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Posts Tagged ‘forehead recontouring’

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

Techniques and Outcomes in Forehead and Brow Feminization

Sunday, September 28th, 2014

 

Forehead feminization Surgery Dr Barry Eppley IndianapolisFacial feminization surgery is a relatively recent plastic surgery procedure that has only been done since the late 1980s. It has been developed to address the need to modify masculine facial features for those with gender dysphoria who need to change their facial identity. As a result it is a well known need for the transgender patient. Certain facial features can have very specific male and female characteristics. Specifically the forehead and the jawline are especially important in facial gender identification.

In the October 2014 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Facial Feminization Surgery: The Forehead. Surgical Technique and Analysis of Results’. Over a four year period, the authors performed 172 forehead reshaping procedures. The results were assessed by cephalometric x-rays and a six month after surgery survey. The specific techniques discussed were incisional access and how the bone areas are specifically reshaped. Incisional access was done through either a hairline (pretrichial) or modified coronal based on the vertical length of the forehead and whether hairline lowering was simultaneously needed. The bone was reshaped through sequencing of frontonasal-orbital reconstruction/recontouring with osteotomy and setback of the anterior wall of the frontal sinus.

No serious complications were observed in this forehead feminization patient series. No hematomas, seromas or infections occurred. There were no complications related to osteotomizing the anterior wall of the frontal sinus such as sinus dysfunction, sinusitis, mucoceles, or air leaks. One patient did develop a cerebrospinal fluid leak from the posterior wall of the frontal sinus that resolved spontaneously within days after surgery by posture measures. Most patients had some degree of forehead numbness with complete recovery starting three months after surgery. No permanent injury to the frontal branch of the facial nerve occurred although some patients  had some weakness which fully recovered weeks after surgery. The average level of patient satisfaction by the after surgery survey was between satisfied and completely satisfied.

Brow Bone Reduction - Bone Flap Technique Dr Barry Eppley IndianapolisThis article highlights several technical aspects of the procedure that one learns by doing this type of surgery over the years. Where to place the incision and how to access the brow area must be initially considered. Whether to place the incision at or behind the hairline depends on how long the forehead is and the natural shape of the frontal hairline. Brow bone reshaping almost always requires removing the anterior wall of the frontal sinus, reshaping it and repositioning it further back into the frontal sinus. (burring reduction is inadequate and the anterior wall of the frontal sinus permits little reduction to be achieved) With the anterior wall of the frontal sinus removed, the nasal root and glabellar region must be reduced to create a more feminine frontnasal junction. Reduction/rehaping of the superolateral brow bone down along the lateral orbital wall must not be forgotten as a more comprehensive approach to the fronto-orbital recontouring.

Despite the rather invasive nature of this type of forehead surgery, complications are remarkably few and significant improvement is always seen. There can be issues that may require secondary revision such as the smoothness of the brow region. This article does not address whether any revisions were required but some low percent can be expected. (3% to 5%)

Brow bone reshaping and associated hairline modifications can effectively alter masculine facial features in the transgender patient with a very low incidence of negative side effects. To really change the forehead/brow area a comprehensive bone and soft tissue approach is needed.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Fat Injections for Brow Bone Break Reduction

Sunday, August 17th, 2014

 

Fat injections have tremendous popularity due to their autologous (natural) source, ease of graft procurement and ability to place the graft in a scar-free manner. While fat graft retention is far from assured, they have been used in a tremendously diverse number of applications where more soft tissue volume is needed.

One such unique application of fat grafts is for forehead recontouring. Historically this is a facial bony augmentation location where applying bone cements or implants is needed to create an outward effect. But surgical incisions are needed, usually in the scalp, for these aesthetic surgeries and that may be more of a scar burden that is worth it to some patients and for some forehead augmentation needs.

One relatively minor aesthetic forehead concern is the presence of or an overly deep brow bone break. Usually seen in men as a masculine feature this is caused by prominent brow bone development (technically frontal sinus growth) that extend out further than the plane of the forehead. This causes an obvious horizontal line of demarcation between the contour of the brow bone and the forehead above it.

fat injections to brow bone dr barry eppley indianapolisfat injections to forehead dr barry eppley indianapolisThe brow bone break can be softened or eliminated by fat injections. It is important to use highly concentrated fat and inject it in a microdroplet technique using the smallest microcannula. This is done through small nick incisions created by a 20 gauge needle along the horizontal break line. Two layers are placed, one above and the other below the galea. This careful and discreet fat injection technique is easy to do since the volume administered is usually less than 5ccs.

Fat Injection to Brow Bone Break Dr Barry Eppley IndianapolisSmall volumes of fat carefully placed can be an effective technique for brow bone break reduction/elimination. Given that the aesthetic problem hardly justifies a more extensive operation, this fat injection technique can be a minimally invasive and sustained forehead recontouring method.

