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Archive for the ‘skull reshaping’ Category

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

Case Study – Head Width Reduction by Muscle Removal

Tuesday, November 29th, 2016


Background: An aesthetically displeasing size of the head can occur at various skull areas. One such area is at the side of the head most commonly located above the ears. When it is too wide there is a noticeable convexity or bowing out of the temporal region above the ears. A more aesthetically pleasing shape at the side of the head is more of a straight line or one with a minimal convex shape to it.

Because the temporal region is located on the side of the skull it is logical to assume that it is bone and can only narrowed by bone reduction. But careful analysis of many CT scans reveals the thickness of the posterior temporal region above the ears is about 50:50 bone and muscle. The thickness of the posterior temporal muscle is a lot thicker than most would think. In men it is 7 to 9mm thick while in women it can be 5mm to 7mms thick.

Thus removal of the posterior temporalis muscle offers an effective treatment strategy for narrowing the side of the head. It can also be done with less scar that would be required for temporal bone reduction.

posterior-temporla-muscle-thicknessCase Study: This 36 year-old male wanted to reduce the fullness on the sides of his head. A CT scan revealed that the side of the head above the ears had a sufficiently thick muscle layer that could allow for a significant reduction.

posterior-temporal-reduction-by-muscle-removal-dr-barry-eppley-indianapolisposterior-temporal-reduction-incision-dr-barry-eppley-indianapolisUnder general anesthesia a straight 5 cm long scalp incision was made just above the ears. The temporalis fascia was split through which the entire posterior temporalis muscle was removed. Closure of the incision made for an inconspicuous scar line.

posterior-temporal-reduction-result-front-view-dr-barry-eppley-indianapolisBilateral removal of the posterior temporalis muscle bellies changed the shape of the sides of his head from convex to straight. With muscle thicknesses that average 7mms, bilateral removal can result in a transverse head width reduction of up to 1.5 cms. This demonstrates that temporal bone removal may not be necessary to achieve a visible head width shape change.


1) The wide side of the head is aesthetically determined by an increased convexity above the ears.

2) An increased head width above the ears is caused by both increased bone thickness  and muscle thickness.

3) Head width or temporal reduction is best done by removal of the entire belly of the posterior temporal muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant for Contour Irregularities

Thursday, November 24th, 2016


Background: The natural oblong and round shape seen in many pictures and diagrams of the skull is not enjoyed by everyone. Many people do have various lumps, bumps and asymmetries of their skull that has developed for a variety of reasons. These are most commonly the ‘blueprint’ of their skull shape determined by their genetics and shaping forces in utero during development.

Such skull asymmetries today are much more likely to be seen in men. This is due to hair loss patterns and the now widely accepted look of having a shaved head or very closely cropped hairstyles. What was once hidden by hair can be uncovered as the hair is lost, exposing the natural shape of the skull. In more significant cases the head shape can be a mixture of hills and valleys and can be a source of aesthetic discomfort for some men.

An irregular skull surface on a male historically can be a difficult aesthetic problem to treat by bone contouring methods. Between a larger scalp scar and the need to intraoperatively apply various bone cements, the aesthetic results may not have justified the surgery. But today’s use of 3D CT implant designs have made skull recontouring more aesthetically pleasing.

custom-skull-implant-for-skull-asymmetry-implant-design-dr-barry-eppley-indianapoliscustom-skull-implant-for-skull-asymmetry-implant-design-back-view-dr-barry-eppley-indianapolisCase Study: This 36 year-old male wanted to improve the appearance and feel of his skull. He was bothered by its shape with one side being flatter than the other and the upper part of the back being flat. Using a 3D CT scan a custom skull implant was designed to make his head have a rounder and more symmetric shape. The implant was not overly thick being 5mms at it thickest portion with feathered margins around all of its edges.

custom-skull-implant-for-skull-asymmetry-intraop-implant-dr-barry-eppley-indianapoliscustom-skull-implant-for-skull-asymmetry-intraop-placement-dr-barry-eppley-indianapolisUnder general anesthesia a curved 9 cm long scalp incision was made. Wide subperiosteal undermining was done along the outlines of the implant’s design. The implant was able to be inserted due to its thin and flexible. Great care was taken to ensure that the implant was positioned properly and all edges were unfolded and flush with the skull’s surface. Small microscrews were used to tack down and stabilize the implant.

Custom skull implants do not have to be large and are often smaller than one would think. For the patients who has some skull irregularities, obtaining a smooth skull shape often requires an implant design that is thin but evens out the outer skull contour. The use of 3D designing from a CT scan makes this possible.


