Background: The narrow head shape is defined as having a decreased bi-temporal and bi-parietal bony skull widths. These can be determined by actual measurements but, more importantly, it can be seen from the outside as well as just looking at a 3D CT skull scan of the patient. The narrow head shape may often involves the front (forehead) and the back (occiput) as the more narrow head shape is not always just limited to the sides. (temporal area) It is possible to have a forehead that has good width with narrow sides of the head just as it is possible to have adequate back of the head width with narrow sides. But when the head narrowing is significant there’s always going to be some involvement of the front or back of the head.
Patients that have a narrow head shape always try to camouflage it with their hair. Long hair or short hair that is flushed out can be a good camouflage method but often involves time to do so to have it look that way as well as a hairstyle that one may not prefer. This is usually the history that the patient with a concerning narrow head shape has. The narrow head shape can be adequately corrected with head widening implants which usually must sit on top of the deep temporal fascia if there is involvement that crosses the bony temperament on either the front, top or back of the head.
When designing custom head widening implants the considerations are: 1) footprint or outline of the implant to cover adequate areas of bony narrowing, 2) size or volume of the implant needed, and 3) how is the implant going to be placed. These three considerations fundamentally break down into the following: 1) does the implant design need to cross the bony temporal line in any area, 2) will scalp expansion be necessary for the size of the implant needed, and 3) well the implant need to be designed in one, two, three or four pieces.
Case Study: This male has long been bothered by his narrow head shape and desired a considerable head widening change. His 3D CT scan showed a definite narrow of his skull width with medial displacement of his bony temporal lines. The narrowing effect impacted the back of the head more than the front with some modest inward narrowing of the sides of the forehead.
A large head widening implant was designed with a footprint that went from the sides of the forehead all the way around the back of the head. It also crossed onto the top of the head to the medially displaced bony temporal lines. It provided 305cc of implant volume.
Given the implant size a first stage scalp expansion was necessary. A scalp expander was placed through a small back of the head incision with the port above the right ear under the skin. Over a three month period injections were done up to 300ccs of saline fill.
At the second stage procedur the scalp expander was removed and the skull implant inserted as four pieces through the back of the head incision. A small sagittal scalp incision aided the putting together of the four pieces once inside the extended scalp pocket. The union of the implant pieces that could be seen through the incisions was secured with sutures and screws. Two drains were placed that existed behind each ear.
Due to his haiur it was impossible to see before and after pictures that would show the changes so a tight nylon cap was used. As per the design the widening effect wrapped around the back greatest the greatest increase in head width.
A
lso as per the design the forehead or front view has less of a width increase anteriorly.
When head widening implants sit on top of the muscle there is going to be s prolonged need for drains with a large surface area implant between the scalp and the fascia. It is usually prudent to leave the drains in for at least 10 days after surgery.
Key Points:
1) Large wide head widening implants require a first stage scalp expansion.
2) Large custom skull implants often have a segmentalized design to keep the scalp incisions small.
3) Because large extended head widening implant sit on top of the temporal fascia there is a need for prolonged use of drains after surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon