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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

Case Study – Small Custom Occipital Skull Implant

Sunday, April 9th, 2017


Background: Aesthetic skull deformities occur in a very wide degree of severities and presentations. While many think that such skull shape issues are probably large and obvious, I have found that some are quite small and often obscure to the casual observer. But to the patient smaller skull defects can be just as disturbing as those that can be clearly seen.

One of the common areas of the skull that is often bothersome is the back of the head. While complaints may be of its size, too big or too flat, there are an equal number that relate to its symmetry. One side of the back of the head being flatter than other, often referred to as plagiocephaly, is a condition that I commonly treat. Whether the patient can see it because they have a shaved head or closely cropped hair or whether they can simply feel it through good hair cover, I have seen patients opt for treatment in either an exposed or camouflaged skull shape.

It is not clear why a skull area that is the hardest for some patients to see can be a source of aesthetic anxiety, but it can be. Since custom implants is now the standard way to treat any broad-surfaced area skull deformities, it becomes possible to effectively treat even the smallest of such skull shape deformations.

Case Study: This 57 year-old male had been bothered for a long time by the shape of the back of his head. There was a dip on the upper right occipital skull and a modest protrusion on the left side. Using a 3D CT skull scan, a small right occipital skull implant was designed to precisely fill the bone dip.

Under general anesthesia and in the prone position, a bilateral occipital skull reshaping procedure was performed through a 7 cm long low horizontal scalp incision. On the left side the bony prominence was reduced by burring along the nuchal ridge. On the right side the custom skull implant was inserted and oriented through implant markers and secured with two microscrews.

Small skull contour defects can often be the hardest to improve without creating other aesthetic issues. As a general rule the smaller the defect the more precise the contour restoration must be. Anything short of near perfection can just be another aesthetic concern. Custom designing the implant creates the best chance of minimizing these potential iatrogenic aesthetic concerns.


  1. Custom skull implants can be made for smaller select skull defects.
  2. One of the most common aesthetic skull deformities is that of plagiocephaly where the back of the head is asymmetric.
  3. Custom occipital skull implants are usually placed through a low horizontal hairline incision on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Cement in Pediatric Skull Reconstruction

Friday, March 17th, 2017


Background: Skull defects occur in children for a variety of reasons. But one of the most common causes is early surgery for congenital skull deformities. When reshaping large portions of the skull their complete healing depends on the natural osteogenic capability of the underlying dura. This is usually very robust at very young ages but fades quickly after the first few years of life.

Reconstructing skull defects in children can be done by several techniques. One method is to use the patient’s own bone to do so. This is the most logical approach but its disadvantages is that one has to create another skull defect site and such bone does not always heal smoothly. The next option would be to use allogeneic or cadaver bone grafts. This saves a donor site but does not get around how smoothly, or non-smoothly, the resultant skull contour will be.

The third skull contouring material is that of hydroxyapatite cements. These synthetic calcium phosphate materials have a long history of use in craniofacial surgery for skull defect and contouring reconstructions. They are less well known for use in children but their value in these pediatric skull applications is no less significant.

Case Study: This 9 month-old infant male cild initially underwent reconstruction for a unilateral coronal craniosynostosis condition. The surgery was performed using supraorbital bar reshaping as well as a barrel-stave technique to expand out the overlying forehead bone.He went on well and when seen years later at age 8 he had a slight flattening of the lateral forehead and a palpable full-thickness bone defect along the original coronal suture line.

Hydroxyapatite Cement Forehead Defect Reconstruction intraop Dr Barry Eppley IndianapolisHydroxyapatite Cement Forehead Reconstruction result Dr Barry Eppley IndianapolisUnder general anesthesia and through his existing coronal scalp incision, the bone defect along the original coronal suture line was exposed. The dura was elevated off of the bone edges entirely around the defect. A Lactosorb mesh plate (resorbable PLLA-PGA) was placed on the underside of the bone and cut to lock in between the dura and the bone edges. Hydroxyapatite cement was applied into the bone defect using the mesh plate as its backing. It was then contoured to be flush with the surrounding skull contours and allowed to set.

Hydroxyapatite cement can be used to both fill in skull defects as well as can be placed as an onlay augmentation material. While more extensively used in adults, it can be just as effectively used in children. There is always the question of what happens to the bone cement as the skull continues to grow. My observation is that the skull bone on top and underneath it and it simply gets pushed out jus like normal skull bone with dow with ongoing appositional skull growth.


