Background: The forehead occupies a full third of the human face and sometimes than that based on the location of the frontal hairline. While the forehead does not draw one’s attention, like the lower two-thirds of the face due to the sphincteric motion of the eyes and mouth, its broad surface can not be overlooked.
Forehead asymmetries are not that uncommon and can result from a variety of causes. One of the most common is that from plagiocephaly where the twisting of the entire skull creates well known front and back of the head asymmetries. It is also seen in varying degrees of isolated frontal facial asymmetries with the smaller facial side having less forehead projection and a lower brow bone position.
Another less common cause of forehead asymmetry is iatrogenic from prior surgery. In performing brow bone reduction or more superior frontal bone reshaping, slight bony shaoe differences may exist or be created between the two sides. While not apparent during the actual operation, these slight differences may become revealed after surgery as the tissues contract down around the expanse of the broad forehead.
Case Study: This young middle-aged male had a prior history of brow bone and forehead reduction surgery. While it took months after surgery to see the final shape of his forehead, it eventually showed a forehead/brow bone asymmetry that was confirmed by a 3D CT scan. The left brow bone, in particular, and the upper forehead were flatter than that of the right side.
Because he already had a full coronal scalp incision, a full open approach was done for wide open access to the forehead. Using PMMA bone cement a thinly design implant was fashioned to visually match that of the right side. The edges were burred down to be very thin at their perimeters. It was secured into place with two small microscrews.
His after surgery results show improvement in his forehead shape between the two sides. Careful inspection shows just a hint of the outline of the bone cement application which is surprising given its paper thin edges and the thickness of his scalp tissues. Whether he may eventually undergo a revision for this aesthetic tradeoff remains to be determined.
Highlights:
- Forehead asymmetry can be created by brow bone and forehead reduction surgery.
- One method of bone augmentation for forehead asymmetry surgery is that of the use of bone cements which requires a wide surgical access for application.
- Any method of forehead augmentation requires the smoothest transition between the material and the natural tissues to avoid any visible lines of transition.
Dr. Barry Eppley
Indianapolis, Indiana