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Most aesthetic skull augmentations are of a significant enough magnitude that the only effective treatment is a custom skull implant. Whether it is the volume or the shape of the needed skull augmentation a reshaped implant made from the patient’s 3D CT scan is the way to go for most patients. But some patients do have very small skull augmentation needs for which numerous non-custom approaches can be successfull used.

Injectable fillers are the most obvious materials that fit into the small skull augmentation treatment category. Numerous synthetic injectable materials and fat can be injected and are perfectly appropriate for small indentations and depressions particularly if they are more scalp-based than skull-bone based. They are also a good technique for fixing edges or small insufficiencies from previous custom skull implant placements. Their downside is their lack of sustainability either from known resorption characteristics (synthetic fillers) or unpredictable volume retention. (fat)

For allogeneic options a variety of implant materials can be used but the choices come down to what is available off-the-shelf that can be modified intraoperatively and made to fit through a very small scalp incision. Absolute rigidity of the material is not needed. One also needs to give some thought to ease of reversibility due to the small incision should modification or removal be needed. How difficult is it to get it back out through the same incision by which it was introduced. For these reasons sheets of either ePTFE (Goretex) or silicone (1 to 2mms thick) are the best materials. I prefer silicone sheeting because it has the physical property of elastic deformation so it is less likely to become unknowingly folded once inside the largely hidden pocket. (ePTFE has no spring or elastic recoil to it)

There may even be some patients who might get a combination of injections and a small implant depending upon the location, shape and size of the skull deficiency.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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