What Type Of Forehead Cranioplasty Do I Need?

Q: Dr. Eppley, I am interested in a cranioplasty. I have a depression in my forehead for the past twelve years. I am twenty-two years of age and this depression started showing around age ten and has just been there ever since. It makes me feel alien, I don’t like taking pictures, I only comb my hair in one style to cover it kind of and I really think that I would be a more confident person had I have a normal forehead. I desire a “normal” forehead, without a sink in it :( . I have attached pictures of what it looks like.

A: In looking at your pictures, what you have is a classic case of what is known as linear scleroderma which creates a deformity known as the ‘coup de saber’ (cut of the saber) effect when it appears on the forehead. It is a condition that usually develops as a child and causes a loss of fat and an indentation in the bone. It is progressive and the tissue atrophy effect eventually burns itself out by the time one is a young adult in most cases. Its causes is not really understood and is currently felt to be related somehow to the nerves. When it appears on the forehead, it usually follows along the line of the first division of the trigeminal nerve. (supraorbital nerve which comes out of the brow bone and extends vertically upward into the forehead) This is why you have a very groove going upward from your brow bone, hence the description ‘cut of the saber’.

I can not tell completely from the pictures about the quality of the overlying skin, which usually is thinned and mottled in color although your skin along the groove does not appear so. (but the pictures are fuzzy) Treatment could consist of fat injections, a minimal incision endoscopic cranioplasty for bone augmentation or a combination of both. I would know exactly what to do by feeling it but I suspect it ail requires a combined fat and bone augmentation technique for optimal forehead augmentation contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Are Bone Cements or Implants Better for Forehead Augmentation/Reconstruction?

Q: Dr. Eppley, I am interested in forehead augmentation/reconstruction for a congenital skull deformity. In terms of using cement on my forehead, by how much can we get an additional thickness there, i.e. what distance can we add to the flatness/deficiency? Why is it cement (on the forehead)  instead of a prefabricated implant? I have a very rough terrain of the forehead. In our opinion the implant’s inner side would hide all the problems beneath, but the cement treatment might be not creating a proper elliptical smoothness unlike an implant should do. Correct us please if we are wrong, it is just to dispel our concerns.

A: The amount of expansion of any skull bone surface is based exclusively on how much the overlying scalp will stretch. How much the scalp can stretch is a function of many factors, including scar from prior surgery and an innate ‘looseness’ factor. As a general statement, skull expansion can achieve up to 25mm in thickness if a full coronal incision is used for access.

Forehead augmentation/reconstruction can be done very successfully, using either intraoperatively applied bone cements or prefabricated implants. One is not necessarily better than the other. A bone cement is an intraoperatively made putty froml iquid and powder components. It is applied as a putty to the bone surface and then shaped by hand to whatever external shape is needed. It has an intimate connection to every nook and cranny of the irregular bone surface as its outer surface is shaped into a smooth round/elliptical shape. Bone cements can be either of PMMA (acrylic) or hydroxyapatite (HA) compositions. Most large volume bone cement cranioplasties use PMMA due to its lower cost. A prefabricated skull/forehead implant is made from the patient’s 3D CT scan using computer designing software for its creation. It is then fabricated in a silicone material for implantation. It too will have a good fit to the underlying bone surface and an external shape of whatever is so designed. It is the costliest of all the alternatives due to the design process.

In short, your perception of the differences between a bone cement and prefabricated implant is not accurate. They are just different ways to get to the same place. They differ primarily, however, in the cost to do them.

Dr. Barry Eppley

Indianapolis, Indiana

Which Bone Cement in Cranioplasty Is Better?

Q: Dr. Eppley, I want to have the flat spot on the back of my head built up. I understand that various materials can be used to do it but don’t know which one would be better. What are my options?

A: Bone cements in cranioplasty can be either polymethylmethacrylate (PMMA) or various calcium-containing materials. All of these materials are joint powders and liquids that are mixed in surgery to create a self-curing putty that offers enough set times to create the desired shape on the bone. The most ‘natural’ bone cement is that of the synthetic calcium compositions, of which the most common ones used are calcium phosphate-based also known as hydroxyapatites. (HA) They are natural to the bone because the inorganic mineral content of human bone is hydroxyapatite. Another calcium-containing bone cement is that of calcium carbonate, known commercially as Kryptonite. It offers superior biomechanical properties (less prone to fracture) than the calcium phosphate-based masterials but is no longer commercially available. Whether PMMA or HA is better for any cranioplasty is based on a variety of factors (cost, inlay vs onlay, size of incision) and not necessarily because one is more natural or more synthetic. There are different material properties for each type of bone cement and these must be considered also.

Dr. Barry Eppley

Indianapolis, Indiana

Are Cranioplasty Materials Permanent And Do They Break Down Or Leak Over Time?

