Background: Skull reshaping is a general term that applies to a variety of surgical techniques designed to alter the shape of the head into a more pleasing shape as desired by the patient. Fundamentally these techniques come down to augmentation by custom designed skull implants and reduction by outer table skull bone removal. While often done as a single skull shape change, augmentation or reduction, they can also be done together to affect a multi-surface head reshaping.
In multi-surface skull reshaping the key issue is incisional access. While custom skull implants can be placed through incisions at their periphery of bone coverage, skull reduction incisions have to be closer to the target as the instruments used to do it are shorter in length. It is obvious if the two skull surfaces are distant from each other two incisions will be needed. However if the surfaces of the skull are close to each other it may be possible to use a single access incision.
Case Study: This male had concerns about this head shape which consisted of three issues; 1) a left flat back of the head, 2) a high top of the head and a 3) modest right temporal posterior protrusion. His 3D skull CT scan showed the first two fairly well due to their bony component.
Using the same scan a custom skull implant was made for the left back of the head using the opposite right side in a mirroring design method. The total implant volume was 79ccs.
For the top of the head reduction there was enough bone thickness to do a reduction but the question was how much of the top of the head could be reduced vs the length of the incision needed to do it. To help him make that decision a diagram was shown illustrating the extent of top of the head reduction vs the size of the incision to do it. Because of his closely cropped hairstyle he chose the smaller incision.
Under general anesthesia and in the supine position a small curved scalp incision was made at the crown of the skull. Through this incision the custom skull implant was placed inferiorly over the left back of the head. Then moving anteriorly a high sped handpiece and burr was used to reduced as much of the top of the head as the incision would allow. The incision was closed with a drain exiting behind the left ear.
Lastly a right posterior temporal reduction was done removing a small amount of muscle using a postauricular incision.
When seen the next day for head dressing and drain removal the improvement in his head shape could be appreciated.
For many skull reshaping patients, men in particular, the incision used for the procedure is a significant aesthetic concern. Thus if possible it is important to do as much surgery as possible through the smallest scalp incision.
Key Points:
1) Multi-surface skull reshaping can involve augmentation of some surfaces and reduction of other skull surfaces to create an overall better head shape.
2) Custom designed implants are the most accurate method of augmenting deficient skull areas.
3) Reduction of prominent skull areas are limited by incisional access as well as the thickness of the outer cortical bone layer.
Dr. Barry Eppley
World-Renowned Plastic Surgeon