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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

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

Case Study – Scalp Reconstruction with Custom Skull Implant

Thursday, June 1st, 2017


Background: Most scalp reconstructions are done for the need to recreate a full-thickness scalp layer. Replacing a full-thickness scalp wound requires all layers of the scalp and must be done by either tissue expansion or rotation flaps of adjacent scalp or the microvascular transfer of distant tissue.

Most partial thickness scalp defects are missing some of the outer layers, most notably that of the skin. Reconstruction consists of skin grafting which can even be done when the defect is down to the bone. (after creating a vascularized tissue bed)

A far less common partial thickness scalp defect is when an outer skin layer is present but the underlying tissues are thinner. This can occur from avulsive injuries or resections where a subtotal scalp resection has occurred or been performed and then skin grafted.. Such a skin grafted scalp will often look deficient and sunken in, like a ‘bite’ has been taken from the skull.

Case Study: This 35 year-old male had a history of chronic scalp infections on the back of his head. They were so severe that it eventually required excision of all occipital scalp skin and coverage with a large skin graft. This solved his scalp infection issue and he remained infection free ever since. As much of a benefit as this scalp procedure provided it left him looking like he has a skull defect. The back of his head look deficient as if a part of his skull was missing.

To rebuild back his head shape a custom skull implant was designed to push the scalp back out in an ear to ear coverage. A paper template was used to measure the length (24 cms) and height (16cms) of the occipital scalp defect from which a custom skull implants was designed.

Under general anesthesia and in the prone position, an incision was made at the top edge of the skin graft-scalp junction all the way across. A full-thickness inferiorly-based scalp fall was raised down into the neck muscle and back over the back ends of the posterior temporal muscles/fascia. Th custom skull implant has multiple perforation holes placed throughout and the top edge beveled for a smoother fit. It was secured with multiple titanium microscrews and closed with dissolveable sutures. A small drain was placed on both sides.

His head dressing and drains were removed the next day. His immediate result showed a normalization of his skull shape and no vascular compromise of the scalp flap.

Scalp contour defects can be treated by skull augmentation. Custom implants provide an assured and smooth soft tissue effect.


  1. A partial thickness scalp defect that has an intact overlying skin layer can be reconstructed (augmented) with an underlying skull implant.
  2. The design of a custom skull implant for an aesthetic scalp thickness deficiency is based on external measurements.
  1. A limited full-thickness scalp flap can be raised to insert the wrap around skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

Scalp Scars in Aesthetic Skull Reshaping Surgery

Tuesday, May 23rd, 2017


In any form of skull reshaping surgery scalp incisions are needed. While every effort is made to keep them as short in length as possible, some incisional length is needed with a resultant scar. Such scalp scars are unavoidable The question from patients is always what does the scar look like and how does it heal afterwards.

Incisional healing on the scalp from skull reshaping surgery is affected by many factors. These include the thickness of the scalp skin, hair density and hair shaft pattern, where on the scalp it is located and how the incision is surgically made and closed. No matter how the scalp incision heals from skull reshaping surgery it is important to realize that it will NOT look like many scalp scars appear after neurosurgery procedures. What one may find on an image search on the internet about scalp scars is almost always after neurosurgery procedures. While not a criticism of neurosurgery, scalp scars from aesthetic skull reshaping procedures is of paramount importance and are almost as important as whatever is done to the skull bone below it.

In my experience in performing aesthetic skull reshaping surgery, I have made ten observations about the resultant scars from the scalp incisions.

  1. Making the incisions with ‘cold steel’ (scalpels) has the lowest risk of injuring hair follicles. (lasers and electrocautery make for the worst scalp scars)
  2. Incisions must be made paralleling how the hair shaft exists the scalp to prevent injury to hair follicles.
  3. Closure of the scalp incision should be done with deep galeal sutures and either fine skin sutures or small metal clips. The dermis (underside of the skin) should not be sutured to prevent injury to hair follicles. There are no scar differences between small sutures or metal clips.
  4. Scalp scars do best on the top and back of the head. Scalp incisions on the sides of the head (temporal region) have a tendency to widen a bit in some patients.
  5. Scalp scars do very well in bald or shaved heads in men. They often do better than in patients with hair.
  6. Scar widening is more likely in skull augmentation than skull reduction procedures. Less tension on the wound closure equals a more narrow scar.
  7. Longer scalp incisions have a greater risk of scar widening than smaller scalp incisions, presumably due to the magnitude of the procedure done. Although more incision length in general increases the risk of scar widening by virtue of its greater length.
  8. Ethnicity does not change the risk of how the scar heals. Darker skin pigments do not have increased adverse scalp scars than that of Caucasians.
  9. I have never seen a scalp scar keloid, only scar hypertrophy. (widening)
  10. Repeated entry into the same scalp scar increases the postoperative risk of widening.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Flat Back of Head Skull Implant

Friday, May 19th, 2017


Background: Skull augmentation today has evolved to augment any area of the head, whether it is the forehead, top, back or sides. This has become possible due to the use of 3D CT scans and implant designing software. This allows the implant design to be done before surgery and also permits a smaller scalp incision to be used for its placement.

The back of the head is a common aesthetic skull deformity caused by either the way the fetus was positioned in utero, the sleeping position of the infant after birth or the genetic blueprint of the skull’s development. To those patients so affected, it can be a lifelong obsession with numerous lifestyle changes to hide or camouflage the abnormal head shape.

