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Background: Aesthetic skull reshaping surgery consists of a wide variety of reductive and augmentative procedure for head shape concerns. One of the most common augmentative procedures is for the back of the head using a custom designed skull implant. This is done for concerns of asymmetry, lack of adequate projection or a combination of both.

Not surprisingly the majority of such skull augmentations are done in men for the obvious reason of greater  head shape exposure. While the lack of hair, or they desire to shave their heads, is why many men seek the procedure this is not exclusively so. A surprising number of men with more ‘hidden’ head shape are bothered by them nonetheless. This may be as much of a tactile issue as it is a visual one.

In correcting back of the head shapes it is often called occipital augmentation or occipital bone reshaping. This is because most think of the back of head as being the entire occipital bone…which it is not. Anatomically the occipital bone actually only makes up the lower half of the back of the head. The upper half, which lies north of the lambdoidal sutures is the paired parietal bones. This not only makes up the upper half of the back of the head but also includes a portion of the crown which involves the back end of the sagittal suture. These bony anatomic areas must be considered in any custom skull implant design for the back of the head. 

Case Study: This male was bothered an asymmetric and flatter back of his head. A 3D CT scan showed the left sided flatness extend all the way to the top of his head with an overall taller skull height as well.

A skull implant as designed to correct they asymmetry as well as add a little posterior projection to the right side as well. The total implant volume was 163ccs. Besides correcting the asymmetry one of the key elements in any skull implant design is that its overall shape must look natural and and flow into the rest of the skull like it belongs there.

Under general anesthesia and in the prone position a 9cm long horizontal scalp incision was made on the back of the head  preserving all hair follicles. A large subperiosteal pocket was created into which the implant was placed. Two microscrews fixed the implant at its inferior edge.

His long-term two year rest showed a correction of his asymmetry and improved back of head projection.

Asymmetry of the back of the head, in theory, is the most straightforward skull implant to design. This is true IF it is only the asymmetry that is desired to be corrected. But adding an increased overall projection and the need to take into consideration how much implant volume it creates overall adds to the complexity of the design. It is a good guideline for most patients to not design skull implants that have volumes that stay within the 150cc range. Skull implants are unique in that their surface area coverage and thickness create a volumetric effect that requires the tight scalp over it to stretch to accommodate it.

Case Highlights:

1) Back of head augmentations for asymmetry and an overall volume increase are the most common custom skull implants in men.

2) Where on the back of the head the maximum projection should be will vary for each patient.

3) The maximum volume for most skull implants based on scalp stretch is in the range of 150ccs.

Dr. Barry Eppley

Indianapolis, Indiana

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