Your Questions
Your Questions
Q: Dr. Eppley, I am looking for a doctor that has done brow bone augmentation. I came across Dr. Eppley and am considering both rhinoplasty and brow bone augmentation to improve my profile view. I want my forehead to come out further, as of right now my eyes are flush with my forehead and it’s very flat. I want more dimension in my face. I wanted to know what you would recommend and how confident yo are with Asian rhinoplasty. Thanks!
A: Thank you for your inquiry and sending your pictures. I have done many Asian forehead and brow augmentation and rhinoplasty procedures. The key question for both procedures are the materials to do them. In the forehead you have the option of either bone cement application through a near complete coronal incision or a custom forehead/brow bone implant placed through a smaller scalp incision. For the rhinoplasty, one of its key elements is the augmentation of the nasal bridge. This can be done using either a cartilage rib graft or a silicone nasal implant.
The use of these various materials for both forehead and brow bone augmentation and rhinoplasty affects numerous aspects of the procedures including cost and recovery. I would need further input from you on these choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in brow bone augmentation as well as orbital floor augmentation. But I don’t want to use any synthetic implant materials to do so. Can Bio-oss (bovine hydroxyapatite) be used for orbital augmentation and brow bone augmentation?
A: Any hydroxyapatite granular material can be used to augment a confined space like the orbital floor or a more open surface like that of the brow bones. Whether a bovine hydroxyapatite will persist or develop any significant bone ingrowth as an onlay material is a matter of debate. (it works best as an inlay bone substitute material) But from a handling standpoint, it can be used for either craniofacial application. Applying the material to the orbital floor is very straightforward. Applying to the brow bones, however, is a bit challenging because access to the brow bones is more restrictive. The ideal way to use it in brow bone augmentation would be an injection technique that uses a brow incision to do so.
While the concept of hydroxyapatite granules is understandably appealing, there are prone to irregularities and asymmetry when applied as an onlay graft. This would be particularly evident when introduced as an injection as the material does not have a smooth linear flow when injected out of a syringe.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temporal and brow bone augmentation. I was wondering what you would suggest for a 26 year old patient with weak temple and brown bones that make me look tired. I want the brow and temple area to be smoother and flatter and my eyes to look less protruding. I was reading about fat injections and was wondering if those can give me the results or would I need something more extreme like implants.
A: Thank you for sending your pictures. For the temporal region I can see where our extended anterior temporal implants will fill out the temporal areas nicely up to the temporal lines of the forehead. Building out the brow bones (supraorbital ridges across the top of the eyes would make the actual eyes look less protruding. The best way to achieve that look would be to make a custom brow bone implant for you off a 3D CT scan. Both procedures could be done concurrently. The temporal implants are placed through small (3.5 cm) vertical incisions back in the temporal hairline. The brow bone implants could be placed endoscopically through small scalp incisions.
The problem with fat injections, particularly for the brows, is that they are unpredictabe in terms of survival. In addition they produce very ‘soft’ push on the outside tissues which may be acceptable for the temples but not for the brows. But as an alternative and potentially more appealing treatment strategy this can certainly be done. And there is little to lose but doing so.
In reality, the placement of implants is not much traumatic than doing fat injections in these areas.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brow augmentation by injectable fat grafting done ten days ago. I had a quick question about after care from the procedure. Should I be avoiding going into a sauna? I figured the heat would increase blood flow to the fat graft, but I just heard about how Vanquish destroys fat cells by warming them to 110 degrees.
A: While high heat is a known detriment to fat cell survival, the actual temperature at which that would occur is around 140 degrees F….not just 110 degrees. Vanquish does help destroy fat cells but that is by causing an internal temperature of the fat in the treatment to reach and be sustained around 45 degrees C. Therefore, I don’t believe the heat from a sauna would make any difference in fat graft survival. While the heat from a sauna may reach 145 degrees, your internal body temperature never rises more than a degree or two. Vanquish specifically creates temperatures at the subcutaneous tissue level of 45 Centigrade plus with the specific purpose of destroying fat cells. External sauna temperatures do not create the same subcutaneous level temperature changes. If they did you would be ‘cooked’ just like the fat cells that were placed by an injectable fat grating technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having brow bone augmentation to give it a deeper and more masculine appearance. I understand that there are various materials available, and I was wondering if you could kindly answer these few questions:
1) Which material would allow for the smallest scar?
