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Aesthetic augmentations of the head can be most effectively done using a custom skull implant approach. Using the patient’s 3D CT scan implants can be designed to contour large surface areas of the external skull bone surface. While these skull implant designs can be made of any of the traditional materials, solid silicone is the only one that can fulfill one of the most important aspects of any form of aesthetic skull reshaping surgery…the use of limited length incisions to execute the procedure. While any material can be placed on the skull through a full ear to ear coronal scalp incision, the resultant long scar is not very appealing to the aesthetic skull reshaping patient.

While the limited scalp incision and the resultant scar is of great aesthetic benefit it does have one major disadvantage…most of the implant is not seen once inside the pocket past the  incision. Thus how does one know for sure whether the implant is properly oriented as per the design? Also how does one know that all the remote edges of the implant are properly unfurled and laying flat?

The answer is that the surgeon is basically blinded as to how the implant is sitting on the skull. And as much as one would think that looking and feeling on the outside of the scalp would answer these questions, it is still not an assured approach. As a result one of the design techniques that I employ is to place a ‘compass marker’ on the implant. This is placed near where I believe the incision will be to provide visual assessment of vertical midline and horizontal orientation of the implant.

While the compass marker is very useful there are still some other techniques that are of implant positioning benefit. The placement of perfusion holes, while used to permit long term tissue ingrowth, are also helpful to move the implant around. Using two large clamps they are inserted into the holes and used as handles to shift the implant around as needed. In essence they provide a method to grab the implant for precise positioning.

The other technique to ensure that the edges of the implant are properly unfolded and smooth is to make a full thickness opening though the implant. Then long malleable retractors can be used to slide under the implant all the way out to its edges to make sure it is properly unfolded. It is very easy to have a feathered edge of the implant folded onto itself and never be detected….until the contracture of the soft tissues around the edges of the implant reveal itself 6 to 8 weeks later.

While the malleability of solid silicone permits large skull implants to be placed through much smaller incisions than one would think possible, this limited visibility requires numerous technique to ensure the implant is both oriented properly and is laying completely flat.

Dr. Barry Eppley

Indianapolis, Indiana

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