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Dr. Barry Eppley

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Archive for the ‘skull reshaping’ Category

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

Case Study – Custom Occipital-Parasagittal Skull Implant

Tuesday, May 2nd, 2017


Background: The skull is a unique collection of bones (plates) that are interconnected and developmentally affect each other. The most common example of his relationship is that of the congenital condition known as craniosynostosis. When a cranial suture prematurely fuses, bone growth perpendicular to the suture is impeded. Thus in sagittal craniosynostosis, for example, the skull becomes long and narrow as transverse bone growth is impeded.

While not as dramatic, microforms of sagittal craniosynostosis will show similar but smaller areas of surrounding bone deficiencies. These are manifest as skull indentations around the original sagittal suture and back around its back edge at the site of the original posterior fontanelle. In the many sagittal ridge skull reductions I have done, most of which involve the posterior aspects of the ridge in front of the posterior fontanelle, show this pattern of bone indentations.

When evaluating a patient for a sagittal ridge reduction it is important to determine the contour of the surrounding bone. This is important as one has to determine if the sagittal ridge can be satisfactorily reduced to the level of the surrounding bone to give a nice rounded skull shape. Or does the surrounding bone need to be built up to meet the level of the maximal reduced ridge to get the desired shape?

Case Study: This 26 year-old male had a previous history of a high posterior sagittal ridge that was effectively burred down. This procedure was done through an existing small sagittal scar that was present from a prior biopsy of the area by prevjous doctors. The sagittal ridge had been burred down as much as possible and he was initially happy with the result. Over time he subsequently decided to build the surrounding bone as well.

Utilizing a 3D CT scan a custom skull implant was designed to fill in the parallel parasagittal contour defects as well as cover over the depressed indentation at the back end of the original sagittal ridge. (the original posterior fontanelle)  The custom skull implant had a U-shape and was fairly thin.

Under general anesthesia the custom skull implant had multiple 4mm perfusion holes placed through it. It was then inserted in a folded fashion though the original small sagittal scalp incision. Once under the scalp the implant was unfolded and positioned as designed. Two small micro crews were placed to prevent any potential of any implants shifting.

The custom occipital-parasagittal skull implant can be a good aesthetic adjunct in the sagittal ridge reduction patient. It can be placed at the same time as the reduction or can be done secondarily if the patient is uncertain as to its contour benefit.


  1. A prominent sagittal ridge often is accompanied by a surrounding upper occipital-parasagittal skull deficiency.
  2. A. custom occipital-parasagittal skull implant can fill in the skull deficiency at the time of or after a sagittal ridge skull reduction.
  1. Such a custom skull implant can be inserted through the same small incision used for sagittal ridge reductions.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Small Custom Occipital Skull Implant

Sunday, April 9th, 2017


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

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

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

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

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

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


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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hydroxyapatite Cement in Pediatric Skull Reconstruction

Friday, March 17th, 2017


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

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

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

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

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

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


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

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Scalp Tissue Expansion in Aesthetic Skull Augmentation

Wednesday, March 1st, 2017


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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Male Occipital Knob Skull Reduction

Wednesday, February 1st, 2017


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

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

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

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

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


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

Dr. Barry Eppley
Indianapolis, Indiana

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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