2) I understand that custom silicone implants will provide the most dependable results, but will hydroxyapatite (HA) be able to provide a similar augmentation?
3) Which would also have the cheapest overall surgical cost – silicone, HA or PMMA?
4) As I’m leaning towards HA, could you also provide the cost of getting this procedure?
Thank you!
A: When it comes to your questions on brow bone augmentation the answers are as follows:
- A silicone brow bone implant can be placed with the smallest scar. Because of its preformed shape it can be inserted and positioned with a limited incision or endoscopic technique. All other forms of brow bone augmentation (except fat injections) require a wide open scalp incision technique with a long scalp scar.
- Hydroxyapatite can provide a good brow bone augmentation if one can tolerate the coronal incision to have it placed. This is a liquid and powder mixture that must be carefully applied and shaped. To do so requires wide open visibility.
- A preformed silicone implant would provide the most economical approach since it has the shortest operative time to complete.
- I will have my assistant pass along the cost of the different brow bone augmentation procedures to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead and brow bone implants augmentation. I’m an Asian male, living in Korea, whose appearance is just like any other Asian’s. My eyes are very big for an Asian’s, but they are pretty much bulging. Besides, the prominence of my forehead and brow bone (I have heard that it’s called ‘supraorbital ridge’ or ‘supraorbital torus’) is very slight. It makes my eyes looked more bulging. And it also makes the distance between my eye and eyebrow look too far. All these all things make me look feminine. It’s really awful. Many people tell me that my eyes looked ‘faggy’.
So I’m considering the forehead and brow bone augmentation with intraoperatively applied bone cement. As you know, preformed custom implants easily makes
empty space between itself and forehead bone, and it can cause fatal side effects like dropsy. So I think bone cement will be better, but I want to know what
you think. I have wondered about this. For years, I have searched for a hospital who does forehead “including brow bone” augmentation surgery, but all hospitals in Korea told me it’s dangerous to use any implants on the brow bone, because there are much important nerve on brow bone region. So I had almost given up, and just at that time, I found your
website in google. So I wonder whether this surgery is really dangerous or not.
Finally, I wonder how much my forehead can be protrude by surgery. You know I am Asian, and I want to make my forehead and brow bone protrude as much as a Caucasian, if it’s possible. I really want to know whether it’s possible or not.
A: I have done forehead and brow bone augmentation over my career by every conceivable method including PMMA and hydroxyapatite bone cements, prefrormed Medpor implants and, more recently, custom forehead and brow bone implants.
Each of these methods have their own distinct advantages and disadvantages…neither one is perfect. Bone cements are very good to use but they require a lot of intraoperative shaping, can be very expensive (HA cements) and can lead to frontal bossing/protrusions if the forehead and brow bones is brought too far forward. (as bone cements should not extend beyond the anterior temporal lines onto the tenporalis muscle fascia where they will not adhere and can lead to visible edging). To place them well, they require a long coronal incision to get adequate exposure way down to the suprarbital ridge. They are also associated with modestly high revision rates particularly when the amount of augmentation needed/desired is significant.
Custom forehead and brow bone implants have numerous advantages over bone cements. Computer designing the implants allows much greater precision and control over the amount and symmetry of augmentation. They can be designed with forehead widening in mind in large augmentations as the material can sit without complications on top of the temporalis fascia beyond the anterior temporal lines. The potential open space under the implant (which I have never seen to be a true problem) can be circumvenyed by screw fixation and the placement of numerous perforation holes in the implant to allows for tissue ingrowth through the implant and down to the bone. A custom implant also allows for a smaller scalp incision to be used to place it since it already has the desired size and shape through preoperative designing.
There is no truth at all that forehead and brow implants are dangerous. They are no more ‘dangerous’ than bone cements. They do not cause ‘dropsy’. They do not have a greater incident or risk to the supraorbital nerves than bone cments.They require the same amount of tissue dissection down onto the brow bones that bone cements do. Forehead and brow bone implants are just as safe as bone cements, they just are another implant option to consider for aesthetic augmentation in this area that has its own unique advantages.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had injectable fat grafting done to my brow ridges several months ago. I like the results of my fat grafting but my only issue is that it leaves the area between the eyebrows (and above my nose) looking hollow. I’m not sure why my surgeon did not inject fat in that region. But could fat be injected there to provide a smooth transition between the brow ridges? I have circled the region between the eyes that is my concern from a stock photo for your reference. Are there any risks associated with fat grafting to the circled area?
