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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

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

Case Study – Fibro-Osseous Occipital Knob Reduction

Saturday, July 15th, 2017


Background: The back of the head is usually a smooth convex shape. While the amount of convexity will vary amongst different people, protrusions on its outer surface are not usually seen as aesthetically desirable. Thus the discrete occipital knob deformity stands out.

The occipital knob deformity is a well known central bony protrusion just above the bottom of the occipital bone. It sticks out like the knob in its name. It is most typically composed of a large growth of bone that develops centrally at the nuchal ridge line. It is a thicker than normal protrusion of bone which when reduced solves the occipital contour concern.

The occipital knob skull deformity is also known as the occipital bun or occipital horn. It is well known to occur in Neanderthal skulls but much less commonly so in modern man. Why it occurs is not known but it is always thought of as a pure bone excess. But in its aesthetic reduction the overlying soft tissue must be considered as well.

Case Study: This 35 year-old male was bothered by the bump on the back of his heads. It was also associated with a thick overlying scalp and a horizontal skin crease both above and below the bump.

Under general anesthesia and in the prone position, the occipital knob reduction was approached through the lower skin crease in non-hair bearing neck skin. The bony bump was identified and reduced down to the surrounding skull bone with a handpiece and burr. Surprisingly the size of the occipital knob was less than its outward appearance would suggest. There was a very thick fibrofatty tissue layer between the skin and the bone which was excised and thinned out. Redundant overlying scalp was also excised.  A small drain was then placed and the wound was closed in layers.

His immediate intraoperative results showed a significant flattening effect to a more normal contour. In this case such a reduction would not have been possible without concurrent soft tissue thinning as well. It appears that in some occipital knobs the overlying scalp becomes thicker than normal, much like that which has occurred with the underlying bone.


  1. The occipital knob deformity is not always a pure bony deformity.
  2. Some occipital knobs have a significant soft tissue component that must also be removed to optimize the flattening effect.
  3. The lowest horizontal skin crease should be used to reduce this type of occipital knob.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sagittal Crest Head Reshaping

Wednesday, July 12th, 2017


Background: There are many different varieties of aesthetic skull shape issues in the adult. While most are from congenital issues related to head molding and are more ‘minor’ in the severity of their expression, some are from variations of true skull pathologies known as crniosynostosis. This is where the sutures that exist between the plates of skull bone during early infancy come together or fuse too early. Such sutural fusions or synostoses create well described head shape abnormalities that are treated in early infancy by bone removal and reshaping. (cranial vault surgery)

But some of these cranial suture abnormalities do not occur completely and do not present with the full blown head shape deformity. Rather they have an incomplete presentation with less severity that was either undiagnosed as a child or was felt to not warrant early aggressive skull reshaping surgery. These are sometimes called microform deformities or, as would be called in urban terms, an odd-looking or unusual head shape.

One of these microform head shapes is that of the adult sagittal crest skull deformity. A variant or  incomplete expression of sagittal suture craniosynotosis, it presents as various types of peaked skull shapes. There is a high or raised bony midline front to back (the crest is always higher in the back) and a relative parasagittal or parallel bony deficiency to the sides. This gives the top of the head various degrees or angles to their head shape when viewed from the front.

Case Study: This 45 year-old male had always been bothered by the shape of his head since he was young. He has a peaked skull shape that was high in the middle and sloped down to the sides. It was also flatter in the back. A 3D CT scan showed that his head was so shaped as a direct result of how it skull had developed.

A surgical plan was devised to improve his head shape through a combination of sagittal crest bony reduction combined with a custom made skull implant that wrapped around three-quarters of his head, filling in the bony deficiencies. The combination of skull reduction and skull augmentation was designed to give him a more rounded and less high skull shape.

Under general anesthesia, his existing curved sagittal midline incision was used to access the procedures. (this was present due to a prior scalp reduction procedure. A 4mm sagittal bone reduction was done with a burring technique to make it flatter. Then the custom skull implant was inserted, positioned and screwed into position

Three months after surgery he had a significant change in his head shape with the elimination of the peaked shape to a more normal rounder shape. While some sagittal height was reduced, it was the augmentation that created the vast majority of the positive head shape change.


