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Posts Tagged ‘skull reshaping’

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.

Highlights:

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

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.

Highlights:

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

Case Study – Anterior Sagittal Ridge Skull Reduction

Saturday, February 6th, 2016

 

Background: The shape of the skull is seen as most aesthetic when it has a curved shape across the top from the front view. This curved shape can be altered by a variety of congenital deformities. One of the most common is an alteration of the midline sagittal suture. When complete premature sagittal suture closure occurs, the entire skull shape becomes very elongated and very narrow. (scaphocephaly or premature sagittal suture craniosynostosis) But more commonly partial or minor variations of sagittal craniosynostosis occur.

With incomplete or minor variations of premature sagittal craniosynostosis occur, a prominent sagittal ridge may develop. It is not significant enough to cause an overall alteration of skull shape, but does present as a visible raised midline bony ridge. It can occur anywhere along the original sagittal suture location.

The sagittal ridge skull deformity has become more of an aesthetic head shape issue for men due to either hair loss or a shaved hairstyle. What once was not noticed or not of an aesthetic concern becomes apparent or a prominent issue when the shape of the skull becomes apparent with loss of hair coverage.

Case Study: This 30 year-old male was bothered by a prominent midline ridge on the front of his head. From the widow’s peak of his hairline back along the midline of the skull for 12 cms,  the raised ridge created a triangular shaped head from the front view.

anterior sagittal skull reduction markings dr barry eppley indianapolisUnder general anesthesia and through a small curved (5 cm) scalp incision, a handpiece and burr was used to smooth down the prominent bony ridge. The midlien ridge was reduced down to the diploic space of the bone, about 5mm to 6mms. The scalp incision was closed in layers with dissolveable sutures after a drain as placed. The drain was removed the following day after putting out about 30cc of blood.

Anterior Sagittal Ridge Skull Reduction result immediate Dr Barry Eppley IndianapolisHis postoperative swelling was moderate and this is how he looked within one day after surgery. The reduction in the midline ridge was immediately evident. He could walk around and really did not look particularly swollen or ‘surgical’ in appearance.

Reduction of the anterior sagittal ridge skull deformity can be effectively done by a bone burring technique. The key is to perform it through the smallest scalp incision possible. Special instruments and a handpiece and burr are used to remove the raised bony ridge as low as possible, blending it into the surrounding skull bone.

Highlights:

1) A sagittal ridge skull deformity consists of a midline raised ridge of bone anywhere from the forehead to the back of the head.

2) An anterior sagittal ridge starts at the old anterior fontanelle  and extends back along the skull for a short distance.

3) A bone burring technique can be effective at reducing the height of the sagittal rudge skull deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Small Skull Implant

Friday, October 9th, 2015

 

Background: Skull defects come in a wide variety of shape, sizes and thicknesses. Correcting them can also be done using a variety of cranioplasty materials. The choice of cranioplasty material depends on a variety of factors including size of the defect, whether it is partial or full-thickness, and the desired location and length of the incision. The smaller the skull defect the more restrictive the cranioplasty options become.

The skull is prone to small contour defects caused by in utero and postnatal positioning, early trauma, and aberrant development. While many people have a perfectly smooth skull surface throughout there are just as many that do not. Many small skull defects are obscured by hair and are aesthetically irrelevant. But in an era where many men now shave their heads or have very short haircuts, the small skull contour defect may become revealed. Or at the least the person may perceive that it is visible.

Small skull defects can be treated by a semi-injection approach (small incision with introduction by an open barreled small syringe) using either different bone cement and substitute materials. (e.g., hydrocyapatite or HTR granules) While they can be effective they are prone to irregularities and are difficult to recontour secondarily.

Case Study: This 30 year old male had a skull indentation at the left temporo-parietal region that measured 5 x 3 cm. It had an indentation depth of 6 to 7mms in the center that feathered upward into the surrounding skull bone. It was very palpable and it had been present as long as the patient could remember.

Small Skull Implant Dr Barry Eppley IndianapolisSmall Skull Implant Indianapolis Dr Barry EppleyUnder general anesthesia a 3 cm vertical scalp incision was made at the back end of the skull defect. Subperiosteal undermining in a circumferential manner around the defect edges extending it 1 cm beyond its borders. A silicone implant was hand carved with a scalpel from a preformed posterior temporal implant design. The thickest part was in the middle and the entire perimeter of the implant was trimmed to a feather edge. Perfusion holes of 3mms diameter were placed and the implant inserted and secured with a single 1.5mm screw at its posterior edge. The scalp was closed with dissolveable sutures and n dressing was used.

