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Archive for the ‘forehead reduction’ Category

OR Snapshots – Bone Fixation of the Hairline Lowering Flap in Forehead Reduction

Saturday, September 9th, 2017


The forehead occupies a major portion of one’s face, up to one third of its vertical height. But when the forehead occupies too much real estate of the face, greater than one-third, it can be too overwhelming and look out of proportion to the rest of the face. By definition the vertical length of the forehead is between the frontal hairline and the eyebrows. (in bald or shaved men the amount that the forehead should occupy no longer applies)

The only method to reduce the vertical length of the forehead (forehead reduction) is a hairline advancement. This is essentially a scalp mobilization procedure that changes the location of the front edge of the hair-bearing scalp through forehead skin removal. Its success depends on how much natural elasticity one’s scalp has. Lowering of the hairline with this procedure can usually be done anywhere from 1 to 2.5 cms in most people.

Since such a forehead reduction is a scalp advancement flap, there will be some tension on the incision line. One of the goals of a hairline advancement is to minimize the tension on the skin closure to avoid postoperative scar widening. Such scar widening would be very obvious as a visible white zone at the edge of the frontal hairline.

A good technique to reduce the tension of the scalp advancement flap is skull fixation. Using outer table burr holes placed with a handpiece and burr, sutures can be placed through the bone tunnels to secure the scalp flap. There are placed at the front edge of the desired advancement edge to maintain its position. This then allows the closure to the forehead flap to be done with little to no tension on it as well as preventing any scalp relapse.

Once the advanced scalp flap is secured by bone fixation, the forehead skin flap is draped over it to determine the amount of forehead skin to be removed. This prevents over resection of forehead skin and serves as the second technique to ensure the best possible frontal hairline scar outcome.

IDr. Barry Eppley

Indianapolis, Indiana

Case Study – Forehead Horn Reduction

Monday, September 19th, 2016


Background: The shape of the frontal skull bone known as forehead is an important aesthetic facial feature. Since the forehead occupies one-third of the visible face it is not surprising that it has significant aesthetic value even though it seems like it is just a flat a amorphous structure. In reality there are very distinct gender differences in the shape of the forehead as well as having a good proportion in size to the rest of the face.

The forehead can have a variety of aesthetic deformities or disharmonies. One such aesthetic problem is the forehead that is too big or protrusive. This is most manifest as an upper forehead bulge or protrusion. Known as frontal bossing the upper forehead sticks out and can even protrude further out than the eyebrows. This is almost always due to an overgrowth of skull bone.

A unique form of a forehead protrusion is that of the forehead horns. While the term horns usually implies a pathology due to a keratinized growth from the skin, forehead horns in frontal skull surgery refers to an overgrowth of bone. This is not to be confused with an osteoma which would never present in a paired or bilateral presentation and is an outcropping of new bone growth not just part of the normal development of the skull.. These paired upper forehead bony mounds may appear like two very distinct paired protrusion or may also have a ‘dumbbell’ appearance if a ridge of bone connects between the two of them.

Case Study: This 25 year-old male presented with concerns about the appearance of his upper forehead. He had two distinct bony protrusions of his upper forehead that were particularly obvious in certain lighting due to the shadowing that it caused. There was also a small horizontal ridge of bone that connected the two more prominent outcroppings of bone.

forehead-horn-reduction-dr-barry-eppley-indianapolisforehead-reduction-incision-dr-barry-eppley-indianapolisforehead-reduction-surgery-technique-burr-guarding-dr-barry-eppley-indianapolisUnder general anesthesia a 5 cm scalp incision was made about 1.5 cms behind his frontal hairline. With the edges of the hairline protected by sponges and using a guarded rotary instrument and burr, the forehead horns were reduced as well as the connection of bone between them. The incision was closed in two layers with no loss of any external hair shafts.

