Background: Forehead augmentation has been done by numerous techniques over the years. Historically it has been most commonly done by bone cements but has largely been replaced today by custom forehead implant designs. Establishing the exact dimensions needed and in a smooth fashion from top to bottom and from side to side is most accurately done by a preoperative design process. The forehead may look like a non-descript and easy surface area to create but occupying the entire upper third of the face and being completely exposed creates an unforgiving aesthetic feature of any irregularities or asymmetries.
A custom forehead implant also offers one often overlooked advantage…the ability to surgically place it through a fairly small scalp incision. This is most manifest in silicone implants because the elastic deformation properties allow them to be folded for insertion, keeping the scalp incision as small as possible. This becomes less true when very stiff and inelastic materials are used. While many get caught up in the perceived need to have an implant material that feels just like bone (when not on bone), this is actually irrelevant as what really counts is what it feels like when it is placed on bone.
Once feature of forehead augmentation that is often overlooked is the need to carry its superior edge further back onto the skull to avoid a sharp and palpable transition. Most foreheads that have an excessive backward slope by definition also have some deficiency on top of the skull as well. The more the backward slope of the forehead becomes the more top of the skull augmentation that is needed to completely correct it. It is possible to augment the entire skull along with the forehead if needed provided the volume of such a large surface area skull implant does not exceed the ability of the scalp to safely expand over it.
Case Study: This male desired to have a combination forehead augmentation as well as a back of the head augmentation as well. His desire was to correct a backward slope to his forehead as well as make it wider/more masculine. He also wanted it to go far back onto the top of the skull to adequately correct the backyard slope. In addition he wanted to augment the top of the back of his head which was also flat.
A combined extended forehead-skull implant was designed to address his total skull needs. It was elected to connect the two pieces for a complete front to back of the head augmentation effect for a smooth overall effect as well as aid in its placement. Its total volume was 150ccs with both combined pieces.
Because it would be very difficult to place such a large implant through one small incision it was made as a two piece design with an irregular midline split across the top.
Under general anesthesia a 9 cm long scalp incision was made on the top of the scalp…where the split of the implant would be. This allowed the subperiosteal dissection to be done down to the brow bones of the forehead and the occipital bone on the back of the head The two piece implant was prepared for placement by placing perfusion holes in the back piece and a few in the forehead piece behind the location of the frontal hairline.
The implants were then inserted in a split fashion and, after setting the forehead piece in place, the back piece was brought up to it. Screw fixation was done on both sides of the implant split.
His intraoperative results showed the immediate improvement in his forehead shape with less backward sloping as well as in increased width with more evident temporal lines on the sides.
Case Highlights:
1) Forehead augmentation is most effectively done with a custom implant approach as all of the augmentation dimensions can be preoperatively selected.
2) In most forehead implant augmentations the effect most go further back onto the top of the skull for a smooth and non-palpable transition.
3) Provided the volume is not excessive the skull augmentation can go the whole way to the back of the head for a near total skull augmentation effect.
Dr. Barry Eppley
Indianapolis, Indiana