Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a combined forehead augmentation and rhinoplasty. Please see the file attached for my thoughts on how I want to look on the front of my face. Please forgive the crudeness of the drawing, I only have Windows Paint on my computer to play with, which is very limited in abilities ;-). It should give you a general idea however. One of my questions is will the forehead augmentation result in a possible simultaneous hairline lowering? Also, how long would the recovery period be?
A: That is actually a very good drawing as it is always important to understand what the patient actually wants. Any forehead augmentation procedure requires a scalp incision which is almost always placed way behind the hairline and does not really result in hairline lowering. That raises the other possibility of making a hairline incision (what we call pretrichial) to do the forehead augmentation and then try to bring the scalp forward to lower the hairline. This would obviously place the incision at the hairline. Just an additional thought although I always feel it is better to have the incision way away from where the cranioplasty material is placed.
When it comes to recovery from a combined forehead augmentation and rhinoplasty (which is actually not a rare combination in my experience), you would expect to look pretty reasonable in about 10 to 14 days. (although all swelling takes about 6 weeks and final refinements up to 3 months after surgery) It is not really a physical recovery but one of appearance.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in forehead augmentation and possibly rhinoplasty. I have put together a compilation of my head shots along with some of the “standard” head models. In short, I feel that I have a huge face and no skull. I would like to achieve a better balance between the two. So the procedures I was thinking of are 1) Forehead augmentation and 2) Skull Augmentation to the sides, up and back (if possible of course, sounds like a lot). I am also considering a rhinoplasty to reduce the width of my nose. Please see the attached compilation and let me know what you think. Thank you so much for a prompt response.
A: I have done some imaging based on what I see as the causes of your face:skull disproportion. Your forehead is sloped at a near 45 degree angle with no brow prominence. When combined with a long overprojecting nose and a short chin, your face looks out of proportion to your skull. By doing a forehead augmentation, shortening the nose and bring the chin forward with a central button implant, there is much better balance between your face and skull. I have attached some imaging to show what effects those procedures might have on your appearance. These imaging predictions are just a first pass on the procedures and more or less changes are possible.
Dr. Barry Eppley
indianapolis, Indiana
Q: Dr. Eppley, I appreciate you doing some computer imaging for my brow bone and forehead augmentation as well as a nasal implant to build up my nose. I have some general questions about these procedures for you
1. Is it possible to choose the exact shape of the augmentation I want? In the example photoshopped photo you sent me, I would prefer to have my forehead augmentation a tad bit less “round” and maintain a bit of a masculine ridge above the brows.
2. I’m wondering how precise can you get with the shape of the augmentation? Is it a matter of injecting the cement under the skin and molding it with your fingers? Or can it be matched to be pretty much what is shown in example photoshopped photos?
3. Regarding building up the nose bridge, how do you avoid the effect of the eyes moving closer toward one another? A bigger nose bridge means the skin on the bridge is pulled forward and therefore pulls on the inner corners of each eye right?
4. Will I have to open up my skull near the hairline in order to access the browbone? Is it possible to go through the nasal openings or perhaps eyelids instead?
5. I keloid very easily… will this be a major problem?
6. Regarding recovery, I’m sure there will be swelling and possibly bruising for a week or so, but how long after that is it noticeable that I’ve had surgery done on my face? If possible, I would like to avoid making it very obvious that I’ve had surgery done, as quickly as possible, without obvious scars.
7. I live far away, would it be ok to board an airline flight soon after the surgery?
A: In answer to your questions:
1) In the male having a brow ridge ‘break’ is important so that is something that I try to do with shaping a male forehead augmentation. By virtue of the way a forehead augmentation is done, the brow ridge break has to be be put by using a handpiece and burr after the material is set.
2) Forehead augmentations have to be done though an open scalp incision under direct vision. There is no method of injecting a cranioplasty material under the skin.
3) I am not aware that nasal bridge augmentation pulls the skin inward at the corners of the eye. That does not occur in a typical nasal bridge augmentation.
4) No as answered in #1 above.
5) Keloids are not a scar phenomenon that I have ever seen in the scalp or the nose.
6) The reality after this surgery is that it will take 2 to 3 weeks to look normal again and can not be done without a scalp scar. Having this type of surgery with ‘one week of recovery and no scar’ is not possible.
