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Archive for the ‘forehead augmentation’ Category

Case Study – Forehead Reconstruction with Hydroxyapatite Cement

Sunday, February 5th, 2017


Background: Many well known congenital skull deformities (craniosynostoses) are treated by early surgery, usually under one year of age. While this allows the developing brain more space to grow and have it help shape the overlying skull, the final shape of the skull is rarely ideally normal. Scar, growth potential and genetics all play a role in preventing a consistent and reliably formed convex skull shape.

Such secondary skull deformities are most manifest in the forehead. Between its visible large contribution to the face and the frequent bone irregularities and temporal hollowing that develops from prior surgeries, the forehead can lack a smooth and pleasing shape. Forehead recession and narrowing along with temporal depressions makes for a commonly seen disproportionate forehead contour. Many of these patients will also have small metal plates and screws across the forehead and brow bones as well as some full-thickness bone defects.

Case Study: This 22 year-old female was originally born with a bilateral coronal craniosynostosis. She has previously undergone both early and several subsequent fronto-orbital reconstructive procedures. Her forehead had a recessed and inverted shape and the temporal areas at the side of the forehead had marked hollowing. There were also several areas of tenderness over the forehead underneath which were palpable metal hardware.

Hydroxyapatite Cement Forehead Augmentation Dr. Barry Eppley IndianapolisUnder general anesthesia and using the full extent of her existing coronal scalp incision, the forehead and temples were fully exposed. Over a dozen plates and thirty small screws were removed. Numerous full thickness bone defects were encountered with intact dura. Using over 150 grams of hydroxyapatite cement,  the forehead, brows and temporal region were built up to more normal contour. All full thickness skull defects were also covered at the same time.

NN Forehead Augmentation with Hydroxyapatite Cement result oblique view Dr Barry Eppley IndianapolisNN Forehead Augmentation withj Hydroxyapatite Cement result front view Dr Barry Eppley IndianapolisHer forehead and temporal areas showed much improved contours once all the swelling had resolved. This fronto-temporal augmentation improved what looked like a constriction band around the forehead just above the brow bones.

The use of hydroxyapatite cement is largely restricted to such procedures as forehead reconstruction due to its high cost. ($100/gram) Its working properties also make it most easily and consistently used with wide open exposure of the bone site. These two reasons keep hydroxyapatite cement from more frequent use in aesthetic skull reshaping surgery.


1) Forehead reconstruction of large contour defects from congenital skull deformities is best treated by hydroxyapatite cement.

2) Hydroxyapatite cement offers a smooth and highly biocompatible contouring material for long-term persistence.

3) The high cost of hydroxyapatite cements makes their use more common in reconstructive forehead reconstruction and not aesthetic forehead augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Forehead Implant

Sunday, January 15th, 2017


The aesthetic correction of a retroclined or sloped forehead can be done by a variety of surgical techniques. Fat has become popular as an ‘easy’ injectable method of augmentation but it is important to remember that it is best used for soft tissue augmentation. In most cases forehead augmentation is a bony deficiency not a soft tissue one. Fat injections into the forehead can be unpredictable in terms of volume retention and smoothness so it is not a primary forehead augmentation procedure.

A variety of implant materials can be used in the forehead. Bone cements have a long history as a skull augmentation material including in the forehead. While effective their use requires a near coronal scalp incision for placement and is prone to irregularities and edge deformities. Their shape also depends on the surgeon’s artistic skills and being able to translate the patient’s aesthetic desires into a moldable shape.

Custom Forehead Implant Dr Barry Eppley IndianapolisAll of the potential negative aspects of bone cements for forehead augmentation are eliminated by the use of a 3D custom forehead implant. The exact shape and edging of the implant are determined and made before surgery. The insertion of the implant is done through a much smaller scalp incision due to its flexible nature. Tissue ingrowth into the implant is fostered by the placement of numerous perfusion holes. The outer smoothness of the augmented shape is assured by its preoperative design.