Skull implants to augment smaller contour defects can be done using silicone implant materials. Such material compositions are easy to shape and insert through a very discrete incision.

Highlights:

1) Small defects of the skull can be corrected by small silicone implants.

2) In very small skull defects, hand carved silicone skull implant can be made during surgery.

3) The incision used to place a small skull implant is usually no more than an inch or so.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Reduction of the Vertex Skull Bump

Saturday, August 8th, 2015

 

Background: The skull is formed by six separate cranial bones which are initially joined by fibrous tissue known as sutures. The union of these sutures is most commonly recognized by the two large open areas between them that remain after birth, the fontanelles or soft spots. The fontanelles allow for rapid stretching and deformation of the  skull bones as the brain expands faster than the surrounding bone can grow together in the first year of life.

posterior fontanelleThe smaller of two most recognized of the baby’s soft spots is the posterior fontanelle.  It lies at the junction of the sagittal and lambdoid sutures and is triangular in shape. The posterior fontanelles usually close over by bone growth within a few months after birth. This is done by a process known as intramembranous ossification where the connective tissue of the membrane covering the posterior fontanelle turns into bone.

This intramembranous ossification process is not always perfect and can lead to either iincomplete bony fill or actual bony overgrowth. Why this bony growth mechanism may become abnormal is not known. When the bone fill is inadequate a depression occurs and is known as a skull dimple. When the bony fill is excessive an overgrowth occurs and creates a visible hump or bump. Either way the skull contour is not smooth and the bony deformity can be very apparent.

Vertex Skull Bump Preop Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a very visible bump at the top of the back of his head which had always been present as long as he could remember. With aging and hair loss the need to shave his head exposed the very prominent and aesthetically bothersome ‘vertex skull bump’.

Vertex Skull Bump exposed intraop Dr Barry Eppley Indianapolis Vertex Skull Bump reduced intraop Dr Barry Eppley IndianapolisUnder general anesthesia a 4cm scalp incision was made perpendicular to the skull bump at the vertex. Subperiosteal undermining exposed the base of the raised bone area in a circumferential manner. A handpiece and burr was used to take done the bony bump to the level of the surrounding skull bone. Any bleeding bone area was covered with bone wax to not only stop the bleeding but prevent any potential for bony regrowth due to a periosteal reaction from any residual blood collection after surgery.

Skull Bump Reduction result top view Dr Barry Eppley IndianapolisSkull Bump Reduction result side view Dr Barry Eppley IndianapolisVertex skull bumps are excessively thick bony overgrowths from the original posterior fontanelle area. It can be safely and sufficiently reduced by a burring technique. Having treated nearly a dozen of them, none of these types of skull bumps have represented a protrusion of the underlying dura with a thin bony covering. A preoperative CT scan would clarify the issue of what constitutes this promordial posterior fontanelle site if desired.

Highlights:

1) One type of abnormally raised skull bump is that which can occur at the vertex or the original posterior fontanelle.

2) The ‘vertex skull bump’ is an abnormally thick segment of bone that permits significant reduction

3) The ‘vertex skull bump’ can be easily reduced through a small scalp incision down to the surrounding skull contour. This is a simple skull reshaping procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Posterior Temporal Implants for A Head Widening Effect

Thursday, July 9th, 2015

 

Background: The shape of the head has many aesthetic components to it not unlike that of the face. While no area of the head as the degree of aesthetic complexity that the face does, that does not mean that cosmetic concerns about specific areas of the head do not exist. They are less well known and treatments for them are even more obscure but public perception is increasing. The popularity of shorter haircuts and men shaving their head has given rise to an increased awareness of head shape concerns.

One aesthetic area of the shape of the head that is rarely discussed from a diagnosis or treatment corner is that of its width. The width of the head is created by the sides of the head which run from the superior attachment of the ear up to the temporal line of the skull. This area lies within the hair bearing area of the broader temporal region and is only composed of muscle (and fascia) and bone. While many think its shape is largely caused by the shape of the temporal bone, the reality is that the temporal muscle makes a greater contribution to its thickness than that of the bone.

