Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘skull reshaping’ Category

Long-Term Fate of Hydroxyapatite Cement in Growing Skulls

Sunday, August 14th, 2016


Skull reconstruction in young children is almost always done by bone reshaping operations. For common craniofacial deformities like numerous forms of craniosynostosis, the deformed bones are removed and put back in a reshaped fashion to allow for brain growth to continue to mold the developing skull shape. But once the child reaches several years of age treating many skull shape issues is beyond what bone reshaping can reliably do both technically and risk-wise.

This issue of what to do with abnormal skull shape issues, either unoperated on or persistent issues after reconstruction, has always been a bit of a dilemma. In essence how to treat skull contour issues that can not or do not justify a craniotomy and bone reshaping approach. Ideally one would want to use bone grafts but they are both unreliable as a contour method and require a harvest site.

Hydroxyapatite Bone cement Dr Barry Eppley IndianapolisThe synthetic bone substitute, hydroxyapatite cement, offer an alternative to the use of bone grafts. As a synthetic calcium phosphate material, it avoids the need for a harvest site and is an easily moldable putty that is applied and allowed to harden. It has been around from various manufacturers for over twenty years. It was originally and still is FDA-approved for inlay (partial or full-thickness) cranial defects. While it is widely used as an onlay bone contouring material as well I am not aware that it has ever been formally FDA-approved to be used as such.

I have used hydroxyapatite cement in children as a cranial contouring materials now for almost two decades. I have found it to be very useful as skull contouring technique and have never seen a single postoperative problem develop from its use. My original animal studies from way back in 1996 showed that bone started to develop growth along the sides of the material in less than three months after its application. But there has always been the unknown issue of what is its fate decades later and does it in any way cause skull growth issues? The assumption has been that it becomes surrounded by natural bony overgrowth and grows along with the surrounding bone.

Hydroxyapatite Cement in Craniofacial Surgery Long Term Result top view Dr Barry Eppley IndianapolisHydroxyapatite Cement in Craniofacial Surgery Long Term Result left oblioque view Dr Barry Eppley IndianapolisHydroxyapatite Cement inj Craniofacial Surgery Long Ternm result obloique view Dr Barry Epplay IndianapolisA recent patient experience provides some insight into the long-term fate of hydroxyapatite cement. I performed a hypertelorism repair in a 3 year-old child back in 1996. One year after that surgery he has some additional contouring of the brow bones and lower forehead using hydroxyapatite cement. Almost twenty years later he reappeared and wanted some additional forehead, brow and nose contouring surgery. Using his original scalp incision the forehead and brows were exposed and the original hydroxyapatite cement sites were examined. They looked like perfectly normal bone. In comparing the original intraoperative pictures to the present day ones, the hydroxyapatite cement seems to have turned into bone.

While I did not dig into the original implanted site to know for sure, I would think the cement had developed bony overgrowth rather than was replaced by bone. At the least this shows that hydroxyapatite cement in growing children’s skulls appear to be very well tolerated without any adverse growth or bone effects. While this is just a single case observation it does support my original assumption about the long-term fate of hydroxyapatite cements when used as an onlay contouring material in growing skull sites.

Dr. Barry Eppley

Indianapolis, Indiana

Parietal Eminence Skull Reduction

Wednesday, August 3rd, 2016


One aspect of skull reshaping surgery are reductive procedures. This could be the removal of bone or muscle depending upon where the skull shape excess exists. Most skull reduction surgeries involve the removal of bone and they consist of either larger surface areas to reduce an overall prominence or are more of a ‘spot reduction’ of specific high spots or ridges.

Parietal EminenceOne such area of spot skull reduction is that now as the ‘parietal eminence’. The parietal bones of the skull are large sides bones that make up much of the side and back part of the top of the head. Crossing in the middle of the bone is a small curved ridge known as the superior temporal line to which is attached the temporalis fascia. At the back end of the bone is a more vertical and smaller ridge known as the inferior temporal line which indicates the upper limit of the muscular origin of the temporals muscle. Near the junction of the superior and inferior temporal lines is the parietal eminence. Also known as the parietal tuber, it is where ossification started for bone formation.

The parietal eminence can be a spot area of the skull that is aesthetically bothersome due to its protrusion. Having reduced it many times I have made some observations about its successful surgical resolution. Reduction of the parietal eminence bone is a fundamental element of its treatment and this is done by a burring technique. The bone is thick enough that a significant reduction can be obtained. As an isolated skull issue that can be done a small vertical incision over it. In other larger skull procedures a more wide open incision provides unimpeded access to it.

Posterior Temporal Muscle and Parietal Skull Reduction intraop Dr Barry Eppley Indianapolis_edited-2Posterior Temporal Muscle Resection and Parietal Skull reduction intraop bnefore and after Dr Barry Eppley IndianapolisBut a part of the parietal eminence is covered by the very superior origin of the temporalis muscle. Not only does the muscle cover a part of the parietal eminence but it is also responsible for contributing to some fullness in the general region. For this reason it can be helpful to remove the posterior portion of the temporalis muscle as well as the parietal eminence skull reduction. This can be illustrated in an actual patient who was having many other skull procedures done through a larger coronal incision. In this example the thing effect of the muscle removal can be seen as a complement to the bone reduction.

As an isolated procedure parietal eminence skull reduction through a limit6ed vertical incision can still accomplish both the bone and muscle removal.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Occipital Skull Reduction

Tuesday, August 2nd, 2016


Background: The shape of the skull  can be highly variable. It can have many presentations due to growth and the influences of external pressures in utero as well as after birth. Most of the time skull shape anomalies do not have much difference in the thickness of the bone. The head shape may be unusual but it is not due to bony overgrowth or excessive thickness of the skull bone.

But in some skull shape abnormalities the bone is actually thicker than normal. This is often seen in occipital protrusions. The back of the head may stick out and one reason is that the bone is thicker. Whether this is seen in smaller occipital knobs or larger occipital protrusions, the bone thickness is increased. This can be seen in plain side view x-rays.

Occipital reduction is one of the most commonly requested and performed skull reductive procedures. Burring of the outer table down to the diploic space can yield very visible external changes. The amount of reduction will depend on the thickness of the bone but can be up to 7 to 8mms or more in some cases.

Occipital Skull Reduction x-rays Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a unique head shape marked by a protrusion at the top, sides and back of the head. In a circumferential ring the protruded skull bone was readily apparent.

Occipital Skull Reduction design Dr Barry Eppley IndianapolisOccipital Skull Reduction technique Dr Barry Eppley IndianapolisRedundant Scalp removal after occipital skull reduction dr barry eppley indianapolisUnder general anesthesia a hemi-coronal posterior scalp incision was made. With anterior and posterior scalp flap elevation, the occipital skull reduction was performed in a grid fashion to maintain an even and regular level of bone reduction. This was done from the crown area down to the nuchal ridge level. A thickness of 8mms was removed in the central thickest region. The prominent points of the parietal skull were also reduced as was the posterior temporal muscle removed. This left a significant scalp redundancy which was posteriorly advanced and removed. It was removed in a manner so that much of the bald spot on the crown was removed.

Occipital Skull Reduction result side view Dr Barry Eppley IndianapolisOccipital Skull reduction result4 back view Dr Barry Eppley IndianapolisHis immediate result seen one day later showed a visible reduction in the prominence of the original skull protrusion. The incision line was very fine and was closed at the skin level with small resorbable sutures. While some greater initial scalp swelling will occur, the final result is expected to be even less as the swelling subsides and scalp shrinks and adapts back down to the bone.

Occipital skull reduction can be successfully and safely performed to make a visible aesthetic change. Surgical access is the key and how small or big the incision is will have an influence as to how much skull reduction can be done.


1) Occipital skull reduction can be done for large skull protrusions provided the bone is thick enough to do so.

2) Removal of the outer table of the skull is the limit of how much the skull can be safely reduced in size for any area.

3) The occipital region can be reduced the most of any skull area as it is the thickest particularly near the its base.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sagittal Crest Skull Reduction with Custom Implant

Wednesday, July 13th, 2016


Background: The shape of the top of the head is highly influenced by the development and growth of the sagittal suture. This cranial suture lies between the anterior and posterior fontanelles (soft spots) that are present at birth and close shortly thereafter. Premature fusion of the entire sagittal suture produces a well known congenital skull defect known as craniosynostosis with an abnormally long and narrow skull shape that requires early surgery for correction.

But there are a variety of much smaller forms of sagittal suture abnormalities which produce a variety of raised midline ridges on the top of the head. Between the original posterior and anterior fontanelles the sagittal ridge can become thickened and sit higher than the surrounding bone. In some cases it is an isolated raised ridge of bone. But in other cases the raised sagittal crest is accompanied by a corresponding deficiency of the surrounding bone. Put together this creates a very peaked skull shape like that of a roof.

