Reshaping the forehead is an uncommon patient request. While the plastic surgery techniques to do so are well known and not new, the need to do forehead contouring is not. Most commonly, forehead reshaping is done on patients who had a congenital skull deformity (e.g., craniosynostosis) or a frontal skull deformity secondary to trauma or after a neurosurgery craniotomy procedure. The cosmetic reasons would be to soften prominent brow ridges or to smooth out some forehead irregularities.
The treatment of forehead irregularities can theoretically be done by either burring down bone or adding a synthetic material to it. In reality, burring down bone on the skull is a limited procedure and can never make as big a difference as one would think. The brow ridges can be burred down but the limiting factor is the underlying frontal sinus. If the overlying frontal sinus bone is thin, then very little bone can actually be taken. Above the brow ridges, burring down forehead bone is very effective for small raised areas that are easily identifiable but is less effective at reducing large surface areas of bone.
Filling in or adding to the forehead bone is a much easier and effective procedure. The real question in forehead augmentation is what material to use. Traditional PMMA (polymethylmethacrylate) has been around for a long time and has the advantages of a very low cost, high resistance to impact forces, and ease of intraoperative contouring. Its main disadvantage is that some patients over time can develop some low-grade reactions to it and it may get loose, become infected or the overlying forehead skin may thin, although these issues are fairly low risk. Newer ‘more natural’ materials such as hydroxyapatite cements (HA) have been available over the past 10 years. HA offers the advantage of being a more natural, less synthetic material as its structure more closely resembles that of bone. Its disadvantages are that it is considerably more expensive, has a low resistance to impact (easily shatters), and is a bit tricker for the plastic surgeon to use. The advantages and disadvantages for HA vs. PMMA must be considered and weighed on an individual case basis.
Regardless of the material used, synthetic forehead augmentation usually requires an open scalp incision which, because of its length, is a significant consideration in a cosmetic procedure. (particularly for men) Endoscopic or limited scalp incisions may be able to be used in small areas of augmentation in carefully selected cases.