Head Width Dr Barry EppleyWhile there are no truly established aesthetic standards for the sides of the head, some general guidelines can be used. A straight line or flat side of the head would be viewed by most as being too narrow. Conversely a significant arc or amount of convexity would be thought of as being too wide. It appears that a slight amount of temporal convexity is the most aesthetic shape when viewed from the front.

Case Study: This 35 year-old male had an underlying congenital skull deformity (most likely occipital plagiocephaly) which has been previously treated by occipital and anterior temporal augmentation. His lone remaining head shape issue was that he felt the very sides of his head were too narrow, more so on the right side than that of the left.

Posterior Temporal (Head Widening) Implants intraop placement Dr Barry Eppley IndianapolisHead Widening (posterior Temporal ) Implants result Dr Barry Eppley IndianapolisUnder general anesthesia, performed posterior temporal implants were placed in a subfascial location on top of the posterior belly of the temporalis muscle. A small vertical incision in the hairline was used since he already had an existing scar there from prior surgery. The thickness of the preformed posterior temporal implants was 4mms. A good fascial closure as obtained over the implants prior to closing the skin.

His postoperative results showed a noticeable but not overdone head widening effect.  The slight increase in temporal convexity gave his head a more pleasing shape with the noticeable fullness. He had no discomfort or restriction in opening his mouth after surgery as has been my experience with all subfascial temporal implants at either the anterior or temporal location.

Highlights:

1) The aesthetics of the side of the head generally have some degree of convexity or can appear as too narrow.

2) Subfascial posterior temporal implants can be placed to create an increased amount of head widening.

3) Generally 4 to 7mms of head width is all that is needed on each side to create a very noticeable difference.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Semi-Custom Implant for Occipital Plagiocephaly

Wednesday, June 10th, 2015

 

occipital plagiocephalyBackground: Occipital plagiocephaly is a well recognized skull shape deformity that is caused by deformational forces. Whether this is the result of intrauterine constraint, post delivery head positioning or both, the thin and malleable skull bones are prone to be inadvertently molded into a deformed shape. This classically appears as a flatness on one side of the back of the head with some protrusion of the opposite side and a well described entire craniofacial scoliosis of varying degrees.

While cranial molding helmets can be very effective at the treatment of deformational occipital plagiocephaly, their effectiveness diminishes after 12 to 18 months of age. Once this non-surgical treatment window has passed, surgery is the only effective treatment. But the concept of surgically taking off the entire back of the head and reconstructing it can be too invasive for many patients and is only appropriate in the most severe occipital flattening cases. As an adult, however, bony reconstruction is not an option given the thickness of the skull bones and the sheer magnitude and risks of major skull reshaping surgery.

Flatness of the back of the head in adults is an often unrecognized aesthetic concern. But to the patient so affected it is well recognized with many maneuvers done to camouflage it from hair styles to hats. Correction of a unilateral occipital plagiocephaly in adults is most effectively and simply done using an implant that is placed on the bone. This type of occipital implant can be done using either custom or semi-custom designs. The surgery to place them remains the same regardless of how the implant is made.

Case Study: This 25 year-old male wanted to improve the shape of the back of his head. He had a significant of the right side of the back of his head which was the direct result of how he slept as an infant. He had all of the typical associated findings with it including a more forward positioning of the right ear (ear asymmetry), some mild left occopital protrusion and other more skull shape changes. He was offered the choice of having a 3D CT scan done and a custom implant made for it or to use an existing right occipital implant (from a custom implant made from another patient) instead. (what I call ‘semi-custom’ implant) Due to economic considerations, he chose a semi-custom occipital implant design.

Unilateral Occipital Implant for Plagiocephaly Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a 9 cm long horizontal incision was made in the low occipital hairline over the nuchal ridge. A full thickness scalp flap off the bone was raised in a wide manner around where the implant would be positioned on the bone. The implant was inserted and positioned so that the thickest portion was over the flattest occipital skull area.

Occipital Implant Results for Plagiocephaly Dr Barry Eppley IndianapolisOccipital Implant Results oblique view for Plagiocephaly Dr Barry Eppley IndianapolisAs would be expected, the change to the back of the head was instantaneous right after the implant was placed. While the maximum degree of occipital symmetry was not obtained due to using a semi-custom (not designed for this specific patient), the degree of improvement was remarkable nonetheless.

