Q: Dr. Eppley, I am interested in having Forehead Augmentation Surgery. I am a transgender woman and I have had my brow bone shaved down. While it improve my appearance, it still did not give me the forehead I am looking for. I want to achieve a more rounded/flat, feminine forehead, right now mine has a slope that is not appealing in a female. 

I have read that the most common approaches are bone cement and custom-made implants. I am interested in learning how much this type of surgery would cost (both with bone cement and implants), and how long would I need to stay in the area.

I am attaching four images, one showing my current profile, another one showing what I would like to achieve, and two more images of a CT Scan that I recently had done showing the anterior and lateral side of my head. 

Thank you very much for your attention to my inquiry. 

A: Thank you for your inquiry and sending your picture. You are correct in that ‘old style’ bone cements and contemporary custom implants are the two most commonly used options for forehead augmentation. There is also a newer standard ePTFE preformed forehead implant. Each has their advantages and disadvantages which ultimately comes down to what incisional access is needed to place them, how far back along the upper forehead and to the sides of the forehead does the augmentation need to cover, how precisely can each method achieve the aesthetic forehead goals in a smooth and even fashion and their costs to perform them.

Because of your prior surgery you undoubtably have a long frontal hairline or more posterior scalp scar for access so the incisional differences between the forehead augmentation methods is irrelevant. If you throw out costs the custom forehead implant is always the best choice because you control every dimension of the implant prior to its placement so achieving the final goal in a smooth manner with no edging is the most assured. Bone cements are also a good option for you because you need to be able to turn down the forehead flap so an open visual field exists to apply, shape and let the cement cure. This requires the long incision which again I assume you have. There are two different types of bone cements, PMMA (plastic) and HA. (hydroxyapatite) HA is the best bone cement to use because it is composed of inorganic calcium phosphate crystals which is the most similar to bone…but it has a significant cost factor to it. PMMA is the most economic bone cement option. Off-the-shelf PTFE (Goretex) forehead implants are used primarily for the Asian female who wants a rounder forehead and limited incisional access to do so. But they are more a central forehead augmentation method.

If you look carefully at your own side view imaging prediction notice that the frontal hairline remains the same indicating that the augmentation shown is more of a central augmentation effect that only needs to feather out as it approaches the hairline. (and probably the bony temporal lines as well to the sides) Given your more central forehead augmentation goals (which are probably in the 5 to 7mm increase at most) and keeping an eye on costs, bone cements vs a preformed ePTFE forehead implant are good choices for you.

As for logistics you would fly in the afternoon/evening before surgery, have surgery the next day and then fly home the following day.

Dr. Barry Eppley

Indianapolis, Indiana