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Background: The upper third of the face is seemingly a rather featureless region  that would not appear to be complex for augmentation. But the reality is that it is one of the hardest facial areas aesthetically to do so given its large surface area and important anatomic areas. There are numerous important upper facial landmarks including the brow bones, the slope and width of the forehead and how the forehead blends into the lateral temporal and upper head areas.

The male poses more challenges than females for upper third facial augmentation because of the need for brow bone augmentation and to usually add forehead width. The brow bones alone have a complex anatomy that is difficult to get just right. And the need to decrease the slope of the forehead will require crossing the bony temporal line on the side of the forehead as well as extending the footprint of the implant further back onto the top of the head.

While a forehead-brow bone augmentation is possible because of the use custom implant designs that does not mean that everyone will get their perfect or ideal result. While the implant is custom designed there is no exact science as to how to make the implant create exactly what the patient wants. And in some cases even a very good result may be secondarily viewed as how to make it even better. (a common occurrence in custom facial implant patient)  

Case Study: This male had a previous custom forehead-brow bone implant with good improvement in the shape and appearance of his upper face. However he desired further horizontal brow bone augmentation and increased temporal width.

His 1st implant design underwent a few changes to meet these additional aesthetic requirements. One of the design changes necessary was the need to make a two piece implant design. As the footprint of the implant was increased posteriorly, to keep the original incision the same length, the implant must be designed in two pieces so they can be inserted separately and assembled once inside the pocket.

Under general anesthesia the new custom forehead-brow bone implant was inserted in two pieces, assembled along the geometric split lines and secured with screws on each side.

The improvement in the brow bone projection and temporal width was seen as was expected from the new implant design.

While many custom implant patients get their expected result from the initial surgery some do not. While all get improvement the custom design process allows for an understanding of the exact cause and effect of the impact of the design to the aesthetic result. That knowledge allows an even better implant design to be made and implanted.

Case Highlights:

1) Major upper third of the face augmentation in males encompasses the brow bones, forehead and temporal regions.

2) Custom implant designs are best guess estimates of the desired aesthetic effect whose exact effect may not be known until implantation and full healing.

3) Larger custom forehead-brow bone implant designs may require a two piece approach to their placement.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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