forehead-horn-reduction-surgery-intraop-results-top-view-dr-barry-eppley-indianapolisforehead-horn-reduction-surgery-intraop-results-side-view-dr-barry-eppley-indianapolisForehead horn reduction is accomplished by removing the outer cortex of the frontal bone. The only preoperative question is what incisional approach is to be used. There are three incision options; 1) a direct approach using a horizontal forehead wrinkle line, 2) a superior pretrichial incision or 3) a more posterior incision back behind the hairline. the first two incision options are the ‘easiest’ since the rotary instrument is on the same linear problem as the bony protrusions. The scalp incision adds a level of difficulty because it is ‘over the top of the hill’ so to speak and one has to change the angle of the drill to reach the bony forehead protrusions. Protection of the hair shaft and follicle also adds a difficult factor as well. But all three incisions can produce equally good forehead horn reduction results.


1) Forehead horns are a pair of congenital upper forehead bony skull protrusions that may or may not be connected.

2) They can be satisfactorily reduced through three different incisional approaches, all work equally well.

3) Bone burring is the corrective technique for forehead horn reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Frontal Bossing Reduction

Sunday, August 21st, 2016


Frontal bossing is a not uncommon forehead condition marked by variable amounts of upper frontal bone protrusion. This can appear as smaller bilateral concentric horns or as an overall larger convexity of the whole forehead. Such frontal bone development throws the whole forehead out of aesthetic balance for either male or female and becomes an inadvertent facial focus. For those so affected camouflage is a frequent management strategy with hairstyles or hats.

In infants and very young children forehead reconstruction can be done by removal and replacement of the reshaped bone. But in adults such an aggressive approach is neither possible or warranted as it is an aesthetic concern. Burring reduction of the prominent portions of the forehead is the contouring procedure used. (frontal bossing reduction)

Frontal Bossing reduction inatrop result top view Dr Barry Eppley IndianapolisFrontal Bossing Reduction intraop result right oblique Ddr Barry Eppley IndianapolisHow successful burring reduction is for frontal bossing depends on the thickness of the frontal bone and the amount of bony protrusion. The best way to determine how much forehead bone can be reduced is by getting a 3D CT scan. Cross-sections of the forehead will beautifully show the thickness of the bone and the three skull layers. Seeing the layers is critical as it is the thickness of the outer cortical layer that matters since this is the location of the skull bone that can be reduced. Burring reduction does not usually go into the central diploic space due to the amount of bleeding that is encountered.

Burring reduction is usually very effective as few people need more than 4 to 6mms of bone reduction to substantially lessen or eliminate their bossing.

Frontal Bossing Reduction technique Dr Barry Eppley IndianapolisBeyond how much bone can be removed is the issue o the incisional location to do it. In most cases either a hairline (pretrichial) or hemi-coronal incision is placed several centimeters behind the frontal hairline. The key is that the incision must allow for a direct line of sight to the bossing to be able to get the rotary instrument in to reduce it. This picture one side reduced compared to the bossing side through a scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Total Forehead Reduction

Saturday, July 30th, 2016


Background: The shape and size of the forehead is an important aspect of facial aesthetics. It is well known that it should compose up to one-third of the vertical facial height.  When exceeding this one-third proportion the forehead can look too large or be too dominant.

The most common reason for a large forehead is a high hairline. The distance between the eyebrows and the frontal hairline is long (usually greater than 6 to 6.5cms) and as a result the forehead looks big. This managed by a hairline advancement whose degree of forehead reduction is controlled by the amount of scalp laxity or how much it can be surgically mobilized.

A more infrequent cause of a prominent forehead is frontal bossing. This is an overgrowth of bone of the forehead, usually the upper portion, which makes it stick out often beyond the projection of the brow bones. The disproportion of the strong upper forehead makes the forehead look imbalanced in addition to being too large. In an adult, the only method of frontal bossing reduction is removal of bone through burring. How much the frontal bossing can be reduced is a function of the thickness of the outer cortex of the skull.

