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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

Scalp Scars from Custom Skull Implants

Friday, November 24th, 2017


Custom skull implants have become a standard technique in my plastic surgery practice for making many aesthetic skull shape changes. Prior to their use, while skull reshaping surgery was possible, it involved the use of much longer scalp incisions and the use of intraoperatively fashioned biomaterials that had a much higher rate of contour issues and need for secondary revisions.

One of the benefits of a custom skull implant is that they can be inserted through a much smaller incision to surface area coverage ratio than other materials. Because these implants are composed of solid but somewhat flexible silicone, this permits them to be temporarily deformed for insertion. Conceptually like a silicone gel breast implant, which is easily deformed to be inserted through a much smaller incision than the size of the implant would suggest, a performed skull implant similarly does so.

With the skull implant’s insertion ability comes the next very important aesthetic question…how does the scalp scar look from doing so? Having seen numerous patients who have received skull implant for the face and body surgeries including some that have comeback for larger implants, I have had the opportunity to see a lot of such scalp scars both with and without hair.

My observation is that most of these scalp scars are impressive for their very fine line and often near total or total undetectability. This does not mean that they are invisible under the closest of scrutiny but many do come close to that low level of detection particular in scalps with hair. For some even under bright lights and forced parting of the hair they can be hard to find.  A shaved head is obviously the ultimate test and many far quite well under that circumstance as well.

Such good looking scalp scars do not happen without effort and attention to detail. Prevention of follicular injury is the key with the avoidance of electrocautery and suture placement at this tissue level. It is not necessary to shave hair for any custom skull implants surgery and, while some external shafts are cut in this process, the roots of the hair remain intact.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Skull Implants with Frontal Hairline Design

Thursday, November 23rd, 2017


Skull implants are a versatile treatment strategy for a variety of head augmentation concerns. Made from the patient’s 3D CT scan they can be designed to provide increases in skull projection that are only limited by the stretch of one’s scalp.

One of the not uncommon indications for custom skull implants is to increase the height across  the top of the head. This is requested by both men and women with no significant gender tendency. While such a procedure can be perform equally in either male or female, the male hairline must be considered in the implant’s design is some cases.

While custom skull implants are made with a feathered contoured edge at its perimeter, there is always the risk of a visible transition in non-hair bearing areas. This is most relevant in the forehead and in the any patient where the front edge of the implant extends beyond the hairline. This becomes extremely relevant in the male with a receded/receding hairline which can affect the design of the front edge of the implant.

When possible a skull implant should be designed with the known location of the frontal hairline. But this is not always possible since the hairline is not seen in CT scans and an intraoperative trial fit may reveal that such a deign is not accurate.

In this event it is possible to modify the implant’s shape by carving to get its frontal edge even or behind that of the hairline’s edge. Shaving of the implant’s edge must be carefully done to create a feather edge as much as possible using large scalp blades. While some edge transition may be palpable at least it will not risk visibility.

While the hairline may to be visible in CT scans, preoperative measurements from the lower edge of the brow bones can be useful in making that design consideration.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – 2nd Stage Custom Skull Implant for Crown Augmentation

Tuesday, November 14th, 2017


Background: Deficiencies of the crown area of the head are unique to females. They often compensate for such skull height deficiencies through hair style camouflage techniques. Two definitive treatment is a custom skull implant made from a 3D CT scan.  While not being able to add unlimited increases in skull height due to the limitations of the stretch of the scalp, they do provide the most effective skull augmentation method know today.

When women consider implant augmentation of the crown and surrounding skull areas, the question is always how much additional height/fullness can be obtained.While every patient’s scalp is different, as a general rule a one-stage skull implant will probably create 50% to 75% of the result many women really want. Much more of a result or even their dream result often requires a two-state approach to achieve. (first stage scalp pander and second stage implant)

But for a variety of reasons, some women may have to opt for a one-stage skull implant even though they know that their skull augmentation result will not be ideal. But this does not mean further augmentation may not be possible later.

Case Study: This middle-aged female had a custom skull implant placed one year earlier for crown augmentation. Her initial implant had 9mms of central projection over the crown. She now desired for augmentation and a new implant was made that doubled the central projection to 18mms.

Under general anesthesia her original scalp incision, which had healed beautifully, was reopened and the implant exposed. The capsular tissue could be seen to e adherent to all of the original perfusion holes which has been placed through it. The implant was separated from these scar bands and removed. It was replaced with the new casual implant whose height increase could be fully appreciated when laid side by side. The scalp closure was tight but secure over it.