A: The area to which you refer between the eyes is known as the glabellar area. It lies between the inside of the eyebrows and, in a male, is a more normally indented area than the brow ridges which overlie the eyes. If the brow ridges have been augmented and the glabellar area has not, then it may well look now by comparison that it is more indented than before. You would have to ask your surgeon why that area was not grafted alone with the brow ridges. I have not specific problem with grafting all the way across the brow ridges, from one side to the other, as long as it is done with a blunt-tipped injection cannula.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like information about brow bone augmentation with calcium hydroxyapatite and customized implants from 3D CT scans. I had a rhinoplasty where the surgeon used transverse and medial osteotomies of the nasal pyramid, and nasal dorsum. I realized that the eyebrows lost support after surgery. The augmentation surgery in the region of the supra-orbital rim or brow ridges with customized implants are made of what material?
A: Brow bone augmentation can be done by different materials which can also control the surgical approach to place them. (incisional access) The traditional and still most commonly performed technique for brow bone augmentation is through an open scalp incision using either PMMA or hydroxyapatite bone cements. When just the brow bone is being done, hydroxyapatite cement is the material of choice. But when the brow bone is being combined with total forehead augmentation, PMMA bone cement is used due to being a more lower cost material per amount of volume. Performed or custom implants can also obviously be placed through such a wide open exposure. Custom brow bone implants made from a 3D CT scan are always made of a silicone material, primarily due to ease of adaptation to the underlying brow bone and cost. Newer techniques of placing custom or preformed silicone brow bone implants are being developed to avoid the larger scalp incision. (endoscopic frontal and upper eyelid incision)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had brow bone augmentation by fat grafting done yesterday, and I think my surgeon placed 8cc per side. I told my surgeon not to be aggressive, but I’m worried that he might have overdone it. It currently looks like an excessive amount of augmentation. Do you think this is what the final look will be, or will the amount of augmentation decrease to a reasonable amount with time?
A: Fat grafting to the face, by injection, is unfortunately not uniform in its outcomes or how well they survive. While there are a lot of variables in what makes an injected fat graft survive, and one can not assume that every surgeon does every step of fat grafting the same, the face has variable rates of fat graft take by region. The brow area has only a moderate fat graft take between 20% to 30%. Thus overinjection is commonly done knowing that much of the injected fat will take. That is why your surgeon uses 8ccs per side with the outcome likely to be only 1cc to 2ccs of fat that will actually take. So what you are seeing today will change and will go down substantially over the first month after brow fat grafting surgery. Ironically the concern you have today (too much) may turn into the opposite concern (too little) six weeks from now.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, One thing I did notice in brow bone augmentation before and after pictures was that the eyebrows seem more raised. This was most apparent to me in brow bone augmentations that were done with bone cement but this also seemed to occur in those that got fat grafts too, albeit to a much lesser extent. Is such an outcome a given? Or can it be avoided in any way? What causes this in the first place?
A: Whether the eyebrow raises after any form of brow bone augmentation is an issue which I nor any patient have ever noticed in any significant manner. At the least no patient has ever told me it was a concern or problem after surgery. It would make sense that some elevation may occur since volume and projection is being added and the overlying skin surface area is not being increased per se. (minus the tissue expansion effect) I do know that the reverse can be true…brows can fall somewhat after brow bone reduction which is why I almost always do some minor brow lifting with most brow bone reductions.
Whatever the browlifting effect that may or may not occur wit brow bone reduction, it does not appear to be significant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really interested in one of the facial procedures (cheek augmentation I think) to improve my smile. I make an effort to smile only to find out that people don’t find it compelling. I am confused and this makes my self-esteem very low. I have small(weak) cheek bones which some how make me look like I am frowning all the time. It was after me noticing my self-consciousness that I started being aware of all the people I found very approachable or had friendly faces, in other words their cheek bones were gently protruding and noticeable from a profile(side view of the face). This, them having strong cheek bones, really made them appear to be ‘ever smiling’ and smile effortlessly even when it is just a grin their evoking. I looked at myself talking in the mirror lately and was evidently stunned, because I would say things but my facial expression was not corresponding with what I say or the way in which I respond to things I said to myself. For instance, when I am surprised my eyebrows don’t rise and no lines on my forehead show, because my eyebrow bone is also flat and I seem not to send my messages across to others other than verbally. A stronger cheek bone with lines on the corners of my lips and bigger eyebrow bones will make my smile sensible.