Case Study: This 34 year male had always been self conscious by the flat back of his head. This concern prevented him from wearing a short hairstyle on the back of his head. He had dreamed his whole life of having a more rounded back of the head. Using a 3D CT scan a custom occipital skull implant was designed to project out the back of his head 12mms and wrap around the sides and the top for a smooth transition into his natural skull bone.

Under general anesthesia and in the prone position, a 9 cm long low occipital scalp incision was made. Wide subperiosteal undermining was done up over the crown and around the sides into the temporal areas. The custom implant was prepared with multiple perfusion holes to allow postoperative tissue ingrowth. Given that the implant was much wider than 9 cms, this required it to be folded for insertion and placement. Once positioned a single microscrew was placed for fixation. The incision was then closed with dissolveable sutures.

The flat back of the head is a not uncommon aesthetic skull shape concern. Once patients realize that a single surgery of 90 minutes can satisfactorily address their skull shape concerns, patients are elated that such a corrective procedure exists. The key is the fabrication of a custom implant in which all implant shaping is done before surgery and ensures a smooth postoperative feel to the back of the head. The only caveat is that there is a limit as to how big the implant can be as the scalp must be able to stretch over it and allow the incision to be closed without undue tension.


  1. The flat back of head can present in a male with the need for a pure horizontal projection increase.
  2. A custom occipital skull implant can increase posterior projection in a completely horizontal direction if desired.
  3. How thick any custom skull implant can be is limited by how much the scalp can stretch.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Occipital Crown Skull Implant

Wednesday, May 17th, 2017


Background: The deficient or deformed back of the head is the most common aesthetic skull deformity. Lack of sufficient projection and a more convex contour are the main reasons patient seek a surgical solution to these concerns. Such aesthetic skull concerns, in my experience, occur equally in women and men. Women find that they have to try and use their hair to hide the lack of occipital shape. Conversely it comes to men’s attention in most cases because they either shave their heads or have a closely cropped hair style.

What has made the augmentation of the back of the head, and just about all skull augmentations, a reliable and effective procedure is the use of custom implants. Such a skull contouring technique allows the precise shaping and design of the augmentation material to be done before surgery and also permits a smaller scalp incision to be used for placement.

While a custom skull implant can be designed to any shape and dimensions, that does always mean it can be successfully placed. The natural flexibility of the scalp or how much it can stretch controls the size of the implant that can be placed under it. This is particularly true when the incisional access is more limited and the elevation of the scalp tissues off of the bone is also more restrictive. Unlike a full coronal scalp incision where wide undermining of the scalp flaps can be done in either direction and larger implants can be placed, the desire in most aesthetic skull augmentations is for a more limited scalp incision. This means that in most patients, the maximal thickness of the implant at its central projection should be under 15mm.

Case Study: This 30 year female felt that the back of his head lacked projection particualrly more in the upper crown area. Even though she currently had a longer hair, this was not always her preferred hair style. Using a 3D CT scan a custom occipital skull implant was designed to augment her crown area with a central thickness of 12 mms.
Under general anesthesia and in the prone position, a 9 cm long mid-occipital scalp incision was made. Wide subperiosteal undermining was done into which the implant, which had been intraoperatively prepared with multiple perfusion holes, was placed. Given that the implant was much wider than 9 cms, this required it to be folded on insertion and then unfolded once under the scalp flap. The tightness of the overlying scalp tissues and the precision fit of the implant on the bone does not usually require any form of implant fixation. The incision was closed with dissolveable sutures. No hair is ever shaved for the placement of skull implants.

One interesting aspect of custom skull implants, that is often asked by patients, is their potential impact on the hair follicles. As seen in this closeup picture the location of the hair follicles, which much deeper than most people realize, is still much more superficial than the implant. Of the five scalp layers the hair follicles are in the second layer with the implant is under the fifth layer.


  1. The flat back of the head occurs in either a complete projection deformity or more or a crown deficiency.
  2. A custom occipital skull implant is the best method for any form of occipital skeletal deficiency or asymmetry.
  3. The thickness and surface area coverage of custom skull implants is controlled by one’s scalp flexibility.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshops – Posterior Temporal Implant for Head Widening

Sunday, May 14th, 2017

The side of the head is typically seen or described as the area above the ears. It is influenced by a variety of constituent anatomic structures including bone, muscle and skin. Their thicknesses and the ratio of tissue proportions between them all contribute to the flatness or convexity of the side of the head. The side of the head can anatomically be described as the posterior temporal region since this is where the posterior belly of the temporalis muscle runs up over the convex skull shape (temporal and parietal bones) underneath it.

Aesthetic concerns about the shape of the side of the head do exist and I have seen patients feel that either it is too flat (not enough convexity) or is too full or wide. (too much convexity) In cases of a desire for greater width or fullness to the side of the head, the method of augmentation is with a custom posterior temporal implant. (side of the head implant).

Placed either under the fascia on top of the muscle or in a completely submuscular position, the posterior temporal implant can increase the convexity or width of the side of the head above the ears as seen in the frontal view. The typical implant thickness is in the range of 3 to 7mms. When you add up both sides that could be a change of 6 to 15mms. The incisional access for placement of posterior temporal implant is either from a small vertical incision in the temporal scalp above the ear or from an incision behind the ear in the postauricular skin crease. The incision choice is based on implant size and thickness as well as the hairstyle of the patient. The point of incisional access determines whether the implant is placed on either top of the muscle or underneath it.

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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