A custom forehead implant offers a superior method of aesthetic forehead contouring in my experience. While it still requires accurate placement of its predetermined design, the number of variables that can lead to undesired effects is reduced by its basic concept.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Cement Forehead Augmentation

Saturday, December 31st, 2016


Background: The shape of the forehead is very gender specific. Men have foreheads with distinct brow bone prominences, a visible brow bone break and a forehead that slopes somewhat less than vertical above it. Conversely females have no distinct brow bone, have a rounded or more convex forehead shape that ideally has a near vertical inclination.

The request for forehead augmentation is females is usually to provide increased convexity and verticality. The female forehead that is flatter and more recessed requires augmentation usually from above the brow bones up to or just past the edge of the frontal hairline. The shape of the augmentation is more important than its thickness or size.

The choice of augmentation material for the female forehead depends on how much surgical exposure is needed and what type of scalp incision the patient can tolerate. The smallest scalp incision with the least exposure needed is the custom forehead implant. For the use of hydroxyapatite cement a longer scalp incision is needed for greater exposure to properly apply the material and shape it as it sets.

forehead-augmentation-with-hydroxyapatite-cement-intraop-dr-barry-eppley-indianapolisCase Study: This 40 year-old female wanted to increase the projection of her forehead and make it more vertical.Through a near complete coronal scalp incision, 65 grams of hydroxyapatite cement (Mimix) was applied to the forehead and shaped until dry. The hydroxyapatite cement was mixed with antibiotic powder in a ratio of 10:1 gram weights.

forehead-augmentation-with-hydroxyapatite-cement-result-side-view-dr-barry-eppley-indianapolisHer postoperative results shows a more convex and vertically oriented forehead shape. The convexity of the augmented forehead slightly exceeds the brow bones as it does in many pleasing female foreheads.

Hydroxyapatite cement is a wonderful skull augmentation material, particularly in the forehead. It heals to the bone without a fibrous interface and can even have some bone growth into its microporous structure when set. Despite this major biologic advantage, it requires wide open access to properly apply the material. This means a coronal or pretrichial incision is needed to get an even application of the material that sets properly.


1) Forehead augmentation can be done by a variety of biomaterials, all of which can produce similar satisfactory results.

2) Hydroxyapatite cement is the most biologically favorable of all forehead augmentation materials.

3) The handling characteristics of hydroxyapatite cement requires wide open exposure for   an aesthetically pleasing forehead contour.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Forehead Augmentation with Hydroxyapatite Cement

Monday, December 12th, 2016

The forehead occupies a third of the visible face. Because it does not have any topographic features that draw one’s attention to it like other parts of the face, its broad non-remarkable surface is not an immediate eye-catcher. But despite being relatively bland, the sheer size of the forehead does play a role in aesthetics and there are well known gender differences in its shape.

The male forehead has the topographic feature of brow bones with a forehead that is flatter and may even have a slight backward slope to it. Conversely women usually have no visible brow bones and a more convex and rounded forehead that is almost completely vertical.

For women that desire forehead augmentation there are a variety of material options to achieve a feminization effect. From bone cements to preformed implants each choice has their own unique advantages and disadvantages. To some degree they are all implant materials and the body responds to them by differing degrees of encapsulation.

hydroxyapatite-cement-forehead-augmentation-dr-barry-eppley-indianapolisFrom a biologic standpoint the argument could be made that hydroxyapatite cement is the most biocompatible material for forehead augmentation. A direct bonding of the material does occur without a fibrous layer at the bone-cement interface. This unique biologic response to it is countered by the need to apply the cement in an open fashion through a coronal scalp incision. It is also the most costly of all forehead augmentation material options.

While there are different forms of commercially available hydroxypatite cement for craniofacial applications, these difference are largely in the material’s handling and set properties.

Case Study – Limited Incision Forehead Augmentation

Sunday, July 17th, 2016


Background: Forehead augmentation in men is often done to correct a pseudobrow protrusion deformity. This is where the position of the brows is actually normal but the superior position of the forehead is deficient. This makes the brow bones comparatively look too strong. This diagnosis can be confirmed by doing computer imaging where the forehead is either brought forward or the brow bones brought back.

In these cases of pseudobrow bone prominence, augmentation of the forehead above is the corrective aesthetic procedure. There are multiple materials to use for forehead augmentation from bone cements to custom implants. In isolated more central forehead augmentation procedures the use of bone cements is the most economical approach.

