What Is The Best Way To Augment The Sides Of My Forehead?
Q: Dr. Eppley, I would like to have my forehead augmented using PMMA bone cement. I understand a coronal incision may be needed but I believe bone cement is my best option for permanent results. Silicone has a long term risk of infection. The sides of my forehead have an indented look which makes the middle part look more prominent. I would like to fill in the side part only too make my forehead one even shape (not my temples but my forehead). I’ve spoken to another doctor and he said he’d do it so I would like to know if you feel comfortable doing it. In the pictures below I would include a picture of me in a lighting where you can see what I’m talking about. I also will circle the area I will like to have filled in, it won’t take a large amount of bone cement. Thank you.
A: In answer to your forehead augmentation questions:
1) The incisional approach to your forehead augmentation would be your existing frontal hairline incision not a coronal scalp incision. It would take a long ear to ear coronal scalp incision to access the forehead as it is way far back. It is more direct and safer to use the existing frontal hairline incision.
2) I believe you are looking to augment the sides of the forehead or the bony temporal lines which you have indicated and I have as well. (see attached) This is the transition zone between the bone and the muscle and the actual area you are trying to augment is not bone but largely muscle fascia. Understanding this anatomic concept is extremely important when determining how to augment it.
3) Trying to put any form of bone cement on muscle fascia is an aesthetic complication waiting to happen. That is an unstable surface to which bone cement will not bond to. For that relatively small area that is almost all muscle fascia I would use a soft tissue augmentation material like ePTFE (Goretex) A 2mm piece cut to the size of the defect with the edges feathered and placed through the hairline incisiion would be what I would do. The hardest thing to achieve along the bony temporal line with any material is an edge transition that is not visible on the outside. ePTFE gives one the best chance to do so.
4) In reality a custom premade silicone implant from a 3D CT scan is the best method to augment this area (I have never seen an infection with them in 30 years) but for cost reasons I think ePTFE is a good alternative option.
Dr. Barry Eppley