Background: The shape of faces is influenced by the genetics of one’s ethnicity. This is well known and seen in the recognized major ethnicities around the world. In the Asian face, for example, the proclivity is for more width then projection in the entire craniofacial skeleton. This is evidenced in the tremendous popularity of the V-line jaw reshaping and cheekbone reduction procedures done throughout many of the Pacific Rim countries.
But increasing forehead projection and acquiring a more rounded shape can not be done by changing the bone itself. It requires augmentation of the bone through the application of various materials. While the use of bone cements can be effective the need for a long scalp incision to place them and the difficulty of getting such materials down low onto the tight brow tissues while it sets makes their use for me aesthetically limited today. Making a forehead implant using 3D design software allows for precise control of its shape and allows it to be inserted through an extremely small scalp incision.
While cheek width can be reduced by repositioning of the bone, adding anterior cheek and midface projection must be done by implant augmentation. Standard cheek implants are not made to achieve this type of midfacial effect and trying to use them to do so does not work. Only a custom midface implant that covers the entire surface of the anterior cheek, maxilla and infraorbital rim can provide the required augmentation effect in the desired location.
Case Study: This Asian female desired forehead reshaping and midface augmentation. She had a prior history of cheek implants placed high and anterior on the cheek but this did not create the desired effect. She also had a chin implant done through an intraoral approach which was positioned very high on the bone.
To achieve her desired facial reshaping changes, a 3D CT scan was used to create a custom forehead implant that augmented the brow bones as well as custom cheek implants that covered the entire surface of the midface from the infraorbital rims down to the base of the nose.
Differences in the effect of the custom midface implants over the existing cheek implants as well as the new shape of the forehead can be appreciated in comparison 3D images.
Through an 8cm scalp incision placed 3cms behind the frontal hairline, an endoscopic dissection was done to make the subperiosteal forehead pocket. The real value of the endoscope is in the periosteal release along the entire superior orbital rims with preservation of supraorbital and supratrochlear neurovascular structures as well as down past the glabella onto the nose. The custom forehead implant was inserted and positioned as designed with double screw fixation.
The indwelling cheek implants and the part of the capsule on the bone was removed. Subperiosteal dissection was done around the infraorbital nerve up to the nasal bones, down along the pyriform aperture and over the complete face of the maxilla. The custom cheek-midface implants was placed by making a cut through the material on the superior side of the infraorbital nerve release which permitted it to be properly seated and secured with a single screw into the zygomatic buttress per side. The differences between the standard vs custom cheek-midface implants could be visually seen in a side by side comparison during surgery.
The combination of forehead and anterior cheek-midface augmentation in the Asian face helps add anterior facial projection which lessens overall facial width.
Case Highlights:
1) Many Asians faces lack forward projection particularly in the forehead and midface areas.
2) Combined forehead and cheek/midface augmentation helps bring the upper two-thirds of the face with that of the lower jaw.
3) Custom forehead and cheek-midface implants made from the patient’s 3D CT scan provides a precise method to control the shape and amount of forward facial projection.
Dr. Barry Eppley
Indianapolis, Indiana