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Background: One of the primary benefits of custom face and skull implants is that they allow for augmentations possibilities that exist by no other surgical method. The results obtainable exceed anything achievable with bone cements or even bone repositioning. (ff that is even possible for the intended result) While the bone surface coverage is made possible by custom implant designs there is no formula or scientific method which provides a precise guide as to the shape and various projections of any implant footprint. Many patients erroneously assume that is what a custom implant design does…but it does not. The shape and dimensions of the implant must be provided with the hope that its effects will approximate the aesthetic outcome the patient desires.

As a result it is not rare that, while the initial custom implant design provided benefit sometimes even substantial, it did not achieve the patient’s goals. This is the same potential outcome that can occur no matter how much thought the patient and/or the surgeon puts into it. You simply can’t completely control the unknown relationship between design and outcome. And seeing the implant on the bone in a design is bit misleading as there is no accounting for the influence of the overlying soft tissue effects on that bony design.

Augmenting the entire upper third of the face technically has more volume than a wrap around jawline implant by a factor of at least 2X or more. As a result with more implant volume the more unpredictable the aesthetic outcome may be.

Case Study: This male had an initial custom forehead brow bone implant with an overall positive aesthetic benefit. However he desired four specific changes; 1) more brow bone projection, 2) an enhanced tail of the brow bone shape that followed his eyebrow form better, 3) more forehead-temporal width and 4) a skull augmentation that went further back onto the top of the skull. His second forehead-brow bone implant design made all of these changes but because of its larger size/footprint a two-piece design needed to be done. (considering surgical placement) 

Under general anesthesia and through his initial beautifully healed scalp scar the first forehead brow bone implant was removed and the two were compared side by side.

The new custom forehead brow bone implant was a two piece design that had a geometric split  line across the top from ear to ear.

It was placed in a segmental technique with the front piece initially inserted and the back piece secondarily. The two pieces were put together tightly and secured with microscrews and sutures. The scalp incision was then closed in two layers over a drain.

His intraop results showed the degree of improvement fro m his 1st to 2nd custom forehead brow bone implant designs.

This is a not uncommon custom implant case where the first result is good but just not quite ideal. How far one wants to go to get there is a function of economics and effort. 

Case Highlights:

1) One of the common lessons learned in custom facial implants is that secondary adjustment or replacement of the first implant design is not rare. Often one learns from the first design to know how to make the second design even more aesthetically pleasing. 

2) In skull implants in particular increasing its dimensions often means it has to have a larger footprint…which may create challenges in its placement.

3) A custom forehead brow bone implant that needs to widen the forehead and the bony temporal lines requires an extended footprint and becomes more like 1/2 a skull augmentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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