Your Questions

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

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

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

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

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

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 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

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

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

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

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

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

Q: Is it possible to reduce the size of my forehead? I do not mean lowering the hairline, because my hairline is already low. My forehead is vertical and almost seems as if I do not even have a forehead to begin with. The shape of my head is very strange. As most people’s head is round or square. My head is like the roof of a house, being pointed at the top making a sort of 60 degree angle. I can feel and hear my head always cracking as if its not stable or solid. I am also not sure it bone can be molded or change shape but I have been able to compress my head through pressure. Very very painful but I was desperate. With a 30 minute span however, it would return back to its original shape. I most know if there is some way to mold my cranium to a rounded shape?

A: First of all, you should now that it is not possible to reshape your skull bone by any form of external pressure, except in newborns where the skull plates are not yet fused. All you are doing by external compression is squeezing the fluid out of your soft tissues overlying the bone. Once released, the fluid returns and your ‘skull’ reverts back to its original shape. I can assure you that your skull is solid and is not ‘cracking’.

It is possible to do some forehead reshaping through an open scalp approach. The bone can be reduced and shaped by about 5 to 6mms, maybe more, in some patients depending upon the thickness of their outer cortical table. This may be enough of a change for some patients to notice a visible difference.

Dr. Barry Eppley

Indianapolis Indiana

Q: I am a male and would be interested in receiving a surgery in order to correct my bulging forehead. Do you perform that kind on procedure on men?

A: Forehead surgery or forehead reshaping can mean different things to various patient, both male and female. The two most common procedures performed on the forehead are brow bone reduction in the male and brow bone reduction/tapering in the transgender patient. (male to female) There are also a variety of other forehead reshaping procedures from defects and asymmetry caused by craniofacial birth defects and trauma and prior neurosurgical/craniotomy operations. Bu, by far, regardless of the diagnosis the vast majority of forehead surgeries are done in men.

The typical cosmetic reason for male forehead surgery is brow bone reduction. Large brow bones, caused by overgrowth of the underlying frontal sinus, can create very prominent bulges in the forehead bone above the eye. (supraorbital rims) While most patients think it is a thickening of the bone and a simple burring down will suffice, this is not so. Rather the frontal table of the frontal sinus (visible brow bone) must be removed, reshaped, and then put back in a more flatter or recessed position. While tremendously effective, the access to perform that procedure requires a long scalp incision. This cosmetic trade-off is a serious one to consider and is usually an issue which prevents most men from having the procedure. Until a more minimally invasive approach to brow bone reduction is developed, most men with prominent brow bones will have to live with them.

Dr. Barry Eppley

Q: I have two forehead bumps that are very distressing to me. They have been there since I was very young. They stick out like horns and I am very self-conscious of them. Can they be taken down and made smooth with the rest of my forehead? What is involved in this type of surgery and what are the risks?

A: Thank you for sending your pictures. I can clearly see the two upper forehead bumps. While they are not true osteomas, they are protrusions of the frontal bone. They can easily and simply be reduced through burring reduction. You can take down the outer table of the frontal bone in these areas up to 5mms to 7mms which should make them smooth and even with the rest of your forehead contour. This can be done through an incision either back in your hairline or just along your hairline. This would result in a very fine line scar. The hairline incision, commonly used in pretrichial or hairline browlifts, offers an advantage in that one could advance the frontal hairline forward if one desired. In your pictures, it appears that your forehead is fairly long between the hairline and the eyebrows. That distance could be easily reduced at the same time by bringing the hairline forward. I have found that to be very helpful with burring down upper forehead prominences as the combination of bone reduction and a shorter forehead length makes for a very smooth and more pleasing forehead shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hello, I am a 28-year old male with very prominent brow bones and I would like to have them reduced to a normal size and shape.  What is involved in doing this kind of plastic surgery? Are there any significant risks and do you think the results will be worth it? Thank you very much and I look forward to your reply.

A: Brow bone reduction is more than just burring down thick brow bone ridges. It actually involves removes the outer plate of the frontal sinus, reshaping it, and putting it back on. A prominent brow bone is really not bone, it is an overgrowth of the frontal sinus. Brow bone reduction is really about reducing the size of the air space of the frontal sinus, in essence making a room smaller by lower ing the height of the roof.

Brow bone reduction must be done through a scalp incision. While the operation is not complex or dangerous for those trained in craniofacial plastic surgery, it requires that expertise and training to be very comfortable doing it. The key aspect in the decision to have the operation, in my opinion, is the acceptance of a scalp scar. One should have a good density of scalp hair and some confidence that all hair on the top of the scalp may not be eventually lost.

Dr. Barry Eppley

Indianapolis, Indiana

Q : I am interested in reshaping my forehead. When I was a child I was diagnosed with craniosynostosis of the middle forehead suture which I think is called the metopic? I had infant cranial reshaping which I am sure helped a lot but since I was so young I can’t remember what it used to look like. I have been bothered by the shape of my forehead since I was a teenager. It appears too narrow for a male and has a slight vertical ridge down the middle of the forehead. What can I do about it now? I am a male and am 24 years of age.

A: What you have is the secondary sequelae of correction of an initial metopic craniosynotosis. That initial surgery is designed to bring out the sides of the forehead (temporal area) which helps create a more normal forehead contour. While this initial surgery is often completely curative, older styles of this form of cranial reconstruction often produced suboptimal results, leaving patients with a minor form of residual metopic craniosynostosis. This is seen as a residual bitemporal narrowing and the hint of the vertical midline ridge.

Secondary forehead reshaping can be done that is infinitely simpler than the initial cranial reconstructive procedure. Rather than bone removal, material is added on the outer surface of the bone. This is known as an onlay or frontal cranioplasty. Using the initial scalp incision, the forehead skin is peeled back to expose the bone. Then using either PMMA (acrylic) or HA (hydroxyapatite, my favorite) material, the bone is reshaped through an onlay spackling method. Any irregularities are smoothed out through an additive approach. Deficient areas are built up and made confluent with the surrounding cranial contours. Emphasis for this problem is on both smoothing the forehead and building up the still deficient temporal areas. This is a relatively simple procedure for those plastic surgeons with training and experience in craniofacial surgery.

Dr. Barry Eppley

Q: I am interested in forehead reshaping. I have a very large forehead which I know takes away from my appearance and I’ve been teased about it alot. How is this procedure done?

A: The forehead makes up one-third of the total face and is frequently overlooked as having a major contribution to one’s appearance. Only when something about the forehead is ‘wrong’ does one take notice of its facial significance.

When a patient feels that they have a forehead problem, they are usually referring to two potential concerns or problems. The issues are usually its shape, which is a reflection of the underlying shape of the bone, or of its length or height, which is a the result of the amount of skin between the frontal hairline and the brows.

Forehead bone problems could be irregularities, bumps or high spots, prominent brow bones, or the narrowness or width of the forehead from one temple to the other. Such forehead problems are treated with frontal cranioplasty procedures where the bone can be reduced or added by different materials. This does require an open approach with a scalp scar needed for access. But with this wide open visibility, a wide array of bone reshaping and contouring can be relatively easily done to the frontal and brow bones.

Too high a forehead or too long of a forehead is a matter of skin reduction. This procedure is essentially a ‘reverse browlift’ where the skin is removed through an incision at the frontal hairline. Instead of the brows coming up, the frontal hairline comes down thus shortening the visible forehead skin to 7cms or less in vertical length.

Dr. Barry Eppley