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Background:  The forehead occupies a full third of the upper face and as such has a major role to play in facial aesthetics. Despite its broad surface area coverage it does not have many distinct features that creates its look. Other than the leading edge of the frontal hairline superiorly and the eyebrows inferiorly it relies on its shape to create its appearance. The forehead shape components include projection, slope and width. Men, unlike women, have the additional shape feature of the mounds of the brow bones.

When increasing the projection of the forehead it is not as simple as limiting the augmentation effects just to the forehead…as this will make it stick out unnaturally. Like any other form of skull augmentation natural effects come from spreading out the augmentation to blend into the surrounding skull areas. This means that it must go back onto the top of the skull as well as potentially out past the bony temporal line onto the temporal fascia. (swide of the head) How far it extends out onto these adjoining areas depends on the amount of forehead augmentation and how much slope change is being done. As a general rule the greater the forehead augmentation projection the further out these implant extensions need to be. 

Other feature to consider in forehead augmentation is implant size. To keep the scalp incision small the implant can only be so big. But with larger implants comes the need for longer incisions…unless one change is instituted in the implant’s design.   

Case Study: This male had a prior custom forehead-skull implant but decided he wanted less forehead projection but a broader implant base that went all the way to the back and further along the sides.

Under general anesthesia the existing scalp scar from the prior surgery was very difficult to find…a testament to how well the scalp can heal when the making and closing of the incision is well handled.

His existing implant was removed and it’s comparison to the new implant could be appreciated when placed side by side.

The implant pocket was extended posteriorly as well as in the temporal areas. The two piece implant design was compared to the incision and its placement through it would seem impossible…if not for the two piece design.

The two pieces of the implant were sequentially inserted and put together along its split horizontal line. At the central union area screw fixation was applied to both sides of the implant.

His immediate intraoperative result showed the desired change in his forehead shape with less upper forehead projection and an increased backward forehead slope..

Case Highlights:

1) Forehead augmentation has many dimensional variables to consider to get a pleasing aesthetic result but one of the most important is surface area coverage.

2) In the narrow forehead the augmentation often must extend way back onto the skull and temporal areas to have a natural looking result.  

3) To place such larger forehead-skull implants through a small scalp incision a two-piece design is needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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