Sagittal Crest Skull Deformity Dr Barry Eppley IndianapolisSagittal Crest Skull Deformity 2 Dr Barry Eppley IndianapolisCase Study: This 50 year-old male was bothered by a skull shape that was becoming apparent as his hair was thinning. He described it as a high sagittal ridge with both sides sloping away from the middle. This gave the top of his head a more triangular shape. This was confirmed by a 3D CT scan.

Sagittal Crest Reduction Dr Barry Eppley IndianapolisCustom Parasagittal Skull Implant design Dr Barry Eppley IndianapolisA two technique approach was proposed for his skull reshaping procedure including reduction of the sagittal crest and a custom skull implant placed around it. The custom skull implant built up both parasagittal regions as well as the upper occipital region and the very top of the forehead.

Sagittal Crest Reduction intraop Dr Barry Eppley IndianapolisCustom Parsagittal Skull Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia an 11 cm long scalp incision was made perpendicular to the sagittal crest across its highest point. Through this incision the height of the sagittal crest was reduced by 5 to 6mms down close to the diploic space. The fibrous suture line could be seen down into the bone. Once the sagittal crest was reduced, the custom skull implant was prepared by making multiple perfusion holes through it. It was then inserted and positioned around the reduced sagittal crest. It was secured into position by several 1.5 x 5mm microscrews.

Custom skull implants can help create a more harmonious skull shape to build up low skull spots when combined with reduction of high bony areas. Many sagittal crest skull deformities must use this combined  approach for the best result.


1) The sagittal crest skull deformity is marked by a high midline crest of bone surrounded by adjoining areas of skull deficiencies.

2) Sagittal crest skull reduction may not be enough to create a more convex head shape in the frontal view.

3) A custom parasagittal skull implant can be a complement to creating a better overall head shape in the sagittal crest skull reduction patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Total Skull Implant with Onlay Cranioplasties

Saturday, June 25th, 2016

Background: There are many procedures that can be done to rebuild the skull including bone replacement and external bone reshaping. (cranioplasty) With today’s computer technology large segments of the skull can be replaced by a variety of materials including HTR, PEEK and PEKK materials. While there are surgeon advocates for all of these materials, I have used all of them and they all offer excellent clinical outcomes. Their handing properties do differ and that must be considered in each patient for their particular skull reconstruction needs.

A computer-generated skull implant is intended for full-thickness bone defects. Whether it be a small or very large full-thickness skull defect, there is no better alternative for skull replacement in adults than the use of a computer-designed implant. The larger the skull defect the more relevant the use of a premade implant becomes.

There are very few cases of the need for a prothetic total skull implant. This would necessitate the loss or removal of the entire skull. Such is the following case and it illustrates that, while the entire skull can be replaced, that does not end the need for further reconstruction efforts. The perimeter of the skull has various tissue attachments which likewise need to be rebuild to complete a total skull reconstruction result.

Current Total Skull ImplantCase Study: This 44 year-old male came with a history of having undergone a total skull removal with subsequent total skull prosthesis placed. (PEEK material) The exact reason his total skull removal came from failed attempts at reconstruction of a congenital sagittal craniosynostosis condition. While his entire skull was replaced by a computer-designed prosthesis, the shape of the implant and the accuracy of its fitting into the remaining skull base its base was less than ideal. He had a very narrow and long head shape and he has complete temporal hollowing and ears that stuck out due to loss of soft attachments.

JA PEKK Implant removal processTotal Skull Replacement Implant design Dr Barry Eppley IndianapolisUnder general anesthesia his first operation consisted of removal of his existing skull implant. This was quite challenging due to the hardness of the PEEK material and the tissue ingrowth through its perfusion holes. A new computer-designed total skull implant made of PEEK material was design and placed that had a better shape. Its anterior-posterior length was reduced and shape across the top of the head was more natural.

While his revised total skull implant surgery was successful with a much improved head shape, he required three subsequent surgeries to create a more appearance. These procedures included fat injection temporal grafting, further only cranioplasties using PMMA material on top of his skull implant, revision of his T-shaped scars and ear setback surgery. (otoplasty) In the end her was able to achieve a much more natural looking head shape.