1) Asymmetries in the shape of the skull are not uncommon and are usually due to congenital origins.

2) The male who shaves his head or has very closely cropped hair often unmasks various skull asymmetries.

3) A custom skull implant made form a 3D CT scan is the most assured way of improve skull asymmetries with the least amount of scalp scar.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Large Custom Skull Implant

Wednesday, October 26th, 2016


large-custom-skull-implant-intraop-dr-barry-eppley-indianapolisSkull augmentation is an essential procedure in aesthetic skull reshaping surgery. While onlay cranioplasty (aka skull augmentation) can be done by using a variety of synthetic materials, larger expansions of the skull’s outer surface are most reliably done using 3D custom implant designs. Using the patient’s 3D CT scan, a custom skull implant can be designed to cover a large surface area of the skull. When placed over the patient’s head prior to insertion it can be seen to be impressive in size.

The implant is placed through a scalp incision as small as possible. Even such a large skull implant can be placed through an incision smaller than its width due to the implant’s flexibility.

How large a skull augmentation that can be accomplished is determined by the ability of the scalp to stretch. After the incision and undermining the scalp can stretch to cover an implant to varying degrees. Each person’s scalp has different amounts of elasticities which is partially related to how thick it is. The thicker the scalp the more it is capable of stretching in my experience. There is an unknown balance in each patient between how much their scalp can stretch vs how large can the skull implant be. This is carefully evaluated and thought through during the custom skull implant design process.

When it is believed that the amount of skull augmentation desired exceeds the ability of the scalp to stretch to accommodate it, a first stage scalp tissue expansion is needed.  A small inflatable device is initially placed and expanded by percutaneous saline injections until the scalp has developed additional stretch. This is usually done six to eight weeks prior to the placement of the custom skull implant. This is needed in less than 10% of skull augmentations in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Occipital Knob Skull Reduction

Sunday, October 9th, 2016


Background: The skull is prone to having numerous types of irregularities on its many surfaces. Bumps and indentations are common and can occur from natural development or from later trauma after birth. The fusion of the various skull plates and anterior and posterior fontanelles affords the opportunity for such skull irregularities to occur.

One such well known skull protrusion is that of the occipital knob deformity. This is a distinct midline outcropping of raised bone on the back of the head that is usually circular in shape. It sticks out as a raised knob that is very visible in men that have close cropped hair or shaved heads. It appears to be a gender specific skull protrusion as I have never seen or heard of it in women.

Why the occipital knob skull deformity occurs is not precisely known. It is also known as the occipital bun or occipital horn and is anthropologically associated with Neanderthal skulls. While common in early man it is relatively rare in modern homo sapiens. It has been theorized that it occurs due to enlarged cerebellum or is a remnant of the adaptation to running. It has also been speculated that it occurs more frequently in more narrow skulls. (although I have seen it in both normal as well as more narrow skulls) Regardless of its origins in the man who has a large knob sticking out from the back of their head it is aesthetically undesireable.

occipital-knob-deformity-dr-barry-eppley-indianapolisCase Study: This 30 year-old male presented with a prominent protrusion on the back of his head. It had been there his entire life and had always bothered him. It was centrally located, firm and at the horizontal level of the middle of his ear.

occipital-knob-reduction-by-burring-dr-barry-eppley-indianapolisoccipital-knob-reduction-incision-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, a 6 cm horizontal skin incision was in  a scalp skin crease just below the occipital knob. The thick scalp tissues were elevated off  of the bony protrusion where it was reduced down to the level of the surrounding skull using a handpiece and large cutting burr. This left some redundant scalp which was also trimmed and closed.

occipital-knob-reduction-intraop-result-dr-barry-eppley-indianapolisThe occipital knob deformity is caused by an excessive outcropping of bone growth. It is composed of solid bone and is thicker than the surrounding occipital skull bone. It can be safely reduced through an incision that leaves a minimal scalp scar. Most men would prefer this barely detectable scalp scar to have a smooth and rounder back of the head shape.


1) The occipital knob deformity is a congenital bony protrusion on the back of the head.

2) It is an outcropping of thicker skull bone that can be reduced by a bone burring technique.

3) Occipital knob skull reduction is done through a small horizontal incision either right over it or just below it.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant for Occipital Plagiocephaly

Sunday, September 25th, 2016


Background: Plagiocephaly is a well known congenital condition that results in a variety of craniofacial skeletal malformations. One of the most consistent findings is that of flatness of the back of the head. This flatness occurs as a result of the overall twisting rotation of the skull around its vertical axis. The flatness on one side of the back of the head is often accompanied by some protrusion on the opposite side of the occiput. This protrusion may only appear so because of the contralateral flatness or may be actually beyond what the normal shape would be.

