Can Brow Bone Reduction and Chin Augmentation Be Done At The Same Time?

Q: Dr. Eppley,   I think my eyes are slightly uneven but I doubt anything can be done about that and that’s okay. I would like to change the prominent eyebrow structure from the center of my face extending to the outside supraorbital ridges. (brow bone reeduction) They are also slightly uneven. People often ask me if mosquitoes bit my eyebrows. The other thing that bothers me is my weak jaw line. I push my lower jaw out so its less obvious. (chin augmentation) 

I know I will never look like a super model, its not even something that I want. I would just like a more symmetrical, angled, softer looking face. Thank you so much for your time and effort, Dr. Eppley. I hope it’s what you need in order to assess for possible procedures.

A: Thank you for sending your pictures. What they should is considerable brow bone protrusion from the glabella to the outer orbital rim. Even without x-rays I can tell that is due to significant frontal sinus hypertrophy and will require an osteoplastic bone flap setback technique for your brow bone reduction and not just burring alone to get a significant reduction. The brow bone protrusion you have is very similar to what I see in men with two distinct medial brow bone mounds. The slope of your forehead is also fairly retroclined and it would be ideal to augment the upper forehead at the same time to really change the entire shape of your forehead.

From a chin standpoint, it is both horizontal and vertically deficient in regards to being in balance to the rest of your face. While a sliding genioplasty would be the historic solution (due to the need for increased vertical chin height), my newer vertical lengthening chin implant (small size in your case) would work well as it brings the chin both forward and down. (at 45 degrees) This would a very good solution for you that is more cost effective than a sliding genioplasty with a much quick recovery as well.

Now that I know exactly what need to be done, I will have my assistant pass along the combined costs of the procedures to you on Monday.

Dr. Barry Eppley

Indianapolis, Indiana

 

What Are The Options For Forehead Reshaping?

Q: Dr. Eppley, I’m wanting to find out more about the different options available for forehead reshaping. Are there alternative procedures to the shaving technique? For example are there any kinds of forehead implants, fat injections that can be used to smoothen the forehead. I will also be sending pictures within the next week or two for a more accurate price range, but can you tell me the average price range for these kinds of procedures? Thank you very kindly.

A: There are numerous different options for forehead reshaping including bone cements, custom implants and even fat injections. (not my preference but an option) When it comes to brow bone reduction, bone removal and reshaping usually works much better than shaving/burring for any significant reduction. As you can see between manipulation of the brow bone and the forehead above it, there are a variety of techniques. Which one may work best for you and what trade-offs you are willing to accept in doing them are issues to yet be discussed. It is better to determine first what methods you would choose and then an accurate cost for the surgery can be given. There are no ‘average’ costs for possible combination forehead procedures that we yet don’t even know what they would be.

Dr. Barry Eppley

Indianapolis, Indiana

Can A Hairline Advancement Be Done With Forehead Bone Reduction?

Q: Dr. Eppley, i want my forehead made smaller with a shorter hairline. I would like to have a procedure at your facility to have the central frontal bone vault reduced to about 5mm and the glabella the triangular area in between the eyes over the nose and under the brows,I had a interview with a previous surgeon who was actually to far from me to travel but he was saying my scalp is flexible   Enough to bring it down to 2 cmd maybe another half once he loosened this area underneath my scalp. I forgot the name of it,do you have any idea what he’s referring to and do you use this same technique?

A: You are referring to a hairline advancement procedure as part of an overall forehead reduction. This requires the scalp be loosed up so it can be brought forward and the hairline lowered. The more natural scalp flexibility one has, the easier and more hairline advancement that can be achieved. This is often done with frontal bone remodeling such as frontal bone reduction and some brow reshaping/contouring. You are correct in assuming that about 5mms of frontal bone can be safely reduced by burring.

Dr. Barry Eppley

Indianapolis, Indiana

Can Forehead Reshaping Removes My Hard Horns?

Q: Dr. Eppley,I am interested in some form of forehead reshaping.  I have two hard-like horns or lumps on my forehead. They have been there since I was a teenager. Now that I am in my early twenties it bothers me greatly. They feel like really hard like bones. They really affect me and bring my self esteem down. I’ve been to my family doctor and I was told it was really nothing. I am hoping you can help me. I have attached pictures from different angles for your assessment.

A: One of the most minor forms of forehead reshaping is reduction of prominent bulges. Your pictures show a very classic example of them and how protuberant they can be. Thank you for sending your pictures. They are the type of forehead bulges/osteomas/horns that I have seen many times. They are common excess growths of the forehead bone and are almost always on both sides.They are benign and normal but obviously not aesthetically desireable. They can be burred down to make for a more smooth confluent forehead contour. Depending upon the shape of the rest of your forehead and how much they can be burred down, it is sometimes also helpful to build up with bone cement around the area to get a really smooth forehead shape. That shaping consideration aside, the only other issue to consider is one of surgical access. You have to have an incision somewhere to gain access and this would be back in the scalp. Thus one has to accept a very fine line scalp incision to do it. Fortunately even in men with thinner or thinning hair cover, the scalp incision heals well with very minimal scar.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Frontal Sinus Be Reconstructed After Brow Bone Reduction?

Q: Dr. Eppley, years ago I had a brow-bone reduction surgery for facial feminization. Unfortunately, the surgeon I chose tried some novel procedure that ended up leaving me with a missing anterior sinus wall and bone chips lodged in my frontal sinus. Another surgeon, an ENT, then obliterated my frontal sinus with hydroxyapatite. This fixed the air leaks and replaced the missing bone, but left obvious irregularities in my forehead. I recently had a CT scan done and discovered that he also failed to completely obliterate the sinus; there is still a cavity on the left side. I came across your page while doing research and discovered that you had a lot of experience in forehead work as well as craniofacial experience, and I was wondering if this was something you think you could fix. I’m hoping to have the last of the sinus obliterated with hydroxyapatite or similar and to have the defects in my frontal bone filled. 

A: In doing brow bone reduction surgery, removing the anterior table of the frontal sinus and putting it back as morselized bone chips is not going to be a successful strategy. (as you have discovered) This will leave one with significant indentations and irregularities over the brow bones. Repairing this problem with frontal sinus obliteration by mucosal lining removal, obliterating the frontal sinus ducts with bone grafts and then filling it with hydroxyapatite cement up to the level of the desired brow bone shape is the correct treatment. However if one fails to get out all the lining or does not obliterate the frontonasal ducts, a residual frontal sinus cavity will remains which could be a source of infection.

I am going to assume that this residual sinus cavity is located near the frontonasal ducts underneath the hydroxyapatite cement. If this asymptomatic and the cavity is clear, then I would just fill in the outer brow bone contour and leave it alone. However, if it is a source of pain or frontal sinus infections, then it should be removed and obliterated with cement along with the brow bone/forehead contouring.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Sunken Brow Bone Be Reshaped?

Q: Dr. Eppley, I had an operation on my forehead almost 16 years ago that changed my life. My frontal sinus was backed up causing me to have had my forehead bone removed and replaced with my hip bone in fear that it was infected. I have a cut along my hair line but my forehead does not look the way I wish. How much does a reconstruction cost to have some material to over lay the bone for a more normal look? Thanks!

A: I am assuming based on your description that you originally had a frontal sinus obliteration procedure in which the sinus lining was removed and filled in with an iliac marrow graft. This undoubtably healed in a very irregular fashion, leaving the brow bone area with an

uneven contour that may even be a bit sunken in. The brow bone/forehead contour can be significantly improved by an onlay frontal cranioplasty using hydroxyapatite cement. That can be done using your existing hairline scar. In order to properly estimate costs, please send me a picture of your forehead for my assessment so I can see how much cement may be needed which can highly influence costs.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Forehead Indentations Be Filled In?

Q: Dr. Eppley, I desire a smoother, lower forehead. Currently I have indentations on each side of my forehead that run all the way down to my cheekbone arches. I would really like to have those indentations filled in using bone cement or some other reliable material. I also have a high forehead and would like to have it lowered. My forehead looks big and masculine right now and does not fit well with the rest of my face. I have attached pictures of me for your review.

