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Archive for the ‘forehead recontouring’ Category

Technical Strategies – Pretrichial Approach to Forehead Craniotomy Defect Reconstruction

Tuesday, January 6th, 2015


Craniotomies that involve the frontal and/or frontotemporal bones are commonly done for a variety of intracranial problems such as bleeding from trauma or for access to tumors. While the bone flap is put back into position using low profile plates and screws and the detached temporalis muscle resuspended, residual skull deformities are common.

Frontal skull deformities can occur if the bone flap settles to any degree as it heals or the craniotomy line does not heal by bony union. This can leave a palpable edge or visible ridge across the forehead along the original craniotomy line. A portion of the forehead may also be flatter or more recessed. The temporal region can also develop a visible concavity due to temporalis muscle atrophy from its initial detachment.

Forehead Hydreoxyapatite Cement Augmentation with Pretrichjal Incision Dr Barry Eppley IndianapolisThese after craniotomy contour defects of the forehead and temple region can be built back up by bone cement augmentation very successfully. But it is not always necessary to completely reopen part or all of the original scalp incision. This incision (now scar) is often way far back from the forehead region and may be well healed with regrowth of hair around it. A more direct and simpler approach to the forehead defects can be done through a pretrichial or hairline approach. Bone cement can be introduced through this closer and more limited incisional access.

The pretrichial incision is a standard approach for a cosmetic browlift so it usually heals in an inconspicuous manner. Using an irregular or zigzag incision pattern that parallels the frontal hairline ensures that it will heal with a scar that is hidden along its edge. The pretrichial approach to craniotomy defects of the forehead in selected patients can simplify the secondary correction of their residual contour problems.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Forehead Augmentation for Forehead Horns

Tuesday, October 21st, 2014


Background: The desirable features and shape of the male forehead is well known. It consists of a brow bone prominence, a superior brow bone break and a smooth slightly convex shape of the upper forehead to the hairline. A wider or more square forehead shape is often seen as an asset as well. Some put great stock in the appearance of the forehead in a man and it certainly can have a strong or weak appearance depending on the shape of the frontal and brow bones which make up its bone structure.

Regardless of gender, one of the desireable features of an attractive forehead is having a smooth contour. Irregularities or indentations are easily seen on the forehead given its broad surface area. This is particularly true in men who do not commonly have a hairstyle that can completely obscure the forehead.

Central indentations of the forehead are not rare in men and are the result of natural development. When present they often create the appearance of upper forehead prominences or horns. This is an artificial appearance that exists mainly because of the depression between them and the lower brow bones. Those who have these forehead horns often feel they make one look older and cast a shadow on the forehead which makes it look uneven even thought the forehead horns aren’t really that raised.

Case Study: This is a 17 year-old male teenager who was bothered by the appearance of his forehead. It had an irregular uneven appearance and he was teased about how it looked. His forehead had a central horizontal depression between the upper forehead and the brow bones that made it look like he had two forehead horns.

Forehead Augmentation with Hydroxyapatite Cement intraop Dr Barry Eppley IndianapolisUnder general anesthesia a coronal scalp incision was used to access the entire forehead. The forehead was built up with hydroxyapatite cement, filling in the depressed area in the center of the forehead. This created a smoother frontal bone shape which also eliminated his superior brow bone break.

Forehead Recontouring result front viewForehead Recontouring result oblique viewHis results showed a much improved forehead shape with complete elimination of his forehead horns and any shadowing effect. His scalp scar was essentially undetectable across the entire length of the incision.

Case Highlights:

1) In some men, a depressed upper forehead accentuates their brow bone prominence and can even create the appearance of forehead ‘horns’ or prominences.

2) Forehead augmentation through hydroxyapatite cement can effectively smooth out indented forehead contours.