Beyond infancy there is no non-surgical treatment for occipital plagiocephaly. As an adult surgical contouring through bone removal and reshaping is also not a viable option. For a largely cosmetic deformity the magnitude of the surgery does not justify the associated risks and inevitable contour deformities that would result. This leaves the only treatment for asymmetries of the back of the head as an onlay approach.

Building out the back of the head by expanding the bone contour can be done using a variety of bone cements or silicone implants. The concept of custom skull implants has proven to be the superior technique as it allows the exact implant design to be determined before surgery. In addition it allows the surgery to be done through the smallest scalp incision.

occipital-implant-for-plagiocephaly-design-dr-barry-eppley-indianapolisoccipital-implant-design-for-plagiocephaly-dr-barry-eppley-indianapolisCase Study: This 35 year-old male had a congenital plagiocephalic skull deformity with a flat back of the right side of the head which was bothersome to him. He had a history of multiple prior hair transplants using a linear strip harvest method across the back of his head. Because of concerns of scalp tightness a first stage fat injection session was initially. A custom skull implant was made using a 3D CT scan that built up the flatter side of the back of his head. By computer design the thickness of the implant was only 8mms to achieve symmetry with the opposite side of the back of his head.

custom-occipital-implant-fo-asymmetry-dr-barry-eppley-indianapoliscustom-occipital-implant-for-plagiocephaly-intraop-positioning-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, his entire occipital scalp scar from his prior hair transplants was excised. This was good opportunity to have an uncommon amount of surgical access to place the implant. It also was an opportunity to do a simultaneous scalp scar revision at the same time. The skull implant had multiple perfusion holes placed through it prior to implantation. The arrow markers placed into the implant surface allowed for its proper orientation.

custom-occipital-implant-for-plagiocephaly-intraop-result-oblique-view-dr-barry-eppley-indianapoliscustom-occipital-implant-intraop-result-back-view-dr-barry-eppley-indianapolisHis immediate surgical result show adequate augmentation of the flatter side of the back of his head that was symmetric with the opposite rounder side. The use of his hair transplant scar made for convenient access for implant placement. But anytime there is a linear scar across the back of the head this also means that there is a tissue deficiency which may impact whether a scalp implant can be safely placed. In this case the thickness of the skull implant was modest at only 8mms. But fat grafting was still initially done just to be certain that some stretch of the scalp could occur.


1) The most common presentation of plagiocephaly is flatness on one side of the back of  the head.

2) The best correction for occipital plagiocephaly in adults is a custom occipital inplant made from a 3D CT scan.

3) A custom occipital implant is placed through a low occipital hairline incision from the prone position during surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Parietal Eminence Skull Reduction

Thursday, September 8th, 2016

The reduction of skull lumps and bump is a not uncommon request in skull reshaping surgery. Raised areas of the skull can occur for a variety of reasons although the most common is congenital, being just the way that the skull formed.

One unique type of skull lump is not really a lump at all. Known as the parietal eminence it develops from the parietal bone. This skull bone is situated on the sides and roof of the skull, is quadrilateral in shape and has four borders and four angles. Its external shape is convex and near its center is the parietal eminence from which it is formed by ossification. This ossification process begins about the eighth week in utero and gradually extends outward in a radial pattern from the eminence to the margins of the bone.

Because the parietal eminence is the epicenter of the parietal bone it can appear as a prominent bump. Roughly the size of a quarter it can discerned in oblique profile views and, even with hair, can be easily palpated.

parietal-eminence-reduction-by-burring-dr-barry-eppley-indianapolisParietal eminence skull reduction is a form of ‘spot’ cranioplasty. Using a handpiece and drill the prominent high spot of the bone can be satisfactorily reduced. In doing so there are two key components of the procedure. The first important technique is how the bone is reduced. A small skull problem deserves a small incision. Using a high speed handpiece and burr around hair through a small incision runs the real risk of getting hair entangled and pulled out  by the rotation of the burr. Guarding the full length of the burr with a rubber guard allows a smooth reduction to be safely done without risk of hair injury.

parietal-eminence-reduction-incision-dr-barry-eppley-indianapolisWhen making an incision for parietal eminence skull reduction, the incision need to be vertical in orientation and only about 4.5 cms long. But rather than just a straight line, it is aesthetically better to create an irregular zigzag line with a few sharp angles placed between the visible hair shafts. This allows the incision to heal amongst the hair in the most inconspicuous manner.

Parietal eminence skull reduction is a very effective procedure that can be done with limited scalp and hair trauma that leaves an inconspicuous scar.

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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