Background: There are a variety of established aesthetic head shape deformities that have been assigned well known names. One of these is that of scaphocephaly or a boat-shaped head which is a literal translation of the name. Because a boat is long and narrow this is exactly how such a head shape appears. In the scaphocephalic head shape there are many variations of it with different amounts of decreased head widths, increased head lengths and increased head heights. These differences are seen as a result of it actual cause…whether it is from a sagittal suture origin or from a deformational cause.
Of these three adverse dimensional head shape changes (width, length and height) in scaphocephaly the one constant is that of a decreased bitemporal width or a head that is too narrow in the front and back views. While always associated with a bit of the other two dimensional changes (sagittal crest and occipital length) they may or may not need to be addressed as part of the need for head width increase.That decision depends on their magnitude as well as the associated ‘cost’ of additional scalp incisions needed to do so.
The only effective head width increase method are custom skull implants. Such implants can be designed too be submuscular, subfacscial or suprafascial in placement. The pocket location is determined by whether the augmentation needs to stay within or go beyond the bony temporal line, particularly in the forehead. But most significant head widening implant augmentations need to extend beyond the bony temporal line to aesthetically look right and blend in with the rest of the skull. The greatest aesthetic width increase in my experience is in the 7 to 9mm range due to implant placement and keeping the incisions limited in lengthen and location.
Case Study: This male had a lifelong desire to improve the shape of his narrow head. He was not bothered by its front to back head length. The only noticeable increase in height was an anterior sagittal bump.
Using his 3D CT scan head widening implants were designed that wrapped around the side of the head, crossing the bony temporal lines.
The maximum width increase was 7mms at the posterior end of the anterior temporal region.
The anterior sagittal crest was measured at 3.8mm of safe bony removal.
Under general anesthesia three incisions were made, a small superior anterior scalp incision behind his frontal hairline, and paired postauricular incisions behind his ears. Through these incisions subperiosteal dissection was done on the forehead and top of his head and on top of the deep temporal fascia on the sides. The head widening implants were inserted and positioned through these incisions with careful attention given to his placement in the forehead to prevent eventual implant edging. Once positioned they were secured with microscrews through the sagittal scalp incision. Then the sagittal bump was reduced with a high speed handpiece and burr.
Closure was done over a drain on each side of his head. His intraoperative results showed a wider head but one that was not overly done or too wide.
Head widening implants can be very effective at scaphocephaly corrections due to their wrap around design if needed. While effeetive I always worry about implant edging on the forehead which is an unforgiving area for blending the bone and implant together seamlessly. Despite the most careful surgical efforts whether that surgical risk is avoided will not be fully known for 2 to 3 months after surgery when all the swelling is gone and the soft tissue shrink wrap effect has been fully seen.
Key Points
1) The adult scaphocephalic head shape is most typified by being too narrow more than any other dimension.
2) Custom head widening implants are most effective at increasing bitemporal width.
3) In custom head widening implants that cross over onto the sides of the forehead implant edging is the major long-term aesthetic concern.
Dr. Barry Eppley
World-Renowned Plastic Surgeon