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Background:  The shape of the forehead is affected by many surface contour features. Its height and width are most evident in the frontal view. Its shape and any contour irregularities are most seen in the side and oblique views. When deficiencies exist in any of these forehead features an augmentative approach is needed. While several techniques exist for forehead augmentation, the greater the complexity of change need, the more the value of a computer design approach has merit.

While many aesthetic forehead augmentations are understandably focused on making a more substantial shape change, not all are. For some patients a smoother forehead surface or the correction a modest concavity or backward slope is all that is needed. With these more modest forehead changes the need for a more minimally invasive approach takes on paramount importance.

Such a minimally invasive surgery approach typically refers to the size of the incision needed to do the procedure. In reality what is done inside I would not consider minimally invasive as making a tissue pocket over the forehead for any shape change purpose is definitely invasive. But very much like browlift surgery, an endoscopic browlift is often viewed as less invasive than an open browift because the incisions needed for it are much smaller…even though what is done on the inside is virtually the same.  The better term should be a ‘minimal incision’ technique for that is what has actually become less.

Case Study: This middle aged male desired to have a smoother forehead. He was bothered by its irregularities and asymmetries as well as wanted a smoother transition into the top of the skull behind the hairline. Using his 3D CT scan a custom forehead implant was design to cover the desired surface area from above the brow bones back to the top of the skull. It thickness was fairly thin at 3mm centrally. What it created was a completely smooth forehead between the bony temporal lines and softened the slope of the forehead up behind the hairline.

Under general anesthesia a 3.5cm long scalp incision was made at the back end of where the forehead implant was to end. Blunt subperiosteal dissection was done down to the brow bones inferiorly and beyond the bony temporal lines laterally. To insert the custom forehead implant it was rolled onto itself and inserted through the much smaller incision. Once inside it was unrolled, positioned using the midline marker and secured with two point screw fixation. It was closed over a drain with resorbable sutures.

Forehead augmentation can be done for very modest changes which are nonetheless important to the patient. In doing so it is important to have precision in the design of the augmentation as well as a minimal incision approach to its placement. A 3D custom design approach is the only method to achieve this augmentation precision and a silicone implant is then only material which can permit a small incisional placement method. In the male with close to zero hair coverage the small incision for placement becomes paramount.

Case Highlights:

1) A smooth forehead in some patients is just as important as a bigger or smaller one in others.

2) A custom forehead implant can be used to create a smoother forehead shape and a gradual transition into the skull on the top of the head.

3) A thin custom forehead implant can be placed through a remarkably small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

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