3) Forehead augmentation with bone cement needs to be done through an open scalp approach and can have very acceptable scar outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Removal and Reconstruction of a Large Forehead Osteoma

Tuesday, September 30th, 2014


Background: Bony raised bumps on the forehead are not rare and are known as osteomas. They occur due to the development of normal bone under the periosteum of the non-hair bearing forehead. They are benign overgrowths of bone that are non-mobile. They are thought to usually be initially associated with a perforating vein through the bone which may serve as a nidus for their growth. They can occur from trauma due to bleeding, no obvious reason at all or as a hereditary trait.

The vast majority of forehead osteomas are small and benign and involve only the most outer aspect of the skull bone. They usually can be simply ‘popped off’ or easily separated from the outer forehead bone for removal. It is important, however, to initially obtain a skull film or CT scan beforehand to make sure the bone lesion does not extend down past the outer cortex of the skull bone.

Large frontal osteomas that are more than just a bump on the forehead are rare. But they present differently due to their size and their association with other symptoms such as pain. A CT scan will show that the osteoma is more aggressive as it extends deeper into the skull bone and is a truly expansile bone lesion. Simply removing the outer aspect of the osteoma will not be curative with these bone tumors.

Forehead Osteoma closeup Dr Barry Eppley IndianapolisForehead Osteoma Dr Barry Eppley IndianapolisCase Study: This 34 year-old female had developed a low growing bump on her left upper forehead over the past three years. As it had been larger she began to develop sensitivity when pressing on it and more recent onset headaches.  A CT scan showed an invasive osteoma that had penetrated beyond the outer cortex of the forehead bone but also down into the inner cortex with expansion on the intracranial surface.

Forehead Osteoma Excision Dr Barry Eppley IndianapolisForehead Osteoma Bone Reconstruction Dr Barry Eppley IndianapolisUnder general anesthesia a bicoronal scalp incision was made to expose the entire forehead. A large frontal bone flap was cut and removed that incorporated the entire osteoma. The osteoma portion was removed and the remainder of the normal bone saved. This cranial bone segment was split into two pieces and was used to reconstruct a portion of the outer cortex of the forehead with plates and screws. To ensure optimal smoothness, the remaining bone defect not covered by bone with hydroxyapatite cement.

Forehead Osteoma Reconstruction result front view Dr Barry Eppley IndianapolisForehead Osteoma Reconstruction result left oblique view Dr Barry Eppley IndianapolisThree months after surgery she maintained a smooth and symmetric forehead contour. Most of the numbness of the forehead had resolved and she no longer had any headaches.

The vast majority of forehead osteomas as small, benign and easily removed by separating them from the surrounding bone. Large and more infiltrating osteomas are rare  and can cause significant symptoms by their expansion of the persiosteum and even pressing on the dura. They require a full thickness bone flap to safely remove them from the underlying dura. Reconstruction can be done by a variety of skull restoration methods using bone grafts, alloplastic materials or a combination of both.

Case Highlights:

1) Large osteomas of the skull are uncommon but can be particularly deforming in the forehead and are often associated with pain. (headaches)

2) Full thickness resection of forehead osteomas requires a craniotomy flap for access.

3) Reconstruction of the resultant full-thickness forehead defect can be done by autologous bone grafts combined with contouring bone cement.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Fat Injections for Brow Bone Break Reduction

Sunday, August 17th, 2014


Fat injections have tremendous popularity due to their autologous (natural) source, ease of graft procurement and ability to place the graft in a scar-free manner. While fat graft retention is far from assured, they have been used in a tremendously diverse number of applications where more soft tissue volume is needed.

One such unique application of fat grafts is for forehead recontouring. Historically this is a facial bony augmentation location where applying bone cements or implants is needed to create an outward effect. But surgical incisions are needed, usually in the scalp, for these aesthetic surgeries and that may be more of a scar burden that is worth it to some patients and for some forehead augmentation needs.

