Your Questions
Your Questions
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, 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: Dr. Eppley, I banged my forehead when I was 11, I’m now 19 years old. I have been left with a noticeable dent in the middle of my forehead and would like it to be less noticeable. A cut type of scar would be much more acceptable than the dent that I have now. I would much prefer a cut scar from surgery that I can cover with make up, rather than a dent that A LOT of people notice and feel they need to point it out to me. Thank you!
A: If this forehead indentation is bone based or from soft tissue atrophy, it may be best treated by building up the bone underneath it. (frontal cranioplasty) This would be a ‘scarless’ way to do it and it could be done from a small incision back in the scalp where it would not be noticeable. While the indented forehead area could be excised if it was small enough, I woudl question whether a scar would be a good trade-off for the indentation. The size of the indentatio could also preclude the excisional option. I would have to see pictures of the indentation to see what would be the best surgical treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in having a more round forehead appearance. It is too flat and doesn’t seem to fit the rest of my face. I would like to know the best method for forehead augmentation; fillers, implant, or bone grafts. Thank you!
A: Thank you for your inquiry and sending your pictures. I can clearly see that there is a disproportion between the projection and shape of your forehead (and the upper portion of your nose, the frontonasal junction) compared to the rest of your face. Your entire lower forehead and brow needs to be built out, including an upper nasal (bridge-frontonasal junction) augmentation. I have done some imaging to show what that would look like based on the one photo that you have sent. Forehead augmentation can not be done with fillers, bone grafts or preformed synthetic implants. It requires a moldable cranioplasty material that is specifically moldeded in surgery to the desired forehead shape and allowed to harden. The two basic types of cranioplasty materials are hydroxyapatite and acrylic. (PMMA) Each has their own advantages and disadvantages. Because of your recessed forehead/brow area, the nasal junction of the forehead is severely recessed. That would need to be built up with a small bridge implant placed through the inside of the nose. If not done, building up the forehead/brow will make that area look even more recessed inward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in improving the shape of my forehead. It slants backward rather significantly and I would like it to be more vertical as it goes upward from my brows into my hairline. Can this be done with Kryptonite foreheasd augmentation? How much filler would be needed and what would be the cost?
A: I have done a side view imaging prediction to show that forehead augmentation can make a real difference in eliminating the backwards slope of your forehead by incrementally increasing adding volume from above the brows to the top of the skull. While there is no question this procedure can be done very effectively and get your desired aesthetic result, there are several important issues about the technique to do it. While an injectable or endoscopic Kryptonite procedure is very desireable due to its minimal scar approach, this would not be the best method to do it for several reasons. The volume of material needed is likely 40 grams or more to add the necessary amount of augmentation. That makes the use of Kryptonite prohibitively expensive, making the cost of the material alone for the procedure in excess of $12,000. When it comes to this volume of material needed for forehead augmentation, acrylic or PMMA is far more cost effective with a material cost that is about 1/10 that of Kryptonite. Secondly, and of equal importance, is that a smooth contour of the forehead augmentation is absolutely essential. It is often assumed that the thickness of the forehead and scalp tissues makes slight asymmetries or unevenness aesthetically tolerable, but this is only true when the augmentation is in the hair-bearing scalp. On the forehead, every irregularity will eventually be seen and most certainly felt when the swelling goes down and the overlying tissues adapt to the new forehead contour. With the current use if injectable Kryptonite, it is not possible to get as smooth of a result as that with an open PMMA frontal cranioplasty or forehead augmentation.
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
Q: I am looking to go about getting a procedure to make my forehead larger in height (length) and width and also to build around the temple area. But also my hairline is very low and am wondering if I get the forehead implants would I somehow be able to move my hairline up to show more of my forehead? After forehead implants what can be done about my hairline when getting this procedure.
A: Forehead augmentation, technically known as frontal cranioplasty, involves applying a moldable material to the forehead that then hardens fairly quickly. During the hardening process, it can be shaped in all dimensions including projection, width and height. These materials must be applied to bone and not soft tissue. Therefore, you can not widen the temple area as this is muscle not bone. The temple area requires a differernt material/implant approach.
With forehead augmentation, there may be some small vertical lengthening of the forehead when it is ‘expanded’ by augmentation. It may be in the range of 1/4 to 1/2 inch greater distance between the frontal hairline and the eyebrows. There is a limited amount of length increase that can be done. But this small increase, combined with greater forehead convexity, may make it appear slightly bigger than it really is. It may be possible to lengthen and stretch the forehead skin after augmentation through a coronal or scalp type of browlift technique but I doubt one would find that necessary later.
Dr. Barry Eppley
Indianapolis Indiana
Q: I desire to have cosmetic surgery next year with the wishes of making my forehead larger both in length and width. Can you inform me with what this procedure is called and also with all the information there is to know on this surgery (including risks, the type of implants used, how long it takes for the healing process, the cost of the surgery, how you go about customizing the implant and etc). Please respond as soon as you can with a detailed response. Thanks so much.
A: You are specifically asking about forehead augmentation. This is a procedure done through a scalp incision approach Augmentation of the forehead contour can be done using any of the cranioplasty materials, which include PMMA (acrylic), HA (hydroxyapatite cement) and calcium carbonate. (Kryptonite) Each of these materials has its own advantages and disadvantages. Large forehead augmentations (which you are referring to) is best done with PMMA due to cost considerations. These materials allow wide variability in adding to the brow ridges if desired and increasing the amount of frontal bone convexity, width and smoothness. These are liquid and powder mixtures that are put together and applied to the forehead in a putty form and then shaped by hand to the desired new forehead shape and allowed to harden. The operation takes about 2 hours and is done under general anesthesia as an outpatient procedure.