A semi-custom occipital implant offers a cost-effective approach to treatment of occipital asymmetry due to congenital plagiocephaly. It is successful because the shape of the skull deformity is fairly predictable and the thickness of the scalp provides some forgiveness for edge-transitions.

Highlights:

  1. Unilateral occipital plagiocephaly can be effectively treated as an adult by the placement of an implant for skull reshaping/augmentation.
  2. Unilateral occipital implants can be custom made or a semi-custom type implant can be used.
  3. An occipital implant for a flatness on one side of the back of the head is placed through a low occipital hairline incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Cap Implant for Skull Irregularities

Monday, May 4th, 2015

 

Skull Shape Dr Barry Eppley IndianapolisBackground: The shape of the skull can be almost as variable as each individual in many ways. But the one similar characteristic is that most skulls do have a smooth surface from the forehead to the back across the top. This is seen in many plain skull model examples where a smooth surface is usually evident.

But despite the depiction that a skull has a smooth surface, it does not always occur. For a variety of developmental reasons drive by sagittal suture and anterior and posterior fontanelle closure, the skull may develop a variety of surface irregularities. While across the top of the top of the skull the most common irregularity is a sagittal crest or ridge, generalized lumps and bumps may appear. The skull is otherwise of normal thickness but it just isn’t smooth.

While there are undoubtably many people who do not have a perfectly smooth skull to the touch, the presence of hair provides a visual camouflage of it and makes it tolerable. But in the male who shaves his head or lacks hair coverage, the skull irregularities can be quite visible and aesthetically distressing.

Lumpy Misshapen Skull Dr Barry Eppley IndianapolisCustom Skull Cap Implant design Dr Barry EppleyCase Study: This 35 year-old male had gone from long time usage of a hair prosthesis to that of a shaved head look. In so doing he was now aware and very conscious of how the surface of his head looked. He described it as being uneven, irregular and with high spots throughout. A 3D CT scan conformed that this was due to the bony shape of the skull. His goal was to have a smooth more rounded head shape across the top. This was designed to be accomplished by making a thin skull cap implant to cover the entire top from front to back staying along the temporal lines at the sides.

Custom Skull Cap Implant incision Dr Barry Eppley IndianapolisCustom Skull Cap Implant placement on skull Dr Barry Eppley IndianapolisCustom Skull Cap Implant placement with screw fixation Dr Barry Eppley IndianapolisUnder general anesthesia, a curved posterior scalp incision was made that was less long (wide) than the implant. Subperiosteal undermining was done over the entire scalp where the implant was to be located. The implant was inserted through the incision in a partially folded fashion and positioned. Prior to placement multiple perfusion holes were made through the implant. After placement absolute stability was assured with two small titanium screws.

A skull cap implant is a slightly different skull augmentation implant in that it is designed to create a smoother skull but not necessarily a larger or more augmented one. Because it is a thin implant (in this case 6mm maximal projection at highest point) it can be inserted through a relatively small scalp incision. Because it is placed partially folded it is critical that one makes sure that the edges of the implant are laying completely flat prior to closure. Thin implant edges can easily remain folded and are hard to detect by feel and impossible to see through a limited scalp incision.

Case Highlights:

1) The normally smooth surface of the skull can in some people be very lumpy which can be visible in the bald or shaved head male.

2) A thin custom made skull implant placed over the lumpy part of the skull can create a smoother scalp surface and feel.

3) A thin custom made skull cap implant can be placed through a relatively small scalp incision.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You Didn’t Know About Custom Skull Implants

Thursday, March 5th, 2015

 

Unlike facial implants, the use of skull implants for aesthetic head reshaping has a very short history. While the use of facial implants dates back more than five decades in plastic surgery, skull implants have been done for just a few years. It has not been that skull implants are radically different or more complex to perform, it is just that there are no preformed skull implants currently available. With facial implants, there are dozens of different preformed options for the nose, cheek, orbital rim, chin and jaw angle areas.

custom occipital implant design side view jmUntil preformed standard size skull implants become available for certain head shape concerns, they will have to be custom made custom for each patient based on their specific anatomy from a 3D CT scan. As custom skull implants are becoming more used due to improved manufacturing technology, there is still little public awareness about them. Here are some things you may not know about custom made and manufactured skull implants.

