Skull Augmentation

Q: Dr. Eppley, I am interested in skull augmentation. I have a very odd head shape which really causes me to struggle with every day life. I would seriously consider surgery if It would help me have a more natural looking head shape. I have attached a couple of photos. Ive never spoken to any one about it as no one has that head shape like me and doctors wont be able to do anything and i’ve never seen anything about skull surgery except from the service you offer. I hope you can help.

A: Based on the pictures you have provided, what I see in a flat area on the upper back of the head. If this is your concern, it is not rare in my experience and is the single most common female skull shape concern and surgery that I perform. This is ideally treated by a custom skull implant made from a 3D CT scan. The amount of skull augmentation possible depends on the amount that the scalp can stretch. Usually most natural scalp laxity can accommodate an implant up to 12 to 15mm at its central thickness. Greater amounts of skull augmentation (20mm plus) require a first stage scalp tissue expander to create the looseness and amount of scalp tissue needed to safely cover a thicker implant.

Dr. Barry Eppley

Indianapolis, Indiana

Cranioplasty

Q: Dr. Eppley,  I’m a 35 year old man interested in a cranioplasty procedure. I haven’t been able to find a plastic qualified surgeon who is capable of performing cranioplasty in my or neighboring countries. There is a clinic in Korea. However their method is not predictable since reshaping given by surgeon at the time of operation by using bone cement requires a bigger incision. I have to undergo skull reshaping surgery due to a flat back of my head as well as the top head which is also flat head on top. In addition forehead recontouring and hair line lowering needs to be done. These procedures must be done in same session because of scalp efficiency concerns. In my case I guess scalp tissue expansion is gonna be first stage prior to skull augmentation in order to achieve maximum silicone implant thickness and to allow the hairline to come forward. I have copies of 3D CT scan in my hand so would please let me know which steps will be taken from now on? Kind regards.

A: You are correct in that those cranioplasty or skull augmentation areas and hairline lowering procedures would require a first stage scalp expansion procedure. I would need to see some pictures of your head as well as eventually a CD of your 3D CT scan. Given that you desire a combined hairline lowering and skull augmentation, the custom designed skull implant would need to be placed through the frontal hairline incision.

Dr. Barry Eppley

Indianapolis, Indiana

Skull Augmentation

Q: Dr. Eppley, I am interested in skull augmentation. I haven’t managed to find any possibility here for my skull flat shape and also smaller size, which is always a problem due to hiding its flatness in a puffy hair and that takes a lot of time and doesn’t allow me to wear the desired hair style. I’m 34 years old and I am struggling with such issue for a lifetime, and now I’m seriously looking for a permanent fix. My forehead is also flat and what I’ve lately done was to get injected fillers in my forehead, its corners and all over it, for creating a nicer curvature which is not a permanent but only temporary one, then within 1 year or a year and a half, I need to re-do this process which is not the most desirable fix, also only temporary.  I’ve been reading about a latest discovery, Kryptonite, and also learning about you Dr Eppley from online and also searching your website, and I’ve noticed you’re extremely experienced and a specialist in such matters.  I’d like to kindly ask about your opinion, if some injections with suitable bone adhesive (Kryptonite or otherwise) would solve my problem permanently, without any side effects or other later surprises?  I’m aware the injections would be the quickest fix, especially when 1.5 cm to 2 cm height in my skull’s curvature would be perfect and also a bit at the top back, plus a bit on the laterals for creating more volume around, therefore in a nutshell needing some attached patches in the right spots of my skull. I’m also reading online that such injections would have some side effects and in the longer term may bring some problems, not sure if that’s correct or not?  If possible, I’d appreciate it receiving your kind reply regarding such procedures, or if it’s better going for a whole skull patch addition through a more complex operation?  Obviously, I’d prefer the simplest but most efficient procedure, but if such quick injectable permanent safe fixes don’t exist, please kindly elaborate about the best fit in my case, in order for my forehead to be considered as well and curved accordingly with no weird marks after a possible operation or implants. 