Total Skull Implant reconstruction result front view Dr Barry Eppley IndianapolisTotal Skull Implant reconstruction results side view Dr Barry Eppley IndianapolisTotal Skull Implant reconstruction results back view Dr Barry Eppley IndianapolisWhen the total skull is removed, there is loss of all the muscular attachments in the temporal region. This results in severe temporal hollowing, thinning at the sides of the head above the ears and ears that will stick out. Surprisingly injection fat grafting worked to correct the severe temporal hollowing. This was unexpected given that there was only skin stuck down to the skull prosthesis. Cranioplasties adding additional material on top of the implant was used to help create any deficiencies that the implant did not achieve. Correcting the ears became necessary as the postauricular muscle attachments had been lost allowing the ears to fold forward.


1) Total skull reshaping or reconstruction is a rare procedure that requires several stages to optimize the head shape.

2) The entire skull above the level of the ears can be safely (and only) replaced with a implant made from a 3D CT scan.

3) While the skull can be replaced, the surrounding soft tissue attachments must be considered in the overall skull reconstruction effort.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant for Head Widening

Sunday, June 19th, 2016


Background: Aesthetic skull augmentation can be done for a wide variety of deficient skull shape concerns. Changes can be made in skull height, skull width and frontal and posterior skull projection. In rare cases and with the use of a first stage scalp tissue expander, the entire skull can be augmented through a circumferential effect. Such head size increases are largely achieved through a bone augmentative effect.

One aesthetic head size change request is that of ‘head widening’. This can mean a variety of head shape changes, all of which refers to some increase in the vertical level of the sides of the head. One patient request is to widen the upper sides of the head. This is the transition area between the top of the head and the sides of the head, in essence the sloped area from the sagittal ridge (middle of the head from front to back) down into the upper temporal region across the bony temporal line. Such a skull width increase is largely bony (sagittal ridge to anterior temporal line) but is also partially soft tissue based. (inferior to bony temporal line)

While a variety of skull augmentation materials have been used over the years to help achieve these changes, the recent use of 3D CT scanning and silicone implant design has made the procedure more reliable and effective. When designing such a skull implant to widen the upper half of the skull, the location and thickness of the temporal muscle must be taken into consideration. To do on a 3D CT scan the temporalis muscle must be ‘painted’ on to simulate where it is since this is a bone scan which will not show soft tissue.

Head Widening Implant design Dr Barry Eppley IndianapolisCase Study: This young male felt that the sides of his head was too narrow. In determining what he meant by sides of the head, he indicated that it was the top of the head and down to the sides. He also wanted some crown augmentation as well around the upper occipital region. Using his 3D CT scan, a custom implant was designed to cover these areas with a maximum of 6mms at its thickest area .

Head Widening Implant design thickness Dr Barry Eppley IndianapolisUnder general anesthesia, the custom skull implant was placed through an 8 cm scalp incision. Because the implant was reasonably thin it could be folded and inserted through a length of an incision that was smaller than the width of the implant.

His postoperative results showed the desired change immediately on the operative table as would be expected. Recovery is very minimal with this type of smaller skull implant. While there is some swelling it is ‘hidden’ in the hair and not visible to others. The skull change with this type of implant is modest but appreciable. This fitted in with the patient’s aesthetic head shape desires and amount of commitment needed to do so.

The use of custom designed skull implants today allows for making even subtle head shape changes in a predictable, safe and minimal risk method.


1) A head widening effect can be most reliably achieved with a custom skull implant.

2) The desired dimensions of a head widening skull implant are made from a 3D CT scan of the patient.

3) If the custom skull implant is not too thick, it can be inserted through a relatively small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Bumpit Custom Skull Implant

Thursday, May 26th, 2016


Background: The height of the head can be an important aesthetic issue for some women. Flat or low skull height over the crown area can be seen as an undesirable physical feature. Women will often try to camouflage the lack of crown height by altering their hairstyle with ‘hair heightening’. While this can be effective, it is time consuming and tedious. And not all women have enough hair density to do this adequately.

Bumpit Dr Barry Eppley IndianapolisThis aesthetic skull height concern is illustrated by the invention known as the Bumpit. This semicircular plastic insert on the scalp allows the hair to be ‘volumized’ which makes the height of the head appear taller. While claimed as being a silly and useless invention, the women that use it and find it effective probably do not see it as such.

A surgical and invasive method to create a partial Bumpit effect is the use of a custom skull implant. As a one stage procedure it may allow in some cases for the crown skull height to be augmented from 8 to 12mms. (which is roughly half of the typical Bumpit height of about 25mms) But its effects covers a broader surface area of the skull to blend into the sides of the head with a smooth tapered transition.