7) Most patients return home within 2 to 3 days after surgery by plane.
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 want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose. What procedures would you use and how would you make these changes?
A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get brow or maybe forehead augmentation. My eyes pop out too much and I would like to have deeper looking eyes. Do you think this will help?
A: I would need to see some pictures of your face to determine by imaging whether this would be a good procedure for you. A side view of your face would be particularly useful. By definition, increasing the prominence of the brow bones and forehead will make the eyes appear more deep set and less ‘protrusive’. Brow bone augmentation makes the superolateral orbital rim bigger and, in some cases, patients may also benefit by infraorbital rim augmentation as well to get a circumferential deeper look to their eyes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In the process of researching procedures on skull reshaping, I found and read your entries about skull reshaping/reconstruction on exploreplasticsurgery.com. I have an interested in getting a procedure done. My head is shaped like a triangle. The width and length of my forehead is very small. My overall head is small compared to my body as well. It is only approximately 18 cm long and I am approximately 171 cm in height. For the reason that my temples are so extremely narrow and my forehead is so short I am not able to fit sunglasses or hats. There are no hairstyles that flatter my face. My facial features are not without flaws, but my biggest flaw is the size and shape of my head. My main goal is to have an ample size forehead and head overall. I am aiming for my head to be in proportion with my body and my forehead in proportion to my face. If possible, I would like my head built out at least 2 inches.
In addition, I am in the processing of inquiring about Invisilign to have my overbite fixed and widening of my jaws. I am not sure if I need maxillofacial surgery.
A: In looking at your pictures, I can see that your forehead is narrow in both height and width. I can not tell much about your head size with your hair. One concept to understand is that you can not built out our head by two inches. The scalp will simply not allow for that amount of bone expansion. From a practical and cost standpoint, the idea of making one’s head size bigger in a circumferential fashion should not be considered. That takes an inordinate amount of cranioplasty material. What is practical to consider is forehead augmentation/expansion, building out the forehead with cranioplasty material through a scalp incision. That will help improve the very visible non-hair bearing portion of the skull (forehead) in its relationship to the rest of your face.
In regards to the need for maxillofacial (orthognathic) surgery, you first need an orthodontic work-up. You do not yet know whether your bite can be fixed by orthodontics or a combined surgical-orthodontic approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 24 years old and my brow bone gets getting bigger. Is there something I can do to stop it expanding? Why is it doing it? Can an incision be made on both eyebrows to perform procedure? What would be your best idea without doing a coronal incision? Can a cut be made in my eyebrow so you can burr it down. ( wouldn’t be much) Then somehow either inject a filler into the top part of my forehead to smooth out… what about some kind of implant for the top part of the forehead? Does that need a coronal incision to be placed in?
A: At your age, your frontal sinus development is complete and should no longer be expanding. That is a function of skull growth which is long over now.
An incision can be made along the eyebrows known as the ‘Open Sky’ approach. It runs along the upper eyebrows and crosses over the nose. While it can be done, it is an historic approach that has largely been replaced by the coronal incision. I am not so sure that wouldn’t be more obvious than the coronal incision quite frankly but I wouldn’t yet rule it completely out
The key question about incisional approaches is what exactly needs to be done to the brow ridge to reduce it. In the vast majority of cases it requires infracturing or an osteotomy of the outer plate of the frontal sinus bone. This can only be done through a coronal approach. Usually simple burring is inadequate BUT if one has just a few millimeters of bone that need to be taken down and the area above it is built up with cement, the eyebrow approach may be reasonable. That could be determined beforehand by one simple x-ray known as a lateral skull or frontal sinus film. That would tell us precisely how thick the frontal sinus bone is and how much can be reduced by simple burring.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 28 year old woman with slim build. I have been unhappy with my facial structure and feel that the lower half is “heavy” and undefined while from cheekbones up, it is narrow and flat. I am considering buccal fat removal to even out my lower cheek/ jaw. I wan a slimmer face as well as a more delicate mouth and rounder forehead. A more heart-shaped face, as opposed to my triangular one (bottom heavy) What is your opinion? Thank you!