  1. More severe adult sagittal crest deformities can not be treated by sagittal crest burring reduction alone.
  2. Parasagittal and occipital augmentation using a custom skull implant is needed to correct the bony deficiencies in the mature sagittal crest skull deformity. (sagittal skull reshaping)
  3. A midline sagittal incision can be used to for access to sagittal skull deformities.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant Replacement for Crown Augmentation

Sunday, July 2nd, 2017


Background: The use of custom skull implants for a wide variety of aesthetic head shape concerns has proven to be a a successful treatment strategy. Using a computer design process on the patient’s 3D CT of their skull, the surface area coverage and thickness of the implant can be precisely made. Such designs must take into consideration how much the overlying scalp can stretch to accommodate the implant. But beyond this physical constraint the design of a skull implant has no limitations.

While the computer can design the implant based on the dimensions provided by the surgeon, it can not determine whether that will produce a satisfactory aesthetic outcome. Perhaps one day the computer will be able to tell us how a design relates to outcome but, until that day comes, the surgeon must create the dimensions based on experience and interpretation of patient goals.

For females the most common aesthetic head shape concern is a deficient crown area. The crown of the skull is at the junction of the top and back of the head. This is an area externally that is well known to women as they often manipulate hairstyles to make it appear fuller. For those women so affected the underlying skill area is flatter and lacks adequate projection. A custom skull implant is the ideal way to surgically improve the fullness in this head area.

Case Study: This 42 year-old female presented with a history ion having had two prior skull implant surgeries to improve the fullness of her crown area by another surgeon. She initially had a custom skull implant made from a 3D CT scan placed. While she had an uncomplicated postoperative course, the amount of projection was inadequate. She then had a second surgery where an unknown material was placed underneath and around the implant to try and build it up further. This results in an unnatural bump-like feel and appearance to the crown area of her head.

A new custom skull implant was designed that had a much broader area of surface coverage and was thicker.

In comparing the new custom implant design to the indwelling skull implant the changes in the amount of skull surface area coverage and thickness could be appreciated. A old design (what didn’t work well) always helps in making a new design which will work better.

Under general anesthesia the composite skull implant was removed. The added material was thick layers of Gore-tex, one larger piece and one smaller piece. These were replaced with the larger custom skull implant after dissecting out a larger subperiosteal pocket. The scalp was able to be closed over the new implant without undue tension.

In designing custom skull implants it is important to realize that they need to cover a broader surface areas than one would initially thi\nk. On the design they must look like a natural shape to the skull even though they are added on to it. If they look unnatural or do not blend in well in the design they will appear so on the patient after surgery.

The one indirect benefit of a prior inadequately designed skull implant is that it does serve as a prior tissue expander. A larger implant can be placed as a result of it being there that if no such implant was there at all.


  1. Skull implants must cover a broad surface area to avoid creating a prominent bump.
  2. Trying to build up a deficient skull implant by placing materials underneath it will not lead to a improved outcome.
  3. Custom skull implant replacements are helped in their design by the indwelling implant shape and thickness.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Occipital Skull Implant Markers

Monday, June 19th, 2017


Background: A flat back of head is one of the most common aesthetic skull problems that is treated. It is best augmented with a custom skull implant made from the patient’s 3D CT scan. This lessens dramatically the aesthetic risks of implant irregularities and edge transitions as well as asymmetry of the contours of the augmentation. There is a huge advantage to controlling the shape and thickness of the implant before surgery. This then leaves the role of the surgeon during surgery to ‘merely’ position it on the skull as it was designed.

The other major benefit to a custom implant that is flexible is that it can be inserted through a smaller scalp incision than that of the diameter of the implant. Every cm of scalp incision (or less thereof) can be of valuable aesthetic consequence. This also speaks to the value of a preformed implant whose shape and thickness can not be altered by the insertion process.