Dr. Barry Eppley

Indianapolis, Indiana

Correction of Facial Asymmetry in Adults from Occipital Plagiocephaly

Monday, October 19th, 2009

Occipital plagiocephaly is a well known congenital malformation of the back of the head marked by an oblique slant to the main axis of the skull. It is commonly corrected today by the early institution of either static or dynamic cranial orthotics or helmets. In rare cases if the skull is significantly deformed and does not respond to external molding influences, cranial reshaping can be successfully done.

Plagiocephaly is well known to affect how the face develops. What happens in the back of the skull will influence how the front of the skull and face looks. This occurs in a diametrically opposite manner. The side that is flat on the back of the head will be protrusive on the front….and vice versa. Even in cases where helmet therapy or even surgery has made a well rounded back of the head, the face may still show some of the residual effects as it develops resulting in facial asymmetry. When plagiocephaly goes untreated or was not adequately treated at a young age, this facial asymmetry may become quite apparent.

The facial asymmetry that results from a plagiocephalic influence appears as that of a ‘twisted’ face if one is looking from above. This is apparent by misaligned ears (the ear on the affected side may be pulled forward and down and be larger then the unaffected ear) and facial asymmetry, with the more forward side of the face having a fuller forehead, brow bone, and cheek. The jawbone will be tilted and one’s occlusion (bite) may have a cant to it. There may be differences in the position and shape of the jaw angles and the chin may be deviated toward the ‘weaker’ or more retrusive side.

When the facial asymmetry is very severe, complete facial bone repositioning incorporating orthodontics and multiple jaw orthognathic surgery is needed. But most of such facial asymmetry that I see in my Indianapolis plastic surgery practice is more mild and in late adolescence or adulthood. Patients are looking for less major methods for improving their facial asymmetry.

When one considers improving facial asymmetry, a careful analysis of the face must be done to determine exactly where the imbalances are. Of even greater importance is input from the patient as to which facial prominences they consider to be the good or the bad side. This is very important because weak areas can be built up with implants which is most commonly done because it is easier. But reduction of bone can be done in certain facial areas if they are too prominent.

Options in facial asymmetry correction include from top to bottom: forehead/brow augmentation, forehead/brow reduction, cheek and orbital implants, jaw angle augmentation or reduction, inferior border mandibular ostectomies, and chin osteotomies or implants. Such an array of procedures requires thoughtful and careful preoperative planning. When more than one of these is done during the operation (which is most common), the effects of facial rebalancing can be quite significant. In my experience, at least two or three facial areas are treated at the same time to get the best result.

 While complete or perfect facial symmetry is not obtainable in any case, significant camouflaging of the facial bony asymmetries can be made. Such surgical improvement provides great psychological relief to the facial asymmetry patient and can usually be achieved in a single operation.   

Dr. Barry Eppley

Indianapolis, Indiana

Brow Bone Forehead Augmentation

Thursday, October 8th, 2009

The forehead has a variety of shapes that do differ based on gender. Men will tend to have flatter fuller foreheads with more prominent brow bones (supraorbital ridges) while women’s foreheads will usually be softer, less full, and with flatter brow bones that tend to angle off into the temporal region. Whether it be by a congenital deformity (such as craniosynostosis), frontal tumor resection (craniotomy flap) or from prior contouring purposes (FFS, facial feminization surgery), there are rare instances when one desires to have a fuller or more prominent brow definition restored.

Brow bone augmentation (BBA) is one form of forehead reshaping that can be done. Using synthetic materials as a building material, the bone can be ‘thickened’ and recontoured to alter how the brow looks. Since the eyebrow and the upper part of the eyelid is affected by its underlying bony support, such changes can produce subtle to dramatic differences.

One of the key issues of brow bone augmentation is which material to use. Currently, hydroxyapatite (HA) and acrylic (PMMA) are the only two moldeable materials of choice. Your own bone is usually not a good option since you have to harvest it and how it survives as an onlay is unpredictable. Both HA and PMMA have their advocates but I have gotten good results with both. Either one can do the job. PMMA is much cheaper from a material cost standpoint and is very hard once it sets, being hard if not harder than natural bone. HA is much more expensive, a little harder to work with, and is more fragile to impact. But it is closer to the mineral of natural bone so it has greater compatibility and less risk of long-term body reaction concerns.

There is also the option of a synthetic implant carved out of silicone or polyethylene. (Medpor) This requires a greater degree of skill and time to get all the edges flat and flush with the surrounding bone. It is easy to see how an edge step-off can be felt through the skin unless it is done perfectly. Feathering edges and blending into the surrounding bone is much more assured with the moldable materials. 

The other important consideration of BBA is access. For the most part, an open scalp approach provides the best vision and control of the shape. But this is understandably problematic for most men unless they have a pre-existing scalp scar to use. For most women, this is not a significant issue as a hairline (pretrichial) approach can be done and that scar can really be quite fine and unnoticeable. I know this from a lot of experience with pretrichial (hairline) browlift procedures done for cosmetic purposes.

