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Archive for the ‘forehead augmentation’ Category

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

Technical Strategies – Pretrichial Approach to Forehead Craniotomy Defect Reconstruction

Tuesday, January 6th, 2015

 

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – Male Forehead Augmentation

Monday, December 22nd, 2014

 

Forehead Shapes Dr Barry Eppley IndianapolisBackground: The forehead represents one third of the face and had a valuable role to play in facial aesthetics. Besides the length and width of the forehead, its other major aesthetic feature is its slope. (as most easily appreciated in the side view) This forehead feature is well known to be gender specific. Women have more vertical inclined forehead (with convexity) and a smooth transition into the brow bones. Conversely men have a more inclined forehead with defined brow bones and a definitive break between the brow bones and the forehead.

Most men that desire forehead changes have issues with either the prominence of the brow bones or shape of the forehead above it. While both may be at fault, isolated forehead concerns are usually because of lack of projection. The forehead slopes back too far. The more retroclined the forehead slope is, the more unaesthetic it becomes as it creates more of a ‘neanderthal’ appearance by making the brow bones bigger.

Male forehead augmentation can be successfully done through two methods of bone augmentation. Options include the application of a bone cement (like PMMA) or the preoperative fabrication of a custom designed silicone implant. Each method has its own distinct advantages and disadvantages but both can be very effective. PMMA cement application requires an artistic sense to apply it evenly without over correction or palpable temporal edges.

Case Study: This 35 year-old male wanted to improve the shape of his forehead as he felt it had too much of a backward slope to it. It had a near 55 degree angulation and he wanted it almost vertical in a profile view.

Male Forehead Augmentation result side viewUnder general anesthesia, a limited coronal scalp incision was made without shaving any hair. A limited coronal incision means that it does not go all the way down to the ears but the incision stays 3 to 4 cms above it one each side. The forehead was exposed in the subperiosteal plane down to the brows inferiorly and to the temporal line at the sides. Using 60 grams of PMMA cement mixed with antibiotic powder, it was applied as a putty and shaped using the forehead/scalp flap to create the desired angulation and make it snooth. Once set the temporal and back edges were smoothed. The scalp incision was closed with dissolveable sutures with no use of a drain.

Male Forehead Augmentation result oblique viewRecovery from the forehead augmentation was fairly quick with no bruising or significant eye swelling. The improvement in the slope of the forehead was noted immediately with full appreciation of the final effect by six weeks after surgery. Scalp numbness behind the incision line took over three months to return to normal. The final forehead contour was smooth with the exception of a small indentation behind the hairline on the left temporal side which was not a major concern to the patient.

The historic method of forehead augmentation with PMMA bone cement is still an effective treatment approach. Its biggest drawback is that it must be intraoperatively shaped and this introduces the variable of irregularities or shape issues. Considerable experience is needed in working with bone cements in their putty phase to master their handling and shaping.

Case Highlights:

1) Forehead augmentation in men is usually done to correct a severely backward sloping forehead which accentuates the size of the brow bones.

2) One method of forehead augmentation is the application of bone cement through an open scalp incision.

3) The shape of a male forehead augmentation is to change the slope of the forehead but to still preserve a brow bone break.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Forehead Augmentation for Forehead Horns

Tuesday, October 21st, 2014

 

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

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

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

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

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

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

Case Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Widening Implants

Tuesday, September 9th, 2014

 

Facial implants are commonly used to augment various areas of the face. While historically this had been relegated to the cheeks and chin, their use has been widely extended to many other facial areas as well. One of the newer areas of facial implant use has been the temporal region for correction of excessive temporal hollowing or concavity.

Zone 1 temporal implant results Dr Barry Eppley IndianapolisTemporal implants are uniquely different from almost all other facial implants because they do not augment bone. Rather they are soft tissue implants that augment the amount of muscle volume that exists in the temporal region. What causes temporal hollowing is loss of fat volume and/or muscle, not a change in bone volume. While augmenting the anterior aspect of the temporal bone can be done, it would require a large implant placed very deep under the muscle to create that effect. It is far simpler and more effective to place a smaller implant right under the fascia on top of the muscle which is how newer temporal implants are done today.

High Temporal; Implant Design for Forehead Widening Dr Barry Eppley IndianapolisTraditional temporal hollowing involves the lower half of non-hair bearing aspect of the temporal region just to the side of the eye. (lateral orbit) This is referred to as the Zone 1 temporal region. But other temporal areas can be augmented as well for different aesthetic effects. One of these is the Zone 2 temporal region. This is the upper half of the non-hair bearing area (above Zone 1) which is more to the side of the forehead than it is the eye. It abuts right up against the anterior temporal line of the forehead. Thus augmenting the temporal zone 2 creates a forehead widening effect.

high temporal implant Dr Barry Eppley IndianapolisZone 2 temporal implants, like Zone 1, are placed under the fascia from a small incision in the temporal scalp area. While they are subfascial, the temporalis muscle gets very thin as it approaches the forehead. In addition, the underlying temporal bone no longer is concave but starts to become almost convex as it merges into the forehead. Thus a Zone 2 temporal implant is closer to being a bony augmentation technique rather than a purely muscle implant like Zone 1.

Widening the forehead has been traditionally very difficult. Extending bone cements from a forehead augmentation onto the temporalis fascia can result in a visible line of the material and discomfort. Fat injections can be done but their survival and smoothness if far from assured. Custom silicone implants can be made for forehead augmentation that extends onto the temporalis fascia to both augment projection and width of the forehead. But for those patients that just want a little more forehead widening only, there have been no options to date.

Forehead Widening Implant result Dr Barry Eppley IndianapolisForehead Widening Implant result 2 Dr Barry Eppley IndianapolisZone 2 temporal or forehead widening implants offer s a simple and effective solution to those patients that would like to see just a slight increase in their horizontal forehead width. By placing an implant just to the side of the anterior temporal line under the fascia,  the forehead can be made wider in appearance. This procedure, like Zone 1 temporal implants, has a very rapid recovery with little swelling and discomfort afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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