  1. Skull defects in children can be treated by either bone grafts or hydroxyapatite cement.
  2. When using bone cements in a full-thickness skull defect, a floor against the dura must be created to support the material.
  3. Bone cements offer a facile material to fill and contour skull defects.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Scalp Tissue Expansion in Aesthetic Skull Augmentation

Wednesday, March 1st, 2017


Expansion of the scalp through inflatable devices (‘balloons’) is a well established reconstructive technique. Originally developed to treat lost or missing soft tissues (skin), increasing the size of the surrounding tissues to stretch out and cover what has been lost is the fundamental concept of tissue expansion surgery. Such a concept works best in the scalp where a tissue expander has the greatest stretch on the overlying scalp as it pushes off of the hard skull bone.

Tissue expansion also has a role in aesthetic skull augmentation surgery. With the use of 3D CT design, custom skull implants can be made of almost any design or shape. The limiting factor for such implant placements, however, is whether the scalp can stretch enough to accomodate it. In larger skull implant augmentations, a stage scalp tissue expander must be placed to create the necessary soft tissue coverage.

Scalp Tissue Expander for Skull Augmentation Dr Barry Eppley IndianapolisIn a first state of a two-stage skull augmentation procedure, a scalp tissue expander is placed through a very small incision. It has a remote port placed just above the right ear where the patient can perform the intermittent injections of saline using a needle at home over a six week period.

Unlike traditional tissue expansions in reconstructive scalp surgery, the amount of scalp expansion needed for larger skull implants is much less. It is usually only necessary to stretch the scalp just beyond the look or size of the skull augmentation that the patient wants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Occipital Knob Skull Reduction

Wednesday, February 1st, 2017


Background: The occipital bone of the skull is the very back part that is shaped like a dish and covers the occipital lobes of the cerebellum. Near the bottom of the visible occipital bone is a series of curved horizontal lines known as the nuchal ridges onto which are attached various ligaments and muscles. In the very center of these lines sits a prominence known as the external occipital prominence.

external occipital protuberanceThe highest point of the external occipital prominence is known as the inion. Onto the inion is attached the nuchal ligament and trapezius muscle fibers. It is an enlarged external occipital protuberance that creates the the occipital knob or bun skull deformity. Why it occurs is not known but the fact that it appears to be largely a male skull anomaly suggests it is related to more or stronger muscle attachments onto the bone.

cmoccipital knob 1Case Report: This 26 year-old male noticed a hard lump on the back of his head since he began to wear his hair shorter. He always knew he had a bump on the back of his head but it never bothered him until it became visible with shorter hairstyles. It did not cause him any pain but he did not like the big knob that stick out from the back of his head as it made him self conscious.

Occipital Knob Bone Reduction intraop Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a 7 cm horizontal skin incision was made in the skin crease just below the bony bump. The occipital knob was exposed and had a 13mm projection above the surrounding occipital skull surface with a distinct horseshoe-shape to it. The bony prominence was burred down to be completely flush with the surrounding skull surface. It was solid cortical bone with few vascular channels.

CM Occipital Knob Reduction intraop result Dr Barry Eppley IndianapolisThe occipital knob skull deformity appears to occur exclusively in men, I have never seen it in a female. (It may occur in women it is just I have never seen it yet) It is caused by excessive thickening of the cortices of the bottom of the occipital skull bone. It can reduced completely by a burring bone reduction technique through a fairly small horizontal scalp incision that heals very well. It is a surgery that is performed in an hour with minimal recovery.


1) The occipital knob or occipital bun skull deformity has become more common as more men shave their heads at even younger ages.
2) It is caused by a central prominence of increased bone thickness which can have various shapes.
3) Occipital knob skull reduction is a very safe and effective skull reshaping surgery that provides a permanent contour flattening effect on the back of the head.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Large Custom Skull Implant Replacement

Wednesday, February 1st, 2017


Background: Many areas of the face and the body can be augmented for aesthetic purposes. While the skull is not usually perceived as also be able to be enlarged, it can be done as well. The tightness of the overlying scalp is more restrictive than other body areas so there are limits as to how much skull augmentation can be done.