The issue with frontal cranioplasties with bone cements is that wide open access is usually needed to place them. This is particularly true with the hydroxyapatite bone cements which are like thick putty when mixed and do not have good material flow. A near or complete coronal scalp incision is needed to ensure even application and good feathering at the edges. PMMA bone cement, however, has different material flow properties that permit smaller incisional application.

Case Study: This 25 year-old male was bothered by his prominent brow bones. Through computer imaging it was shown that his forehead above the brow bones was recessed. Augmentation of his forehead above the brow bones was determined to create the best aesthetic result.

Limited Frontal Cranioplasty incision and closure Dr Barry Eppley IndianapolisUnder general anesthesia an 11 cm long irregular scalp incision  was made 3 cms behind the frontal hairline. Subperiosteal dissection was made down to the brow bones and out past the anterior temporal lines. Using PMMA bone cement mixed with antibiotic powder a putty was created. The putty was inserted into the pocket and then shaped through external molding with particular attention paid to creating smooth edge transitions across the brow and temporal lines. Any excess was pushed towards the incision where it was removed before the material completely set. A hand piece and burr was then used to make sure all visible edges were feathered.

Forehead Augmentation with PMMA intraop result Dr Barry Eppley IndianapolisA frontal cranioplasty using PMMA bone cement can be done through a more limited scalp incision. The material flows well and can be shaped externally as it sets. It takes good experience working with the material to be able to get a good shape of it in a partially blinded fashion. Meticulous attention was be paid to edging and the detection and elimination of any irregularities. If any exist they will eventually be seen moths laters when the forehead tissues have fully contracted.


1) Forehead augmentation in men can be done to include the brow bones or done in isolation for the forehead region above it.

2) Using bone cement for forehead augmentation typically requires a long scalp (coronal) incision.

3) Using PMMA bone cement a limited scalp incision can be used for forehead augmentation…if one has a lot of experience using this type of bone cement.

Dr. Barry Eppley

Indianapolis, Indiana

Female Forehead Augmentation

Tuesday, May 3rd, 2016


Female Forehead Augmentation  Surgery Dr Barry Eppley IndianapolisThere are numerous gender differences in the shape of the female and the male face and the forehead is no exception. In fact the forehead can be one of the most significant gender markers. This is seen in the prominence of the brow bone in men and the suprabrow bone break that women don’t (or should not) have. Females should have no visible brow bossing with an overall forehead shape that is more rounded (convex) and a fairly flat (vertical) side profile. While men can have some backward sloping to their forehead, this is not aesthetically pleasing in women.

In female forehead augmentation, one has to have a good knowledge of how to shape the forehead and the materials that can be used to do it. I have used every available implant material that is known to exist for forehead augmentation including numerous types of bone cements and standard and custom made implants.

Female Forehead Augmentation intraop above view Dr Barry Eppley IndianapolisFemale Forehead Augmentation result intraop side view Dr Barry Eppley IndianapolisWhile most of these materials can be used to create a satisfactory forehead augmentation,  none of them are perfect. The most commonly used of these materials is PMMA bone cement because of its ease of use and economical cost. While it takes experience to use it effectively, it allows good working time but comes to a fast set after it is contoured. It can be impregnated with antibiotics for a sustained release from the material for weeks after its implantation. Like all bone cement materials it require a fairly open incision to accurately place if the entire forehead needs to be contoured.

Asian Forehead Augmentation result side view Dr Barry Eppley IndianapolisFemale Forehead Augmentation  result side view Dr Barry Eppley IndianapolisThere are several surgical caveats with its use in female forehead augmentation. It is important to not over augment the forehead particularly in forward projection. Some convexity is needed but one does not want to end up with an overall frontal bossing effect. While its intraoperative application is an artistic judgment, when in doubt less is more so to speak. The goal is more of a completely flat and more vertical forehead.

To avoid too wide of a forehead, it is important to keep the cement application inside the anterior temporal lines. The augmentation should generally not spill over onto the temporalis muscle/fascia. If it does there is some risk of causing discomfort with cement edges on the soft tissues of the muscle.