A: This is what I had thought your concerns were. From a lower face standpoint, what makes your face heavy is the wide lower jaw/masseter muscles. This is due to your ethnicity as you know. There is no type of fat removal, buccal lipectomy or otherwise, that is going to make that change as the problem is not one of fat. It is due to your musculoskeletal structure. Typical options include repeated Botox injections to the masseter muscle to cause it to shrink/atrophy and/or bony jaw angle/inferior border mandibular reduction. There are advantages and disadvantages to either approach which is demonstrated in their injectable (non-surgical) vs surgical approach. From a forehead standpoint, a rounder and more convex forehead is achieved through an augmentation material using a hydroxyapatite cement to build it out. (forehead augmentation) This is done through an open scalp approach.
When these procedure are combined (upper and lower face), this is how a truly effective facial shape change can be achieved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My skull shape is rather problematic. I have a weak forehead (probably about 1 inch), the problem is that the top of my head is not round, there is a noticeable gap, once you hit my hairline, my skull goes flat, it isn’t until about 2 inches further that there is a slope where it increases. I could upload and send you pictures so you can see. Would it be possible to actually build up that ‘missing’ forehead? My other question involves my face width from ear to ear. With the weak forehead, and noticeable cheekbones, and jaw…they add up to making it appear as if I am fat. Other than removing buccal fat, is it possible to shave off some of that and moving the bones further in to reduce the width? Thank you for your time.
A: I would first recommend that you send me some pictures for my assessment. But to provide some general comments, the forehead can definitely be built up with cranioplasty material. The buildup can be extended back up into the skull area. This would need to be done through an open coronal (scalp) approach. When it comes to the face, however, such bony width reductions are much more limited and unlikely to be able to do what you want to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in making my forehead wider. I think it is too narrow for my face. My face has good features and dimensions but starting with my lower forehead it goes up into scalp like a triangle rather than having a forehead width that matches my lower facial width. I think it would look better of my forehead was wider and more prominent. Is this procedure possible and, if so, how is it done and what are the potential complications?
A: Widening a forehead as you have described means expanding its bony contours. Traditional forehead augmentation is done through a scalp incision to build out the forehead with onlay cranioplasty materials but it usually lies on the bone within the edges of the anterior temporal lines. Building out or widening a forehead behind the temporal lines is problematic as that requires lifting up part of the temporalis muscle, which will can easily be done, but almost always results in muscle atrophy seen months later. This potentially can expose the edges of the built out area (cranioplasty material) if they are not perfectly smooth and may make a once smooth transition between the two become more noticeable. Some may refer to widening the forehead as augmentation of the temporal hollows, although that would not normally be considered part of the forehead.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in 1) reduction of large occipital bone by burring and 2) forehead augmentation. Due to a narrow and recessed forehead above the brow bones, this needs to be built up with implant material. Can the scar follow the hairline if it naturally angles back laterally from the most center front couple of inches of the horizontal hairline?
A: Let me answer your two areas of concern with some general statements.
1) Reduction of a large occipital bone is always a question of how much be removed. In other words, is it worth it or not. That is best determined by getting a lateral skull film so measurements can be made to determine how much the bone can be reduced. It definitely can be burred down. The question is…is it enough to make a visible difference.
2) Forehead augmentation does require a scalp incision. generally, it is placed way back in the hairline…more than just an inch or two behind one’s existing frontal hairline. That would be particularly good if one is desiring some occipital reduction as well.
That being said, the first place to start is for you to send me some pictures of yourself for my assessment and then we can have a phone or Skype consultation for further discussion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have indentations on my forehead. On my right side, there is less volume so I have more loose skin and my eyebrow droops. I would like to get the indentations filled in so my forehead looks smoother. Since filling out the area would make my skin more taut, would it fix my eyebrow into a more normal position so it doesn’t droop anymore? My brow bone is also smaller on the right side. Could bone cement build up my brow bone? If so, could that also help lift my eyebrow up? If some skin removal is also necessary, would it cost a lot more?