Custom Skull Implant Dr Barry Eppley IndianapolisCase Study: This 35 year-old female had been bothered by her flat head. She spent a lot of time fixing her hair to hide it and would not go out without a hat when she didn’t have the time to fix her hair. She finally decided to seek a surgical solution. Using a 3D CT scan a custom skull implant was designed to increase her skull height by 9mms at the most central height of the crown

Custom Skull Implant with compass marking Dr Barry Eppley IndianapolisCustom Skull Implant insertion and placement Dr Barry Eppley IndianapolisUnder general anesthesia and in the beach chair position, a limited coronal scalp incision was made.Wide subperiosteal undermining that went just beyond the boundaries of the planned implant size, the pocket was developed. The custom skull implant was opened and muttiple 4mm perfusion holes were placed using a dermal punch. The implant was then inserted and oriented into place using the ‘compass’ markings in the implant. A two later was done for closing the scalp up over the implant. No drain was used

Bumpit Custom Skiull Implant result front view Dr Barry Eppley IndianapolisBumpit Custom Skull Implant result back view Dr Barry Eppley IndianapolisBumpit Custom Skull Implant result side view Dr Barry Eppley IndianapolisThe skull height augmentation was clearly evident and sufficient to satisfy the patient. A one stage custom skull implant can safely create an additional 1 cm of height using a limited scalp incision approach. While greater scalp laxity can be obtained with a full coronal incision from ear to ear, that scar tradeoff for many women may not be worth it. If one needs more than 1 cm of additional skull height, consideration has to be given to a first stage scalp tissue expander,


1) Some women may not have adequate height to the crown of their head for their aesthetic desire.

2) The Bumpit Custom Skull Implant is designed to create additional crown skull height from being placed under the scalp.

3) The extent of  ‘scalp heightening’ that can be achieved with a custom skull implant is determined by the extent of scalp stretch that can safely cover the expanded bone height underneath it.

Dr. Barry Eppley

Case Study – Sagittal Ridge Skull Reduction

Thursday, May 19th, 2016


Background: Perhaps to the surprise of many, men make up a significant percent of aesthetic skull reshaping patients. This is due to the show of the skull shape that occurs with shaved heads, closely cropped hairstyles and thinning hair cover. Men become exquisitely aware of any prominent bony areas or indentations or deficiencies.

One of these aesthetic skull shape issues is that of the prominent sagittal ridge. This midline raised ridge, which occurs mainly along its posterior aspect, is easily seen as the highest part of the skull. The ridge creates a peaked or more triangular shape to the top of the head rather than that of more of a convex shape.

Sagittal skull ridge reduction is done by a burring technique. While this technique is very straightforward, its effects are limited by two factors. The bone can not be reduced by than just into the diploic space. Once the diploic space is entered significant bleeding occurs and this can lead to fluid collections that develop under the scalp after surgery. Because of the visibility of the scalp on the top of the head, the incision used to access the sagittal ridge must be limited. This can influence the extent that the sagittal ridge can be reduced.

Case Study: This 35 year-old male presented with a prominent sagittal ridge closer to the crown of the head. On the most posterior aspect of the sagittal ridge there was an indentation or dip between two areas of the raised sagittal ridge.

Sagittal Ridge Skull Reshaping plan Dr Barry Eppley IndianapolisUnder general anesthesia, a curved scalp incision of 7cms was made perpendicular to the sagittal ridge on its back third. Through this incision the sagittal ridge was reduced by 5ms along its length. At the area of the dip, 2ccs of hydroxyapatite bone cement was applied to raise it up to the surrounding skull contour.

Sagittal Ridge Skull Reshaping result front view Dr Barry Eppley IndianapolisSagittal Ridge Skull Reshaping result side view Dr Barry Eppley IndianapolisA head dressing and drain was removed the following day. The change was immediately seen in the skull contour with a successful sagittal ridge skull reduction.


1) The prominent sagittal ridge is an almost exclusive male skull shape concern.

2) The limits of the sagittal skull ridge reduction is the thickness of the bone and the length of the incision permitted by the patient.