Female forehead augmentation with PMMA bone cement can done successfully with a low risk of revision if the aesthetic goals are understood and the material is applied following these principles.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Custom Forehead Implant Placement

Monday, November 30th, 2015


Forehead Implant Design Dr Barry Eppley IndianapolisAesthetic forehead augmentation to correct a sloped, irregular or deficient frontal bone can be done by a variety of materials placed on top of the bone. Having used every one of them, they each have their merits and each material type can be successfully used in experienced hands. But the forehead augmentation method that has the best results is that of a custom forehead implant.

Endoscopic Custom Forehead Implant incision Dr Barry Eppley IndianapolisBesides being able to create the exact shape and thickness desired before surgery, a preformed custom forehead implant can also be inserted through the smallest scalp incision. While the use of bone cements require a full coronal incision to be placed in most cases, a custom forehead implant can be inserted through an incision that is limited to between the bony temporal lines. This avoids extending the incision onto the temporal area on the sides of the head where the scar can be more easily detected and always gets wider than that across the top of the head.

Endoscopic Custom Forehead Implant positioning Dr Barry Eppley IndianapolisThe biggest concern about placing a custom forehead implant is to get it low enough over the brow bones if that is the way it was designed. Placing a forehead implant that does not involve the brow bones is far easier and adequate positioning is almost never an issue.   But placing a complete custom forehead implant that must go over the brow bones first requires a subperiosteal release and supraorbital nerve dissection. This must be done with an endoscope given the limited size of the scalp incision. Once the forehead implant is inserted checking its placement with an endoscope can also be done.

The use of the endoscopic technique in a custom forehead implant is to ensure as best as possible the extent of the subperiosteal pocket and protection of the supraorbital nerves. It is not used because it can limit the extent of the scalp incision like is done is more traditional endoscopic browlift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Forehead Augmentation

Thursday, September 17th, 2015


Forehead feminization Surgery Dr Barry Eppley IndianapolisBackground: Like the rest of the face, the appearance of the forehead is very gender specific. A female forehead usually has three specific components to it. First there is no perceptible brow bone ridge or brow bone break into the forehead. It is smooth as it ascends from the supraorbital rims into the upper forehead. Secondly, this ascension upward has more of a vertical orientation and not a backwards sloping or anterior protrusion profile to it. Lastly, there is an overall convex shape that is more full centrally and tapers into the temporal regions.

Female forehead augmentation can be done using a variety of different materials from bone cements to preformed and custom silicone implants. The choice of which material method to use depends on a variety of factors not the least of which is the amount of augmentation needed and the type of incisional approach to be used. With a completely open approach to forehead augmentation a viable option is that of bone cements. Such visual access allows for good cement application and shaping which is a critical part of intraoperatively applied onlay materials.

Before custom forehead implants became a treatment option, the gold standard for female forehead augmentation was the use of PMMA bone cements. This is still a useful material choice but does require a scalp incision of some length. A hairline or pretrichial incision can be used if one is also moving the hairline or one can tolerate the location of the scar. The further back in the hairline one goes the longer the scalp incision must be to provide adequate access for cement application and shaping.

Case Study: This 25 year old female wanted to create a better forehead shape. She felt her forehead sloped back too far and wanted more projection, particularly in the central part of the forehead. She already had a coronal scalp incision/scar from a prior procedure.

Female Forehead Augmentation with PMMA Bone Cement intraop Dr Barry Eppley IndianapolisUnder general anesthesia, her coronal incision was reopened and a complete forehead flap developed down to the brows. Sixty (60) grams of PMMA bone cement was prepared with antibiotic powder to create a putty. The PMMA putty was applied to the forehead and shaped by using the forehead flap to spread it out evenly over the forehead until it set. Once set final shaping and smoothing of the edges was done by a handpiece and burr.

Female Forehead Augmentation result side view Dr Barry Eppley IndianapolisFemale Forehead Augmentation result oblique view Dr Barry Eppley IndianapolisFemale forehead augmentation can be successfully done using PMMS bone cement. The material offers a permanent and smooth solution to reshaping the contours of the forehead. A longer scalp incision is usually needed to assure smooth edges. Most females do not need large volumes of material and usually 60 grams of PMMS material are adequate.


1) The ideal shape of the female forehead is that of a more convex shape without brow bone prominences and a near vertical orientation.