A: Forehead augmentation (onlay cranioplasty) by virtue of adding volume would potentially make the skin tighter. There may even in some cases be a slight browlifting effect, although this would be greatest with the brow bone is directly built up. Whether this would occur or not would also depend on how much volume is added. To ensure that this stretching and lifting effect occurs, it would usually be best to do a browlift with the forehead augmentation. This would be easy enough to do since there would be a coronal incision already present. It would not add any appreciable time or expense to do so because of then existing scalp approach for the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead contouring surgery. My forehead is kind of rounded and I would like to have it more like square-shaped. When looking at a profile view my forehead sticks out where my brows are and my eyes look deep in the face. I also have attached a picture of a gentleman that his forehead looks more like square and that is exactly what I’m looking for or something close that will reduce my forehead. Thank You
A: Thank you for sending your pictures. Your forehead shape is a combination of brow bone protrusion and an upper forehead that slopes backward. Together this gives your forehead a 50 to 55 degree backward slant in a profile view. The desired forehead shape that you have shown is almost completely vertical. While that is not completely possible from the forehead shape that you have now, you can make significant improvement in your current shape. To change the slant of your forehead, you need to address the two components of the problem, brow bone protrusion and upper forehead retrusion. This is done through a combination of brow bone protrusion and forehead augmentation above the brow bone area. Neither brow bone reduction or forehead augmentation alone will make this improved shape. It takes this combination ‘ying and yang’ approach to create the substabtial forehead shape change that you desire. I have attached an imaged result of what I can think can be achieved by this approach. This would be done through an open coronal incisional approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an accident when I was 16 that resulted to a dent between my eyebrows. I had a surgery to elevate that dent 10 months ago and it was done by my neurosurgeon because my frontal sinuses were also indented. My forehead now is improved but I can still see a slight dent which is very acceptable. My question is if the bone cement on my forehead will deplete overtime resulting to a more indented forehead again?
A: What you had sounds like an outer table fracture of the frontal sinuses, also known as brow bone fractures. Because this portion of the forehead has only a thin layer of bone in front of the underlying air-filled frontal sinuses, it can be pushed inward with a significant traumatic force. This buckling inward creates the outward appearance of an indentation of the forehead just above the eyes. When a delayed repair is done, it is much easier to build up the contours of the brow bones that it is by repositioning the displaced bone. This is done using any of the available cranioplasty materials. While I don’t know what type of cranioplasty was used for your brow bone augmentation reconstruction, none of them are resorbable. They all are stable biomaterials that do not degrade over time. So your current result will stay stable throughout your lifetime.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a more round forehead appearance. It is too flat and doesn’t seem to fit the rest of my face. I would like to know the best method for forehead augmentation; fillers, implant, or bone grafts. Thank you!
A: Thank you for your inquiry and sending your pictures. I can clearly see that there is a disproportion between the projection and shape of your forehead (and the upper portion of your nose, the frontonasal junction) compared to the rest of your face. Your entire lower forehead and brow needs to be built out, including an upper nasal (bridge-frontonasal junction) augmentation. I have done some imaging to show what that would look like based on the one photo that you have sent. Forehead augmentation can not be done with fillers, bone grafts or preformed synthetic implants. It requires a moldable cranioplasty material that is specifically moldeded in surgery to the desired forehead shape and allowed to harden. The two basic types of cranioplasty materials are hydroxyapatite and acrylic. (PMMA) Each has their own advantages and disadvantages. Because of your recessed forehead/brow area, the nasal junction of the forehead is severely recessed. That would need to be built up with a small bridge implant placed through the inside of the nose. If not done, building up the forehead/brow will make that area look even more recessed inward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am trying to decide on whether forehead augmentation is right for me. If this procedure turns out right I would be beyond grateful but the size of the scalp scar does make me think about whether I should reconsider having this procedure done. But what concerns me most is the risk of asymmetry. I don’t want to have an asymmetrical hair line or forehead in general. I don’t know, however, if that’s a possible negative outcome when getting forehead augmentation. I also don’t want this procedure to change my eye shape. I simply want to add fullness to the area in between my brow bone and hair line. I usually wear hats or head bands at times to give my face an over all nicer flow. In this message I am attaching a frontal pic and an oblique view., I hate taking profile pictures so much but of course its necessary so I can be better evaluated.
A: I obviously can not tell you on a personal level whether forehead augmentation is right for you. All I can speak to are the potential risks and benefits. What I can tell is that through the open scalp approach, the forehead shape can be perfectly built up and be smooth. That is the advantage of seeing completely what one is doing. A nice buildup can be done between the brow ridge and the frontal hairline. It is quite clear were the buildup would be based on your profile view. This would in no way affect your eye shape nor would the forehead or hairline be asymmetrical.
