Your Questions

Q: Dr. Eppley, I am an otherwise very thin healthy 42 year old female searching for a forehead augmentation solution to my upper forehead contour defect. I had what would be considered minor trauma in 2010 (struck forehead on breakfast bar) with a resultant depressed skull fracture. To fix the resultant indentation I have had 2 fat grafts and several Radiesse injections with no resolution. Is there any hope of a repair with a closed procedure; something akin to Artefill w/o Bovine Collagen (allergic)?  Bone graft?  Stem cells?  Can frontal bone be shaved down to create a smoother contour endoscopically?

A: I am not surprised that your frontal defect in the upper forehead could not be adequately contoured/restored with any of the injectable methods that you have had. They simply will not work for a bone contour defect nor is there are injectable material like fat or any other synthetic filler that will work.

There are a variety of minimally invasive procedures, however, that will work for your type of forehead augmentation. Through a small incision in the scalp (3 to 4 cms) done endoscopically, a variety of implant materials can be introduced to smooth out the upper frontal bone depression. These can include PMMS or HA bone cement or even a small semi-custom or custom implant. These are all procedures that can be done under local anesthesia/IV sedation. The most economical approach would be PMMA bone cement. I will have my assistant Camille pass along the cost of the procedure to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My 15 year-old son needs his forehead reconstructed after an injury last year. He lost a portion of his forehead from the fracture and now has a large indentation from his brow up to just under his hairline. Which is better for his reconstruction, a cranial bone graft or a bone cement?

A: From a growth standpoint, his skull/forehead is essentially fully formed so the method of reconstruction is not really important from that standpoint. What counts is how smooth it can be after it heals and will have the least chance of irregularities down the road when all swelling truly subsides. Either a bone cement or bone graft has their own advantages and disadvantages in this regard. A bone cement will give the smoothest contour result by far because it can be molded completely into the defect and smoothly contoured to the surrounding bone edges. While it is a synthetic material, it is made of hydroxyapatite which is the inorganic composition of natural bone so ti is very biocompatible.  While bone grafts are an autogenous material, they are prone to some resorption and hence irregularities down the road. Even though the forehead has thick soft tissue, plate and srew profiles inevitably become evident unless very low profile (< 1mm) devices are used. It is likely that I would do a combination frontal cranioplasty, using bone grafts to obliterate any frontal sinus exposure and bone cement to fill the defect and contour into the surrounding forehead.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a frontal sinus obliteration with a bicoronal approach.  Titanum plates and screws were used to secure a bone flap.  Soon after all the hardware was show thru and I went through a second surgery to have it all removed.  Now i found out the bone flap which was pretty large is resorped, which is no surprise as my forehead has a significant deep “thumbprint” and also other various irregularities.  I am getting mixed opinions.  Cement, no cement “It can be a nightmare”  Iliac bone crest graft. Titanium mesh etc.  Also my soft tissue is thinned out because a portion of the forehead tissue was used in the obliteration.  Can you help me ?

A: It sounds like you had an osteoplastic frontal sinus procedure using a pericranial flap top cover the obliteration. I will assume that much of the frontal bone flap has resorbed, resulting in indentations and irregularities. I have seen this before and I don’t think it will be a ‘nightmare’. It will be scarred for sure and there may be some exposure into the residual frontal sinus areas. It rebuilding the brows and lower forehead, I would definitely use hydroxyapatite bone cement. (not acrylic/PMMA) bone cement. I would not use titanium mesh (as this will cause the same problems you had with previous hardware) or bone grafts. (they will largely resorb also) The thinning out of the overlying scalp and potential exposure to the frontal sinus makes it imperative that the most stable but biocompatible material be used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my 14 year-old son had his foreheasd bone fractured in an accident this past April 2012 . The bone was removed by the doctor then and he now now needs reconstruction of that part. The place is between both eyes with a size of size of 7cm length and 5.5 cms width. The doctor here is saying they will take out a piece of bone from the front table of head bone and put that on. Is it safe? I need your view.

A:What are you are referring to is reconstruction of the forehead with a split calvarial bone graft. That is certainly one accepted cranioplasty method to do the reconstruction and is the only natural or autologous method. It is a well known craniofacial surgical technique and is very safe if done in experienced hands. Given that it is a full thickness frontal bone defect, the size is not too big (7 x 5 cms) and he is only 14 years of age, this is probably the best approach. His skull should be thick enough that the outer table can be removed elsewhere on the skull in a single piece and moved to cover the forehead defect. There are numerous alternative methods that are technically easier such as titanium mesh and hydroxyapatite combinations as well as custom HTR cranial implants, which are also acceptable methods, but the cranial bone graft for his size defect should work well. This is particularly important of the frontal sinuses have been exposed in the defect, which I suspect that they have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Over 10 years ago, I was involved in a car accident and ended up getting a craniotomy and evacuation of a subdural blood clot. Afterward, the craniotomy flap got infected and had to be removed. Because I was a child at the time, some bone actually grew back over the upper forehead defect. But it was not of the same thickness or amount and I have been left with a flat and irregular upper forehead area around my hairline and into the very visible part of my forehead. It is quite noticeable and embarrassing for me and I have always wanted to get it fixed. I have read recently through your writings that it can be repaired with some types of materials that are applied to the outside of the bone. That has given me great hope that there is a solution to this embarrassing problem. I am tired of people staring it! Please tell me about this procedure and how it is done.

A: Based on your description alone, it sounds like you would be an excellent candidate for an onlay cranioplasty procedure. Compared to what you have been through previously, this is a relatively simple operation that produces immediate results. Since you had a craniotomy previously, you have an existing scalp scar. The scalp ius lifted up again and a synthetic cranioplasty mixture is used to apply to the defect and make it perfectly smooth with the rest of the forehead. The available mixtures are a powder and liquid, which when combined, turns hard after it is shaped within a few minutes. There are three specific cranioplasty materials. I would choose hydroxyapatite, specifically Mimix, for your cranioplasty as it is the most like bone and has excellent working charcteristics. I have worked with it for over 15 years, including through its research and development phase, so I know its working properties very well. This is an outpatient procedure under general anesthesia that would take about 90 minutes to do.

Dr. Barry Eppley

Indianapolis Indiana