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Background: The forehead occupies a full upper third of the face and has a significant influence on the appearance of its shape. Part of framing the upper face is also the frontal and temporal hairline which can influence the appearance of the width of the forehead. Also contributing to the width of the forehead is the shape of the face below it. A wide or chubby face can make the forehead appear too narrow. Conversely a thin lower face can make the forehead appear too wide.

When lower facial reshaping or fronto-temporal hairline changes can not make the forehead appear more balanced, direct forehead manipulations are needed. Widening the narrow forehead shape requires the knowledge that the width of the forehead involves the temporal region beside it. While the bony temporal lines serves as the boundary between the bony forehead and the muscular temporal region there are interconnected. While it is possible to narrow the forehead by only reducing the bony forehead, the forehead can not be widened by staying only on the bone. The anterior temporal region must also be widened with it as well.

While expanding the bony forehead is easy to envision by an implant on the bone, temporal widening must be down on top of the muscle as well. (technically on top of the its fascial covering) This allows for a smooth contour from the forehead to the side of the head. This requires a custom pre-designed implant that is not overlying rigid as well as can be made with very feathered edges. 

Case Study: This female wanted to improve the width of her forehead. She felt the shape of her forehead and temporal areaa was too narrow for her face. She always wore her hair up to create the appearance of a wider head and never wore it down as to made her head appear too narrow. She  had a prior extended hairline browlift done with a fairly prominent zigzag scar line.

Using her 3D CT scan a forehead-temporal widening implant was designed to widen the transition between the forehead and the anterior temporal region. It also was designed to create a smoother and slightly fuller forehead shape. Given its large surface area of coverage it was designed in two pieces with a geometric interlocking midline split.

Under general anesthesia and taking advantage of her long hairline scar the forehead flap was developed anteriorly and the scalp undermined posteriorly on the bony top of the head and on the deep temporal fascia on the side of the head. The small medial brow bones were initially reduced by burring.

The custom forehead-temporal implant was prepared in its two piece design. The extent of its surface area coverage could be appreciated when placed on the patient. (appears very much like a helmet)

The implant was placed in two separate pieces and then assembled together once inside the pocket using the geometric midline split. In placement of such a large coverage skull implant with thin edges it is important to make sure the pockets are extended adequately laterally and posteriorly enough to allow the very thin edges of the implant to be fully laid out.

Once the two pieces of the implant were brought together and the split line apposed with sutures, microscrew fixation was used to tighten down the implant to the bone. (both at the brow bone and upper forehead areas) 

Her immediate intraoperative change was readily seen with a wider forehead and anterior temporal region as well as a more vertical and smoother forehead shape. 

It is important to recognize that the forehead is one of the five surfaces of the skull and they are all interconnected to create an overall convex shape of the skull. (each skull surface will have a different amount of convexity) And when increasing the convexity of any one of the skull’s shape it is rare to ever be able to just have one surface area of involvement. Thus to widen the forehead at least the anterior temporal region needs to be involved as well.

Key Points:

1) A narrow forehead is often reflective of an overall temporal narrowing on the side of the head.

2) The forehead can not usually be widened without some temporal widening as well.

3) With forehead and temporal widening the forehead part is on the bone while the temporal part must be on the top of the muscle.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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