Custom Skull Implants Have Made Cosmetic Head Reshaping Possible.  What really separates skull from facial implants from an implant standpoint is their size. Covering broad areas of the skull (e.g., back of the head) creates an implant that would be equivalent to over 20 or more chin implants. Getting such an implant to fit well is much more difficult than smaller facial implants and the margin of error is actually much less because of its size. The custom design and manufacturing of a skull implant makes their use much more predictable for any skull area.

A 3D CT Scan Is Needed To Make Custom Skull Implants. Whether it is done by an actual model or on the computer screen, only a high resolution 3D CT scan of the skull can be used. The scan has to be done using .1mm slices and not the standard 3mm or 1mm slices normally taken. A regular axial or coronal head CT scan will not work nor will an MRI. Today 3D CT scanning is widely available, quick and easy to do acan be done for a few hundred dollars.

The Computer Only Designs What The Surgeon Tells It To Do. While computers and their software have remarkable capabilities, they do not yet know how to create a specific look for any patient. In designing skull implants, it is important to remember that the computer has no innate knowledge of what the size and shape the implant needs to be for what the patient wants to be. The surgeon must work with the design engineer to create the amount of skull surface area (shape) and thicknesses of the implant to create what is believed to cause the ultimate aesthetic outcome. The computer design process will make sure the implants fit the bone perfectly, compensate for any skull asymmetries, have a smooth outer surface and will minimize any edge transitions.

Skull Cap Imnplant Design Dr Barry Eppley IndianapolisThe Limiting Factor In Skull Implants Is The Overlying Scalp. Unlike facial implants, skull implants must carefully consider the tolerance of the overlying scalp tissue to stretch and accommodate it. Facial implants rarely have his consideration because they are smaller and the facial tissues have greater elasticity. The size of skull implants and the tightness of the scalp stretched over a large convex bony surface makes its design of critical consideration. Knowing how large and thick a skull implant can be is a matter of the surgeon’s experience. When the need for large skull implants exist, a first-stage scalp expansion may need to be considered.

Incisional Access Is Of Critical Importance In Custom Skull Implants. With large implants, the need to preserve hair follicles and to not create an additional aesthetic problem (scalp scar), the location and length of scalp incisions is critical. Despite most skull implant sizes they can be placed through relatively small incision in many cases because they are flexible. The implants can also be sectioned into two pieces and ‘reassembled’ once inserted if need be.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Sagittal Ridge Skull Reduction

Sunday, December 21st, 2014

 

One of the most common of all aesthetic raised skull deformities is that of the sagittal ridge. As a result of the fusion of the midline sagittal suture, bone thickening can occur between the original anterior and posterior fontanelles. In its fullest expression such sagittal suture fusion becomes a craniosynostosis. But there are numerous smaller or incomplete versions of craniosynostosis where only a raised ridge of bone occurs down the middle of the skull without causing a lengthening of the skull from front to back or any significant transverse narrowing.

Sagittal Ridge Skull Deformity Dr Barry Eppley IndianapolisThe sagittal ridge or crest creates a prominence that is particularly visible in men with short hair or who shave their head. It makes the top of the head appear as an inverted V as opposed to a more smooth convex shape. Only in animals is the presence of a sagittal ridge normal which is due to the attachment of the strong masseter muscles. The tenporalis muscle in humans is attached far more to the sides of the skull which allows it to have a more recognizable smooth convex shape.

Sagittal Ridge Skull Deformity burring reduction Dr Barry Eppley IndianapolisThe reduction of the sagittal ridge can be effectively done through a burring technique. One key is to keep as small an incision as possible which is located at the back portion of the ridge. While the back portion of the ridge is fairly easy to reduce, the portion of the crest that extends forward is more challenging. The second key is to have long narrow retractors which allows a handpiece and shaping burrs to be  inserted to complete the reduction. Any residual high bony areas located way far forward can be reduced with large diamond rasps.

An important question to answer before this type of skull reshaping surgery is how thick is the sagittal ridge and how much can it be reduced. This can be quantitatively determined before surgery with a 3D CT scan where the bone thickness can be measured. When burring down the ridge it is common, particularly in the back, to encounter large bone bleeders and these are effectively obliterated with bone wax. When the color of the midline bone starts to become a faint blue in color, it is time to stop as the inner cortex is getting thin. Usually up to 7mms of crestal bone can be reduced.

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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