Case Study: This 45 year-old female had a very prominent forehead due to a combination of frontal bossing and a high hairline. (8cms)

Forehead Bone Reduction for Frontal Bossing Dr Barry Eppley IndianapolisForehead Reduction with Hairline Advancement intraop top view Dr Barry Eppley IndianapolisUnder general anesthesia through a frontal hairline incision, the frontal bone was burred down to the diploic space. The amount of bone reduction can be seen with one side reduced (left) and the other untreated. (right) The scalp was then mobilized all the way to the back of the head down to the nuchal ridge and brought forward for her hairline advancement.

Total Forehead Reduction result side view Dr Barry Eppley IndianapolisTotal Forehead Reduction result oblique view Dr Barry Eppley IndianapolisTotal Forehead Reduction result front view Dr Barry Eppley IndianapolisTotal Forehead Reduction hairlinke scar result Dr Barry Eppley IndianapolisHer immediate results showed a dramatic improvement on her forehead shape and proportion. The hairline scar had healed fairly well particularly in the central area which is under the greatest tension.

Total forehead reduction is a combination of frontal bone reduction and a hairline advancement. Both are done through a single hairline incision that extends down into the temporal hairline.


1) A prominent forehead can be caused by with a high hairline, bossing of the frontal bone or both.

2) Total forehead reduction is a combination of frontal bone reduction and a hairline advancement and provides maximal improvement of forehead shape.

3) The pretrichial hairline scar can heal fairly well even though it is under tension at the most central ares of closure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Forehead Bony Reduction with Hairline Advancement

Monday, July 18th, 2016


Background: The shape of the forehead is largely controlled by the development of the frontal bone of the skull. Frontal bossing is the term given to describe a prominent bulging forehead. This is usually most manifest in the upper forehead which can project outward beyond the wide profile of the brow bones in some cases. There are a variety of medical conditions that can cause frontal bossing from congenital skull deformities to hormonal abnormalites. (e.g., acromegaly)

But for many patients this is an aesthetic deformity that has no specific cause other than this is just how the forehead developed. The prominent upper forehead usually appears as a bulge across the upper forehead. It is obvious because it has a size bigger than the patient’s brow bones and also causes a high or long forehead in some patients. A large surface area forehead causes a facial imbalance and disrupts the aesthetic thirds of facial proportions.

Frontal bossing can be reduced to improve facial aesthetics. How much the prominent frontal bone can be reduced depends on the thickness of the bone. Burring reduction is the surgical technique, not formal bone removal (frontal craniotomy) and split bone reduction as would be done in more severe craniofacial deformities.

Case Study: This 23 year-old female had a prominent upper forehead that was aesthetically bothersome to her. She wore her hair short so the entire shape of the forehead was clearly evident.

Forehead Bony Reduction with Hairline Advancement intraop result left oblique view Dr Barry Eppley IndianapolisUnder general anesthesia a pretrichial hairline incision was used to access the forehead. Burring reduction of 5 to 6mms was done throughout the forehead bulge down to a bleeding diploic space. The frontal hairline was then advanced 1 cm from upper temporal to upper temporal areas. The combination of some reduction of the frontal bossing and skin shortening of the forehead created a more balanced looking forehead region.

Total Forehead Reduction result side view Dr Barry Eppley IndianapolisThere are limits as to how much frontal bossing can be burred down. It may be able to be burred down completely or only partially. The hairline advancement provides an adjunctive improvement as it alone creates the appearance of a smaller forehead.


1) Frontal bossing is an aesthetic forehead deformity that is associated with an enlarged upper forehead and a high hairline.

2) The amount of reduction possible for frontal bossing depends on the thickness of the frontal bone.

3) A pretrichial approach to forehead bony reduction allows for frontal hairline advancement as well.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Total Forehead Reduction

Thursday, November 26th, 2015


Background: The shape of the forehead is affected by various hard and soft tissue components. The forehead is framed by the hairline superiorly, the brows inferiorly and the bony temporal lines to the sides. The projection of the forehead is controlled by the thickness of the frontal bone and its degree of convexity and smothness. The height of the forehead is judged by the vertical distance from the hairline to the brow.