The implant materials used for aesthetic or onlay skull augmentation are either bone cements or custom made implants. Each can be effective but in larger surface area augmentations a custom implant becomes more effective with far less risk of contour irregularities or edge transition issues. The use of a custom skull implant becomes particularly advantageous when it become necessary to replace a medically or aesthetically compromised large bone cement cranioplasty.

Large PMMA Skull Augmentation 3D CT imagesCase Study: This 35 year-old Asian male had previously been through a large PMMA bone cement skull augmentation procedure that went from the brow bones back to the bottom of the occiput. It provided a good amount of the desired augmentation (a little strong in the forehead) and had no obvious palpable edges. But he did develop a chronic infection that had been controlled for some time with oral antibiotics. As a result it became necessary to have it replaced. A 3D CT scan shows the extent of the cranioplasty. It makes the bone cement look very irregular and not smooth which it actually was not, this is just imaging artefact.

Large Custom Skull Implant design Dr Barry Eppley IndianapolisLarge Custom Skull Implant dimensions Dr Barry Eppley IndianapolisLarge Custom Skull Implant design color mapping Dr Barry Eppley IndianapolisA new large custom skull implant was designed using the outline of the indwelling PMMA bone cement. The forehead was reduced in thickness as the patient requested. The largest area of augmentation was in the occipital region of almost 25mms. Due its large size over a long convex surface, it was designed to be placed in two pieces.

Remove and Replace Large Skull Augmentation intraop Dr Barry Eppley IndianapolisTwo Piece Custom Skull Implant Dr Barry Eppley IndianapolisTwo piece large custom skull implant top view Dr Barry Eppley IndianapolisUnder general anesthesia and using his existing coronal incision, his PMMA bone cement cranioplasty was removed in three large pieces.  It was rigidly fixed to the skull and no fluid or purulence was found. A slime layer was present on both its outer and inner surfaces consistent with a chronic infection. The bone and overlying underside of the scalp was thoroughly debrided and washed. The two-piece custom implant was reassembled on the patient’ skull and screwed in place with a perfect fit. The overlying scalp closure was tight but could still be competently closed in two layers.

When adequate scalp space exists from a prior implant, a large custom skull implant can be accommodated. This is relevant when the need to replace an existing onlay cranioplasty exists and a full coronal incision is present. This permits a lot of scalp mobility although pericranial releases may be needed due to the development of an implant capsular scar.


1) Large skull augmentations cover the forehead in front and go back to the occipital area on the back of the head.

2) The use of bone cements as a cranioplasty method over a large skull surface area is prone to irregularities and a non-smooth contour.

3) A custom skull implant is the best way to cover large skull areas and be a superior replacement for a prior alloplastic augmentation cranioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Occipital Knob and Roll Reduction

Thursday, January 26th, 2017


Background: The back of the head is not usually given much thought as it not seen by most people including the person themselves. But in today’s world where many men now shave their heads, the entire shape of the skull takes on greater aesthetic significance than ever before. A smooth shape of the skull is now desired regardless of whether it is the front, top, sides or back.

occipital knob deformityThe back of the head, known as the occiput, is prone to a variety of misshapen issues. One of these is known as the occipital knob deformity. This is a well known aesthetic skull deformity where there is a bony projection in the midline at the bottom of the occipital skull along the nuchal ridge. It projects outward as a knob of bone and has also been called an occipital bun. In x-rays it can clearly be seen as a dense projection of bone disrupting the convex shape of the back of the head.

Why the occipital knob occurs is not known but it sticks out from the back of the head very prominently in some men. While it can occur just as an isolated bony skull deformity, it often has an excess of scalp tissue on top or above it. This roll of scalp tissue can be magnified since it sits down at the back of the head where it joins the neck. In thicker-necked men or men with thick scalp tissue, the occipital scalp roll can be just as significant an aesthetic issue as that of the bony projection.

Case Study: This 35 year-old male had a hard bulge on the back of his head as long as he could remember. It was not an aesthetic issue before he decided to shave his hair when it started to thin. Right under the projecting knob was a deep horizontal skin crease. Extending out from the sides of the knob was a thick skin roll.

Occipital Knob reduction intraopOccipital Roll Reduction intraop DR Barry Eppley IndianapolisUnder general anesthesia and in the prone position, the occipital reshaping procedure as done by initially incising along the existing horizontal sin crease. An elliptical full-thickness scalp excision was done exposing the underlying bony knob. The bony knob as reduced by burring to a smooth contour with the surrounding skull bone. Wedges of thick subcutaneous tissue was taken from both the upper and lower undermined skin flaps before they were closed in multiple layers with dissolveable sutures for the skin.