A:  The indentations to which you refer are the temporal fossa, which is largely a soft tissue space filled with the temporalis muscle to the side of the forehead. It extends from the anterior temporal line at the edge of the forehead down to the zygomatic arches inferiorly. While these could be filled in with bone cement deep under the muscle, that would not be my approach and could be improved much more simply. Silicone temporal implants can be placed under the deep temporal fascia and on top of the muscle. This is a more effective, reliable and cost effective technique.

When you speak to a large forehead, I am assuming you mean a high one in which the distance is vertically long from the eyebrows to the frontal hairline. That is different that a large forehead in which the frontal bone is bossing or prominent. While the forehead can be vertically shortened by a centimeter or so through a frontal hairline advancement and skin excision, I would be very cautious about performing that procedure in you. A forehead reduction results in a scar along the frontal hairline. In pigmented skin types like yours, I would be concerned about how such a scar may turn out. Hair density and hairstyle is also an important consideration is deciding about the aesthetic merits of a forehead reduction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Protruding Forehead Be Reshaped?

Q: Dr. Eppley, my head is mildly deformed looking from the side. The forehead bulges out at the top and makes my head look too long from the side view. I want my forehead to have a more curved look that angles backward. I have attached a side view which shows me before and after I have done some computer imaging to show the forehead shape I am after. Can this look be surgically achieved?

A: Thank you for your inquiry and sending the photo attachments. What you are talking about is a cranial reduction/forehead reshaping which would be done by a burring removal technique. The important question is whether it can be reduced enough to achieve the result you are looking for. That is best answered by knowing how think the outer table of the cranial bone is. That can be evaluated by simple plain x-rays of the skull (AP and lateral views). From these films the amount of bone that can physically be removed (outer table) can be measured. There is no question some reduction be done, I (and you) would want to know the best we can beforehand if it is enough to justify undergoing surgery for it.

Dr. Barry Eppley

Indianapolis, Indiana

 

Can My Forehead Be Reshaped As It Slopes Backward Now?

Q: Dr. Eppley, I am interested in forehead contouring surgery. My forehead is kind of rounded and I would like to have it more like square-shaped. When looking at a profile view my forehead sticks out where my brows are and my eyes look deep in the face. I also have attached a picture of a gentleman that his forehead looks more like square and that is exactly what I’m looking for or something close that will reduce my forehead. Thank You

A: Thank you for sending your pictures. Your forehead shape is a combination of brow bone protrusion and an upper forehead that slopes backward. Together this gives your forehead a 50 to 55 degree backward slant in a profile view. The desired forehead shape that you have shown is almost completely vertical. While that is not completely possible from the forehead shape that you have now, you can make significant improvement in your current shape. To change the slant of your forehead, you need to address the two components of the problem, brow bone protrusion and upper forehead retrusion. This is done through a combination of brow bone protrusion and forehead augmentation above the brow bone area. Neither brow bone reduction or forehead augmentation alone will make this improved shape. It takes this combination ‘ying and yang’ approach to create the substabtial forehead shape change that you desire. I have attached an imaged result of what I can think can be achieved by this approach. This would be done through an open coronal incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Forehead Horns Be Removed?

Q:  Dear Dr. Eppley, I am a young women and am very insecure about my forehead. It’s very large and I’m tired of bangs. As you can see in the pictures, my forehead sticks out because of the “horns” I have smacked in the middle of my forehead. It feels hard. It may just be the bone but I still want to see if any procedure can be done to make them go away or, if not, make them less noticeable when light is shown on them.

A: I can see by your pictures that you have an upper frontal bone bulges, often what people refer to as ‘horns’. There are two approaches to making your forehead smooth and less prominent. The simplest approach, and I suspect the one of most interest to you, is to do a burring reduction of these bumps to make your forehead smooth and less prominent. This would be done through an incision way back in the scalp. The other approach to forehead smoothness is to build up the forehead below and around it with a cranioplasty material. This would not only make your forehead smooth but would also give it greater convexity which is viewed by many women as a desireable forehead feature. Both of these forehead reshaping/reduction approaches will work to make the forehead smooth adn get rid of the bumps, it is just that the shape of the forehead in profile view will be different depending upon which one you would choose.

Dr. Barry Eppley

Indianapolis, Indiana