I would say there is a very good chance that your need to wear hats may be eliminated…at least if this is the reason you are wearing them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in improving the shape of my forehead. It slants backward rather significantly and I would like it to be more vertical as it goes upward from my brows into my hairline. Can this be done with Kryptonite foreheasd augmentation? How much filler would be needed and what would be the cost?
A: I have done a side view imaging prediction to show that forehead augmentation can make a real difference in eliminating the backwards slope of your forehead by incrementally increasing adding volume from above the brows to the top of the skull. While there is no question this procedure can be done very effectively and get your desired aesthetic result, there are several important issues about the technique to do it. While an injectable or endoscopic Kryptonite procedure is very desireable due to its minimal scar approach, this would not be the best method to do it for several reasons. The volume of material needed is likely 40 grams or more to add the necessary amount of augmentation. That makes the use of Kryptonite prohibitively expensive, making the cost of the material alone for the procedure in excess of $12,000. When it comes to this volume of material needed for forehead augmentation, acrylic or PMMA is far more cost effective with a material cost that is about 1/10 that of Kryptonite. Secondly, and of equal importance, is that a smooth contour of the forehead augmentation is absolutely essential. It is often assumed that the thickness of the forehead and scalp tissues makes slight asymmetries or unevenness aesthetically tolerable, but this is only true when the augmentation is in the hair-bearing scalp. On the forehead, every irregularity will eventually be seen and most certainly felt when the swelling goes down and the overlying tissues adapt to the new forehead contour. With the current use if injectable Kryptonite, it is not possible to get as smooth of a result as that with an open PMMA frontal cranioplasty or forehead augmentation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley I am just wondering how I am able to fix the dent in my forehead above my brow bone? I want a more smoother look. How much would the procedure cost?
A: You are referring to the area above the brow ridges where you would like it to be more smooth and confluent as it goes upward into the upper forehead. That is a common request amongst females that I get. This involves adding material above the brow bone so that it creates a flatter, or even a convex shape, to the forehesad area. This has to be done through an open scalp (coronal incision) That cost for this type of frontal cranioplasty procedure is in the range of $8500. Several features influence the cost of the procedure including the type of material used for the cranioplasty procedure. (hydroxyapatite vs. kryptonite vs acrylic) This is an outpatient procedure that usually takes about 2 hours to complete. There would be some swelling of the eyes afterward as gravity pulls swelling downward. The trade-off for this forehead improvement is a permanent fine line scar in the hairline and some slight permanent numbness of the scalp near the incision line.
You may feel free to send me some pictures of your forehead for my assessment and your suitability for this procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I want to achieve a completely caucasian look, I am Asian. Do you have any recommendations for my forehead? I am doing a hairline lowering procedure soon, should that be done before or after a forehead/browbone augmentation? Since there will be a scar from the forehead procedure right? I have attached some pictures for you to see me.
A: Thank you for sending our pictures. It is not clear to me what type of hairline lowering procedure you are doing. If it is being with a frontal hairline incision (scalp advancement), then the forehead augmentation should be done at the same time. If the hairline lowering is being done by hair transplants, then the forehead augmentation should be done first so the scalp scar will lie behind the grafted area. Improving the convexity of the forehead is what many women want to achieve, particularly those of Asian ethnicity.
As for other facial recommendations, it is not possible for you to have a ‘completely caucasian look’. Some facial areas may be tweaked but you can’t change the basic foundational look of your face. Tell me what you think would make the greatest difference in your face. In other words, what facial areas do you think would make you look less ethnic? In looking at your pictures, I do not see major areas of change but options do include the creation of an upper eyelid crease, buccal lipectomies, rhinoplasty, chin augmentation and jaw angle reduction.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in forehead augmentation to make the slope of my forehead less so and longer. I was hoping to retain my brow ridge prominence somewhat as that is a family trait…and in fact I’d like to keep the forehead looking sloped and straight as opposed to rounded and convex….keep it similar to how it is now, except for perhaps slightly raising the hair-line and moving it out a bit, while making the slope of the forehead greater, but certainly no where near convex. In other words, just as the brow ridges end moving toward the hair line, all of that forehead area I was hoping to making steeper, but still straight and non convex, and at the very top where the hair line is i was hoping to making higher and more in line with the rest of the forehead. Is that not possible? I don’t know how these surgeries work… in other words, I don’t know what the limitations are for the shape of the molds and their complexity…but I certainly didn’t want a drastic change in the forehead. How “complex” can the moulds be made that fit into the forehead region? What is the potential for tweaking certain aspects?
