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Archive for the ‘forehead augmentation’ Category

The Contemporary Use of Custom Forehead Implants

Sunday, February 11th, 2018


Augmentation of the forehead is done for a variety for reasons which differ based on gender and ethnicity. In women it is usually to create a rounder and more vertically inclined forehead which often does not include the brow bones. In men it is either for brow bone augmentation alone, correction of a backward forehead inclination or for a combined forehead-brow augmentation effect.

Historically forehead augmentation was done using bone cements. While this method can be effective for some more modest aesthetic forehead improvements, its use requires a full or nearly full coronal scalp incision as well as the need to intraoperaively shape the material. While intraoperative material shaping may seem appealing, it relies entirely on the surgeon’s ability to do so and is more limited for complex shapes particularly if it involves the brow bones.

Custom forehead implants have become the contemporary method for an type of augmentation of the upper facial third. While its solid silicone material can appear to be a disadvantage due to lack of tissue ingrowth/adherence, its many other advantages far outweigh this one biologic ‘disadvantage’. First and foremost, custom forehead implants are made before surgery through the use of computer design. This means that any shape and thickness of the forehead augmentation can be created provided the surgeon believes the overlying scalp/forehead tissue can accommodate it. This is of tremendous relevance when the augmentation involves the brow bones since this area is very hard to adequately augment with bone cements.

The second advantage of custom forehead implants is that they can be placed through a much smaller scalp incision. Because the implant is flexible it can pass through an incision that has less of a length than the widest part of the implant. At the very least the scalp incision does not have to extend beyond the lateral temporal lines…and keeping the incision away from the side of the head (temples) helps tremendously with incision camouflage.

The third advantage of custom forehead implants, which on the surface may not seem so, is that it is easily reversible. Should a revision of the forehead implant be necessary, it can be removed and reinserted in the straightforward manner in which it was inserted.

Most forehead augmentations do not usually need large amounts of augmentation in terms of thickness or forehead expansion. Conversely, however, their shape demands are often very specific and the outline (footprint) of the implant is critical. The surface of the forehead may seem fairly flat but it is more complex than usually perceived and changing that surface into a more desirable outer contour is best done with preoperative computer designing.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Forehead Augmentation using Bone Cement

Monday, February 5th, 2018


Background: The forehead occupies a large surface area of the face and the broadest uninterrupted facial contour. Between the brows bone and the frontal hairline, it is a vast expanse of skin that can only be judged by its size and overall shape. While its more superficial features undergo frequent aesthetic manipulations (Botox, injectable fillers and brow lifts), the bony shape of the forehead does not. This, however, does not mean it is not capable of being changed but it is more of a surgical endeavor to do so.

The shape of the forehead can be very gender specific as is well known in facial feminization surgery as well as facial masculinization surgery. Beyond the very gender specific feature of the more prominent male brow bones, the female forehead has a more vertical inclination as seen in the side view and a more rounded shape between the temporal lines on the sides of the forehead best seen in the oblique or superior-inferior views.

Female forehead reshaping to create a more pleasing shape often involves augmentation of the frontal bone in a shape specific manner. There are two surgical techniques to perform it using different materials and incisional approaches. The traditional technique involves the application of bone cements placed through a wide open exposure. Such exposure is needed because bone cements, regardless of their material composition, are applied in a putty-like fashion and then shaped and allowed to set. Such applications can not be disturbed by the pressure of a tight overlying scalp/forehead flap less significant contour deformities be created in the augmentation. Not to mention that getting the right forehead shape initially requires good visualization.

Case Study: This young female had a more recessed and triangular forehead shape with a slight backward vertical inclination.

Under general anesthesia and through a full coronal scalp incision, the forehead was exposed down to the brow bones. Using hydroxyapatite bone cement the forehead was  built up with emphasis on increasing projection between the temporal lines and giving the forehead a rounder shape with more vertical inclination.

These forehead augmentation efforts created a rounder more convex shape that did not increase any brow bone projection.

Hydroxyapatite is one option for a forehead augmentation material. One could argue it is the ideal forehead augmentation as its inorganic hydroxyapatite crystals allows direct bone bonding to it. But because of how it is applied and shaped it requires a full coronal incision to use it properly. In addition at a material cost of $100/gram, and a typical case may require at least 50 to 75 grams, adds considerably to the overall expense of the surgery.


1) The shape of the female forehead is one of greater convexity and a more round shape when viewed from above or below.