A: It sounds like you have a good grasp on how to improve your facial appearance. By your own description you know that cheek augmentation by implants, possibly combined with brow bone augmentation, would help your smile both outside and in.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know the differences in the frontal view after orbital decompression and brow bone augmentation? I would like to get deeper set eyes but I know decompressions has a lot of side effects. Do you have photos of before after to show for brow bone augmentation? Thank you
A: Orbital decompression will not produce deep set eyes in a normal patient. While orbital decompression is effective for the patient with protruding eyes (exophthalmos), this is because it is an abnormal protrusion and dropping out the orbital floor bone will give the enlarged eye a space to fall back into. In the normal non-enlarged eye, dropping the orbital floor will only make the eyeball fall lower and not back. Thus in the frontal view, the eyeball may look lower and the pupil drops down closer to the lower eyelid margin. Conversely, brow bone augmentation combined with lateral orbital rim augmentation will make the eye look deep because it moves the bony rims around it further forward. This can be shown by looking at before and after pictures of brow bone/forehead augmentation which can be seen on my website in the Facial Reshaping section under those specific procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will the silicone implants have to be custom made, or will you be able to carve them during the procedure? Out of curiousity, but why don’t more surgeons perform brow ridge augmentation with silicone implants? Being able to bypass a large scalp incision seems like a huge plus. Also, with silicone brow ridge implants, will it look unnatural if I smile or animate my face, especially since there doesn’t seem to be much soft tissue coverage in the region. I’m also assuming that the implants will be screwed in, will there be any substantial risks to this? Will recovery also take a long time?
A: The reason that any form of brow bone implants has not been historically done is for two reasons. First, there are no preformed brow bone implants that are available and, even if there were, there would likely be some fit problems. Secondly, only more recently has computer technology made it possible to take a 3D CT scan of the patient and make on the computer screeen exclusively the exact design and size that meets the patient’s aesthetic desires and will have a perfect fit to the underlying bone during surgery like a crown on a prepared tooth.
With the brow bone implant secured to the bone there will be no animation deformities, just like when open brow bone augmentation is done. The biggest risks to the procedure are asesthetic, does it look natural (not overdone) and is there good symmetry. (here is the value of computer-designed implants) Recovery is aesthetic, meaning how long for swelling and any bruising to go away. That will depend on the approach used to placed the implants, endoscopically (7 to 10 days) and through the upper eyelids. (3 weeks)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve read your articles on brow bone augmentation and was wondering if silicone implants could be used instead of hydroxyapatite or PMMA? Apart from the scalp incision, could the silicone implants be placed through any other incision (upper eyelid)?
A: Performed silicone brow bone implants could be placed either through an upper eyelid incisional approach or through an endoscopic technique through two small scalp incision. Because they would be made of a flexible silicone material, they can be inserted in two separate pieces and ‘assembled’ once inside. If this brow bone augmentation technique is done, it is best to make the preformed silicone implants beforehand using a 3D CT scan of the patient.
Dr. Barry Eppley
Indianapolis, Indiana
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
Q: Dr. Eppley, I appreciate you doing some computer imaging for my brow bone and forehead augmentation as well as a nasal implant to build up my nose. I have some general questions about these procedures for you
1. Is it possible to choose the exact shape of the augmentation I want? In the example photoshopped photo you sent me, I would prefer to have my forehead augmentation a tad bit less “round” and maintain a bit of a masculine ridge above the brows.
2. I’m wondering how precise can you get with the shape of the augmentation? Is it a matter of injecting the cement under the skin and molding it with your fingers? Or can it be matched to be pretty much what is shown in example photoshopped photos?
3. Regarding building up the nose bridge, how do you avoid the effect of the eyes moving closer toward one another? A bigger nose bridge means the skin on the bridge is pulled forward and therefore pulls on the inner corners of each eye right?
4. Will I have to open up my skull near the hairline in order to access the browbone? Is it possible to go through the nasal openings or perhaps eyelids instead?
5. I keloid very easily… will this be a major problem?
6. Regarding recovery, I’m sure there will be swelling and possibly bruising for a week or so, but how long after that is it noticeable that I’ve had surgery done on my face? If possible, I would like to avoid making it very obvious that I’ve had surgery done, as quickly as possible, without obvious scars.
