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Posts Tagged ‘forehead augmentation’

Case Study: Custom Male Forehead Implant

Thursday, July 31st, 2014

 

Male Forehead Surgery Dr Barry Eppley IndianapolisBackground: The male forehead is uniquely different from that of females. It has more prominent brow bones, a well defined brow break and a forehead that has no more than 10 to 20 degree angulation backward into the frontal hairline superiorly. This is quite different from a female’s forehead which ideally has little to no brow prominence and a more vertical and convex forehead shape.

Forehead augmentation is less common in men than females. Usually most men who present for aesthetic forehead surgery have brow bones that are too prominent and they want them reduced. But occasionally a man may want a more masculine forehead shape that has the aforementioned male forehead features as well as some increased width.

Traditionally, reshaping a forehead using an augmentation method has been done using bone cements. Through a full coronal incision, the bone cement is mixed, applied and shaped through wide open exposure. This allows for the best shape creation and to eliminate the risk of any edge or transitional material concerns into the surrounding tissues. But such hand shaping must rely on the surgeon’s skill and experience at creating the desired forehead shape.

Custom Forehead Implant Design Dr Barry Eppley IndianapolisCase Study: This 28 year-old male wanted a masculine forehead shape. He desired the classic male forehead features with more brow bone protrusion, a brow bone break and less vertical angulation upward. His present forehead had minimal brow bones and a very retroclined forehead slope. Using a 3D CT scan, a one-piece forehead implant was designed with the requisite features.

Custom Forehead Implant result side view Dr Barry Eppley IndianapolisUnder general anesthesia, a limited coronal scalp incision was made well behind his existing hairline with no shaving of hair. Subperiosteal elevation was done down to the brow ridges with release of the periosteum. Dissection was carried out onto the deep temporal fascia. The custom implant was inserted, seated and secured into position along its upper edge with three small self-drilling titanium screws. The scalp incision was closed in layers with dissolvable sutures.

Custom Forehead Implant result oblique view Dr Barry Eppley IndianapolisA custom forehead implant is an ideal method to get the best fit and shape for an augmentation effect. It also makes the operation take less time which nearly offsets the increased cost of making the custom implant. A somewhat smaller scalp incision can also be used. In addition with a more assured aesthetic outcome the risk of revisional surgery is also lessened.

The use of custom implants for the craniofacial area continues to grow and expand and its use in the forehead represents another example of its growing role in aesthetic facial surgery.

Case Highlights:

1) Forehead augmentation in men is designed to increase the prominence of the brows and decrease the posterior angulation of the forehead.

2) Forehead augmentation can be done using either intraoperatively applied bone cement or preformed custom implants.

3) Forehead augmentation with custom implants made from the patient’s 3D CT scan provides an optimal fit to the bone and the best smoothness and symmetry in the implant’s shape.

Dr. Barry Eppley

Indianapolis, Indiana

Minimal Incision Forehead Augmentation Cranioplasty

Monday, October 7th, 2013

 

Forehead augmentation is done for a variety of aesthetic reasons including increasing the convexity and projection of the forehead. A forehead that slopes back too severely or lacks brow bone projection can be built up by an onlay or augmentative cranioplasty. This is always done with an alloplastic material rather than a bone graft due to its simplicity and long-term predictability of volume and shape.

Amongst synthetic cranioplasty materials to use for forehead augmentation are the bone cements which include PMMA (methyl methacrylate) or HA. (hydroxyapatite) Each has their own advantages and disadvantages but the one difference that usually determines which one is used is cost. PMMA offers high volumes of material at a very affordable cost. HA is the more ‘natural’ cranioplasty material but its high cost usually precludes patients choosing it.

In the September 2013 issue of the Journal of Craniofacial Surgery an article was published entitled ‘Using Methyl Methacrylate for Forehead Augmentation for Aesthetic Purposes’. In this paper, the experience using an outpatient procedure for PMMA for aesthetic forehead contouring was reviewed over a 6 year period. In 210 patients, a limited incision scalp incision was made and PMMA material was placed and molded through the skin.  The amount of PMMA was only 10 to 40 grams with a mean amount of 25 grams. In following the patient an average time of nearly four years, most patients were satisfied with the results. The authors conclude that aesthetic forehead augmentation using methyl methacrylate is an effective surgical procedure with minimal side effects and a high degree of patient satisfaction.

While the use of PMMA for forehead augmentation is not new, this study is unique because of the limited incisional approach and the small volume of material used. This is really forehead augmentation for a small amount of increased forehead fullness or convexity. PMMA is the only cranioplasty material that can be used in this approach as it can be pushed through a small incision as a congealed putty mass and then shaped from the outside by hand. This is very similar to the approach I use for a minimal incision occipital cranioplasty.

What this study also shows is the safety of PMMA as an onlay cranioplasty material. While it is more of an ‘unnatural’ material than HA, its lack of bone bonding or bone ingrowth does not detract from its long-term successful and uncomplicated use.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Forehead Augmentation for Correction of Pseudo Brow Protrusion

Tuesday, August 20th, 2013

 

Background: A brow bone prominence is largely a male feature caused by a greater pneumatization (expansion of air cavity) of the frontal sinuses than in women. While female brow bones are relatively flat, most men will have some degree of prominence or ridging that creates a brow bone break as it ascends into the forehead. Thus some degree of a brow prominence is well tolerated in men and may even be aesthetically desireable as a strong gender trait.