While a smaller scalp incision is of aesthetic benefit, it also severely limits a view of the implant’s position on the skull bone. Not seeing the circumference of the implant’s position on the skull bone can potentially create implant malposition. A curved implant on a curved bone surface under the compression of the overlying scalp can make it seem that just about any implant position is correct.

Case Study: This 57 year-old female had long been bothered by the flatness of the back of her head. (crown area or upper occipital region) Using a 3D CT scan, a custom occipital skull implant was designed to maximally augment the deficient skull area within the constraints of what the scalp stretch would allow.

Under general anesthesia and in the prone position, a 9cm long irregular scalp incision was made over the nuchal ridge. From this incision wide subperiosteal undermining was done with instruments up over the crown way into the top of the skull towards the forehead. The custom skull implants was inserted by folding the sides under creating a more narrow rolled tube. Once inserted the folded sides were unrolled and the implant flattened into the shape by which it was designed. It was then properly positioned by using the compass marker manufactured into the back edge of the implant to get both the midline positioning as well as having no right or left tilt. It was then secured with two small microscrews and the incision closed.

Most custom skull implants benefit in positioning with an embossed compass marker, regardless of what skull area they cover. The limited view of the implant with discrete scalp incisions requires visible registrations to aid in its orientation.


  1. A custom occipital skull implant is the most effective way to build up a flat back of the head.
  2. Proper  positioning of a skull implant in which the scalp incision. permits limited visibility requires a registration mark on the exposed part of the implant.
  3. A compass marker provides a 3D orientation method for skull implant positioning.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Two-Stage Skull Augmentation with Custom Implant

Sunday, June 11th, 2017


Background: The size of one ’s head is a personal matter based on how one sees it. Some people feel their head is too big while others feel it is too small. While there are specific ratios and numbers for head to face size, what ultimately matters is how the person themselves see it. I have seen a lot of patients with concerns about their head size and in most the cases their concerns are visibly evident.

A larger head is hard to hide but a smaller head size can be camouflaged through a variety of head wear and hairstyles. Women can camouflage a smaller head size using their hair. Fuller hairstyles give the illusion of a bigger head. But eventually some women tire of the effort of making their hair a certain way or their hair becomes damaged by continually doing so.

The small head can be augmented to some degree using custom skull implants. The thickness of the skull bone can be doubled in many cases to create an overall larger head size. How much a skull implant can do so depends on the natural stretch of the scalp, which can not be precisely determined beforehand.  My experience has shown that about 12mms of central implant thickness can be tolerated in most people. The scalp can safely stretch over an implant and allow for a comfortable incisional closure. More implant thickness or volume requires a first-stage scalp expansion procedure.

Case Study: This 30 year-old female ha done been bothered by the small size of head. She wanted a head that was taller and face her better balance to her face. A 3D CT scan showed a skull shape that  was normal but did not have a convex shape to the top. It has more of a flatter profile from front to back.

Her 3D CT scan was used to make a custom skull implant that added a lot of height (1t5mms) as well as broader coverage over the rest of her skull. Given its desired size it was felt that her scalp would not stretch enough to be placed without a first stage expansion.

A scalp tissue expander was placed in a first operation with a remote port placed under the skin above the right ear. She was able to place 110cc of saline volume into the expander over the next six weeks.

During a second operation the custom skull implant was placed  through a minor extended scalp incision that was limited to just across the top of her head. The scalp closure was tight but closed comfortable with metal clips.

Her results at just two weeks after surgery showed a nice increase in her head height and a well healing scalp incision.

Larger or more extreme skull augmentation require scalp expansion first. At the time of the implant placement the capsule from the expander misty bone removed from the bone as well as from the edges of the expander capsule. This will allow the scalp to fully maximize its expansion through these scar releases.


  1. The size of any skull implant depends on the stretch of the soft tissue to accommodate it.
  2. Larger skull augmentations require a first-stage skull expansion to ensure that there will be enough scalp to close over it.
  3. The timing between the placement of a scalp tissue expander and the secondary placement of a skull  implant is usually around six weeks.

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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