7. I live far away, would it be ok to board an airline flight soon after the surgery?
A: In answer to your questions:
1) In the male having a brow ridge ‘break’ is important so that is something that I try to do with shaping a male forehead augmentation. By virtue of the way a forehead augmentation is done, the brow ridge break has to be be put by using a handpiece and burr after the material is set.
2) Forehead augmentations have to be done though an open scalp incision under direct vision. There is no method of injecting a cranioplasty material under the skin.
3) I am not aware that nasal bridge augmentation pulls the skin inward at the corners of the eye. That does not occur in a typical nasal bridge augmentation.
4) No as answered in #1 above.
5) Keloids are not a scar phenomenon that I have ever seen in the scalp or the nose.
6) The reality after this surgery is that it will take 2 to 3 weeks to look normal again and can not be done without a scalp scar. Having this type of surgery with ‘one week of recovery and no scar’ is not possible.
7) Most patients return home within 2 to 3 days after surgery by plane.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get a forehead burr hole filled from a previous craniotomy that I had done. If you used hydroxyapatite (HA) material, would the HA be applied directly on the burr hole coming to direct contact with the dura? Would a mesh and screws be also used?
In addition, I want to get my brow ridges built up as they are a little flat for a guy. Do you favor having the the eyebrow implants custom-made or would you make them during the surgery? Can’t HA cause a necrosis of the surrounding tissue during curing? What would be the advantage of using HA for the eyebrow ridge implant over medpor, PEET, or any other existing material?
A: In answer to your questions:
1) When reconstructing/filling in burr holes, it is first necessary to dissect the soft tissue/scar from both around the hole and the bone edges to identify clearly the bony margins. This scar tissue directly lies over the dura so the material does not lie in direct contact to the dura. Even if it did, however, this would be of no consequence or concern. Because they can be some ballooning of the scar/dura into the burrhole, it can occasionally be necessary to push this tissue down so the bone edges of the hole are exposed. This is done with a small piece of titanium mesh (no screws) whose edges grip the bone to keep it in place.
2) I am not sure where you get the impression that any cranioplasty material, HA or even PMMA, can cause any tissue necrosis during curing. HA is a completely cold curing material that has no exothermic reaction during setting. Even PMMA, which does have an exothermic reaction during curing, is very mild and never exceeds 110 degrees F. The actual temperature at which tissue damage could occur is at 142 degrees F and above. Decades ago the original PMMAs had high cure temperatures but those versions no longer exist. This has never been an issues with HAs and, when they were introduced in the mid 1990s, that was one of their big advantages over PMMA, a neutral set temperature.
Brow ride augmentation can be done nearly 10 different ways, largely depending on what material is being used. In the right hands, they all can be effectively done from an aesthetic standpoint. What one has to look at then is the material’s biology, what is the process to place them and the cost to do it. The most biologically compatible material is HA because it is composed of the inorganic content of bone, calcium phosphate. This bone will bond directly to it and may even get a small amount of bone ingrowth. It is also the easiest to place and mold into a desired shape. All other typical synthetic facial implant materials, such as silicone, Medpor and Gore-tex, must be hand carved at the time of surgery from a block of material. While this is very doable, it adds to surgical time and the they must be screwed into place for stability. Materials such as HTR and PEET must be made beforehand off of a 3-D skeletal model. Between the costs of the model and the fabrication of the implants, this could easily add up to $10,000 in cost to the surgery. That would be acceptable if there was some overwhelming biologic advantage to the these materials, but there is not.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to get brow or maybe forehead augmentation. My eyes pop out too much and I would like to have deeper looking eyes. Do you think this will help?
A: I would need to see some pictures of your face to determine by imaging whether this would be a good procedure for you. A side view of your face would be particularly useful. By definition, increasing the prominence of the brow bones and forehead will make the eyes appear more deep set and less ‘protrusive’. Brow bone augmentation makes the superolateral orbital rim bigger and, in some cases, patients may also benefit by infraorbital rim augmentation as well to get a circumferential deeper look to their eyes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am really interested in getting Brow Bone Augmentation surgery done.I am a 21 year old girl with big eyes. But my problem is that my eyeballs stick out from my upper eyelids making me look really ugly and scary to people. Now I want to get this surgery done but I have very important questions that I would like you to answer for me. Will brow bone augmentation surgery help hide my eyeballs that stick out? I have a perfect nose and i like my nose just the way it is, but i’ve been told that having my full brow bone augmented could lead to changing the shape of the nose. Is this true? I would like to know the price range for a full Brow Bone Augmentation (BBA) surgery. I know this answer has to do with the type of material used, but out of an estimation I would like to know a range of price for both HA and PMMA. Lastly are the results of the BBA surgery permanent,meaning my eyeballs will be hidden for the rest of my life without worrying about any bad affect on my eyes in the long run. THANK YOU.
