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

Can My Forehead Be Reshaped To Get Rid Of My Horns?

Q: I am wanting to get my forehead fixed. It just never grew in right and I have been made fun of since I was a kid. Photos may not look bad but I have been called horn head, hell boy, and square head all my life and I just want it to look a little better. I have two prominent ‘horns’ for lack of a better word on my forehead. I don’t know if these are just bone growths or my brain sticking out. They feel hard though. I have attached a picture so you can see them. Can these be burred down or something to make them look better?

A: Based on the one picture that I could see, it looks like you have two bulges on the sides of your forehead creating that look. These are very much like larger osteomas. The skull is thicker in these bulging areas. Reducing the bony bulges is actually fairly easy by burring them down to make the forehead less square and more round. The trick to it, however, is getting there to do it. The best approach would be a coronal (scalp) incision across the top of the scalp but that resultant scar (fine as it is) may not be a good choice for a male.The other approach is an endoscopic one where much smaller incisions are used. The access is not quite as good but I should still be able to burr down the prominent areas.

Dr. Barry Eppley

Indianapolis Indiana

Can You Give Me Some Advice On Forehead Recontouring?

Q:  Dear Dr. Eppley, I wonder whether you could give me some advice about forehead recontouring.  I have a very prominent brow and two bony protusions on my forehead.  I look fine straight on but at 45 degrees I look extremely hollow-cheeked and my eyes look abnormally deep-set.  I tried cheek implants about 15 years ago (they have since reabsorbed) but of course these only made my eyes look even deeper-set.  I also have a very strong chin and nose but can’t reduce these either because they go some way to balancing out my brow line.  Would you be able to provide me with some idea as to my suitability for surgery? Thank you very much.

A: Occupying the upper one third of one’s face, the shape and size of the forehead can impact significantly one’s facial balance and appearance. Your description illustrates that quite clearly. The brow bone area, known medically as the supraorbital rims, is a bony prominence like the cheeks and chin in the lower two-thirds of the face that has cosmetic significance. When it is normal (not protruding) one does not give it a second thought. When the brow bones are excessive, however, it can change the look of one’s entire face…and changing other parts of the face will not really ‘hide’ the brow protrusion or its impact on how one’s eye area looks.

While the shape of the forehead and brows is significant, it is not commonly surgically changed. This is not because the possible forehead recontouring procedures are difficult, have high risks, or involve a long recovery, as they do not. It is because it requires an open approach with a scalp incision and a resultant scar in the scalp. For women this is not usually a major stumbling block, but for most men it is. Since many more men have forehead concerns than women, this makes the number of cosmetic forehead contouring procedures that are done fairly small.

Dr. Barry Eppley

Indianapolis Indiana