Vertical forehead reduction can be of benefit when the hairline to brow distance is about 6.5 cm and longer. Numbers aside, one knows when the forehead is too long by their own aesthetic sense. Shortening the length of the forehead is done by moving the hairline forward or more inferior through extensive scalp undemining and mobilization. A powerful procedure, the hairline or scalp advancement can make a dramatic difference in the appearance of the upper third of the face.

Bony forehead reduction is done to either narrow the shape of the forehead or eliminate any obvious bony projections. This is a bone burring technique that is usually done to narrow the width of the forehead, reduce the amount of its forward projection (convexity) or smooth down so called forehead horns. This almost always need to be done through an open approach afforded by a hairline incision.

Case Study: This 40 year male had a long forehead due to receding frontal hairline and a wide and bulging forehead due to its bony shape. He had a prior hair transplant procedure with a linear strip scar on the back of his head. His desire was for a shorter forehead length and a less wide and bulging forehead.

Total Forehead Reduction result front view Dr Barry Eppley IndianapolisTotal Forehead Reduction result oblique view Dr Barry Eppley IndianapolisDue to his prior hair transplant harvests from the back of his head, it was elected to do a first stage scalp expansion to ensure enough scalp could be mobilized for the hairline advancement. This was done using 120cc of scalp expansion by fill volume. During the second stage through a hairline incision, the tissue expander was removed, the bony forehead reshaped by burring and the hairline advanced 2 cms. Small temporal rotational scalp flaps were also done to eliminate the temporal recession areas.

Total Forehead Reduction result side view Dr Barry Eppley IndianapolisTotal forehead reduction can be done through bony contouring and a hairline advancement. Using the ‘central’ pretrichial hairline incision positioned between the forehead and the scalp, both forehead reduction procedures can be successfully done. His history of strip occipital harvests for hair transplants did necessitate a first stage scalp tissue expander which would not normally be needed in most cases.

Many patients with high and long foreheads have a combination of a posteriorly recessed hairline and bony forehead bossing. Preoperative computer imaging will show whether the apparent forehead bossing is a function of just a high forehead and an exposed upper forehead bony contour or whether a true excessive forehead convexity exists. A very wide or broad forehead in the frontal view, however, is an excessive bony width problem for which a hairline advancement will not improve.


  1. Forehead bossing is treated by bony reduction of forehead width and projection. (forehead contouring)
  2. Vertical forehead reduction is a soft tissue procedure where hairline advancement is done. (scalp advancement)
  3. Total forehead reduction is when both bony and soft tissue procedures are done simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Bony Forehead Reduction with Hairline Advancement

Monday, August 10th, 2015


The long or high forehead can be challenging to treat. The vertical length of the forehead is typically judged to be too long if the distance from the eyebrows to the frontal hairline exceeds about 6.5 cms. This is obviously a subjective judgement as the aesthetics of the forehead defies any exact number. But when the length of the forehead violates the 1/3 rule (bigger than the lower middle and lower facial thirds) it will be typically thought of as being too long or high.

Forehead Reduction with Hairline Advancement intraop top view Dr Barry Eppley IndianapolisShortening the height of the forehead is usually done by a forehead reduction procedure known as a hairline lowering. This is really a scalp advancement which is done by undermining and mobilizing the entire scalp all the way back to the nuchal ridge of the occiput. Combined with galeal releases the frontal hairline may be capable of being lowered 2 to 3 cms in many patients. Such forehead reduction is very powerful and can have a dramatic effect on the appearance of the upper face.

When considering a hairline advancement, it is also important to assess the shape of the bony forehead as well. Frontal bossing can be a contributing factor to a large forehead. While bring the hairline forward may begin to cover a bony protrusion it can not completely obscure it.

Forehead Bone Reduction for Frontal Bossing Dr Barry Eppley IndianapolisForehead Reduction with Hairline Advancement intraop side view Ddr Barry Eppley IndianapolisA total forehead reduction procedure consists of both a hairline advancement and bony forehead reduction. They can be done through the same pretrichial incision. By reflecting the forehead skin down to the brow bones, the frontal bone is exposed and can be burred down and reshaped. The limits of the bone reduction are based on the thickness of the frontal bone but usually can be reduced at least 5 to 7mms. Often times it is the slope of the bony forehead that needs changing as much as how far it protrudes forward.