Occipital Knob and Roll Reduction result Dr Barry Eppley IndianapolisOccipital Knob and Roll reduction intraop Dr Barry Eppley IndianapolisIt is more common to have to remove scalp tissue when treating the bony occipital knob  than not. This is evident beforehand in men with short necks, thick scalp tissues and evidence of one or more horizontal skin rolls. The tradeoff in doing so is a fine line horizontal scar. But when a skin roll is present there usually is a deep skin crease anyway.


1) The bony occipital knob deformity on the back of the head is often associated with an excess of scalp tissue as well.

2) An occipital contouring procedure combining bony knob reduction with excision of excess scalp tissue produces a smooth convex back of the head contour.

3) This combined occipital knob and roll reduction procedure is done through a horizontal skin crease incision.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Two-Piece Custom Skull Implant

Saturday, January 21st, 2017


Skull reshaping using implants is the only effective method for augmenting head shape. While certain bone and muscle removals can be done for more limited skull reductions, skull augmentations can produce much more dramatic changes. In essence, the stretch of the scalp is far more permissive than the thickness of the skull bones.

In very large skull augmentations the scalp can become a limiting factor and may require a first-stage scalp expansion. But beyond the ability of the scalp to accommodate a large skull implant, getting the proper shape and dimensions of the implanted material is the other major challenge. This is overcome today using a custom design approach with a 3D CT scan. Custom skull implants can now be made to cover any area of the skull including the entire bony skull if desired. (forehead back to occiput)

Two Piece Custom Skull Implant Dr Barry Eppley IndianapolisManufacturing very large or total custom skull implants is difficult because they can cover more than a 180 degree arc with thin edges. To avoid manufacturing problems, a two-piece approach to the implant’s fabrication and insertion can be done. Creating two interlocking edges allows for a two-piece custom skull implant to be accurately reassembled on the patient’s skull the way it was designed.

Very large skull implants are most accurately placed using a long scalp incision. This patient shown here already had a full coronal incision so its total length was used. If such a long scar was not already present, a shorter incisional length could be used.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Macroporous Custom Skull Implant

Wednesday, January 11th, 2017


Custom skull implants have become a reliable and safe method of various types of skull augmentation. Made from the patient’s 3D CT scan, they cover the desired skull surface with a precise fit and a smooth outer surface that blends well into the surrounding bone/muscle areas. The most careful judgment has to be made in the thickness of its design so a competent and not overly tight scalp closure is obtained.

An obvious but often overlooked feature of most custom skull implants is that they are ‘large’. They can cover a significant surface area of the bony skull. This places an implant between the thick overlying scalp and the bone. While I have never seen this to cause any problems, it would be desirous to have some increased fibrovascular connections between the scalp and the bone. Since a silicone skull implant is not naturally porous this is not a biologic property such an implant would naturally have.

custom-skull-implant-ready-for-placement-dr-barry-eppley-indianapolisTo help achieve some integration of skull implants with the surrounding tissues, the concept of perfusion holes is used. This is were many 3mm to 4mm circular holes are placed through the implant. They can be thought of as ‘perfusion holes’. They will permit a very rapid tissue ingrowth through them, reconnecting the scalp and the bone with these tissue connections. They also serve to take one large implant pocket and make it many small pockets through this natural tissue quilting effect.

While these perfusion holes also help to fix the implant more securely into place, it does not make it any more difficult to remove or modify it later should the need arise. The tissue bands can be broken fairly easily in that process.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant in Sagittal Ridge Skull Reshaping

Sunday, December 18th, 2016


Background: The shape of one’s skull is determined by numerous factors. But the most important two are the cranial sutures and the underlying expanding brain. The sutures permit the growing brain to increase in size without constriction by a tight overlying ‘bone box’. These sutures are strategically placed to allow a circumferential expansion of the skull while keeping the different pieces of the skull together.

One of the key and most evident cranial sutures is the one that runs down the midline of the skull and initially connects the front and back soft spots. This long suture allows the skull to grow in width. When the sagittal suture fuses together too soon a well known abnormal skull shape ensues marked by a lack of skull width and a very long skull length. (sagittal craniosynostosis)

There are different degrees or expressions of sagittal craniosynostosis, some of which may escape early surgical intervention or felt not severe enough to justify infantile cranial vault surgery. They present in adulthood with prominent sagittal ridges, narrow bitemporal widths and a triangular shape to the top of their head when viewed from the front. Skull reshaping of these deformities in adults requires a completely different surgical approach than what is used in infants.