One relatively minor aesthetic forehead concern is the presence of or an overly deep brow bone break. Usually seen in men as a masculine feature this is caused by prominent brow bone development (technically frontal sinus growth) that extend out further than the plane of the forehead. This causes an obvious horizontal line of demarcation between the contour of the brow bone and the forehead above it.

fat injections to brow bone dr barry eppley indianapolisfat injections to forehead dr barry eppley indianapolisThe brow bone break can be softened or eliminated by fat injections. It is important to use highly concentrated fat and inject it in a microdroplet technique using the smallest microcannula. This is done through small nick incisions created by a 20 gauge needle along the horizontal break line. Two layers are placed, one above and the other below the galea. This careful and discreet fat injection technique is easy to do since the volume administered is usually less than 5ccs.

Fat Injection to Brow Bone Break Dr Barry Eppley IndianapolisSmall volumes of fat carefully placed can be an effective technique for brow bone break reduction/elimination. Given that the aesthetic problem hardly justifies a more extensive operation, this fat injection technique can be a minimally invasive and sustained forehead recontouring method.

Dr. Barry Eppley

Indianapolis, Indiana

Contouring Techniques for Forehead Bony Lumps Bumps and Ridges

Sunday, April 6th, 2014


While the skull is prone to have a variety of lumps and bumps, they are more of an aesthetic concern when they occur on the forehead. Any forehead irregularity becomes a very noticeable entity as the surface area of the forehead occupies up to 1/3 of the visible face. Commonly seen as a smooth surface, with the exception of the bilateral brow break in men, any outcrop of bone becomes very apparent and is often aesthetically bothersome.

Forehead Bony Bumps and Lumps Dr Barry Eppley IndianapolisWhile there are numerous types of hard and soft tissue lumps that can occur on the forehead, the most common bony types are osteomas, exostoses and midline ridging. Osteomas can occur randomly anywhere on the forehead and are often the result of trauma and usually appear due to an osteoblastic response to a small subperiosteal bleed. They are like a mushroom growth on the bone. Bony exostoses, also called forehead horns, are symmetric bilateral natural growths or thickenings of the outer cranial table. (although they can be asymmetric or appear on just one side) They do not have a distinct base like that of an osteoma. Midline ridging is a raised area of bone that runs down the upper central region of the forehead. It is a variant of the neonatal metopic suture and may be considered an expression of a  microform of metopic craniosynostosis.

Reduction of any of these forehead lumps and bumps can be done by a variety of surgical methods but they all share the common need for bone reduction/bony contouring. How the bony deformity is accessed will influence, favorably or unfavorably, what bony reduction can be used. Endoscopic techniques will almost exclusively limit one to using an osteome and thus is really only used for osteoma removal which can easily be severed from its more narrow base. But every other forehead bony deformity must use a more effective contouring method and needs to be done through an open hairline or scalp incision.

Angled Drill for Skull Bump Reduction Dr Barry Eppley IndianapolisA handpiece and burr is the most rapid and effective method for forehead bony deformity reduction. The high speed of the rotating burr can make quick work of any projecting bony areas. But access is often a problem. Most handpieces are straight and coming from an incision above across a convex upper forehead keeps the working end (burr) of yhe instrument away from the bony surface. This is simply solved by using an angled handpiece which is also longer than the standard straight handpiece. The angle of the handpiece overcomes the curvature of the upper forehead.

Bone Rasp for Skull Bump Reduction Dr Barry Eppley IndianapolisThe other useful tool for forehead bump reduction is a large rhinoplasty rasp. Its teeth may work a lot slower than a rotating burr but with repetitive stroking a slow and smooth reduction can be achieved. Even though it is a straight instrument and is a bone reduction manuever that is done only by feel, it is a very safe technique that creates a safe and even bone surface. It is especially good for smoothing out any areas that were initially reduced by endoscopic burring.