Reducing the bony forehead and changing its slope also provides more room for additional hairline advancement. Its reduction may allow an additional .5cm of hairline advancement to be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Contouring Techniques for Forehead Bony Lumps Bumps and Ridges

Sunday, April 6th, 2014


While the skull is prone to have a variety of lumps and bumps, they are more of an aesthetic concern when they occur on the forehead. Any forehead irregularity becomes a very noticeable entity as the surface area of the forehead occupies up to 1/3 of the visible face. Commonly seen as a smooth surface, with the exception of the bilateral brow break in men, any outcrop of bone becomes very apparent and is often aesthetically bothersome.

Forehead Bony Bumps and Lumps Dr Barry Eppley IndianapolisWhile there are numerous types of hard and soft tissue lumps that can occur on the forehead, the most common bony types are osteomas, exostoses and midline ridging. Osteomas can occur randomly anywhere on the forehead and are often the result of trauma and usually appear due to an osteoblastic response to a small subperiosteal bleed. They are like a mushroom growth on the bone. Bony exostoses, also called forehead horns, are symmetric bilateral natural growths or thickenings of the outer cranial table. (although they can be asymmetric or appear on just one side) They do not have a distinct base like that of an osteoma. Midline ridging is a raised area of bone that runs down the upper central region of the forehead. It is a variant of the neonatal metopic suture and may be considered an expression of a  microform of metopic craniosynostosis.

Reduction of any of these forehead lumps and bumps can be done by a variety of surgical methods but they all share the common need for bone reduction/bony contouring. How the bony deformity is accessed will influence, favorably or unfavorably, what bony reduction can be used. Endoscopic techniques will almost exclusively limit one to using an osteome and thus is really only used for osteoma removal which can easily be severed from its more narrow base. But every other forehead bony deformity must use a more effective contouring method and needs to be done through an open hairline or scalp incision.

Angled Drill for Skull Bump Reduction Dr Barry Eppley IndianapolisA handpiece and burr is the most rapid and effective method for forehead bony deformity reduction. The high speed of the rotating burr can make quick work of any projecting bony areas. But access is often a problem. Most handpieces are straight and coming from an incision above across a convex upper forehead keeps the working end (burr) of yhe instrument away from the bony surface. This is simply solved by using an angled handpiece which is also longer than the standard straight handpiece. The angle of the handpiece overcomes the curvature of the upper forehead.

Bone Rasp for Skull Bump Reduction Dr Barry Eppley IndianapolisThe other useful tool for forehead bump reduction is a large rhinoplasty rasp. Its teeth may work a lot slower than a rotating burr but with repetitive stroking a slow and smooth reduction can be achieved. Even though it is a straight instrument and is a bone reduction manuever that is done only by feel, it is a very safe technique that creates a safe and even bone surface. It is especially good for smoothing out any areas that were initially reduced by endoscopic burring.

scalp access for skull bump reduction dr barry eppley indianapolisVarious forehead lumps and bumps can be reduced through minimal incision techniques using a variety of instruments including osteotomies, burrs and rasps. By working though small scalp incisions, forehead contouring can be done without visible skin scars if desired.

Dr. Barry Eppley

Indianapolis, Indiana

Long-Term Hairline Stability in Pretrichial Browlifts

Saturday, January 11th, 2014


When it comes to forehead rejuvenation a variety of browlifting strategies exist. Three of the browlifting methods use a superior or scalp incisional access to do the procedure. The most popular of these is the endoscopic technique which uses a few small scalp incisions and an epicranial tissue shift to create its brow elevation effect. It is popular because of a lack of significant incisional lengths even though it does also result in some forehead lengthening.

