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Background: The head, and more specifically, the skull can be reduced like almost any other face or body part. The desire for skull reductions comes in different magnitudes of size. Some enlargements are small, such as osteomas, bumps and horns, and can usually be completely removed as the problem is relegated to the outer cortical layer of the skull. Larger skull reductions involve plates of bone in which the amount of reduction may be more incomplete as the same outer cortical limit of removal applies regardless of the size of the hypertrophy.

 In larger skull reductions done for aesthetic purposes the length of the scalp incision is limited…which introduces the need for a different approach to the reduction. If unlimited surgical access is done through a long bicoronal scalp incision the wide open exposure allows for a more back and forth movement of the high speed handpiece and burr. But through a smaller scalp incision the visibility is limited to long tunnels using retractors in which a back and forth burring reduction method over a large skull area can not be effectively done.

Aesthetic skull reductions, regardless of the exposure, must be done a bit like mowing the lawn. There has to be a specific pattern or regimen to the reduction to ensure a smooth and even removal and so no area is missed. But unlike mowing the lawn aesthetic skull reductions are done through with limited exposure so the pattern technique to doing them has to take a more ‘central’ approach.  

Case Study: This male was bothered by the raised area of the crown of his skull in a circumferential manner. The area of protrusion was similar to wearing a thin cap over the crown. By palpation the edges of the protrusions could be felt like the edge of a small ring. 

Under general anesthesia and in the prone position a 9cm curved scalp incision was made without shaving any hair. Through a very thick scalp the underlying skull bone was exposed which had a yellow color. The skull surface was thickened and irregular.

From this central incisional location outer cortical bone cuts were made in a radiating fashion from a single central area circumferentially. A total of 6 bone cuts (rays of the sun) were done on each side of the incision.

At the intersection of all bone cuts at the location under the incision this central area was reduced down to the diploic space. (creating the body of the sun so to speaks with all the radiating lines of bone cuts from it) With these linear grids made the bone was then sequentially removed between the lines one area at a time in a ‘tunnel’ technique of visibility. The amount of bone dust/debris with burring that is created can be considerable so lots of irrigation is needed to keep the area clean and visible.

Once all outer cortical bone was removed and a drain was placed and the scalp incision closed in two layers.

His immediate intraop before and afters showed the degree of reduction.

When seen the next day for dressing and drain removal the amount of skull reduction could be appreciated in the upright position.

Key Points:

1) All skull reductions involve a decortication of the outer layer of the skull whose magnitude of effects depends on the amount of surface area reduced.

2) Aesthetic skull reduction emphasize a limited scalp incision for which a radiating pattern of grid bone reduction is used.

3) Larger surface area skull reductions are tedious but an effective result depends on diligence in sticking with the grid pattern of bone removal.


Dr. Barry Eppley

World-Renowned Plastic Surgeon

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