A: What you asking about brow bone augmentation is true. It can help deepen the look of the eyeball. It is just a question of how much. It has no effect on the appearance of the nose or the function of the eyes. The results would be permanent since the materials used are non-resorbable. The total cost of the procedure is in the range of $ 9500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had an accident when I was 16 that resulted to a dent between my eyebrows. I had a surgery to elevate that dent 10 months ago and it was done by my neurosurgeon because my frontal sinuses were also indented. My forehead now is improved but I can still see a slight dent which is very acceptable. My question is if the bone cement on my forehead will deplete overtime resulting to a more indented forehead again?
A: What you had sounds like an outer table fracture of the frontal sinuses, also known as brow bone fractures. Because this portion of the forehead has only a thin layer of bone in front of the underlying air-filled frontal sinuses, it can be pushed inward with a significant traumatic force. This buckling inward creates the outward appearance of an indentation of the forehead just above the eyes. When a delayed repair is done, it is much easier to build up the contours of the brow bones that it is by repositioning the displaced bone. This is done using any of the available cranioplasty materials. While I don’t know what type of cranioplasty was used for your brow bone augmentation reconstruction, none of them are resorbable. They all are stable biomaterials that do not degrade over time. So your current result will stay stable throughout your lifetime.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, what are the different techniques used in brow bone augmentation? What are the pre-operative and postoperative things to consider? Thank you so much.
A: When it comes to brow bone augmentation, the first consideration is what part of the brow does one want augmented? Most patients want the whole brow done and it must be approached through a scalpor coronal incision. There are some patients who just want the tail of the brow augmented and that can then be done through an upper eyelid incision. The next consideration is what material to use. There are four options including preformed implants and three mixtures which are applied and then harden which include acrylic (PMMA), hydroxyapatite (HA) and Kryptonite. (calcium carbonate) Because of moldability to the brow bones and that more volume can be obtained, I prefer the mixture materials. There are arguments to be made for any of them and they all will work. Considerations must be given to cost, long-term tissue acceptance and fracture resistance. From a cost standpoint, acrylic is best and is the most fracture resistant but there may be some tissue thinning over many decades of implantation. (emphasis on the word…maybe) HA and Kryptonite are very similar to bone so there will never be any problems with tissue acceptance but they are more easily fractured (theoretical concern, not one I have ever seen) and cost more. The choice of any of these materials for brow bone augmentation must be done on an individual patient basis.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like my brow bones enhanced but I think I only need the outer 2/3rds of the browbone or even just the outer 1/3 (the area underneath the eyebrow) plus a little bit on the temple that’s connected to the brow. I want the area to look flat but padded up and not stuck out like a ridge. I don’t want to end up looking like a neanderthal. So I think only the outer brow bone needs enhancement but I do not know how it would look esthetically in practice. I’m not a plastic surgeon. Have you done many outer 2/3 of the browbone enhancement surgeries before? How do they look? Would you mind sending me some before and after pictures? I am thinking of getting juvederm to the area first to see how it would look with the permanent filler. Should i do that? I also have a low nose bridge which I want to enhance a little bit. If you don’t mind I’ll send pictures. What are the chances of scarring with the upper eyelid approach? Where is the incision going to be? In the eye crease? I think saw you mention to someone else the Q&A about preparing the periosteal, what does that mean? Why do you prefer the hydroxyapatite paste instead of kryptonite bone cement for this procedure? I’m sorry for asking too many questions Dr. Usually when you search about enhancing the brow bone on the web, only the stuff about silicone forehead implants come up, which seems rather drastic and scary to me. You’re the first Dr who have said the 2/3 browbone enhancement is a viable option.
