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Dr. Barry Eppley

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Posts Tagged ‘frontal cranioplasty’

Case Study: Forehead Reconstruction with Hydroxyapatite Cement

Friday, September 28th, 2012


Background: Loss of the frontal or forehead bone can occur for a variety of reasons, usually from depressed fractures or loss of a craniotomy flap from infection. With removal of the protective bone cover, the brain and its dural covering sit directly up against the skin not only creating an obvious depression but pulsating with each heartbeat. Forehead reconstruction carries the highest aesthetic demands of any skull defect because it is the most visible in a non-hair bearing area and may involve the brow bone and brow ridge area.

There are almost a dozen methods of forehead skull reconstruction from split-thickness cranial bone grafts to computer-generated custom implant pieces. When skillfully done, any of these reconstructive methods will work satisfactorily. Their various advantages and disadvantages change based on the size of the forehead defect. The larger the bone defect becomes the more a synthetic approach becomes an appealing option.

One well established synthetic cranioplasty material for reconstructive use is hydroxyapatite. Consisting of the inorganic mineral content of natural bone, it is highly biocompatible although it does not get replaced by bone. It ends up creating a dense firm bone-like material that blends smoothly into the surrounding bone edges. It does not have the same strength as the normal double cortical layer skull bone but is strong enough to be an adequate skull substitute.

Besides the aesthetics of forehead skull defects, it is the only skull area which is contiguous with the air-filled frontal sinus cavity. This is a potential source of contamination and is a frequent source of forehead infections if a tissue layer is not created between it and the bone reconstruction material.

Case Study: This 13 year-old teen age boy was involved in a motor vehicle accident and sustained a severely depressed frontal forehead fracture and a large laceration down the center of his forehead. This required an urgent neurosurgical procedure with bone removal and repair of the dura. After three months of healing, he was left with a large depressed central forehead area (10 cm x 6 cm) that extended from the scalp down to the brows with a well healed vertical forehead scar. A 3-D CT scan shows the size of the defect and its involvement with the brow area and the frontal sinus.

Under general anesthesia, the forehead bony defect was accessed through his existing vertical scar from the scalp down to the area between the brows. The skin was lifting off of the dura and the surrounding bone edges. Near the brow area, the frontal sinus cavity was encountered as a 2cm x 2cm hole above the level of the dura.

The frontal sinus was clean and healthy with normal mucosal lining. A large pericranial tissue patch was sutured around all edges to create a thick tissue partition between the frontal sinus and the reconstruction site.

After the pericranial patch was placed, a floor was created for the reconstruction using titanium mesh. Thin 1mm titanium mesh was cut just larger than the bone defect and its edges were slipped under the defect to become a self-locking floor. This not only provided a containment method for the hydroxyapatite cement but keep the dural pulsations off of the hardening reconstruction.

Using a well known hydroxyapatite cement (Mimx, Biomet Microfixation, Jacksonville, FL), the activating liquid and calcium hydroxyapatite powder were mixed together into a putty consistency. This was then poured into the bone defect and molded into shape, recreating the lost brow bone area and the forehead above it.  The forehead skin was then closed and scalp scar removed prior to its closure in the hair area.

His surgery was done as an outpatient and he went home the same day. His head dressing was removed the next day and his sutures in the scalp removed ten days later. He had a smooth forehead result right with elimination of the forehead depression and the dural pulsations.

Case Highlights:

1) Reconstruction of the bony forehead can be done by a variety of techniques and hydroxyapatite is a well established cranioplasty material for full-thickness skull defects.

2) Forehead reconstruction which extends down into the brow area must take into account the frontal sinus and have a plan to keep it separate from any implanted material.

3) The properties of hydroxyapatite in a full-thickness skull defect needs reinforcement or a floor to add both strength and a containment method for the material.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Secondary Hydroxyapatite Cranioplasty Reconstruction

Thursday, April 7th, 2011

Background:The forehead occupies the upper third of the face and has variable degrees of convexity based on gender and genetics. It is structurally composed of very strong bicortical bone at its upper two-thirds and the much weaker aerated brow bones at its lower third underneath the eyebrows. While the forehead can resist significant forces, up to more than 100kgs of impact, it can be fractured and displaced. The brow bones, however, fracture at much lower impact forces.

Because it takes such a tremendous force to fracture the frontal bone, most such injuries also cause brain trauma and frequently need neurosurgical intervention. Often a craniotomy is done and the forehead bone is reconstructed at that time. But some cases do not involve the need for neurosurgery and the forehead defect is lefted untreated. These forehead contour defects are then reconstructed secondarily.

Case Study: This is a 37 year-old male who sustained significant forehead trauma and fractures from a fall from a scaffolding at his work one year previously. He recovered from his head trauma and had fullneurological recovery. He had a large indent in his forehead and a well-healed vertical laceration that extended from his hairline down to his eyebrow. A CT scan shows the degree of outer cortical table impaction from his frontal sinus upward.

An open cranioplasty was performed by re-opening his healed laceration. Through this approach the forehead tissues could be lifted back onto the normal undepressed contours of the bone in a circumferential manner. The infractured bone was largely healed and there was no communication into the frontal sinus cavity. An hydroxyapatite paste was prepared, packed into the defect and made smooth with the surrounding bone. In less than 10 minutes, the hydroxyapatite paste hardened and the incision closed.

He had complete restoration of his forehead contour and its convexity and his incision healed without problems. This procedure was done as an outpatient and completed in less than 90 minutes. His postoperative pain and forehead swelling was minimal.

The hydroxyapatite cranioplasty concept is now about 15 years old in its clinical use. It offers an advantage over old-style PMMA (acrylic) in that the material is more biocompatible and actually integrates into the tissues. It is more expensive than PMMA and is far less impact/fracture resistant.But I have never yet seen that be a secondary cranioplasty problem. Due to the handling of the material it must be placed through an open approach. In some cases, small incisional access can be used to place the material.

Case Highlights:

1) Forehead defects from trauma involve changes in the contour of either the solid portion of the forehead and/or the more fragile brow bones.

2) Contour reconstruction of the depressed forehead can be done with the onlay cranioplasty material, hydroxyapatite, in an open technique.

3) Frontal cranioplasty can be done through either a coronal (scalp) incision or an existing forehead laceration if it is big enough.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions on Forehead Reshaping and Contouring

Monday, February 8th, 2010
  1. What influence does the forehead have on one’s appearance?

The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.

The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.

A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women. 

2. How is forehead reshaping done?

Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.

They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.

3. How is brow bone reduction done?

In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only has  thin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.

In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.

A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone. 

4. How is brow bone augmentation done?

Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.

PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.

Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.

5. Can other areas of the forehead be reshaped besides the brow bone?

The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.

6. What is the recovery after forehead reshaping? What complications can occur?

Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.

Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?

7. What can I do if my forehead is too long?

Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.

The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference. 

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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