Pretrichial Open Browlift Scar Dr Barry Eppley IndianapolisA very effective but less popular browlift method is the pretrichial or hairline technique. Making an irregular incision along the frontal hairline, the brows are lifted but without elongating the forehead. While this does place a scar along the frontal hairline, in the properly selected patient with good frontal hairline density, the scar can heal remarkably well and has rarely been a concern in my experience. There is always the understandable concern, however, if whether this incision negatively affects hair growth after healing and in the long-term. (does hair loss occur along the incision)

In the January 2013 issue of Plastic and Reconstructive Surgery, an article was printed entitled ‘Cessation of Hairline Recession following Open Forehead Rejuvenation’. Over a 15 year period, 31 patients had browlifts done using either the endoscopic (17) or open pretrichial incision (14) approaches. Measured photographs of eyebrow to hairline distances were done at 1 and greater than 8 years after surgery and compared to other cosmetic surgery patients who did not have forehead rejuvenation. Their results showed that over the long-term only the pretrichial group had a stable or improved hairline position without any signs of recession. No separation was seen between the scar and the hairline in the pretrichial incision patients.

This study is very relevant to not only pretrichial browlifts but other procedures that use incisions along the hairline such as a hairline lowering/advancement surgery for forehead reduction. Whether it is a woman or a man (but particularly in men), there is always the concern that hair loss may occur along the incision from surgical trauma or that long-term hairline recession may occur. These findings in this paper allay those concerns and suggest that the incision may have some protective effect in the long-term for follicular preservation…and intriguing but as of yet unexplainable biologic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Forehead Feminization with Combined Brow Bone Reduction, Browlift and Hairline Lowering

Sunday, April 21st, 2013


There are numerous surgical procedures to feminize a masculine facial appearance. They include jawline reshaping (chin and mandibular angle reduction), rhinoplasty, cheek reduction, tracheal shave and forehead reduction/reshaping. While every transgender patient’s face is different and may need just a few or all of these facial feminization procedures, the forehead is one of the top considerations for most patients. The female forehead has a very distinct shape with a rounded contour from the brows up to the hairline with no obvious bone break.

Forehead reshaping incorporates reduction of the prominence of the central glabellar region as well as the projection of the brow bones. The brow bones must not only be deprojected but should also have the tail of them near the lateral orbit reshaped to have more of a sweeping effect up and towards the temples. Since this procedure requires an open scalp approach, this creates the oportunity to lower the frontal hairline as well. Together this type of foreheadplasty has a significant impact on the gender identification of the face.

The prominent glabella and brow bones are always due to the pneumatization of the front sinus. In cases of minor protrusion, the outer table of the frontal sinus can be simply burred down. Unfortunately this rarely can be successfully done due to the thin bone thickness overlying the frontal sinus. A few millimeters of change is rarely enough to make a noticeable external change. Most patients require the anterior wall of the bone to be removed, reshaped and repositioned back into place with resorbable sutures or metal microplates and screws. This method sets back the bulging bony prominence while preserving sinus function. The outer brow bone areas that lie outside of the sinuses can be reshaped as desired by burring.

When significant brow bone reduction is done (flattening of the bone), there is the potential for an excess of overlying skin. Loose skin on the brows can result in sagging or overlying brow ptosis. This can be easily addressed at the time of the brow bone reduction by a comcomitant browlift using the transcoronal or hairline incision made for access to the brow bones. An alternative approach is a direct browpexy from the galea below the eyebrows to underlying bone holes or the fixation plates (if used) above the reshaped brow bones.

A final component of the feminizing foreheadplasty procedure is the potential to simultaneously lower the frontal hairline. A long forehead (> than 6.5 to 7 cms between the brow and hairline) is unaesthetic for any gender but is particularly so in the male to female transgender patient. If a hairline approach (trichophytic) is used, a simultaneous scalp advancement can be done by securing the galea of the advanced scalp by sutures to bone holes in the outer table of the skull. By bringing the scalp forward, the lifted forehead skin will need to be trimmed creating a combined forehead skin reduction and browlift.

Ultimate feminization of the forehead can be done by simultaneous brow bone reduction, browlift and hairline lowering.

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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