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Custom implants are the most effective strategy for achieving any significant skull augmentation effects. One of their most common uses is for improving the shape of the flat or asymmetric back of the head due to plagiocephaly or brachycephaly. Such custom skull implants are done in both males and females in equal proportions. While the depressed or flat back of the skull shapes share similar patterns of projection deficiencies one distinguishes the male vs female skull augmentation its hair.

Working with female skull augmentations require a willingness and expertise in hair management. While intracranial brain surgery requires shaving of the head, aesthetic extra cranial skull augmentations do not. (nor would the patient permit it) Large amounts of long hair may initially appear daunting and impossible to safely work through but it can be done without as much difficulty as one would think.

In the prone position the hair is parted along where the scalp incision needs to be. The part does not need to be perfectly straight . In fact an irregular jagged part line is preferred as this creates a more natural and unseen scar line. The hair is then put into pony tails both above and below the part line. No hair is trimmed or removed. Sterile towels will drape off most of the hair near the incision hair is still exposed.

The scalp incision must be made parallel to the exit of the hair follicles from the scalp to avoid injury to them. On the back of the head the hair is almost always going to exit in a very downward direction. On the crown and top of the head the direction of hair exit from the scalp will be different and may even be more anterior. Scissors are used to dissect past the hair follicles and then, and only then, is electrocautery used for a more bloodless dissection down to the bone.

Once the implant is placed antibiotic powder is applied over the implant and under the incision as an additional precaution for infection prevention. Then the incision is closed with resorbable sutures. The two ponytails are released and the hair combed out and put into one single ponytail which covers over the incision.

In aesthetic skull augmentations I do not have the luxury of a broad smooth hair free scalp surface.You have to work with the hair gives that it is an aesthetic procedure. Despite the hair exposure into the surgical field this does not appear to increase the risk of infection. This is a testament to the superb blood supply of the scalp and the skull bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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