A non-open scalp approach (endoscopic) can be used in select cases of forehead augmentation. When it is the central or more upper parts of the forehead that are being augmented, the endoscopic approach using PMMA as an injectable material can be done. PMMA can be injected and pushed around as a congealed putty and shaped by external molding through the forehead skin. HA is a quite different material and its handling properties do not permit anything but an open approach scalp approach. But working down at the brow area, which is a very low point for endoscopic visualization, is even difficult with PMMA. Therefore, I would advocate an open approach for any amount of brow bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana 

 

Forehead Augmentation With Synthetic Materials

Wednesday, December 10th, 2008

Reshaping the forehead is an uncommon patient request. While the plastic surgery techniques to do so are well known and not new, the need to do forehead contouring is not. Most commonly, forehead reshaping is done on patients who had a congenital skull deformity (e.g., craniosynostosis) or a frontal skull deformity secondary to trauma or after a neurosurgery craniotomy procedure. The cosmetic reasons would be to soften prominent brow ridges or to smooth out some forehead irregularities.

The treatment of forehead irregularities can theoretically be done by either burring down bone or adding a synthetic material to it. In reality, burring down bone on the skull is a limited procedure and can never make as big a difference as one would think. The brow ridges can be burred down but the limiting factor is the underlying frontal sinus. If the overlying frontal sinus bone is thin, then very little bone can actually be taken. Above the brow ridges, burring down forehead bone is very effective for small raised areas that are easily identifiable but is less effective at reducing large surface areas of bone.

Filling in or adding to the forehead bone is a much easier and effective procedure. The real question in forehead augmentation is what material to use. Traditional PMMA (polymethylmethacrylate) has been around for a long time and has the advantages of a very low cost, high resistance to impact forces, and ease of intraoperative contouring. Its main disadvantage is that some patients over time can develop some low-grade reactions to it and it may get loose, become infected or the overlying forehead skin may thin, although these issues are fairly low risk. Newer ‘more natural’ materials such as hydroxyapatite cements (HA) have been available over the past 10 years. HA offers the advantage of being a more natural, less synthetic material as its structure more closely resembles that of bone. Its disadvantages are that it is considerably more expensive, has a low resistance to impact (easily shatters), and is a bit tricker for the plastic surgeon to use. The advantages and disadvantages for HA vs. PMMA must be considered and weighed on an individual case basis.

Regardless of the material used, synthetic forehead augmentation usually requires an open scalp incision which, because of its length, is a significant consideration in a cosmetic procedure. (particularly for men) Endoscopic or limited scalp incisions may be able to be used in small areas of augmentation in carefully selected cases.

Dr. Barry Eppley

Indianapolis, Indiana

Options for Brow Bone Reduction in Men and Women

Sunday, September 28th, 2008

The need to change the shape of the forehead or brow bone is very uncommon. Reshaping the forehead or the brow bone  (the bone below the eyebrows) is possible but  there are different procedures that can be done based on the shape of the forehead and the brow bone.

The shape of the skull between a male and a female is often quite different .The male forehead often has fullness over the brow bone known as brow bossing or a supraorbital prominence with a flatter forehead above this area. The female forehead, conversely, has a more convex or curved forehead shape and little or no significant supraorbital bossing. Such forehead shapes confer a masculine or a feminine look.

 

The degree of brow bossing and the forehead shape helps determine what type of surgical recontouring needs to be done. With the exception of one other important consideration…the frontal sinus. The frontal sinus, an air-filled bone cavity,  sits right under the brow bone and how developed it is will affect surgical choices. For this reason, any surgical efforts at forehead/brow modification should have a simple skull x-ray (side view) prior to surgery.

 

In those patients with mild to moderate brow bossing and thick skull bone over the frontal sinus (or are missing a frontal sinus), bone reduction  by burring can be done with a nice result. When brow bossing is present but the bone thickness over the frontal sinus is thin, simple bone reduction contouring is impossible without entering the frontal sinus. Many try just a little bone reduction, without entering the sinus, but this does not make enough difference to justify the effort. Removal of only 1 or 2 mms of bone is not enough to make a difference.  In these situation, one option is to open the frontal sinus, burr down the edges of the bone and put the ‘outer lid’ back in a more inward contour, thus preserving the frontal sinus. The other option is to obliterate and fill the sinus with a bone substitute material, making a more flatter brow  contour with the bone paste or cement. (and not put the outer table of bone back) I have done both and both of them will work. If I can get a good brow contour and still leave the frontal sinus present and functioning, that is my preferred choice.

 

Any forehead and brow contouring requires an open approach through a scalp or hairline incision. The forehead skin must be ‘peeled back’ to get good access for the surgery. An endoscopic approach or more limited approach is not adequate to do a good job. In most females, the hairline and hair density patterns make an open approach possible. When this procedure is considered in  males, the hair issue makes an open scalp approach potentially more problematic.

 

The most common patient, in my experience, for brow bone reduction is in female feminization surgery (FFS) where reducing the prominence of the brow bone helps in the overall facial conversion of the male to a female appearance. In a few select males with very prominent brow bones, this procedure can make a big difference in softening the more ‘neanderthal’ facial appearance.

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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