Background: There are a wide variety of skull shape deformations almost all of which have a congenital origin. While the craniosynostosis skull shapes are the most recognized and are reconstructive procedures for their correction (bone removal and reshaping) most skull shape concerns are less severe and are more of an aesthetic concern. Despite their far more frequent occurrence they are less familiar and their methods of correction largely unknown.
One such aesthetic skull issue is the narrow head. The narrow head is the result of having a decreased bitemporal width which can present in different variations or extent. In more complete forms the head is narrow from front to back meaning from the forehead to the occiput along the sides of the head. This creates a pinched appearance with a flattening of the temporal lines, a narrow forehead and a reduced crown height around the back of the head.
In these more complete forms of narrow heads a wrap around skull augmentation is needed which requires a custom skull implant design. In placing such large surface area coverage skull implants there are two important considerations….does the patient have enough scalp stretch to accommodate it and how can it be placed through limited scalp incisions.
Case Study: This female had long been bothered by her narrow head shape. Along with the narrow head shape she also did not like the flatness of her crown area. In looking at her 3D CT scan in the front view it did not look particularly narrow compared to how she looked externally. In the side view the scan showed a mild flattening in the posterior crown area.
Using her 3D CT scan custom head widening implants were designed to widen the side of her head as well as add some fullness to the crown area. For placement purposes it was designed in three pieces to pass through small scalp incisions. The total three piece implant volume was 226ccs.
Given the implant volume and being a thin Caucasian female this required a 1st stage scalp tissue expander placement to ensure that the implant would fit and not cause undue stress to the hair follicles. The tissue expander over four months was filled to 250ccs of saline.
At the 2nd stage procedure the scalp tissue expander was removed through the same incision by which it was placed. This initial scalp incision had healed so well it could not be located at the time of the skull implant placement. The tissue expander was removed, bony capsulectomies and circumferential capsulotomies were then performed to create an adequate pocket for the size of the implant.
The three piece skull implant design was opened, laiod out and compared to the removed tissue expander. It is not important that the tissue expander has the same footprint (base shape) as the skull implant. Its role is to create enough volume expansion under the scalp for the implant to comfortably fit.
Given the small scalp incision on the back of the head the implant piece was further sectioned into two pieces using a geometric split cut. (now creating a four piece skull implant)
The four pieces of the implant were inserted and pieced back together by external feel through the scalp. To aid the union of the four pieces of the implant on the top of her head a small sagittal incision was used. At these two incisions the implant was secured with sutures and micro screws. The scalp incisions were closed over a drain with resorbable sutures in two layers.
Her immediate intraoperative result showed the increased forehead and side of the head width.
When seen after a few days before going home the increased in head width could be seen.
In this two stage skull augmentation procedure for head widening and crown augmentation the two fundamental hurdles to a successful large surface area implant placement were addressed. (near 360 degree augmentation effect) The use of a 1st stage scalp expansion and designing the implant to be placed in multiple pieces allows for an achievable and safe aesthetic head reshaping procedure to be done.
Key Points:
1) The narrow shaped head has a decreased bitemporal width that often extends onto the side of the forehead. (pinched head look)
2) The narrow head can be widened by extended temporal implants that may wrap around the back of the head for crown augmentation as well. Such large surface area skull implants often require a prior scalp expansion.
3) Near wrap around custom skull implants have to be designed and inserted in pieces to keep the scalp incisions limited.
Dr. Barry Eppley
World-Renowned Plastic Surgeon