehead/top of head, and then another picture of what I am thinking I would like my forehead to look like. I look at pictures of myself (such as this one) and worry if it is only a small amount that can actually be added onto one’s skull, and if I am drastically unrealistic in my hopes, what are the limiting factors? Some of the ones I read about (like the amount the skin will stretch on one’s head) seem like the major one.
A: What you are seeking is a commonly performed aesthetic craniofacial procedure, forehead augmentation. This is done for a variety of forehead shape concerns, one of which is to change a sloping backward slanting forehead to a more vertical one. While the limiting factor is how much the scalp and forehead skin can stretch, the result you are desiring to achieve is largely very realistic and within the ability of the scalp to accommodate a greater volume and convexity underneath it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty but think I may need more. I’m trying to find a way to make my side profile look nice and pretty. I hate my nose as its quite large and has a small bump on it therefore I really want rhinoplasty. I also have a small slanted forehead and small chin so it looks like my face goes into a point at my nose. What would be best to change this? Please help, many thanks.
A: By your description, your three main side profile features have an imbalance. Your nose is too big and the forehead and chin is too small, creating the profile that you dislike. In trying to figure out what procedures you may need that creates the best change, it would be important to do some computer imaging. The procedures of rhinoplasty and chin and forehead augmentation must be looked at individually as well as in comboantion to see which creates the best change. It probably goes without saying that all three create the greatest profile improvement but do you really need them all. I suspect that the rhinoplasty and chin augmentation alone may be sufficient and produce the best return on the effort but that remains to be proven by the imaging predictions. Please send me a side profile picture at your convenience to help you make that determination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation/reconstruction for a congenital skull deformity. In terms of using cement on my forehead, by how much can we get an additional thickness there, i.e. what distance can we add to the flatness/deficiency? Why is it cement (on the forehead) instead of a prefabricated implant? I have a very rough terrain of the forehead. In our opinion the implant’s inner side would hide all the problems beneath, but the cement treatment might be not creating a proper elliptical smoothness unlike an implant should do. Correct us please if we are wrong, it is just to dispel our concerns.
A: The amount of expansion of any skull bone surface is based exclusively on how much the overlying scalp will stretch. How much the scalp can stretch is a function of many factors, including scar from prior surgery and an innate ‘looseness’ factor. As a general statement, skull expansion can achieve up to 25mm in thickness if a full coronal incision is used for access.
Forehead augmentation/reconstruction can be done very successfully, using either intraoperatively applied bone cements or prefabricated implants. One is not necessarily better than the other. A bone cement is an intraoperatively made putty froml iquid and powder components. It is applied as a putty to the bone surface and then shaped by hand to whatever external shape is needed. It has an intimate connection to every nook and cranny of the irregular bone surface as its outer surface is shaped into a smooth round/elliptical shape. Bone cements can be either of PMMA (acrylic) or hydroxyapatite (HA) compositions. Most large volume bone cement cranioplasties use PMMA due to its lower cost. A prefabricated skull/forehead implant is made from the patient’s 3D CT scan using computer designing software for its creation. It is then fabricated in a silicone material for implantation. It too will have a good fit to the underlying bone surface and an external shape of whatever is so designed. It is the costliest of all the alternatives due to the design process.
In short, your perception of the differences between a bone cement and prefabricated implant is not accurate. They are just different ways to get to the same place. They differ primarily, however, in the cost to do them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know the differences in the frontal view after orbital decompression and brow bone augmentation? I would like to get deeper set eyes but I know decompressions has a lot of side effects. Do you have photos of before after to show for brow bone augmentation? Thank you
A: Orbital decompression will not produce deep set eyes in a normal patient. While orbital decompression is effective for the patient with protruding eyes (exophthalmos), this is because it is an abnormal protrusion and dropping out the orbital floor bone will give the enlarged eye a space to fall back into. In the normal non-enlarged eye, dropping the orbital floor will only make the eyeball fall lower and not back. Thus in the frontal view, the eyeball may look lower and the pupil drops down closer to the lower eyelid margin. Conversely, brow bone augmentation combined with lateral orbital rim augmentation will make the eye look deep because it moves the bony rims around it further forward. This can be shown by looking at before and after pictures of brow bone/forehead augmentation which can be seen on my website in the Facial Reshaping section under those specific procedures.
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, there is something wrong with my face but I can’t figure it out. I used to think it was all because of my nose which is big but I think it is more than that. There is some other part of my face that just isn’t right that makes me look unbalanced or disproportionate. I have attached some pictures for your insights and recommendations.
A: Thank you for sending your pictures. What I see about your facial proportions are two things:
1) A nose that is very broad at the tip and middle 1/3 and a bridge/dorsal line that is low.
2) A forehead that is narrow and very flat.
Ideally a rhinoplasty with tip narrowing and dorsal line augmentation would make the nose more proportionate. Also a forehead augmentation to give it greater convexity from the brows up to the hairline would also be an aesthetic addition.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in a forehead cranioplasty but I have an unusual request for it. I also want to add width to the sides to make my forehead wider. What would be the safest method and how would you do the augmentation (implants or cement)?
A: Your question is a very good one. Normally I would use an acrylic or hydroxyapatite bone cement for a frontal cranioplasty but yours is not the standard frontal cranioplasty. Adding width to a forehead requires going past the anterior temporal line of the forehead into the temporal muscle area. Thus one has to decide whether the augmentation should be done on top of or under the temporalis muscles to add the width. There are arguments to be made for either approach. If the material is placed on top of the muscle, it has to have a very feathered edge and edge demarcation or visibility of the implant-muscle transition will occur. This would be much more possible with a preformed silicone implant than an intraoperatively formed bone cement augmentation. Conversely, raising the temporalis mucle and putting the width augmentation under it requires reattachment of the muscle over it and that is frequently associated with some muscle atrophy and resultant overlying indentation/contour. With bone to bone contact throughout, a bone cement would be preferable.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in forehead augmentation to improve my sloping forehead above my eyebrows. I can see how that would improve the shape of my forehead in the profile view but I am curious what will happen in the frontal view. I have attached a front picture of me and marked with arrows the area of my forehead that I see as too narrow.
A: You bring up a very critical point in your forehead concerns. The area to which you have shown the areas is not the bony forehead. That is the soft tissue temple area. That would be unaffected by a bony forehead augmentation and may well look somewhat more narrow as the bony forehead comes forward. (probably won’t change it very much if at all) To improve temporal fullness or width, that requires a temporal shell implant placed on top of the muscle to build up that area. (make it wider) It is common to not be aware that the width of the bony forehead stops at the anterior temporal line that runs above the corner of the eye back into the scalp. This is where building up the bony forehead stops. Beyond that line to the sides the contour is controlled by the temporalis muscle and deep fat pad.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Hi, I’m a female with a fairly prominent brow and small, receding forehead I’d like to improve. My face as a whole is convex rather than flat: Can the areas outside my eyes be “filled?” How would forehead augmentation affect deep wrinkles? Thank you!
A: Thank you for sending the edited picture. What I see is a mildly recessed forehead and a very recessed chin. The combination of the two is why your facial profile is convex. I have done some imaging for a forehead augmentation (not brow) and a chin osteotomy or sliding genioplasty. Your chin is too short for an implant and it also needs some vertical lengthening as well as bringing it horizontally forward. Also forehead augmentation usually will soften deep horizontal wrinkles as the skin is stretched out by the underlying material expansion.
Dr. Barry Eppley
Indianapolis,Indiana
