Background: All areas of the skull can be aesthetically augmented with custom designed implants…the most effective method to do so. Augmenting the side of the head is unique, however, because most of it is covered by muscle and not bone. The most important landmark for the side of the head augmentation is the bony temporal line which runs from the brow bone anteriorly back along the top side of the head to end back at the side of the occipital bone posteriorly. The relevance of the bony temporal line is that this is the origin of the temporal muscle and serves as the barrier between partial or complete side of the head augmentation.
Very limited side of the head augmentation is that of anterior temporal hollowing which can be done by standard temporal implants. (Type 1 and 2 temporal augmentation) More significant head widening requires augmentation of the entire muscle or even beyond that of the bony temporal line. In Type 3 temporal augmentation the entire muscle is augmented with an implant placed beneath the muscle from incisions placed behind the ears. These are patients have a normal bony forehead width. But when the forehead isa so narrow the augmentation must cross onto the bone which requires implant placement on top of the muscle to create a smooth wrap around head augmentation..
Case Study: This male had a narrow side of the head shape which was associated with a narrow forehead shape as well, indicating an overall narrow skull shape. In the front view of his 3D CT scan the decreased bifrontal width could be appreciated compared to the posterior biparietal width. In the side view of the 3D CT scan a flattened upper back of the head was apparent which caused the posterior temporal line to be lower than normal.
To improve his forehead and side of the head width as well as augment the upper back of his head wrap around custom skull implants were designed that went from the side of the forehead and crossed the back of the head.
For surgical placement purposes a midline split was done in the implant on the back of the head creating a two piece implant.
Under general anesthesia the two pieces of the custom wrap around skull implants were placed on the patient to determine their pocket locations.
Through five small incisions (bilateral postauricular, one central back of the head and two very small frontal hairline incisions) the pocket on top of the deep temporal fascia and onto the bone outside of the temporal line was created. The implant was placed in two separate pieces initially through the postauricular incisions in a folded shape. Once inside the created pockets they were unrolled and joined in the midline on the back of the head. (sutured together) The front end of the implants was placed onto the forehead areas and secured with a small micro screw on each side.
The two postauricular incisions were closed over a drain on each side.
The back of the head and frontal hairline incisions were is similarly closed with resorbable sutures.
His immediate intraop change in his head width can be seen in the frontal view.
Similarly the change in head shape could be seen in the oblique views as well.
Drains were removed 4 days after the surgery with the expectation that there will likely be a need for a few aspirations of fluid in the first few weeks after the surgery.
Implants that wrap around the head for improved width and shape can be desired and placed with very limited scarring. But because it is necessary to placed the implant on top of the deep temporal fascia there is a need for more prolonged drainage and resolution of most fluid collections can take a few after the surgery to fully resolve.
Key Points:
1) Widening of the side of the head can be done by staying inside the bony temporal lines (Type 3 temporal augmentation) or extending outside the bony temporal lines. (Type 4 temporal augmentation)
2) When the forehead is narrow the augmentation must cross the bony temporal lines for a more complete head widening as is known as wrap around head widening implants.
3) Placement of wrap around head widening implants can be done through limited scalp incisions that leave little scarring.
Dr. Barry Eppley
World-Renowned Plastic Surgeon