A: The simple answer to your question is that no method injectable skull enlargement works well and has lots of complications. Kryptonite is no longer available and has been removed from clinical availability. The only effective method of significant skull augmentation (and a 1.5 to 2 cm enlargement would be considered significant) is a two-stage surgical procedure. The first stage is the placement of scalp tissue expander (to gain the room for the bone expansion) and the second stage is the placement of a custom skull implant made from a 3D CT scan. Like all surgical procedures, they are not risk free but this approach has had few complications in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Subnuchal Skull Implant

Q: Dr. Eppley, I am interested in a custom implant in the subnuchal region of my occipital skull. I know that fat grafting is another options to augment this area due to the neck muscles attaching to the skull there. My questions are what are the possible complications could be, and if you have seen these types of complications in any of the other skull shaping patients you’ve operated on.   Hypothetically, in my case, I believe that such an operation could involve clearing/removing a 2cm width band under and parallel to the nuchal ridge on one side before in order to have the implant attached.  Would this have a severe effect on head and neck movement and/or cause long term pain?

If this is not a viable option I’m curious as to whether an implant could be placed in a pocket over the muscles/tendons and not directly against the skull.  I have read that implants used in other areas (ie. breast implants) are at times placed within or over muscles and are not secured to any hard body structure. Could an implant be placed in the subnuchal area over the tendons, thus avoiding their separation from the skull? Subsequently if there was an implant placed this way, and if a portion of the implant extended to an area of the skull without/ not covered in tendons, could it then be attached there? Alternatively is there a method of fixation to the skull that could occur through the tendons (i.e., with screws) to secure an implant in place. I ask this after reading of non-secured implants causing erosion of tissue with micro-movement over time.

At this time I am willing and able to pursue a surgery if there could be an intervention that was safe effective visually and that is stable over time. I would be grateful for any input you may have.

Nuchal Ridge Implant Dr Barry Eppley IndianapolisA: Placement of a subnuchal skull implant for low occipital/upper neck augmentation would have to be placed on top of the muscular fascia as opposed to under it against the bone. Stripping the muscular attachments off the bone is associated significant discomfort and  recovery of neck motion. Once in the subcutaneous tissue plane between the skin and the fascia the implant will generate a layer of scar around it which will keep it in placed. (much like a breast implant)

Greater occipital nerveThe only anatomic risk of placing an implant in this area is the greater occipital nerve. Fortunately this nerve lies under the muscular fascia and does not common through until higher up over the bone.

Dr. Barry Eppley

Indianapolis, Indiana

How Big Can Skull Implants Be?

Q: Dr. Eppley, I called you last week regarding my upcoming skull surgery with Dr. Eppley. I was wondering if there are clearly defined size restrictions on the silicone implant. My head is small all the way around so I’d like to augment both the front sides and the back. However I’m not sure if this would be possible without tissue expansion. Presumably, the answer would depend on how much I wanted to augment each area, so I’m wondering if there are some kind of numerical limits on that. 

I am primarily concerned with augmenting the frontal sides, so I need to figure out how much width I would need to sacrifice there in order to be able to do a little bit of an increase in the back as well. This is not something I would want to guess on or eyeball, so a little more clarification would be really helpful. 

Additionally, I want to make sure that if for any reason I have problems with the implant, I can get it removed quickly and for a small/ reasonable fee. I’m sure I will love it, but I just want to know that it can be removed if I really hate it for any reason. 

A: Your assumption that there are size limitations for skull implants based on how much the scalp can stretch is a correct assumption. Unfortunately there are no established methods or means to determine what that limit. It is exclusively based on my experience in doing skull implanty procedures. If the implant is being placed through an open coronal approach, the scalp does become fairly ‘stretchy’ and good numbers are about 7mm to 9mms all the around. That may not sound like much but in skull implants which cover a broad area that effect can be quite profound and more than one would think.

The beauty of silicone skull implants is that they are relatively easy to place and reverse if desired.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Skull Augmentation Material?

Q: Dr. Eppley, Hi. I have about a half inch of bone loss in my parietal regin going all the way to the back of my head and bone loss in my back of my head. I saw that you performed an implant on some with a similar problem with silicon. I wanted to know if there was anything else available because I don’t feel comfortable about putting silicon in my body. Would fat transfer work or would you recommend something else. I have had this problem for years, but hair is thinning out and I am not able to cover it up like I used to. Thank you!

A: There are lots of different materials that can be used for skull augmentation or fill in of defects.The one major issue with all of them is that wide open exposure is needed to apply them to the bone site. In other words, a long scar across the top of your head. The reason that custom silicone implants are one of the most popular forms of skull augmentation is that they can be placed through much small and more discrete incisions and do not run the risk of any contour or edge transition problems. There are no effective injectable methods of skull augmentation. While fat can be injected, its survival is highly unpredictable as well as how smooth it might be. (which it wouldn’t) But there are no adverse effect from using fat other than how well it may or may not work.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Implant Material For Forehead and Back Of The Head Augmentation?