Case Study: This 42 year-old male desired to change his skull shape. It had bothered him since his hair had thinned when he was younger and he had managed his head shape concerns by constantly kept his head covered by hats and caps. He had been through several unsuccessful hair restoration treatments including scalp reduction and scalp micropigmentation.

sagittal-ridge-reduction-3d-ct-planning-dr-barry-eppley-indianapoliscustom-skull-implant-design-for-sagittal-ridge-deformity-dr-barry-eppley-indianapolisHis skull reshaping surgery was planned using a 3D CT scan. Some reduction of the most prominent height of the sagittal ridge was imaged and around it a custom skull implant designed to build up the deficient parasagittal and upper occipital skull areas.

skull-reduction-and-implant-surgical-plan-and-incision-dr-barry-eppley-indianapolisskull-implant-and-sagittal-reduction-intraop-dr-barry-eppley-indianapoliosUnder general anesthesia his old midline scalp reduction scar was used for surgical access. The posterior sagittal ridge was burred down and the custom skull implant placed.  Despite the amount of scalp expansion caused by the implant, the incisional closure was not excessively tight.

custom-skull-implant-results-front-view-dr-barry-eppley-indianapolisHis several month postoperative result showed a life changing improvement in the shape of his head. It had a more round shape and the elimination of any sagittal ridging.

Adult skull reshaping of the sagittal ridge deformity always involves some reduction of the height of the ridge. But in more severe cases this alone is inadequate. Building up the skull around it essential and this is most effectively using a 3D design approach to the custom skull implant.


1) The prominent sagittal ridge skull deformity seen in an adult is caused by an untreated infantile sagittal craniosynostosis of varying expressions.

2) Reshaping the adult high sagittal ridge requires a combination of some sagittal ridge reduction and major parasagittal augmentation.

3) A custom skull implant is the most effective method for a major skull reshaping change.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Shaping Custom Skull Implant

Sunday, December 11th, 2016


Background: The top of the head usually has a slightly convex shape between the temporal lines that border its sides. This normal superior skull shape can be altered during development and often occurs by how the midline sagittal suture develops and grows. In many cases of undesired superior skull shapes, the sagittal suture line becomes a raised ridge creating a peaked shape to the top of the head.

Rather than a raised ridge the top of the head can also develop without much convexity. It can be relatively flat between the temporal lines creating a more square head shape. While this flatness can be camouflaged by various hairstyles, it can still be very bothersome to some who are so affected.

The best way to create increased convexity to the top of the head and a little bit more height is with the use of a custom skull implant. It does not have to be particularly thick or big to have a noticeable effect. Designed to add skull height between the temporal lines, it extends from behind the frontal hairline back past the crown area down slightly into the occiput.

heightening-skull-implant-design-dr-barry-eppley-indianapolisCase Study: This 44 year-old male disliked the very top of his head, feeling that it was too flat and did not have a nicer more rounded shape. Drawings of his desired head shape change showed that a cap on the top of the head gave the desired effect. Using a 3D CT skull scan, a custom skull implant was designed that added convexity to the top of the head without adding much vertical height.

heightening-skull-implant-placement-dr-barry-eppley-indianapolisUnder general anesthesia, a small 7 cm long scalp incision was made closer to the back of the head. The custom skull implant had numerous perfusion holes placed throughout it. After the development of the subperiosteal pocket, the implant was inserted in a folded fashion. Once inside the implant was unrolled, positioned as designed and secured with two small titanium microscrews.

small-skull-augmentation-results-front-view-dr-barry-eppley-indianapolissmall-skull-implant-augmentation-results-side-view-ddr-barry-eppley-indianapolisA custom skull implant can be designed to create a cap for the top of the head to increase its convexity. This provides a more rounded head shape, a small amount of vertical height and a small amount of additional front to back length.


1) The shape of the top of the skull can be flat, have an irregular shape or be asymmetric.

2) The top of the head can be augmented with a custom skull implant to increase his height or make it have a more convex shape.

3) A custom skull implant to smooth out the top of the head can be inserted through a small scalp incision.

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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