scalp access for skull bump reduction dr barry eppley indianapolisVarious forehead lumps and bumps can be reduced through minimal incision techniques using a variety of instruments including osteotomies, burrs and rasps. By working though small scalp incisions, forehead contouring can be done without visible skin scars if desired.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Augmentation in Men

Thursday, October 11th, 2012


The forehead occupies a major part of one’s appearance, comprising the entire upper third of the face. The variable part of anyone’s forehead is the hairline, particularly in men. Most male foreheads get longer with age for the obvious reason of a receding hairline. The relative constant features of the forehead that are easily discernible are the eyebrows and the shape of the underlying brow bones. There is also the intervening territory of the skin and the natural contour of the frontal bone between the hairline and the brows, even though it is frequently overlooked.

While the forehead may seem to many an irrelevant facial feature, there are well known differences in forehead shapes between women and men. Like the jawline, the forehead is a significant structural feature of gender.  The male forehead has more of a sloped appearance in profile with the edge of the frontal hairline being more protrusive to the eyebrows in profile. It may also have more of a square shape in the front view. Men will have more prominent brow ridges with a brow break point above the eyebrows before the forehead slopes backward. Women usually have no brow ridges and lack a backward slope. The female forehead has more of a vertical inclination with a rounded or convex shape.

The most common form of forehead reshaping surgery is augmentation of the brow ridges and frontal bone. Many more women than men undergo forehead reshaping surgery, most likely because of hairline and hair density issues. But some few men still have the procedure as they value the improvement of their frontal skull/forehead as more important than a scalp scar. Most commonly these men have a severe sloping inclination to their forehead in profile, an inclination that exceeds the more aesthetically acceptable inclination of 10 to 15 degrees and lack of significant brow ridges.

Besides the all important scalp scar issue in male forehead augmentation is the choice of augmentation material. There are four implantable forehead materials to be considered. By far the most common is methylmethacrylate or PMMA. A self-curing plastic polymer, it is mixed during surgery as a liquid and powder and molded into shape and allowed to set. Its popularity is due its low associated cost in an area of craniofacial augmentation in which often at least 60 or more grams of material is needed. It is the easiest cranioplasty material to shape and becomes as hard as bone. Another material option is hydroxyapatite (HA), a synthetic ceramic material. It is also a liquid and powder composite that is used like PMMA during surgery. It is slightly harder to work with and good experience is needed when using it as an onlay augmentation material. But it is the ultimate biocompatible augmentation material because it is composed of the inorganic component of natural bone, calcium phosphate. Its high cost limits it use in large augmentations for some patients.

There are also a few preformed forehead augmentation implant s available as an off-the-shelf option. But their sizes and shapes are very limited and I find them completely impractical for the unique forehead aesthetic needs for most patients that I see. The last option is to prefabricate a custom forehead implant. This requires a 3-D model made from a CT scan from which a mold is hand fashioned. It is then sent for manufacture in either silicone or a special form of PMMA known as HTR polymer. HTR is a sintered bead implant that is comprised of PMMA coated with pHEMA, a very hydrophilic material. This gives it unique properties of tissue ingrowth. The HTR polymer material is preferred over silicone as it is not only porous to allow fibrovascular ingrowth but has a long history in skull reconstructions in over 100,000 cases for the past 20 years with an incredibly low rate of implant complications.

Regardless of the material used, it needs to be shaped to create an improved male forehead. There is no exact science to forehead sculpting and it is more art than anything else. Besides the vertical inclination and the creation of a visible brow ridge, the often overlooked part of forehead augmentation is the transition into the temporal area. A patient has to appreciate that you can not extend the implanted material beyond the anterior temporal line which is the end of the width of the forehead bone. This is much more narrow that most people realize. Therefore, one has to decide to have a visible and palpable edge to the width of the forehead which can be acceptable in men but never in women.