A: Forehead augmentation is not done by a preformed implant or a mold. It is done by cranioplasty onlay materials. These are mixed together at the time of surgery and applied like plaster of paris. It is then shaped by hand until the desired form is obtained and then allowed to set or cure. The average working time is about 10 minutes for this process. It is a very artistic technique which is why one has to have a very good idea what type of forehead shape the patient wants. You have been quite explicit as to your forehead shape desires which is good. Given the volume of material needed (at least 40 grams), PMMA (acrylic) is best for you because of the cost issue with that volume of material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am looking to go about getting a procedure to make my forehead larger in height (length) and width and also to build around the temple area. But also my hairline is very low and am wondering if I get the forehead implants would I somehow be able to move my hairline up to show more of my forehead? After forehead implants what can be done about my hairline when getting this procedure.
A: Forehead augmentation, technically known as frontal cranioplasty, involves applying a moldable material to the forehead that then hardens fairly quickly. During the hardening process, it can be shaped in all dimensions including projection, width and height. These materials must be applied to bone and not soft tissue. Therefore, you can not widen the temple area as this is muscle not bone. The temple area requires a differernt material/implant approach.
With forehead augmentation, there may be some small vertical lengthening of the forehead when it is ‘expanded’ by augmentation. It may be in the range of 1/4 to 1/2 inch greater distance between the frontal hairline and the eyebrows. There is a limited amount of length increase that can be done. But this small increase, combined with greater forehead convexity, may make it appear slightly bigger than it really is. It may be possible to lengthen and stretch the forehead skin after augmentation through a coronal or scalp type of browlift technique but I doubt one would find that necessary later.
Dr. Barry Eppley
Indianapolis Indiana
Q: I desire to have cosmetic surgery next year with the wishes of making my forehead larger both in length and width. Can you inform me with what this procedure is called and also with all the information there is to know on this surgery (including risks, the type of implants used, how long it takes for the healing process, the cost of the surgery, how you go about customizing the implant and etc). Please respond as soon as you can with a detailed response. Thanks so much.
A: You are specifically asking about forehead augmentation. This is a procedure done through a scalp incision approach Augmentation of the forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic), HA (hydroxyapatite cement) and calcium carbonate. (Kryptonite) Each of these materials has its own advantages and disadvantages. Large forehead augmentations (which you are referring to) is best done with PMMA due to cost considerations. These materials allow wide variability in adding to the brow ridges if desired and increasing the amount of frontal bone convexity, width and smoothness. These are liquid and powder mixtures that are put together and applied to the forehead in a putty form and then shaped by hand to the desired new forehead shape and allowed to harden. The operation takes about 2 hours and is done under general anesthesia as an outpatient procedure.
This is a highly successful procedure whose trade-off is a fine line scar in one’s scalp. The typical cost range for the procedure is $8500 – $9500. Healing is quite rapid and one can look fairly normal in about 10 days after the operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a bit disappointed with the way that I look and I would like to fix some things. I believe a forehead augmentation would help me look a lot better. One of the changes I would like my forehead to undergo is to put the hairline at a higehr height, so my foehead would become a bit higher. That means building up the upper forehead area about 1 to 2 cms. I don’t think it is necessary to build up any area of the parietal bone. These are the changes I desire in the hairy part of my forehead. The second change I desire is in the brow bone. I have the feeling that from the side, it doesn’t look masculine enough because the brow bone doesn’t stick out as it should in a male. I think an augmentation of a few millimeters and a reshaping with nice corners would improve the way my brow bone looks. The second change I would like to do is the slope of my forehead. The slope of my forehead is very good but somewhere between the hairline and the brow bone the frontal bone has a small ‘puddle’ and I think it should be built up too. Those are the changes I want to do for my forehead and I hope that an endoscopic bone augmenttaion would help. How many grams of cranioplasty material woould be used for this? I have attached a side view of my forehead for you to see its shape.
