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Background: One of the features of the male forehead is that it has a more backward slope than that of a female. How much of a backward slope that is acceptable is a matter of personal preference. But the location of the frontal hairline can influence the appearance of the forehead slope in profile. The more recessive the frontal hairline is the greater the slope of the forehead will appear as it exposes more of the front part of the top of the skull.

Going further back in the midline from the top of the forehead is the sagittal suture line. This suture line continues backward from the forehead at the bicoronal suture line with a slight convexity until it reaches the crown at the back of the head. In some recessed foreheads the sagittal crest is elevated due to early premature sutural fusion. This is not a true sagittal craniosynostosis but a very minor version of it. A slightly prominent sagittal crest can appear as the forehead/top of the skull slopes backward in profile. The combination of a sloped forehead with a high posterior sagittal crest goes the head shape an unfavorable appearance in profile.

Treating both a high sagittal crest and doing a forehead augmentation through the same small scalp incision is possible. Obviously this could be easily done through a long coronal scalp incision but this is aesthetically unacceptable in a male.  

Case Study: This male desired to improve the backward slope of his forehead  without making it excessively prominent. At the same time he also wanted a raised sagittal crest reduced. 

Using a 3D CT scan of his skull a custom forehead implant was designed that added 6mm of maximum projection at the top of the forehead. To make for a smooth transition into the skull this required the implant to extend further back not the top of the skull. The custom forehead implant volume was 74ccs.

Using the 3D CT scan the location and amount of sagittal crest reduction could also be determined.

Under general anesthesia a 6cm horizontal incision was made at the middle portion of the sagittal crest. Working posteriorly and anteriorly the sagittal rest was reduced by high speed burring. 

Subperiosteal dissection was done superiorly all the way down to the brow bones. When completed the custom forehead implant was inserted, positioned and secured into position with two small microscrews at its posterior end near the incision.

The change in his forehead slope could be seen in profile immediately after the insertion of the implant. 

While much of the focus on forehead augmentation is how it appears in profile, the most precarious part of any forehead augmentation is how it appears in the frontal view. While men may want to widen their forehead doing so must be done carefully. It is real easy in a narrow forehead to make too much of a change (add too much width or make it too square) The key is to avoid making the temporal lines too prominent or obvious in the design. 

Case Highlights:

1) One reason men seek forehead augmentation is to decrease a backward slope and make it a bit wider.

2) A high sagittal crest raises the height of the head and can make some contribution to the appearance of the slope of the forehead in profile view.

3) The combination of sagittal crest reduction and the placement of a custom forehead implant can be done through the same small scalp incision on the top of the head.

Dr. Barry Eppley

Indianapolis, Indiana

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