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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

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

OR Snapshots – The Customizable Custom Skull Implant

Wednesday, September 27th, 2017


Custom made skull implants are the best way to perform almost any type of skull augmentation. Covering potentially large surface areas of the skull in a smooth manner is very difficult when attempted by traditional bone cement materials. The computer designing process does what no surgeon can do as well with the naked eyes and their own hands. While the computer design process can make whatever implant dimensions the surgeon chooses, the question is always what exact aesthetic will it create and whether this aesthetic result meets the patient’s head shape goals.

In some rare cases the patient may desire some reductive modifications to their skull implant. (additive modifications usually require a new implant) This is most likely to occur after the implant is in place or after the patient has ‘worn it for awhile’. Like all other facial implants such modification is possible through an implant shaving process. Unlike facial implants, however, the skull implant has a much large surface area which makes it more challenging to make the changes smooth and even on a curved surface. This requires a larger than normal scalpel blade and good experience in such implant manipulations.

Most commonly reduction of a custom skull implant is to reduce a certain area of thickness or to remove one of its contours. Such reductions need to be done over a much larger surface area of the implant than one would think. As a result it also requires a wider amount of incisional exposure than one may want to do. But good results from such implant modifications come from not trying to do so from limited exposures where visibility is compromised and the pocket for instrument manipulation is too restrictive.

Dr. Barry Eppley

Indianapolis, Indiana

The Peaked Shaped Custom Skull Implant

Saturday, September 16th, 2017


Custom skull implants make it possible to effect many different types of aesthetic head shape changes that were not possible just a decade ago. Fabricating the implant from the patient’s 3D CT scan, the only restrictions to its design and size is the limits of how much the scalp can stretch to accommodate it. Placed through relatively small scalp incisions, such custom implants can correct skull asymmetries, help make for a rounder head shape and add volume to flat areas of the skull.

The objective of most aesthetic skull surgeries is to make for a rounder head shape. This is usually assessed in the front view with how it looks across the top the head in its arc from ear to ear. Like facial shapes, head shapes come in heart, square, pear, rectangle, round, oval, diamond and oblong when viewed from the frontal perspective. Most patients would choose the round or oval head shape as the most aesthetically pleasing and this is the form that most skull implants are designed to achieve.

But a few patients may want a non-traditional head shape that does not fall into these classic head shape descriptions. One such example is that of the peaked or sagittal head shape. This is where a raised midline ridge is evident with an overall head shape that is more square. This makes for three distinct angles to the head shape, one in the midline and the one on each side as it transitions into the temporal or side of the head. Some patients replicate this head shape look by their hairstyles. But such head shapes are possible to create by a custom skull implant that is designed to do so.

Such a designed skull implant will show its shape the best in men that have very short cut hair or who shave their head.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Granule Skull Reconstruction

Sunday, August 20th, 2017


Background: The skull, while often perceived as a solid piece of bone, is not. It is actually composed of three layers, very much like an Oreo cookie. There are the outer and inner solid cortical layers (the cookie) and then there is a thinner inner layer which is softer known as the diploid or marrow space. (the filling)

Many skull defects occur as a result of injuries caused by fractures of varying degrees of the bone’s thickness. When the skull fracture does not significantly displace the inner cortical table and does not disrupt the dura, there is no need for surgical reduction. But such fractures often do displace the outer cortical table resulting in contour defects. The soft tissue will eventually follow the depressed bone inward as scar contracture and healing ensure.

Case Study: This 24 year-old male was involved in a car accident in which he sustained blunt trauma to his right upper forehead. He sustained a full thickness skull fracture with a small underlying epidural bleed. He was not treated surgically and he went on to a full recovery. As he healed he developed a circular indentation over the fracture site. A 3D CT scan showed that it was due to a bone indentation caused by his previous skull fracture.

Under general anesthesia, a semicircular hairline incision was made for access and the defect exposed. The fractured bone was stable and no effort was made to elevate the fracture segments. The defect was filled with hydroxyapatite granules and covered with a 1m thick resorbable plate with screws for containment.

His after surgery result showed the restoration of a smooth external forehead/skull contour.

The use of hydroxyapatite bone substitute today in skull reconstruction, and for almost the past twenty years now, has been with using it in a bone cement form. This provides the best method of application as it is contoured into the defect site and then sets before wound closure. But hydroxyapatite can be still used in granular form which allows for true fibrovascular ingrowth and even some bone ingrowth as well. Its use is restricted to a completely contained skull defect with an underlying floor and walls.