Dr. Barry Eppley

Indianapolis, Indiana

Gender Differences in Forehead Recontouring Surgery

Tuesday, February 8th, 2011

The forehead occupies a major part of the face, up to one-third of its total length. It is a major contributor to facial aesthetics even though it appears largely as a blank slate. Because it has few identifiable features (only the eyebrows) other than wrinkles, it is often overlooked as a facial feature which can be modified. Botox and browlifts affect change in the overlying soft tissue, but the bony shape of the forehead  

The forehead is outlined by three features which create the visual impression of its overall size. The top of the forehead is marked by the variable position of the frontal hairline which differs greatly by female vs. male gender. The bottom of the forehead is evidenced by the eyebrows and the supraorbital rims, which is the ridge of skull bone just above the eyes. The sides of the forehead are defined by the temporal ridges, the edges of the bony forehead where it meets with the large temporalis muscle.

It is the shape of the bony forehead (amount of convexity) and the prominence of the brow ridges that help define a more masculine or feminine appearance. In times past, its shape was also thought to impart the degree of intellect of an individual. This is most commonly portrayed in movies where the villians, monsters and other evil-doers will usually have big and bulging foreheads, often being grotesquely distorted.

As a gender marker, the forehead has some well-defined features. The forehead differs in the areas of the brows and the mid forehead and the skull’s shape affects the drape and contour of the skin. A long forehead is generally more acceptable in a male, largely because the variability of a receding hairline (particularly in an M-shaped pattern) is well known and expected. The bone ridge running across the forehead above the eyes, known as brow bossing (supraorbital rims), is more pronounced in males. The degree of acceptable brow protrusion is not well-defined and it can certainly become excessive causing an over-masculinized or Neanderthal appearance. Male brow protrusion should be enough to create a noticeable break between the brow ridge and the forehead bone above it. It may also extend off to the side tapering down onto the lateral orbital rim.

While a long forehead is generally acceptable for the male, it is not in a female. Females have almost no discernable brow bossing because their foreheads are more rounded with a fairly flat front. In profile, female foreheads are more vertical instead of backward sloping. This means that some brow bossing may be aesthetically acceptable but there is no break between the brow ridge and vertical forehead bone above it, it should flow very confluently without a noticeable transition. The amount of convexity in profile view, however, is important and it should not stick out further than the lowest edge of the brow ridge. The sides of the brow ridges are also more tapered towards the temples unlike the male which can be more boxy or square-shaped.

These aesthetics considerations are critical when it comes to performing recontouring of the forehead in men and women. While forehead reshaping is often thought of as exclusively being done in facial feminization surgery, it is not in my experience. I have done as many if not more forehead surgeries in gender-stable patients. It is the nuances of the brow shape and how it flows into the upper forehead in both frontal and profile views that can make the difference between a good vs. an unhappy surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Brow Bone Forehead Augmentation

Thursday, October 8th, 2009

The forehead has a variety of shapes that do differ based on gender. Men will tend to have flatter fuller foreheads with more prominent brow bones (supraorbital ridges) while women’s foreheads will usually be softer, less full, and with flatter brow bones that tend to angle off into the temporal region. Whether it be by a congenital deformity (such as craniosynostosis), frontal tumor resection (craniotomy flap) or from prior contouring purposes (FFS, facial feminization surgery), there are rare instances when one desires to have a fuller or more prominent brow definition restored.

Brow bone augmentation (BBA) is one form of forehead reshaping that can be done. Using synthetic materials as a building material, the bone can be ‘thickened’ and recontoured to alter how the brow looks. Since the eyebrow and the upper part of the eyelid is affected by its underlying bony support, such changes can produce subtle to dramatic differences.

One of the key issues of brow bone augmentation is which material to use. Currently, hydroxyapatite (HA) and acrylic (PMMA) are the only two moldeable materials of choice. Your own bone is usually not a good option since you have to harvest it and how it survives as an onlay is unpredictable. Both HA and PMMA have their advocates but I have gotten good results with both. Either one can do the job. PMMA is much cheaper from a material cost standpoint and is very hard once it sets, being hard if not harder than natural bone. HA is much more expensive, a little harder to work with, and is more fragile to impact. But it is closer to the mineral of natural bone so it has greater compatibility and less risk of long-term body reaction concerns.