A: For the area of brow bone that you want enhanced, an upper eyelid approach is the best way to go. It is much closer to the bone area to be augmented and is done through an upper eyelid crease incision. This is the same incision used for standard upper blepharoplasty procedures. The material of choice is hydroxyapatite cement. This material must be placed through an open incision, contours nicely, sets up quickly, and is less expensive than Kryptonite bone cement. Many people are enamored with the injection approach with Kryptonite but they misinterpret it like it is the same as injectable fillers for soft tissue. It still requires an open pocket dissection and then must be contoured from the outside by hand without actually seeing the bony contours. That may be fine for a large skull area but when it comes to working with very discrete contours this is not good and will very likely pose irregularities that will have to be revised later.
The tail of the brow can be either reduced or augmented (lateral brow bone augmentation) through the upper eyelid approach. I have done both very successfully. A scalp approaach is needed, however, when the entire brow needs to be modified.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr Eppley, I just read a reply you wrote to a patient inquiring about forehead and orbital rim with either implants or hydroxyapatite paste to which you reply that Kryptonite Bone Cement would be a better option. I want to get your opinion on which material is the best choice for filling out the outer brow bone area(just very slightly). I’m asian, I have eyelids and round shaped eyes but my brow bone looks very weak, which makes me look tired unless i wear eye shadows/shading which I think have lead to my eyelid skin aging prematurely. My eyelids have started looking a bit saggy and I’m only in my late 20s. I want to have the appearance of having more developed brow bones (which looks normal on an asian person) i think this should also help keep my lids from sagging. I want to know if Kryptonite Bone Cement would be a good option for the browbone in my case? Or should i try something else? I’m also considering fat grafts. Please get back to me and let me know what you think is best. Thanks very much.
A: When it comes to brow bone augmentation, it is my opinion that it is always better long-term to add to the bone with a material of similar hardness…provided that the trade-off to doing it (incisional approach) does not leave any significant scarring. Fat injection grafting is a reasonable option nd it does offer simplicity and ease to do with a natural material. (fat) But how volume will stay and what its shape will be is not always predictable.
You have said one key statement in your inquiry…‘filling out the outer brow bone area’. It is critically important to know what specific brow area one wants to augment. If it is just the outer two-thirds or tail of the brow, then that could be done through an upper eyelid approach and adding hydroxyapatite paste. That would by far be the best way to do it and is very straightforward. If one needs the entire brow augmented, then I would use an endoscopic approach with Kryptonite bone cement. By this approach, it could be injected and then molded under endoscopic guidance.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley. I would like to inquire about brow bone implant. Do you mind taking the mind to answer some of my questions? 1) Are there any limitations to brow bone implant? Can it stretch as much as we want? 2) Will the eyes change its expression after the implant? I tried pulling out the skin at my eye brown area and there seems to be a difference. 3) Will the eyes appear bigger or smaller after the implant? 4) Lastly, is lowering my eye browns accurate to determine how I would look like after the brow bone implant? Thank you for your attention. Hope to hear from you soon.
A: In answer to your questions about brow bone augmentation, let me clarify that building up with brow area is done using typical cranioplasty materuials and not just a carved or pre-shaped implant. With that being said: 1) The size of brow bone augmentation can be done to just about whatever size someone wants. 2) The muscle activity around the eyes will not change after brow bone augmentation. But a stronger brow appearance may make the eye area look different. 3) While the actual size of the eye will not change after brow bone augmentation, they may look little deeper set in some patients. 4) The horizontal position of the eyebrows does not change after brow bone augmentation. They are pushed outward and perhaps a millimeter or so downward but they do not shift downward to any significant degree.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am an Asian American wanting to ask question to Dr. Eppley about a procedure. Is it possible to add material to the orbital rim to make it more deep? If so, what material and risks are involved?
A: When asking about building up the orbital rims, this is known as brow bone augmentation. By building out the brow bones, the globe or eyeball, will appear deeper. This is essentially a masculinizing procedure. Any of the cranioplasty materials can be used for brow bone augmentation and some plastic surgeons even use preformed or hand-carved synthetic implants. (which is not a technique that I use) The issue is not the type of material that can be used, since they all can work well, but the approach in which to do it. An incision is needed and the options include a scalp incision (for complete brow bone augmentation) or an upper eyelid incision. (for lateral brow bone augmentation) In a male with a high or variable hairline, a scalp incision is not usually cosmetically acceptable. This is less of an issue for a female.
Dr. Barry Eppley
Indianapolis, Indiana