2) Female forehead augmentation can be done using bone cements but require a more open scalp incisional approach to do so.

3) A coronal scalp approach to a female forehead augmentation is best reserved for those women having  other skull procedures or who already have a full coronal scalp scar.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Glabellar Augmentation in Forehead Narrowing

Friday, May 8th, 2015


Reshaping a wide and prominent forehead is done by bone reduction, removing as much outer cortical bone of the skull as is needed to create more of tapered forehead shape. Most of the bone removal is done on the sides crossing the anterior temporal line as needed. This usually requires release of the superior attachments of the temporalis muscle and fascia.

Many wide foreheads also have a central flat area either in the glabellar or just above the glabellar region. This is normal and even expected as the wider the forehead the more likely it will have a flat profile. While not all wide foreheads have this central flatness it is important to look for it

Glabellar Augmentation in Forehead Dr Barry Eppley IndianapolisForehead Narrowing with Glabellar Implant Dr Barry Eppley IndianapolisAs a complement to forehead reshaping to achieve a more narrowed look, augmentation of the flatter central or glabellar area can be helpful. This is most easily done by adding a small amount of PMMA bone cement to the area and contouring it smooth and flush with the surrounding frontal bone. Because it is a small implant it is best to secure it with small titanium screws that are placed flush to the implant.

Adding a small amount of central projection to the central forehead can help make the look more narrowed and contoured when done with aggressive side bone reduction. This is an easy addition to an open forehead recontouring procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – Custom Forehead Implant for Central Depression

Thursday, February 19th, 2015


Background: The shape of the forehead is well known to be gender-specific. Women usually prefer smooth convex foreheads with no obvious brow bone prominences. Conversely, men usually desire evidence of a brow bone with a break into the mid-forehead with a more retroclined  shape into the upper forehead. While I have seen males and females cross these classic forehead shape differences with iterations in between, these general preferences remain.

Male Forehead Shape Dr Barry Eppley IndianapolisThe male forehead shape is more ‘complex’ than that of the female. With brow bone prominences that stick out further than the central forehead, combined with a slight glabellar indentation, the male forehead has more subtleties in its shape. Changes in these subtleties can result in aesthetic imbalances that cast shadows or create undesired profiles.

When men have too much brow bone protrusion it can make the mid- to upper forehead look too far back. Conversely, a recessed forehead can make the brow bones look like they are too big. This is an important distinction to make as the treatment approaches to either one are very different. Computer imaging can help make the diagnosis as to whether it is the forehead or the brow bones that are the source of the aesthetic concern.

Case Study: This middle-aged male did not like the shape of his forehead. He liked the amount of brow bone prominence that he had but felt the central forehead directly above it was too recessed. This created an unaesthetic shadowing which he desired to be improved/eliminated.

Custom Central Forehead Implant Design Dr Barry Eppley IndianapolisUsing a 3D CT scan, a custom forehead implant was made to fill in the central depression. Its shape had an extension that went into the glabellar indentation and it blended into all the other forehead area with a fine edge taper. (< 1mm) Its greatest thickness at its midportion was 4mms.

Custom Central Forehead Implant desigtn and locationUnder general anesthesia, a small zig zag incision (3cms) was made between the hairs just behind the frontal hairline.  A subperiosteal pocket was developed through this incision, taking it just to the limits of the presurgical marks on the forehead. The custom implant was prepared by making five 2mm holes through the implant. (perfusion/fixation holes) The implant was easily inserted, positioned and the scalp skin closed with resorbable sutures.

Custom Central Forehead implant intraop side view Dr Barry Eppley IndianapolisWhile the type of custom implant is small, it is the most accurate method to create a smooth central forehead augmentation. Other methods of forehead augmentation exist, such as bone cements, but they require longer incisions to insert and the risk of edge transition visibility/palpability is higher.

Case Highlights:

1) Forehead depressions and contour irregularities require bone augmentation.

2) The simplest and most reliable form of forehead contour augmentation is with the use of a custom forehead implant which can be done through the smallest incision and the least invasive procedure.

3) ‘Prominent’ brow bones in men can be artificial as the real bony problem is a backward forehead slope or depression above the brow bones.

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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