Q: Dr. Eppley, I’m interested in cranioplasty augmentationsurgery but have a few more questions. 

1. Is this correction permanent meaning is it reversible? is it expected to last a lifetime?

2. You mention PMMA is harder than hydroxyapatite, will i feel the difference? 

3. Is the hardness of hydroxyapatite similar to real bone? Will it feel more natural to me?

4. Will I experience foreign body sensation with this “implant”

5.  I’m not an expert on the anatomy of the skull but i’ve read that there are gaps between the bones of the skull even when they are fused. how will this type of correction subtle dynamics of contraction and expansion of my skull bones, once a material like hydroxyapetite is plastered onto them? 

6. Is there potential for leakage/breakage of material and if so what are the health, carcinogenic, or risks.

7. Is there risk of allergic reaction to the material?

Thank you for the work that you do.

A: In answer to your questions:

1) All cranioplasty materials are permanent,  meaning that they do not degrade, break down, and never need to be replaced because they wear out. They are, however, fairly easily removed so they are completely reversible.

2) There is no external feeling difference between PMMA and HA. Their biomechanical differences are largely that of laboratory testing.

3) There are no feel differences between PMMA and HA and they will feel both natural and just like your own bone.

4) Patients do not report that they feel like they have a skull implant in place. It feels just like bone.

5) There are no gaps between adult skull plates. That is an in utero and neonatal phenomenon.

6) Cranioplasty materials are fully polymerized and do not break down, leak, or degrade over time. There are no long-term health or carcinogenic risks.

7) While infection can occur from their surgical placement, there is no known risk of an allergic reaction to HA and very rare risk to PMMA.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Way To Fix This Dent In My Head?

Q: Dr. Eppley, Wow. Information about dents on a persons head is next to impossible to find on the internet. I have about dent on the very top of my head that is about 2 inches in diameter, so it is a fairly large dent. After an accident, some skin was literally ripped from the top of my skull. Eventually, the skin did grow back, but I have no hair there now as the hair follicles went with the skin when it was ripped from my skull. The main problem is though I have a dent in my head there too. At first I thought that all the tissue ( the matter under the skin ) didn’t grow back even though the skin did. Recently, a CT scan showed that part of my skull was thin, so now I don’t know if I have the dent because I need tissue or if it’s because of my skull. Is there any way to determine what the actual cause of this dent is, and if it’s the skull, would anything procedure done to the skull raise the tissue so that it is flush with the rest of my head?

A: While I don’t know the details of your original injury, it strikes me as unlikely that you would have pushed in your skull or removed the outer layer of cranial bone with an avulsion type injury. My suspicion is that this is more of soft tissue defect than bone. the scalp is incredibly thick in many patients particularly of your ethnicity. If you lost enough scalp to remove the hair what is healed is now a partial thickness of scalp which can certainly create an ‘indentation’. The definitive answer, however, would be the CT scan which should clearly show what the bone looks like underneath of the scalp…if the scan was done using coronal images and not just axial slices. I would need to see the the scan and pictures of your scalp defect to definitively determine the anatomic basis of your head indentation.

If it is just soft tissue you can have the defect excised and the hair-bearing scalp defect loosened and used to repair the defect. If there is a loss of bone component to it this can be simply filled in with hydroxyapatite cement (cranioplasty) and the hair-bearing scalp tissue closed over it.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Cost Of Skull Augmentation?

Q: Dr.

Eppley, I am interested in skull augmentation.  I have heard of Osteobond being used overseas.  Is an expander needed? I have a normal shape, just want to make it larger.  What is the estimated cost?  Thank you, I appreciate your time.

A: Whether an expander is needed for skull augmentation depends on how much skull expansion is desired and where that expansion on the skull is needed. Please send me some pictures so I can do imaging to get a feel if yours is a one-stage or two-stage skull augmentation. Knowing that and the material used plays a major role in the cost of the procedure.

Osteobond is not an FDA-approved cranioplasty material in theU.S. The approved options here are polymethylmethacrylate (PMMA, Cranioplast) and hydroxyapatite (HA, Mimix and others).

Dr. Barry



Should A Cranioplasty and Rhinoplasty Be Done Together Or Separately?

Q: Dr. Eppley, I have some questions regarding cranioplasty, rhinoplasty, and septoplasty. I have a form of craniosyntosis and my skull has indentations that could be improved by a cranioplasty, I also have a severe deviated septum and crooked nose that needs correcting by having a combination of rhino/septoplasty. Insurance will cover the procedures for my nose to get corrected. I believe I have seen somewhere on your website where someone asked a question similar to this, and you said something along the lines of

it is ideal to get the cranioplasty and rhino/septoplasty all done at once. That probably is not a possibility in my case, because getting my insurance to cover the cranioplasty is going to be difficult, so I am going to have to put that off for now until I have the money to get it done.  

My questions are:

1.Would it be OK to get rhinoplasty/septoplasty done before getting a cranioplasty? 

2.Or is it better to get the cranioplasty done first? 

3.Or does it not matter at all in which order I get these procedures done?


A: In answer to your questions:

1) Insurance may cover the septoplasty portion of your nasal deformity but not the rhinoplasty portion.

2) Insurance will not cover any type of cranioplasty for skull recontouring. Indentations of the skull are not a medical condition but a cosmetic one.

3) The order of septorhinoplasty and cranioplasty is a matter of personal preference. There is no medical reason as to how they staged or in what order.

Dr. Barry Eppley

Indianapolis, Indiana

How Is The Material Fixed To The Skull In Cranioplasty?

Q: Dr. Eppley, I am looking at building up the back of my head. In reading your blogs you say that you usually add about 60 grams of material. But I don’t know how that would look and whether that is enough. I went on with my experiments, but rather than water I used plasticine which conveniently has a density close to PMMA, to check the volume. I adapted it to the back of my head like an implant would be, and as you said the change is bigger than one would expect (I tried 60g and 80g). So if the trade-off for a bigger volume is ‘longer or more full coronal incision’, could you tell me what would be its size and location for 60g and 80g? (I’m not sure I’ve read around 10 centimeters for 60g on your blog) As a side question, how would you attach the implant to my skull?

A: That is a clever way to see how much volume 60 grams of cranioplasty material is. Remember that it will also look bigger than you think when placed under the scalp skin. To get this amount of material on the back of the skull, an incision of 14 to 16cms long is usually needed. Onlay cranioplasty materials are fixed to the skull by first applying small screws to the skull bone allowing them to set up about 3 or 4mms above the bone. When the material is then applied this gives it something to hang onto to like rebar used in concrete. While screw fixation may not be absolutely necessary for augmentative skull reshaping, I prefer it since it is simple to do and adds a bit of security for prevention of implant mobility.

Dr. Barry Eppley


Should I Get Hair Transplantation Before Or After Skull Reshaping?

Q: Dr. Eppley, I have contacted you in the past about questions I had regarding indentations I have on my skull, and about fixing them with a cranioplasty. You responded by telling me that I would require an open approach cranioplasty and the incision would be bilateral from ear to ear. Along with having a large indentations on my skull, I also am going bald. I am interested in getting a cranioplasty done by you and also am planning on getting a FUE hair restoration at some point.
My questions are:
1. If I was to get a FUE hair transplant/restoration would it be better to do it before or after the cranioplasty?
2. Would it make sense to do it after, so it mite be able to help cover the scar? or does it even matter?
3. Also can you diagnose what the name of the medical term/condition is that I have wrong with my skull by looking at the attached pictures I have here?

A: In answer to your questions, you would always want to do hair tranplantation AFTER a cranioplasty. This is because it would also give one the opportunity to place hair grafts along the scar should that be necessary. While this could always be done after, you would like to have that option during the initial FUE procedure. Usually that is not necessary but it is a theoretical option that you want to keep available given that bothi of these procedures are elective and can be done anytime in any order.

I believe what you have is a very incomplete form (microform expression) of bicoronal craniosynostosis. This is because you have deep indentations (like a constricting band) right along the exact location of the underlying original coronal suture locations.

Dr. Barry Eppley


Can I Use Bone For My Cranioplasty?

Q: Dr. Eppley, I am inquiring about a natural method for cranioplasty. I have a forehead defect including a hole through the bone from a prior craniotomy for a brain tumor. The size of the forehead defect measures about 9 x 2 cms and represents the area where the bone flap appears to have settled inward. Can I use my own bone to reconstruct this forehead defect area?

A: Cranial bone flaps, despite using rigid fixation, can heal inconsistently or undergo some resorption leaving an outer contour depression. There are multiple ways to do a cosmetic or reconstructive cranioplasty with a variety of materials, bone being one of the options. If the defect is small enough, one could use natural bone, in other words cranial bone grafts. While natural bone has understandable appeal, it is actually not the best way to do most cranioplasties. B

esides having to harvest the bone (and creating another bone defect), bone grafts are notoriously unreliable and predisposed to incomplete or total bone resorption particularly when used as an onlay. The more reliable way to perform most cranioplasties is to use hydroxyapatite cements. They are structurally stable, do not resorb and can be shaped perfectly to any defect whether it is an inlay, onlay or a combined cranial defect. They are also composed of hydroxyapatite, a calcium phosphate mineral, which is highly biocompatible with natural bone. While bone will never truly grow into it and replace it, bone will bond directly to it. The type of forehead defect that you have would do well with a hydroxyapatite cement cranioplasty.

Dr. Barry Eppley

Indianapolis, Indiana