3) Sagittal skull ridge reductions can usually be reduced from 5mm to 7mms.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting A Custom Skull Implant Visible Edge

Tuesday, May 10th, 2016


Custom skull implants have become a successful method for correcting many types of skull deformities where augmentation is needed. Interestingly, and perhaps not surprisingly, many aesthetic skull deformities are most apparent in men due to a ‘lack’ of hair. Whether the exposure of the skull is due to a shaved head, a short hair style or a thinning scalp cover, the shape of the skull becomes readily apparent.

Custom Occipital Implant design Indianapolis Dr Barry EppleyOccipital Dents Custom Skull Implant result Dr Barry Eppley IndianapolisBesides the shape and thickness of the skull implant design, it is especially important in custom skull implants in men to pay close attention to all edges of the implant. All of the implant’s edges (360 degrees) needs to be a feather edge. Even a 1 or 2mm edge will create a visible step off (edge transition) that will eventually be seen when all swelling subsides and scalp tissue contraction occurs around the implant. Early results after surgery in the first few months will appear smooth but by six months after surgery a visible edge may be seen.

When treating visible edge transition in an aesthetic custom skull implant, there are two traditional treatment options. The implant may be remade and a new one placed. Or the existing implant may be removed, the slight edge shaved down and reinserted. Neither of these two implant modifications options are particularly appealing.

Skull Implant Edge Transition Fat Grafting Dr Barry Eppley IndianapolisSkull Implant Edge Transition Fat Grafting result left side Dr Barry Eppley IndianapolisAnother option would be to perform fat injection grafting along the visible edge of the custom skull implant. Fat grafting is minimally invasive and can be performed with no significant recovery. While the scalp is not known to have a high fat graft take due to its inherent tightness, it does permit fat to be injected into it. In a single case in which I have treated a visible anterior edge of a custom skull implant with fat grafting, it’s visibility was essentially eliminated and persistently so at three months after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Sagittal Ridge Reduction with Parasagittal Augmentation

Sunday, April 10th, 2016


sagittal skull sutureBackground: The shape of the top of the head is highly influenced by the sagittal suture. The sagittal suture is a connective tissue joint between the two parietal bones of the skull. The sagittal suture in an adult connects the bregma (the intersection of the sagittal and coronal sutures above the forehead) back to the vertex. (highest point on the skull) In adults the sagittal suture does not close completely until around thirty years of age.

At birth the sagittal suture is open. But if it closes in utero, a classic skull deformity develops at birth known as scaphocephaly. (sagittal craniosynostosis) This creates a very long and narrow head due to the restriction of the growing brain to push out on the skull bones now restricted by the fused suture.

But deformities of the sagittal suture can occur in less dramatic presentations. Slight disturbances of sutural fusion can cause ‘micro’ forms of sagittal growth disturbances known as a sagittal ridge or sagittal crest. This appears as a prominent ridge of bone that is higher than the rest of the top of the skull and can be seen clearly as a ridge running down the middle of the top of the skull. It can some or all of the sagittal line and is usually most prominent at the vertex of the skull.

Case Study: This 35 year-old male was bothered by the shape of the top of his head. He felt it was too tall in the middle and did not have a nice round normal skull shape. It was shaped more like a roof with a peaked middle and sides that angled downward.

Sagitttal Reduction Parasagittal Augmentation intraop Dr Barry Eppley IndianapolisUnder general anesthesia, a zig zap scalp incision was made across the top of his head in between his braided hair style. Through this incision the sagittal ridge was reduced by burring. The area between the reduced sagittal ridge and the temporal lines on the side was augmented with a thin layer of PMMA bone cement.

Sagittal Ridge Reduction Parasagittal Augmentation result front view Dr Barry Eppley IndianapolisA Sagittal Ridge Skull Reduction result side view Dr Barry Eppley IndianapolisSkull Reshaping Scalp Scar Dr Barry Eppley IndianapolisHis after surgery results showed the change in the shape of the top of his skull. The height of the sagittal ridge was reduced and the sides of the skull were raised to create an overall smooth convex shape. The scalp incision healed well and blended in with his hairstyle pattern.

More prominent sagittal ridge deformities can not be satisfactorily lowered by bone burring due to the thickness of the bone. Adding height to the sides of the reduced sagittal ridge (parasagittal augmentation) aids in making a more pleasing shape to the top of the skull.


1) Certain sagittal ridge skull deformities have an associated parasagittal deficiency creating more of a peaked or triangular head shape.

2) Sagittal ridge skull reduction can be combined with parasagittal augmentation using bone cements to create a more natural shape to the top of the head.

3) A limited coronal scalp incision can be used for top of the head skull reshaping.

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits