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Background: The appearance of the skull has a wide variety of shapes. But it most commonly has a front to back oblong shape that has curved round shape from the front that is deemed the most aesthetically pleasing. The shape from ear to ear across the top of the head should be a smooth convexity from the side muscular temporal regions transitioning across the bony top of the skull. This transition zone, known as the temporal lines, should not be too narrow to prevent loss of its convexity.

There are certain congenital skull conditions, known as craniosynotoses, that do affect the skull shape as it develops. One of these is sagittal craniosynostosis due to premature sagittal suture closure. This allows the skull to grow long in length but narrow in width. This results in a very narrow skull that often has a triangular or peaked appearance from the front view. Due to the severity of the skull deformity, most of these affected individuals undergo early cranial vault reconstructive procedures to allow the rapidly expanding brain to help achieve a more normal skull shape.

But sagittal skull deformities do not always come in full expression and there are lesser degrees of their manifestations. Some would call these microform expressions of sagittal craniosynotosis. They can be very minor or more moderate in appearance. But they all appear with a a higher and and more narrow skull shape that creates a more triangular rather than a convex shape from the front view.

Case Study: This 26 year-old male had long been bothered by the shape of his skull. He had a very peaked skull shape that he felt was too high and too narrow. He did not like its very triangular shape which he likened to that of a house roof. He wanted a better skull shape so he could feel more normal and go one with the rest of his life without being embarrassed about his unusual looking head.

Under general anesthesia, a curved coronal incision was made across the top of the head from 1 cm. above each ear to the other side. Full-thickness scalp flaps were reflected in the front and the back to reveal the entire skull. The skull from above was very narrow and long with a raised sagittal ridge. Initially, a handpiece and burr was used to lower the sagittal ridge 5mm to 6mms from the forehead to the back of the head. Then the sides of skull were built up along the reduced sagittal ridge to the temporal line with PMMA material. Several 1.5mms titanium screws were placed one each side to anchor the PMMA material. All edges were then smoothed with a handpiece and burr. The scalp incision was then closed in two-layers using resorbable sutures.

He wore a head dressings and drains for the first 24 hours. Thereafter no dressings were used. he did eventually require needle aspiration of a seroma in the temporal area but this posed no long-term problems. He had substantial improvement in his skull shape, going from a triangular appearace to a more round convex form from the front view.

The peaked or triangular skull shape is often a manifestation of some form of sagittal craniosynostosis. It can be improved by a combination of lowering the ‘peak’ and filling out the side ‘valleys’. The limiting factor is that the narrow skull beyond the temporal lines can not be augmentted with material as it is covered with temporalis muscle.

Case Highlights:

1) The severely triangular-shaped head is usually the result of some degree of congenital sagittal craniosynostosis with a longer front to back length and a narrow skull width.

2) Skull reshaping of the triangular or peak-shaped deformity can be done by sagittal bone reduction, parasagittal augmentation or a combination of both.

3) A coronal incision is needed for wide open exposure to perform this form of skull reshaping.

Dr. Barry Eppley

Indianapolis, Indiana

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