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

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

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

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

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

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

The desire for forehead reshaping in adults is done for three reasons. Most commonly, it is someone who has a residual forehead deformity due a congenital skull deformity. (e.g., craniosynostosis) As one gets older, or as hair loss occurs in men, the frontal skull deformity becomes more aesthetically obvious. Secondly,  a frontal skull deformity exists due to an injury or after a neurosurgical craniotomy procedure has been done. Lastly, for those individuals going through a gender transition (female to male), the slope of the forehead or the prominence of the brows may be desired to be increased.

For any of these reasons, forehead augmentation (frontal cranioplasty)  involves expansion of the existing bone boundaries. It is not practical to try and do this by manipulating the skull bone in most cases, as there is an easier and more effective solution…..build up the bone with synthetic materials. While I always try to avoid synthetic materials when it is possible, their use in forehead augmentation is the only practical and reasonable option in the vast majority of cases. (onlay cranioplasty) As such, a good working knowledge of the available synthetic materials for the skull is important.

Fortunately, adding to the forehead bone is not a technically difficult procedure. The two questions about it are: what type of material to use…and access to the bone. Forehead augmentation has two very moldable and adaptable materials to build it up with. Traditional PMMA (polymethylmethacrylate) has been around for a long time and has the advantages of a very low cost, high resistance to impact forces, and ease of intraoperative contouring. Its main disadvantage is that some patients over time can develop some low-grade reactions to it and it may get loose, become infected or the overlying forehead skin may thin, although these issues are uncommon. It does generate a lot of heat during its setup (polymerization) but this is managed by cool water irrigation. Newer ‘more natural’ materials such as hydroxyapatite cements (HA) have been available over the past 10 years. HA offers the advantage of being a more natural, less synthetic material as its structure more closely resembles that of bone. Its disadvantages are that it is considerably more expensive, has a low resistance to impact (easily shatters), and is a bit tricker for the plastic surgeon to use. It generates no heat during its setup but is very sensitive to moisture and is easily deformed and pushed around during its set up phase. At this time, there are no long-term clinical studies that give a decided advantage to one material or the other.

Other synthetic options include pre-made or custom-made synthetic implants. They can be made of either silicone rubber (most common), gore-tex, or poplyethylene. In most cases, these would have to be prefabricated based on a skull model of the patient to get the best and most exacting fit. Any irrergularities will be obvious in the contour of the forehead so a precision fit is essential. I don’t find that these onlay custom implants offer any advantages over PMMA or HA in terms of better long-term outcomes or reduced risks of complications.

Regardless of the material used, synthetic forehead augmentation is all about access. The asiest and most predictable way to place it is through an open scalp incision. While this is the best and easiest way to do, there is always the cosmetic trade-off of this scar. When more limited or endoscopic access methods are used, one has to use PMMA because it is easier to mold through intact skin and will predictably stay where it is placed and molded. Endoscopic forehead augmentation is a more limited procedure due to its more limited visual access.

Dr. Barry Eppley

Indianapolis, Indiana

Reshaping the forehead is an uncommon patient request. While the plastic surgery techniques to do so are well known and not new, the need to do forehead contouring is not. Most commonly, forehead reshaping is done on patients who had a congenital skull deformity (e.g., craniosynostosis) or a frontal skull deformity secondary to trauma or after a neurosurgery craniotomy procedure. The cosmetic reasons would be to soften prominent brow ridges or to smooth out some forehead irregularities.

The treatment of forehead irregularities can theoretically be done by either burring down bone or adding a synthetic material to it. In reality, burring down bone on the skull is a limited procedure and can never make as big a difference as one would think. The brow ridges can be burred down but the limiting factor is the underlying frontal sinus. If the overlying frontal sinus bone is thin, then very little bone can actually be taken. Above the brow ridges, burring down forehead bone is very effective for small raised areas that are easily identifiable but is less effective at reducing large surface areas of bone.

Filling in or adding to the forehead bone is a much easier and effective procedure. The real question in forehead augmentation is what material to use. Traditional PMMA (polymethylmethacrylate) has been around for a long time and has the advantages of a very low cost, high resistance to impact forces, and ease of intraoperative contouring. Its main disadvantage is that some patients over time can develop some low-grade reactions to it and it may get loose, become infected or the overlying forehead skin may thin, although these issues are fairly low risk. Newer ‘more natural’ materials such as hydroxyapatite cements (HA) have been available over the past 10 years. HA offers the advantage of being a more natural, less synthetic material as its structure more closely resembles that of bone. Its disadvantages are that it is considerably more expensive, has a low resistance to impact (easily shatters), and is a bit tricker for the plastic surgeon to use. The advantages and disadvantages for HA vs. PMMA must be considered and weighed on an individual case basis.

Regardless of the material used, synthetic forehead augmentation usually requires an open scalp incision which, because of its length, is a significant consideration in a cosmetic procedure. (particularly for men) Endoscopic or limited scalp incisions may be able to be used in small areas of augmentation in carefully selected cases.

Dr. Barry Eppley

Indianapolis, Indiana

Expanding or enlarging the forehead to a more desireable contour is most commonly considered in adults or teenagers who have had a congenital skull deformity. Most of these had some form of craniosyostosis, with or without early craniofacial surgery, and are now left with forehead irregularities, depressions, or a forehead that severely slopes to the temple area making it look too narrow. Other needs for forehead augmentation are from previous trauma cases with frontal bone fractures, neurosurgery patients with craniotomy defects, and rarely a female to male facial conversion patient.

All forehead augmentations use some form of synthetic material to add on top of the bone. The use of acrylic or PMMA, a liquid plastic that hardens after being mixed, has been around for many decades and consistently works well. The more recent uses of bone cements or HA (hydroxyapatite), which similarly harden after mixing, are of more recent use. I have used a lot of each and either PMMA or HA has its own set of advantages and disadvantages. PMMA is less expensive, sets up more reliably in surgery, and can be injected through an endoscopic technique (for small areas)  if one wants to avoid a large scalp scar.  It also sets up very firmly and gets as hard as any thick plastic material. Its biggest disadvantage is that it is truly a non-natural synthetic material and its long-term implantation may have higher risks of rejection or infection. HA is a more natural material that is similar to bone in structure but it sets up slower and can be more difficult to work with through small incisions. It usually is best placed through a more open scalp incision. Once set, HA is softer than PMMA and if exposed to a large impacting force, it will potentially shatter like a ceramic dinner plate. My decision as to what material to use for any particular forehead depends on the operative technique. For open forehead approaches, I will use HA. For endoscopic techniques, I will use PMMA.

Building up the forehead is similar to sculpting with clay. The forehead bone is exposed and the chosen material is applied and molded into the shape one desires. Whether it is done through an open approach when one uses the fingers to mold and shape or done through an endoscopic technique where the fingers mold it through the forehead skin, the procedure is not difficult and provides an immediate result that should not change over time. The most difficult decision for the patient is whether a larger scalp incision is acceptable or whether the endoscopic ( a few small scalp incisions) approach is preferred. Smaller or spot forehead augmentations can be done endoscopically. Larger or more complex forehead augmentations are best done with an open scalp approach.

Dr. Barry Eppley

Indianapolis, Indiana