Patients can be initially content with their skull augmentation result but grow desirous of more as they accommodate to the change. Or that may chosen the one-stage approach for practical reasons, hoping it will be enough but are that it might not be. Either way, an indwelling  skull implant does act as a tissue expander for which s larger implant can be successfully placed later.


1) For additional crown of the skull augmentation effect, a second custom skull implant can be placed after the first one.

2) An indwelling skull implant acts as a tissue expander, allowing for a second large implant to be placed that would not have fit the first time.

3) Doubling the central area of projection can usually be safely achieved in the second custom skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Head Widening Temporal Implants

Thursday, November 9th, 2017


The width of the head is determined by how wide it is above the ears.  This is known as the temporal region and consists of a very uniquely shaped temporal bone and varying thicknesses of the temporals muscle over it. By the eye the temporal bone is very concave and the temporalis muscle is correspondingly very thick. (anterior temporal zone) Back by the ears, the temporal bone is much thinner, has a convex shape and the overlying temporalis muscle is much thinner. (zone 2)

While the side of the head is really comprised of both temporal zones, the perception of its width is determined more by the zone 2 region than zone 1. With a more narrow head width the shape of the head above the ears may be either a straight vertical line or even tilted in with a more narrow temporal line distance across the top of the head.

The narrow head can be effectively widened through the use of specially designed temporal implants. Placed either above the muscle in the subfascial plane or between the muscle and the bone (this is based on incisional access), the side of the head can be substantially widened. Traditional use of temporal implants is for the anterior or zone 1 region and by comparison these performed implant are relatively small. But when covering all of the zone 2 region and the poster part of one 1, head widening implants cover a far greater surface area.

The size of head widening temporal implants suggests that they would be hard to surgically place, but they often are not much thicker than 5mm to 7mms. Because there are two sides to the head, a pair of head widening temporal implants causes a more substantial widening effect that one may think based on the numbers alone.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant for Improved Back of Head Contour

Thursday, November 9th, 2017


Background: Augmenting skull or head shape deficiencies used to be fairly impractical. The traditional method of cranioplasty surgery involved long scalp incisions and the tedious application of bone cements to add shape to the head. Besides the scar there was a  very high rate of contour irregularities and a lack of adequate augmentation effect. This is not a particularly appealing option for many patients whose interest is in aesthetic skull reshaping where one must be careful to not tradeoff one problem for another. (large scar, contour irregularities)

Custom skull implants made from 3D CT scans have changed the entire approach to all forms of aesthetic skull augmentation. Like the use of any other preformed implant used in the face and body, small incisions are used through which a malleable implant with a predetermined size and shape is inserted. The skull is no different in this regard, it just has lacked a method to create the desired implant.

The back of the head is one of the most common skull augmentation procedures. Whether it has an overall flatness, asymmetry or a lack adequate projection and shape, custom occipital skull implants are requested equally between men and women.

Case Study: This young male had long been bothered by a flatness and asymmetry of the back of his head. He desired some modest improvement in the overall occipital contour. A 3D CT scan showed the lack of roundness in side profile and the asymmetry in a top view.

A custom occipital implant was desired to provide a better contour and make it more symmetric. His goal was a very modest thickness with the maximum projection of 6mms. An implant with much greater thickness was initially provided but he requested it be half the traditional recommended thickness.

Under general anesthesia and in the prone position, the actual implant  could be seen in its intended position when placed on the outside of his head. Through an 8cm scalp incision placed just above the nuchal line, the subperiosteal pocket was made and the implant inserted and positioned. It was secured with 2 microscrews at its base.

The immediate intraoperative view from a top view with the patient in the prone position showed how much difference was possible even with a relatively thin skull implant.

There is no doubt that the best method to reshape the back of the head, even in more modest shape deformities, is with a custom skull implant technique. Beyond the shorter incision needed to place it, getting a smooth and even contour would be next to impossible wit bone cements in a reliable fashion.


1)  A custom skull implant is commonly done for the back of the head.

2) A smoother and more symmetric back of the head is always a common goal regardless of implant size.

3) Thinner skull implants are easier to insert but great care must be taken to ensure their thin edges are fully unrolled.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Placement of Perfusion Holes in Custom Skull Implants

Monday, November 6th, 2017


Custom skull implants have become in my practice an effective and low risk strategy for many aesthetic skull shape concerns. Compared to any other implant used above the shoulders, skull implants are comparatively large which is appropriate given the size of the skull. But a small implant just isn’t going to work for many head shape augmentations as adequate surface area coverage is the key to their effectiveness.

The use of a solid silicone material is best for custom skull implants as it offers a range of benefits that no other material has. It can be placed through the smallest scalp incision because its solid form is largely foldable. Its flexibility allows it to fit to the bone on a curved surface. Of great importance is that it can be made from a 3D CT scan at a cost that is not prohibitive.

But because it is not a porous material, it becomes surrounded in the subperiosteal skull pocket by an enveloping capsule. In essence a large scar pocket exists deep under the scalp that contains the implant. While I never seen that issue alone to cause a problem in custom skull implants, I would prefer some form of tissue ingrowth to change a large single implant pocket into many smaller ones.

One technique to create some tissue ingrowth into a solid silicone skull implant is to make many holes through it at the time of surgery. Using a 4mm dermal punch I place many through and through holes through the implant to allow for tissue ingrowth into and through the implant after surgery. This will also allow for increased  tissue adherence of the surrounding capsule to the implant.

In performing several skull implant replacement surgeries (patients wanted bigger implants) the concept of placing perfusion holes has been validated. Tissue growth has been observed making the surrounding capsule adherent to the implant at these areas.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – A Standard Preformed Skull Implant for Female Crown Augmentation

Friday, November 3rd, 2017


Background: While skull surgery has been around for more than a century, such surgeries have been done for reconstructive reasons to replace missing portions or correct significant congenital skull shape deformities. Aesthetic skull surgery, however, is much more recent and consists of reducing prominent bony areas or improving its shape through augmentation materials. The use of custom implants made from the patient’s 3D CT scan is the most effective skull augmentation material today.

One of the more common aesthetic skull deformities that is treated by a custom implant is that of the crown. The crown refers to the area at the upper back of the skull. It begins at the point where the top of the head begins to curve downward to the back of the head and ends at a point just above the nuchal line of the occipital bone. It is semi-circular in shape.

A crown skull deficiency is a common female concern and is often manifest by hairstyle manipulations to camouflage a deficiency or in an effort to make a normal crown look even higher. The commonality of this head shape concern is evident in the commercial product known as a ‘Bumpit’ which serves as an external prosthetic means to make the hair on the crown area look higher or fuller.

Case Study: This young female had long been bothered by the flatness over the crown of her head. She was tired of teasing her hair up to improve the appearance of her head shape. While the crown area looked flat, one could put their hand on it and it felt like a large flat circular area. Because she lived in another country and could not obtain a 3D CT scan, a true custom skull implant could not be made. Instead, I used an implant design from my large custom skull implant catalog from other patient designs. The implant design chosen covered the area needed and had a central projection of 15mms. Given the the skull is a convex surface and the implant had some flexibility to it, it was presumed that it would have a good fit.

Under general anesthesia and in the prone position, a low horizontal occipital incision was made and a subperiosteal pocket developed up over and beyond the crown of her head. Sitting the implant on the patient’s head it could be seen that it had the right shape and projection where it was needed. Placing the implant showed a fit and degree of improvement like it was custom made for her. Even though the implant had multiple perfusion holes placed and its fit into the pocket was very tight, two microscrews were placed to ensure complete stability

While a custom made approach to implant fabrication for augmenting aesthetic flat skull contours is always ideal, certain types of skull augmentations may be able to be done with preformed skull implants. The crown of the head is one of the most amenable to this approach even that its surface area of coverage needed is fairly standard. The amount of implant thickness that the typical female scalp can stretch is also well known by experience and that is usually up to 15mms of central projection.

For those females that have a crown skull deficiency, this type of ‘bumpit’ implant that is performed may work well for their aesthetic needs. Not having to get a 3D CT scan and have a custom implant designed does lower the overall cost of the surgery.


  1. 1) One of the most common skull augmentations is in females who have a crown deficiency.
  2. 2) A custom skull implant is traditionally used in all large surface area skull augmentations.
  3. 3) Standard shaped and sized skull implants can be effective for crown skull augmentations which avoids the needs for a preoperative 3D CT and time needed for implant planning.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques in Skull Reduction

Monday, October 30th, 2017


The size of one’s head is most significantly influenced by the shape of the skull. While there are soft tissues that also envelope it, its size is a reflection of its overall dimensions and convexity. As a result, major reductions (1 cm or greater) in skull size or specific bony areas is not possible without creating a full-thickness bone defect.

But despite these bone thickness limitations, this does not mean that meaningful reduction in the skull can not be done. The skull has three layers very much like an Oreo cookie, an inner and outer cortical layer and a much thinner middle diploid space (marrow) layer. This can clearly be seen in standard skull x-rays.  It is the outer layer of the skull that can be reduced or roughly up to one-third of the skull’s thickness can be removed.

Outer table skull reduction is done by a bone burring technique. A high speed handpick with a fluted carbide burr can efficiently remove the outer table bone and transform it into bone dust. Over larger skull areas an effective approach is to create a grid pattern across the curved skull surface. By creating these 2 x 2 cm square islands of bone, it allows the proper depth to be placed just on the outer aspect of the diploid space and also ensures a more even level of bone removal. It is easy when reducing large skull surfaces to not be completely even at the depth of bone removal. So it is helpful to check oneself at regular intervals with smaller sections of bone reduction.

Because skull reduction is done right down to the diploid space, there is going to be some blood oozing from the bone (what I call ‘bone sweat’) right after surgery. For this reason the use of small drains for a day or to after surgery is needed to prevent any buildup of blood under the periosteum of the scalp. It also helps with lessening the amount of swelling and/or bruising that might find its ways down onto the face after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Reconstruction of Large Pediatric Skull Defects

Sunday, October 15th, 2017


Background: The correction of congenital skull deformities with early cranial vault reconstruction is a well established surgical therapy. Such early skull manipulations are based on two fundamental principles of the infant’s skull. First, the bone is thin and can fairly easily be removed, reshaped and re-inserted. Secondly, the osteogenic regenerative power of the dura at such early ages allows any bone defects around the bone reconstruction to fill in with new bone.

But despite the potential osteogenic capability of the dura in infants, full-thickness bone defects still do occur. Often they are small and are at the junction of reassembled skull bone pieces from the initial reconstruction. But in rare cases the skull defects may be much bigger, reflective of bone defects left behind from large bony advancements from contour expansions.

The reconstruction of skull defects in children can be done by a variety of methods. While bone may be considered an ideal material, the successful splitting of cranial bone in children is not an assured outcome. A variety of synthetic materials and implants are available to ‘patch’ such skull defects. Each has their own unique handling characteristics.   

Case Study: This 9 year-old female was originally born with bilateral coronal craniosynostosis for which she underwent a fronto-orbital advancement at 11 months of age.  At five years of age it could be seen that large full-thickness defects remained that never filled in with bone from the wake of the fronto-orbital advancements.

Under general anesthesia, the skull and bone defects were exposed through her original coronal scalp incision. The bone defects were lined with resorbable mesh plates by separating the dura from the bony edges so the plates could be slide under and be held into place. Hydroxyapatite cement was applied onto the plates and built up to the surrounding bone edges for a smooth skull contour.

After surgery x-rays show the hydroxyapatite cement, which while containing the inorganic mineral hydroxyapatite, is actually more dense than bone even if it is structurally weaker. The long-term of such hydroxyapatite cements is not resorption and replacement with bone. Rather it will serve as as substrate onto which bone will grow across its outer surface, re-establishing a bony bridge across the defects.


  1.   Full thickness skull defects are not rare after infantile cranial vault reconstruction surgery.
  2. While hydroxyapatite cement may be the best reconstructive material choice for the pediatric skull, its weak biomechanical properties are not favorable to be used alone.
  3. Creating a stable floor with resorbable mesh plates allows hydroxyapatite cement to be successfully applied in full thickness skull defects in children.

Dr. Barry Eppley

Indianapolis, Indiana

The Value of Flexibility in Custom Skull Implants

Saturday, October 14th, 2017


The use of custom skull implants has revolutionized the treatment of many aesthetic skull deformities. Being able to precisely locate the defect and design an implant from the patient’s 3D CT scan that can augment it provides an unparalleled accuracy in improving head shape contours. This is particularly effective in skull asymmetries or augmenting skull deformities where the outline of the bony contour defect can be clearly seen. But it is also equally effective in general augmentations to built out flatter skull contours.

While the value of 3D implant designing can not be under appreciated in aesthetic skull reshaping surgery, the material composition of the implant is also important. While one would think that a rigid implant that resembles the hardness of bone would be appropriate, this is actually counter productive. Such a firm implant would require a long scalp incision to insert which in many cases would need to be a full coronal scalp incision. This would be aesthetically unacceptable for many patients.

The use of a solid but flexible silicone material is of great value in custom skull implants. As the material has some flexibility, this allows it to be inserted through much smaller scalp incisions. It really is quite analogous to that of breast implants. How does a breast implant with a much bigger base diameter than the length of the incision get inserted? Because the breast implant is malleable and can be temporarily deformed to pass through a small skin hole. While custom skull implant are not deformable as they are a solid silicone material (and not a gel like that of breast implants), they have some flexibility. This material flexibility allows the implants too be bent, rolled or twisted so that it can be inserted. Once the implant is inside the larger tissue pocket, it can be manipulated into position and be unrolled to lay flat.

But because a custom silicone skull implant has some material flexibility, this does not mean it does not feel firm like bone once in place. Like wallpaper on a wall, once in place  with the backing of the bone a custom skull implant will feel just like bone.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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