Background: Skull implants are used today to treat a variety of aesthetic head shape concerns and deformities. While many think of skull implants of filling in craniotomy or other traumatic skull defects, aesthetic skull implants are placed in a subperiosteal onlay fashion to build out usually normal thickness skull bone areas. Skull implants placed in this manner are used for correcting skull asymmetries, flat spots, irregularities or just to create an overall larger circumference to the head.
The success of skull implants is partially dependent on the overlying scalp. The scalp has to stretch to accommodate what is placed beneath it. The skull implant can not be too large or too thick or the scalp will be too tight and the incision to place it will not be able to be closed. The bigger the skull implant or the larger the skull surface area that it covers the more that the scalp tissue is ‘recruited’ from elsewhere as the overall scalp stretches to accommodate the implant pressure underneath it.
Interestingly, some patients think that a skull implant will naturally have a bit of a facelifting effect. They envision that the upper pull of the scalp will translate into a distant effect low on the face. This is not what occurs, even in the largest of skull implants that I have placed. But there are certain circumstances with skull implants where a browlifting effect can be created.
Case Study: This 42 year-old female presented for a combination of forehead contouring and a near circumferential skull implant to build up the sides and the back of the head. A custom skull implant was designed with maximal thickness of 8mms in the back.
Under general anesthesia, a pretrichial incision was made. Going anteriorly the slope of the forehead was reduced by bone burring. Going posteriorly the scalp was elevated over the temporal and occipital regions of the scalp. The custom made implant was inserted, trimmed where needed and secured with small titanium screws. Prior to placement multiple perfusion holes were placed through the implant.
Her postoperative results showed a larger circumference to the head but also that she had developed a significant browlifting effect. This was a desireable aesthetic side effect of the skull implant. It occurred most likely because the access point for the implant’s insertion was at the frontal hairline. (pretrichial incision) As the scalp behind the incision became elevated, closing the pretrichial incision (after elevation of the forehead flap and contouring) resulted in the brows moving upward.
Highlights:
1) Custom kull implants of substantial size can elevate the scalp through underlying volume addition.
2) If a skull implant is placed close enough to the frontal hairline and of sufficient size it can have a browlifting effect.
3) The pretrichial approach to skull implant placement can both contribute to a browlifting effect from skull implants or can be used to create a browlift if desired.
Dr. Barry Eppley
Indianapolis, Indiana