A: Thank you for sending your pictures. Despite the relative poor image quality, it is clear as to your forehead concerns. I think there is no doubt you would benefit by forehead augmentation (frontal cranioplasty) but I need to clarify what is and is not possible. To achieve a good result, your forehead augmentation can not be done closed or endoscopically.There is no way to ensure a smooth and confluent result by any type of injectable approach. Your forehead reshaping is too complex for that it would have to be done through an open approach requiring a scalp incision. Secondly, the volume of augmentation material that you require makes the use of Kryptonite too expensive. You likely require about 40 grams of material. Your most economic approach would be acrylic (PMMA) where such a volume of material is economically feasible. Thirdly, it is not possible to buildup your forehead as much as 2 cms, the scalp incision could not be closed afterward.
One cm. at most is what is possible. Lastly, your frontal hairline may come up a bit with the augmentation but not substantially so. It is not possible to buildup your forehead an surgically move your hairline back at the same time.
These are some practical considerations for you to consider.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in making my forehead more vertical and round. I also want to have more height and width of the top of the skull. Do you think this is possible using the injectable Kryptonite method? I have attached some pictures for you to see the shape of my forehead. Let me know what you think.
A: Thank you for sending your pictures. I think I understand completely your forehead shaping objectives which would involve a cranioplasty fill of the forehead to make it more vertical from the brows up in profile (increased convexity) and to add width in the frontal view. This fill, in essence, is really to camouflage the slight brow bone prominence you have and will make the entire forehead more smooth and confluent. I have attached some imaging which is limited by the quality of the images you sent but I think it conveys the objectives.
In achieving this result, I do not think the injectable approach is best. It will take a prohibitive amount of material (cost wise) and the shaping must be perfect to have a happy end result. The evolution of the injectable cranioplasty approach is not quite far along in terms of experience to reliably give the best result for this more complex reshaping of a very visible facial area.Therefore, an open approach is best using PMMA (acrylic). That will allow an adequate amount of material to be used at a reasonable cost and get the best shape and smoothness of the forehead augmentation. The open cranioplasty approach in a male, however, is limited by the willingness of the patient to accept a scalp scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: Do you do forehead augmentation to make a flat forehead rounder using PMMA? If so how much does this cost and how is it done?
A: Forehead augmentation can be done with a variety of materials. The use of PMMA (acrylic) is historic for forehead augmentation and offers the most economical approach for the procedure. It generally costs in the range of $8500 to $9500, all surgical costs included.
Forehead augmentation with PMMA requires it to be done through an open scalp approach due to the working characteristics of the material.
There is a technique for forehead augmentation using Kryptonite Bone Cement which can be done through an injectable approach using very small incisions. Its cost is higher than that of a PMMA frontal cranioplasty.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m a male in my thirties and I would like to have surgery to give my orbital rim and forehead a more masculine (protruding) appearance. I had a craniotomy 3 years ago which has left a dent on my forehead which I would like to eliminate. I understand that solid HA is more porous than the moldeable putty type which would allow tissue growth and ossification. I would like to know answers to the following questions. 1) In order to make my forehead more prominent would it be possible to use 3-D CT scan technology to customize a solid HA implant instead of using moldable HA paste? 2) Could the customized HA implant be made with an interior mesh to make it less brittle? 3) Would a customized HA implant in solid form be easier to work with than HA in paste? 4) Could using a solid HA implant present problems such as fluid accumulation, visible borders, migration or extrusion. I thank you for your time.
A: Thank you for your excellent and thoughtful cranioplasty questions. I can answer of your HA cranioplasty questions by saying that I really don’t use the HA pastes anymore. In their day they were state of the art and they were wonderfully moldeable, but they are brittle. This is no different that HA blocks or HA custom implants which actually are just as brittle and much harder to work with. The newest and more improved cranioplasty material is Kryptonite Bone Cement. It offers easy molding and shaping into the defect, sets up and gets just as hard as bone, and is truly porous (unlike most HAs which are not except the blocks) which allows tissue ingrowth. This is clearly the superior cranioplasty material and eliminates all of your stated concerns and questions.
Therefore, based on these working properties of Kryptonite, HA is no longer used and a 3-D CT scan model is not necessary beforehand since there is no advantage to making a pre-formed implant. (which is now a disadvantage and very costly)
I see no problems at all doing forehead and orbital rim augmentation and any contouring of a forehead indentation with Kryptonite Bone Cement through your existing scalp scar and open approach.
Indianapolis, Indiana
