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Archive for the ‘skull reshaping’ Category

Case Study – Custom Skull Implant for Contour Irregularities

Thursday, November 24th, 2016

 

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Large Custom Skull Implant

Wednesday, October 26th, 2016

 

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Occipital Knob Skull Reduction

Sunday, October 9th, 2016

 

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implant for Occipital Plagiocephaly

Sunday, September 25th, 2016

 

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Parietal Eminence Skull Reduction

Thursday, September 8th, 2016

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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.

Highlights:

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.

Highlights:

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.

Highlights:

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


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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