  1. Small skull defects can be treated by a wide variety of cranioplasty materials.
  2. In a small partial-thickness skull defect, hydroxyapatite granules can be used to fill the defect and create a smooth cranial contour.
  3. A resorbable cover can be used as a roof for a hydroxyapatite granule skull reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sagittal Crest Skull Reduction

Sunday, August 13th, 2017


A bony ridge that runs down the midline of the head is known as a sagittal crest. This is a palpable raised ridge of bone that when high enough can cause a peak-shape to the head from the front view. The normal more convex shape off the head becomes more triangular shaped. This is most commonly an aesthetic concern in the male that either has very short hair or shaves their head.

Reduction of the sagittal crest skull deformity is done with a burring technique. Using a high speed handpiece and carbide burr, the bone is shaved down to a smooth contour. The bony ridge is thicker than normal skull bone so it can be safely reduced. But because this is an aesthetic deformity thoughtful consideration must be given to the incision needed to do the burring.

Working through a small scalp incision using a high speed handpiece safely requires protection of the surrounding hair and skin edges. This is best done by stapling gauze sponges along the edges of the scalp incision as well as placing a rubber guard over the length of the shaft of the burr. This prevents any risk of hair getting caught up in the rapidly rotating burr or its shaft. It is also important to only operate the handpiece when totally inside the subperiosteal tissue tunnel along the bony sagittal ridge.

Sagittal crest skull reduction can be done both effectively and safely through a fairly small scalp incision. This incision is usually placed perpendicular to the sagittal crest. In posterior sagittal crests the incision is placed on its most posterior end. But in long or more extensive sagittal crests the incision is placed at its midpoint to provide equal access to both ends of the bony deformity.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Occipital Skull Implant

Saturday, August 12th, 2017


There are over fifteen types of aesthetic skull deformities. But the most common amongst them is various forms of flattening of the back of head. Perhaps because the back of head is exposed to various pressures in utero and after birth more than any other area of the head, it is prone to deformational pressures that can cause its shape to be flatter. This flatness can affect just one (plagiocephaly), both sides (brachycephaly) or even subtotal portions of either side.

The most effective treatment for flat back of the heads, regardless of its size, is a custom occipital skull implant. Made from the patient’s 3D CT scan, the implant design can be made to cover all flat areas and match any asymmetries between the right and left sides. The flexibility of a silicone implant allows the precisely-designed implant to be inserted through the smallest possible scalp incision usually placed at the mid-portion of the occipital scalp.

In surgery the flatness of the head can be fully appreciated. With the patient asleep in the prone position, wetting of the hair allows the back of the head shape to be completely seen. Laying the custom implant on it allows one to see how much the contour can be improved. Because it is not under the scalp its size looks smaller than the bone area that it will cover and shows more projection that will be actually achieved.

Recovery from skull implant surgery is fairly quick. One can expect some swelling and bruising in the temporal areas on the sides where the implant is primarily placed. This is to be expected due to the subperiosteal dissection needed to make the implant pocket. Since the dissection is done under general anesthesia in the prone position, combined with effects of gravity, such tissue fluids work their way towards the face. The facial swelling and bruising resolves by ten days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Posterior Sagittal Crest Reduction

Sunday, August 6th, 2017


Background: The sagittal suture is the fibrous connection between the two parietal skull bones running down the midline of the head. It remains as a soft tissue connection until the second or third decide of life when it closes and disappears. Premature closure of the suture in utero or early after birth results in the well known scaphocephaly condition or sagittal craniosynostosis. Skull growth is inhibited perpendicular to the suture and, as a result, the head becomes very elongated and narrow in width shortly after birth.

The sagittal suture connects anteriorly with the coronal sutures whose interface is known as the anterior fontanelle early after birth and later as the bregma when the soft spot closes. The sagittal suture connects posteriorly with the lambdoid sutures which is known as the posterior fontanelle in the first few years of life and later as the lambda when the fontanelle closes.

In some individuals a raised sagittal crest develops along the original line of the sagittal suture. It is usually highest just in front of the lambda and decreases in height coming forward towards the bregma. This is known as the posterior sagittal crest deformity. A line may be seen coming all the forward to the forehead but the highest point is in the back, making the skull height highest at the back end of the sagittal suture rather at the vertex in the middle portion of the suture lines.

The posterior sagittal crest deformity is an aesthetic skull deformity that is seen exclusively in men in my experience. This is probably because it becomes an issue for treatment when hair loss occurs and men shave their heads. It appears as a distinct triangular point in the front view and gives the head a midline peaked appearance.

Case Study: This young male presented for treatment of his raised posterior sagittal crest. It appeared as a raised ridge in the side view and as a triangular point in the front view. A 3.5 cm curved scalp incision was marked just behind the posterior crest for surgical access.

Under general anesthesia, the scalp incision permitted a midline subperiosteal tunnel to be made into which a handpiece and burr was placed for reduction. The crest of bone mass reduced by burring from back to front to reduce its height and make for a smooth contour into the sides. Cleaning out the bone dust allowed it to shaped into a pasty mound representing the amount of crestal bone removed. The incision was closed in layers with fine dissolvable sutures for the skin.

The posterior sagittal crest represents one part of the sagittal suture that closed just a bit early but not enough to create the full blown expression of sagittal craniosynostosis. It always affects the back part of the sagittal suture with lesser degrees of bone height coming forward. It is effectively reduced by a bone burring reduction. It is important to wash out all bone dust created and to seal any bleeding vessels in the bone with wax to ensure reactive bone formation done not occur.


  1. The posterior sagittal crest represents a microform of sagittal craniosynotosis that partially affects just one part of the suture.
  2. Burring reduction of the raised part of the suture line is done through a small scalp incision.
  3. The raised sagittal crest represents thicker bone so complete reduction of it is usually possible.

Dr. Barry Eppley

Indianapolis, Indiana

Custom Skull Implant Design for Occipital Plagiocephaly

Monday, July 31st, 2017


Flattening of the back of the head is one of the most common aesthetic skull deformities. It can occur either as a total or bilateral flattening of the back of the head (occipital brachycephaly) or on just one side. (occipital plagiocephaly) The actual occurrences of either type of occipital skull deformity is not known and the only relevance of their occurrence is to that of the affected patient. In my clinical experience, asymmetry of the back of the head is the more common presentation seen for aesthetic treatment.

Plagiocephaly is a term that applies to an overall twisting of the skull shape around a vertical axis of rotation. This means that usually both the front and back of the skull are affected. The side that is flat on the back, the opposite front side will also have some degree of flattening as well. In most cases of plagiocephaly the occiput is more severely affected or flattened than that of the forehead.

Occipital plagiocephaly, or flattening of one side of the back of the head, is always best treated by a custom skull implant. Using a 3D CT scan, a near exact replica of the skull contour can be created of the opposite more normally shaped side. While the opposite normal side may actually have a bit of excessive protrusion, it is rarely reduced due to the extra length of the incision needed to do it in most cases. These custom skull implants can be placed through fairly small incisions and, besides the exactness of the correction, is their main advantage.

Because the overlying scalp is often slightly thinner on the flatter side, it is usually best to overcorrect the flatter side by about 10% to compensate. This means increasing the central projection or thickest part of the implant to make up for any overlying soft tissue deficiency.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Secondary Custom Skull Implant Replacement

Friday, July 21st, 2017


Background: Various forms of skull augmentation have become a common procedure in my practice. From flatness on the back of the head, a narrow head width, the desire for greater skull height and shape to a more projecting forehead and/or brows, custom skull implants can more than adequately meet these needs with a safe and fairly predictable outcome.

Such skull implants are very powerful but their amount of augmentation possible its ultimately controlled by the stretch of the scalp. Because of some patient desires for results that exceed what the scalp will allow, the concept of a two-stage skull augmentation was developed. In the first stage a scalp tissue expander is placed which creates the subperiosteal pocket space needed for the placement of a large custom skull implant as the second stage.

With one and two stage custom skull augmentations, the patient must traditionally decide up front which direction they want to go based on their aesthetic head shape goals. If a patient knows that they really want a larger type result they may opt for the standard two stage approach upon front. But some patients who may be uncertain or for economic or logistical reasons go instead for the immediate placement of the implant. But what if one does so and then they decide later they want a larger skull augmentation?

Case Study: This 28 year-old male has a prior custom skull implant placed one year previously. Since it as an immediate insertion of an implant the thickness over the crown of the skull was 8mms. While he was content with its size at that time he now desired to have even more augmentation. He has a very well healed semi-coronal scalp incision.

A new custom skull implant was designed that increased the thickness over the crown out to 14mm, an effective increase of 70% over his original implant size and volume.

Under general anesthesia, his existing coronal incision was re-opened and his skull implant exposed and removed. The difference in the height of the two implants could be seen when placed side by side. The new implant was inserted after the creation of multiple perfusion holes and the scalp incision closed with minimal tension over it.

This is not the first time that I have performed a secondary larger skull implant to replace an existing one. In each case, as this patient demonstrates, the first skull implant does act as an effective tissue expander. There is more stretch of the scalp to be had even though the initial implant has a capsule around it. This is a relevant observation for those patients who may ideally want a much larger skull implant but are limited at the time for a variety of reasons to a one-stage skull augmentation approach.


  1. Like any other form of body enhancement patients may want to increase the size of their augmentation later.
  2. A larger skull implant can be placed secondarily after a first one which acts as a ‘first stage’ tissue expander.
  3. The scalp expansion effect of a first skull implant generally allows for a 50% or greater in volume for the second skull implant.

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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