There is also the option of a synthetic implant carved out of silicone or polyethylene. (Medpor) This requires a greater degree of skill and time to get all the edges flat and flush with the surrounding bone. It is easy to see how an edge step-off can be felt through the skin unless it is done perfectly. Feathering edges and blending into the surrounding bone is much more assured with the moldable materials. 

The other important consideration of BBA is access. For the most part, an open scalp approach provides the best vision and control of the shape. But this is understandably problematic for most men unless they have a pre-existing scalp scar to use. For most women, this is not a significant issue as a hairline (pretrichial) approach can be done and that scar can really be quite fine and unnoticeable. I know this from a lot of experience with pretrichial (hairline) browlift procedures done for cosmetic purposes.

A non-open scalp approach (endoscopic) can be used in select cases of forehead augmentation. When it is the central or more upper parts of the forehead that are being augmented, the endoscopic approach using PMMA as an injectable material can be done. PMMA can be injected and pushed around as a congealed putty and shaped by external molding through the forehead skin. HA is a quite different material and its handling properties do not permit anything but an open approach scalp approach. But working down at the brow area, which is a very low point for endoscopic visualization, is even difficult with PMMA. Therefore, I would advocate an open approach for any amount of brow bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana 


Forehead Contouring and the Coronal Incision

Thursday, August 27th, 2009

Contouring of the forehead is an uncommon procedure in plastic surgery but the techniques to do it are not. Whether it is to reduce frontal bossing, soften prominent brow bones, or change the slope of the forehead, the forehead can be reshaped in a variety of dimensions. Most reduction changes are more subtle to moderate due to the limitations of the thickness of the skull and the presence of the underlying brain or frontal sinuses. Building up the forehead can produce changes that are more significant as there are no such anatomic restrictions.

Forehead contouring developed from craniofacial plastic surgery techniques. One of the basic craniofacial tenets is that of the approach and using direct vision to see the entire surgical field. Using a coronal or scalp incision, the forehead tissues are degloved or peeled back from the scalp down to the orbital rim. With this amount of access, forehead bone manipulation is fairly straightforward. Whether it is bone reduction by burring, sinus osteotomies for reduction, or adding synthetic materials for augmentation, one is unrestricted in options with this exposure.

 More males than females desire forehead and skull reshaping in my Indianapolis plastic surgery practice experience. The limiting factor for males fulfilling that desire is the scalp scar. Males are more limited in having a hidden scar due to the location of their hairline and hair density. Most plastic surgery procedures are about making trade-offs…trading off one problem for another. The trade-off of a scalp scar for a better shaped forehead must be considered carefully in most males. This is rarely such an issue for females.

As craniofacial surgery techniques has evolved, more limited incisional or endoscopic approaches have been tried. In general, these are not particularly effective for most forehead procedures. They can be used to remove small osteomas or soft tissue masses and are very effective for cosmetic browlift and supraorbital nerve decompressions. But the access is too limited and the instrumentation is not sufficiently developed to allow for much bone manipulation. I have done a few synthetic augmentations endoscopically but only partial or subtotal areas can be done satisfactorily this way.

The only other incisional option is an upper eyelid incision but this can only be used for brow bone shaping. The eyelid incision provides good access to the mid- and lateral brow. But the inner brow area is blocked by the important sensory nerves that exit out from the bone there.

The bottom line is…most forehead contouring must be done using the full coronal incision. The magnitude of the deformity will determine whether the scalp scar is a reasonable aesthetic ‘problem’ to replace it. The forehead deformity and one’s concerns about it should be sufficiently significant to make coronal incision worth it.

Dr. Barry Eppley
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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