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Background: The  shape of the forehead has well known gender differences. Male foreheads have a slight backward slope, visible brow bones both medially and laterally as well as more width with potentially visible temporal lines at the sides of the forehead. These are forehead characteristics that are far more difficult to surgically create than the rounder and more vertically inclined female forehead that also lacks visible brow bone prominences.

The only way to successfully achieve all of these features in a male forehead augmentation is a custom forehead-brow bone implant design. In designing such an implant key questions are how strong should these features be? In other words how much brow bone projection as well as their shape is needed along with the prominence of the bony temporal lines on the sides of the forehead. There are no absolutes in these dimensions and various factors need to be considered such as size of the patient as well as how strong of a change the patient desires.

One unique type of forehead augmentation change is in the transmale patient. Masculinizing the upper forehead in this type of patient, more times than not, focuses on not trying to make it too strong or overdoing the change. This is, of course, open to interpretation and preoperative computer imaging is the only way to known exactly the type of upper facial augmentation changes the patient is seeking.   

Case Study: This male desired masculinization of the forehead which lacked any brow bone prominences, was round bun shape and had a backward slope to it. Using his 3D CT scan a custom forehead implant was designed that included the brow bones. Maximum brow bone projection was 5mms with 4mms of added projection at the upper forehead. The forehead width was increased to just over the existing non-visible bony temporal lines. To have the forehead augmentation flowing smoothly into the surrounding skull it extended onto the top of the skull and ending at about the middle of the top of the head.

Under general anesthesia and through a 7 cm scalp incision placed well behind the frontal hairline the implant pocket was created by wide subperiosteal undermining. The more adherent tissues over bathe brow bones was released using the aid of an endoscope. One of the interesting observations about custom forehead implants is when placed on the patient on top of the skin they always look too small.

One inserted and positioned as per the design, double screw fixation was done on the part of the implant visible through the incision. The scalp incision was then closed in multilayer resorbable sutures.

The intraoperative changes showed the immediate masculiniazation of his forehead shape.

There is a delicate balance between a custom male forehead implant that is too strong or one that is not quite strong enough. More times than not the former will occur as opposed to the latter. As a general rule most males desire brow bone projections 5mms or greater. So when a modest augmentation is desired keep the brow bone projection at 5mms or less and have only faint visible temporal lines to be seen.

Case Highlights:

1) Masculinizing the forehead can be done for both cis-males and transmales with a custom forehead-brow bone implant.

2) The key elements in custom implant design for the male forehead are increased brow bone projection and a slightly wider and flatter forehead shape.

3) Through a small horizontal scalp incision placed near the back portion of the implant an endoscopic dissection is done across the brow bones to ensure that the implant sits low enough at its inferior end.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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