This is a highly successful procedure whose trade-off is a fine line scar in one’s scalp. The typical cost range for the procedure is $8500 – $9500. Healing is quite rapid and one can look fairly normal in about 10 days after the operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am a bit disappointed with the way that I look and I would like to fix some things. I believe a forehead augmentation would help me look a lot better. One of the changes I would like my forehead to undergo is to put the hairline at a higehr height, so my foehead would become a bit higher. That means building up the upper forehead area about 1 to 2 cms. I don’t think it is necessary to build up any area of the parietal bone. These are the changes I desire in the hairy part of my forehead. The second change I desire is in the brow bone. I have the feeling that from the side, it doesn’t look masculine enough because the brow bone doesn’t stick out as it should in a male. I think an augmentation of a few millimeters and a reshaping with nice corners would improve the way my brow bone looks. The second change I would like to do is the slope of my forehead. The slope of my forehead is very good but somewhere between the hairline and the brow bone the frontal bone has a small ‘puddle’ and I think it should be built up too. Those are the changes I want to do for my forehead and I hope that an endoscopic bone augmenttaion would help. How many grams of cranioplasty material woould be used for this? I have attached a side view of my forehead for you to see its shape.
A: Thank you for sending your pictures. Despite the relative poor image quality, it is clear as to your forehead concerns. I think there is no doubt you would benefit by forehead augmentation (frontal cranioplasty) but I need to clarify what is and is not possible. To achieve a good result, your forehead augmentation can not be done closed or endoscopically.There is no way to ensure a smooth and confluent result by any type of injectable approach. Your forehead reshaping is too complex for that it would have to be done through an open approach requiring a scalp incision. Secondly, the volume of augmentation material that you require makes the use of Kryptonite too expensive. You likely require about 40 grams of material. Your most economic approach would be acrylic (PMMA) where such a volume of material is economically feasible. Thirdly, it is not possible to buildup your forehead as much as 2 cms, the scalp incision could not be closed afterward.
One cm. at most is what is possible. Lastly, your frontal hairline may come up a bit with the augmentation but not substantially so. It is not possible to buildup your forehead an surgically move your hairline back at the same time.
These are some practical considerations for you to consider.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in making my forehead more vertical and round. I also want to have more height and width of the top of the skull. Do you think this is possible using the injectable Kryptonite method? I have attached some pictures for you to see the shape of my forehead. Let me know what you think.
A: Thank you for sending your pictures. I think I understand completely your forehead shaping objectives which would involve a cranioplasty fill of the forehead to make it more vertical from the brows up in profile (increased convexity) and to add width in the frontal view. This fill, in essence, is really to camouflage the slight brow bone prominence you have and will make the entire forehead more smooth and confluent. I have attached some imaging which is limited by the quality of the images you sent but I think it conveys the objectives.
In achieving this result, I do not think the injectable approach is best. It will take a prohibitive amount of material (cost wise) and the shaping must be perfect to have a happy end result. The evolution of the injectable cranioplasty approach is not quite far along in terms of experience to reliably give the best result for this more complex reshaping of a very visible facial area.Therefore, an open approach is best using PMMA (acrylic). That will allow an adequate amount of material to be used at a reasonable cost and get the best shape and smoothness of the forehead augmentation. The open cranioplasty approach in a male, however, is limited by the willingness of the patient to accept a scalp scar.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m a male in my thirties and I would like to have surgery to give my orbital rim and forehead a more masculine (protruding) appearance. I had a craniotomy 3 years ago which has left a dent on my forehead which I would like to eliminate. I understand that solid HA is more porous than the moldeable putty type which would allow tissue growth and ossification. I would like to know answers to the following questions. 1) In order to make my forehead more prominent would it be possible to use 3-D CT scan technology to customize a solid HA implant instead of using moldable HA paste? 2) Could the customized HA implant be made with an interior mesh to make it less brittle? 3) Would a customized HA implant in solid form be easier to work with than HA in paste? 4) Could using a solid HA implant present problems such as fluid accumulation, visible borders, migration or extrusion. I thank you for your time.
A: Thank you for your excellent and thoughtful cranioplasty questions. I can answer of your HA cranioplasty questions by saying that I really don’t use the HA pastes anymore. In their day they were state of the art and they were wonderfully moldeable, but they are brittle. This is no different that HA blocks or HA custom implants which actually are just as brittle and much harder to work with. The newest and more improved cranioplasty material is Kryptonite Bone Cement. It offers easy molding and shaping into the defect, sets up and gets just as hard as bone, and is truly porous (unlike most HAs which are not except the blocks) which allows tissue ingrowth. This is clearly the superior cranioplasty material and eliminates all of your stated concerns and questions.
Therefore, based on these working properties of Kryptonite, HA is no longer used and a 3-D CT scan model is not necessary beforehand since there is no advantage to making a pre-formed implant. (which is now a disadvantage and very costly)
I see no problems at all doing forehead and orbital rim augmentation and any contouring of a forehead indentation with Kryptonite Bone Cement through your existing scalp scar and open approach.
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