Excessive pneumatization of the frontal sinuses creates a brow bone prominence that extends well beyond the natural plane or slope of the forehead. Whether a brow bone prominence in some cases is excessive is a matter of personal judgment, in others it is so extreme that it is obvious. Brow bone reduction surgery, usually by an osteoplastic flap method, is the only effective treatment to reshape this lower portion of the forehead.

When considering whether brow bone reduction should be done, the shape of the forehead above it must also be considered. In many cases, the upper forehead is normal and setback of the brow bones is all that is needed. In other cases, a combination of brow bone setback and forehead augmentation produces the best profile change. In rare cases, the brow bone position is normal and it is the excessively sloped forehead that is the culprit. (pseudo brow bone prominence.

Case Study: This 35 year-old male felt he had too strong of a brow bone and disliked his forehead shape. He had a significant retroclined angulation to his forehead and this raised the question as to whether his brow bones had too much horizontal projection or that the forehead projection was deficient. Computer imaging was done to determine whether brow bone reduction or forehead augmentation produced a better forehead profile appearance.

Under general anesthesia, he had a coronal (scalp) incision placed way behind his hairline (16 cms) and raised to expose his forehead down to his brow bones. The forehead above his brow bones was built up using 50 grams of hydroxyapatite cement into a smooth transition into the upper forehead and staying within the temporal lines and off of the temporalis muscles. (fascia)

His after surgery result showed exactly what was predicted by computer imaging beforehand. He has a much better forehead shape and his brow bone prominence was ‘gone’.  Changing the slope of his forehead was the source of his aesthetic forehead deformity.

Of great interest for any man is the risk of adverse scarring from a coronal scalp incision. Scalp incisions in men must be done with the greatest of care and concern for the aesthetic outcome. The healing of his incision, as judged across the top where his hair was the thinnest, was amongst the finest that I have ever seen. (very hard to detect even on the closest of inspection)

Case Highlights:

1) A prominent brow bone can be the result of a recessed forehead. (pseudo brow bone prominence)

2) Computer imaging done in the profile view can determine whether forehead augmentation or brow bone reduction produces the better aesthetic facial result.

3) Forehead augmentation is done through an open scalp incision and can be done with either hydroxyapatite or acrylic bone cements.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Hydroxyapatite Forehead Augmentation

Monday, July 29th, 2013

 

Background: Although the forehead occupies almost 1/3 of the entire face, it is the one bony facial structure that is least changed for aesthetic purposes. Chin, cheeks, noses and jaw angles are far more commonly surgically altered than the much larger forehead.

The most common forehead change is augmentation of a flat or recessed forehead shape.  When doing so it is important to take into consideration the gender of the patient. Women desire a more convex forehead shape that has a more vertical inclination. Men desire a stronger brow bone appearance with a brow bone break into a more oblique or backward forehead inclination to the hairline.

Forehead augmentation requires two elements, an open coronal scalp incision for access and a synthetic material to add to the bone. Forehead augmentation materials include PMMA (acrylic) and hydroxyapatite (HA) powder and liquid compositions as well as preformed implants made from a 3D CT scan. Most commonly the liquid and powder compositions are used due to their lower cost and the lack of any need for preoperative CT scanning.

While both PMMA and HA can create very successful forehead augmentations, there are some material differences. PMMA is the most ‘synthetic’ of the two, costs less per volume of material and achieves a material strength that is at least as strong as bone if not stronger. HA is often viewed as the more ‘natural’ of the two since the mineral hydroxyapatite comprises about 70% of the inorganic composition of human bones. It costs more than PMMA per gram of material and takes more grams per surface area to achieve the same augmentation effect.

Case Study: This 35 year-old female wanted more prominent brows and forehead projection for her naturally flatter forehead. She specifically wanted a conservative augmentation of about 5 to 6mms of increased projection (forehead/brow augmentation) and wanted to use hydroxyapatite material.

Under general anesthesia, a coronal scalp incision was made 4 cms behind her natural thick hairline from ear to ear. With the forehead soft tissues reflected downward, the entire forehead and brow bones were exposed. A total of 50 grams of Mimix (one brand of HA cranioplasty material) was mixed together with antibiotic powder and applied as a putty. As it was setting the material was shaped into a smooth convex shape upward from the brow area. Once set the forehead tissues were repositioned and the scalp incision closed with dissolveable sutures.

Like all forehead augmentations she had about a week of visible swelling around the eyes. It took a full three weeks for most of the forehead swelling to subside. When seen back a year later her scalp incision was so well healed that it was virtually undetectable.

The most natural material for forehead augmentations is hydroxyapatite. (HA) Studies have shown that bone does bond directly to the material without a fibrous (scar) interface. However due to its higher cost it should be reserved for use in more modest forehead augmentations. When pronounced or significant volumes of material are needed for a large area like the forehead, PMMA offers an effective and economical alternative bony material.

Case Highlights:

1) Forehead augmentation in females is done to improve the shape of a flat forehead to a more convex one.

2) Forehead augmentation requires the application of a synthetic material of which the most common are the intraoperatively-shaped bone cements.

3) The most natural synthetic material for forehead augmentation is an hydroxyapatite composition which is a non polymer-based material.

Dr. Barry Eppley

Indianapolis, Indiana

The Psychological Aspects of Facial Structural Surgery

Wednesday, March 21st, 2012

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

 

Biomaterials for Forehead Augmentation – PMMA (Acrylic) vs HA (Hydroxyapatite)

Sunday, March 29th, 2009

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

Forehead Augmentation With Synthetic Materials

Wednesday, December 10th, 2008

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

Forehead and Brow Bone Augmentation Surgery

Monday, September 29th, 2008

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


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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