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Skull reduction is an effective head reshaping procedure for the properly selected patient. It is based on removing part or all of the outer cranial table down to or just stopping short of the underlying diploic space. Because that leaves the inner cranial table it is a safe procedure that has no risk of intracranial exposure.

One of the most commonly request skull areas to be reduced is the back of the head. Too much projection or protrusion is the concern that creates a posterior elongation of the head that has too much convexity.  In some cases it may be an asymmetry with one  side of the back of the head being too round compared to the other side. Understandably these back of the head concerns are typically manifest in males that have short hair or shaved heads.

The key question is deciding whether the procedure can achieve the patient’s aesthetic goals is how much reduction is needed. This is obviously determined by the thickness of the outer table of the skull and the incision used to access it. X-rays can be helpful in that regard although I find computer imaging to be just as useful. Showing the patient a modest reduction to determine their response is a helpful criteria. Patients usually take two approaches to their occipital reduction goals….any reduction is a benefit or some may have a very specific skull reduction goal. Most patients take the former approach.

Skull reduction is a procedure done by high speed burring. This often looks like it is not doing much…until one looks at the bone dust that is being generated. If I compare it to harvesting split-thickness cranial bone grafts, the amount of bone debris that is created is impressive. It is a tedious procedure and attention must be paid to a grid technique to avoid getting ‘lost’ or creating a lot of irregularities. It becomes even more tedious as the size of the incision must be kept small for aesthetic purposes.

I always worry about whether enough bone is being reduced to meet the patient’s goals. But most of the time patients seem to be happy as they share their after results with me with email pictures.

Dr. Barry Eppley

Indianapolis, Indiana

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