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Background: Craniofacial surgery is a collection of bone reshaping procedures of the skull and upper face that is typically used to treat various congenital deformities. While most commonly perceived as being done in very young patients, many craniofacial operations can also be done in older patients as well.

While craniofacial surgery produces some remarkable results, there are almost always going to be some contour sequelae from their execution. This could be the result of non-healing bone gaps, irregular bone contours, hypertrophic bone formation or from the fixation devices left behind. There are also associated soft tissue sequelae from scalp incisional scars, temporal muscle hollowing and subcutaneous fat atrophy. All of these issues become apparent over time with continued growth in young patients and complete healing in older patients.

While seemingly trivial compared to the magnitude of the original problem and the operation used to treat it, improvement in these contour issues can offer an enhanced aesthetic outcome in some craniofacial surgery patients. It is very much like putting the ‘icing on the cake’ and completing the final layer of the reconstruction.

Case Study: This female had a history of multiple hypertelorism surgeries using orbital box osteotomies as an adult. While her intercanthal distance had been satisfactory corrected she had multiple contour issues including temporal hollowing, forehead contour irregularities and flattening and a narrow skull shape. Her goal was to have a rounder forehead and skull shape with temporal hollowing correction. To achieve this effect a fronto-temporal skull implant was designed to cover the entire forehead and superior and lateral orbital rims and the entire temporal regions crossing completely over the top of the skull. Because of its surface area coverage it was designed as a two piece construct.

Under general anesthesia her existing wide coronal scalp scar was excised and the anterior scalp flap rotated forward down along the lateral orbital rims and zygomatic arch. The two-piece custom skull implant had multiple 5mm perfusion holes placed throughout with the exception of the forehead. It was then fitted into the forehead and skull area and the two pieces united with permanent sutures and small titanium screws.

Custom skull implants can be used for a wide variety of aesthetic effects. Smoothing out irregular contours after prior surgery is one effective use of them. Being able to apply the implant through wide open access from a prior coronal incision allows the design to cover a large surface area.

Case Highlights:

1) Many types of cranial vault and orbital reconstructive surgery leave contour deformities as a sequelae of the bony cuts and movements.

2) Custom skull implants can be used to smooth out forehead, temporal and skull contours of both bone and soft tissue.

3) Such contouring skull implants only need to be a few millimeters thick but can cover broad surface areas to exert their smoothing effects.

Dr. Barry Eppley

Indianapolis, Indiana

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