2) One method of forehead augmentation is the use of bone cements done through a full coronal scalp incision.

3) Augmenting the lateral or temporal sides of the forehead, with or without increased central projection, creates a more vertically inclined shape that is rounder.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Forehead-Temporal Implant Replacement

Wednesday, July 19th, 2017


Background: The size of the forehead has a major influence on the appearance of one’s face, occupying the entire upper third of it. Beyond its size the shape of the forehead is also important with many gender specific features. In general, males have stronger brows, a wider forehead and a gentle backward slope to it. In contrast female have no brow bone protrusion, a convex forehead shape that has a more vertical orientation.

\Of all the facial bones, the forehead is the least commonly augmented. Intraoperatively shaped bone cements and preoperatively shaped custom implants are the two most common methods of forehead augmentation. Given the advantages of a more thought out forehead shape design and the ability to place it through a small scalp incision, custom forehead implants are usually the superior treatment approach.

But the success of a custom forehead implants comes down to its design. While computer designing an implant has many advantages, what the best shape and dimensions are that can create the patient’s desired forehead shape  is not a mathematical calculation. It is an art form that is based on the surgeon’s understanding of the patient’s desires and experience in appreciating the effects of various designs on the outward aesthetic outcome.

Case Study: This 25 year-old male had a custom PMMA forehead implant placed through a full coronal scalp incision six months previously. While the implant provided some brow bone augmentative effect, it did not extend all the way top the forehead and created a line of demarcation at the mid-forehead level. He was interested in having an implant design that covered his entire forehead as well as extended outward further into the temporal areas.

A new custom forehead-temporal implant design was made that covered more than 100% greater surface area than his indwelling implant. It covered the entire forehead back behind the frontal hairline, extended over the entire anterior temporal region down to the zygomatic arches as well as added a few more millimeters of brow bone augmentation.

Under general anesthesia, his existing coronal incision was re-opened and his forehead implant exposed and removed. The difference in surface area coverage between the removed and new custom forehead-temporal implant was significant.

The new style of custom forehead implant was then inserted and secured with small microscrews to the bone and sutures of the temporal extensions to the temporal fascia.

When designing a forehead implant there are four surface areas or zones to consider. They are the brow bones, the mid- and upper forehead, the temporal lines and the temporal zones. (often referred to as the sides of the forehead) The coverage or lack oil coverage of these areas must first be considered before determining what thicknesses they should be.


  1. Subtotal forehead implants often leave the forehead inadequately augmented.
  2. Custom forehead implants must consider the impact on the entire forehead as well as the adding temporal regions.
  3. Complete frontal augmentation covers the entire forehead as well as the temporal areas.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Augmentation by Fat Injections

Sunday, April 30th, 2017


Forehead augmentation can be done using a variety of materials and methods. It is probably most popular worldwide in Asians who often have a flatter and less convex forehead shape. While the use of synthetic materials is the most effective and assured forehead augmentation method, m both in terms of shape and longevity, it is an invasive procedure that requires some form of a scalp incision to have the forehead implant material placed.

Given the success of injectable fat grafting for facial voluminization, whether it could work as well in the forehead remains an intriguing consideration as another option for forehead augmentation in select patients.

In the March 20178 issue of the International Journal of Plastic Aesthetic and Reconstructive Surgery a paper was published entitled ‘Micro-autologous Fat Transplantation (MAFT) for Forehead Volumizing and Contouring’. In this paper The authors report on 178 patients (167 female, 11 male) over a 5-year period with an average nearly three year followup. Using harvested fat that was prepared by centrifugation, the forehead was augmented by an injection gun device. The procedure took under one hour to complete and averaged around 10ccs of injected fat. Not complications occurred such as infection, irregularities  or nerve injuries occurred, The authors reported that over 80% of the patients were satisfied with their results.

The proper title for this paper should have been Small Volume Forehead Augmentation by Injected Fat. With an average injection volume of just 10ccs of fat placed the amount of forehead augmentation obtained was very modest and in the central forehead location. In my forehead augmentation experience such a small amount of forehead augmentation would satisfy few patients even with an uncomplicated outcome.

But for those patients that seek very modest forehead augmentative changes, fat injection is a good technique as it avoids any scar from incisional access and has no significant risks. Like all fat injections, the survival and persistence of the fat transplants are not assured. But low volume micro fat grafts in the facial area has a known high rate of retention and the forehead should be no exception..

Dr. Barry Eppley

Indianapolis, Indiana

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

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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