Background: Custom skull implants are typically used for correcting various skull contour deficiences and often have some appreciable soze and thicknesses. While creating a smooth contour change is a necessary part of that typical form of augmentation it is not usually the sole reason for the patient to undergo the procedure. But custom skull implants can be an effective method for skull surface smoothing if the contour irregularities can tolerate a small amount of augmentation as well. The following case illustrates their usage f0r that exact effect.
Case Study: This male had a prior history of numerous skull reshaping procedures. Years ago he had a frontal bossing reduction procedure done through a superior scalp incision. It apparently was overdone and left an irregular skull surface which led to secondary efforts at resurfacing through only bone grafts. These largely resorbed and an overall irregular skull surface remained. He subsequently treated the skull contour irregularities with radiesse injectable fillers. This never produced a completely satisfying solution and he sought a more effective and permanent solution. His 3D skull CT showed the location and amount of the injectable filler.
Using his skull scan a large surface area thin custom skull implant was designed to create a smoothing effect.
The total skull implant volume was 30ccs with a maximum thickness of 3mm which was largely over the area of the original frontal bossing reduction. (the red color is the maximum thickness of 3mms)
Under general anesthesia part of the original scalp incision was opened to expose the skull bone. Interestingly the color of the bone was very dark (black-green color), an unusual color for any human bone, but may be due to the prior skull procedures. Is that a typical effect of skull reduction surgery…no. But I have seen this color of skull bone before from other patients.
The custom skull implant covered a large surface area but was very thin.
In creating the implant pocket by dissection the prior skull procedures and the indwelling filler posed no issues with its creation. In placing large surface area skull implants through limited scalp incisions (which is always how it is done) it is important to create on the implant some markings to help guide placement. Once the implant is inside the pocket there is no way to determine how it is positioned. Only what you see of the implant through the limited scalp incision is the only visual method you have. Thus compass-like markings placed on the implant prior to placement can be of help. Once the implant is in good position it it then secured with two small microscrews. The scalp incision is then closed over a drain.
In such thin contouring skull implants the definitive aesthetic outcome will take months to fully see. Between the initial swelling and the need for the shrink wrap effect of the overlying scalp soft tissues the smoothness created by the surface of the implant will take some time to see.
Key Points:
1) Prior skull reshaping procedures can leave the bone surface irregular and asymmetric.
2) Injectable fillers can be used to try and improve minor skull contour irregularities but are not a long term solution.
3) Custom skull implants can create a skull smoothing effect if they are very thin and cover large bony surface areas.
Dr. Barry Eppley
World-Renowned Plastic Surgeon