Q: Dr. Eppley, I have few question regarding forehead augmentation and back of the head augmentation. I would appreciate your kind answers to each of them one by one.

1. Which procedure is more durable, bone cement or implant?

2. Can you please tell the advantages and disadvantages of each?

3. Is it possible that bone cement is filled without cutting the scalp, so we fill the scalp by injection three to four time(interval of ten days) and it may increase the whole head size?Because i fear of cutting scalp and tissue expander. 

4. Is bone cement strong enough like skull bone?

5. Which procedure do you recommend?

A: For forehead and occipital (back of the head) augmentation, there are two basic materials that be used…bone cement and preformed implants. In answer to your questions:

  1. Both material are equally durable. Neither can degrade, be broken down or will ever need to be replaced because they ‘wear out’.
  2. Each material type has its own unique advantages and disadvantages. Bone cements must be mixed, applied and shaped during surgery thus taking more operative time to do. Preformed implants are made before surgery off of a 3-D CT scan of the patient’s skull. By computer design they provide the best and most symmetrical augmentation with the least risk of any irregularities at the implant-bone transition areas. They can also be done with less operative time. From a cost standpoint, they are roughly equal.
  3. With either approach, a scalp incision is needed. There is not injectable cranioplasty technique for this size of skull augmentation areas. There is no need for a tissue expander with your dual augmentation.
  4. The resistance to fracture is roughly equal between PMMA bone cements and skull bone.
  5. I find both procedures can make for successful skull augmentations. The choice between the two is a matter of personal preference and which one sounds better for each patient. Both type of forehead and skull implants can be done very successfully.

Dr. Barry Eppley

Indianapolis, Indiana

Will My Skull Augmentation Need A Tissue Expander?

Q: Dr. Eppley, I am interested in skull augmentation I was wondering if you ever use an inflatable under the crown of skull to inflate skin so you can have more room to shape head? My niece needed an inflatable on her leg when she was young, which they used when they removed cancerous skin. I believe they can do this if area on skull needs extra skin to cover cement. If you do this, maybe you can tell he how much and my procedure can be a two step procedure. If I can pay for this and come back when time for procedure to correct and reshape flat areas. Please let me know. Not sure what the procedures are called but I may need more serious fix and may need more room for reshaping.

A: When it comes to skull reshaping or skull augmentation, you are referring to a two-stage approach initially using a tissue expander. For larger amounts of skull augmentation, particularly for a flat back of the head, more scalp is needed. A small scalp tissue expander, slowly inflated over six weeks, creates more than enough extra scalp tissue to cover any degree of augmentation desired.

Dr. Barry Eppley

Indianapolis, Indiana

How Effective Is Skull Reshaping Surgery?

Q: Dr. Eppley, I’m currently struggling with a flat back of the head and a small head too. Can skull reshaping surgery be done on me to add any implant to mainly the back and top parts of my skull that would give me a decent sized head that is also well rounded ? How effective is this surgical procedure and what are the possible negative effects of any implant on my actual skull?

A: Skull reshaping (augmenting a flat area) can be done to almost any part of the skull and its limits are based on how much the scalp can stretch to accommodate the volume of augmentation. Based on what one’s expectations are, it can be a highly effective procedure. I would have to see some pictures of your head that show the flatness and then do some computer imaging to see if what skull augmentation can do is sufficient. It is always important before surgery to find out if the changes meet a patient’s expectations and to determine how much volume is needed to create that augmented effect.

There are no known long-term effects of the materials used in skull augmentation as it relates to the bone or the overlying scalp tissues. Bone resorption is not known to occur nor is scalp thinning over it.

Dr. Barry Eppley

Indianapolis, Indiana

After Skull Reshaping Can One Play Contact Sports?

Q: Dr. Eppley, I am interested in skull reshaping for a flat spot on the back of the head. My son is twelve and has a noticeable flat on the back of the right side of his head. He has not said anything about it yet. In preparation for the possibility of coming to see you, I have an important question. Does getting kryptonite mean he will never be able to play contact sports such as football again?

A: Skull reshaping that involves building out flat or depressed areas is done by applying a bone cement material on the outer aspect of the skull. In answer to your specific question, kryptonite as a cranial augmentation material is no longer available and has not been so since late 2011. In answer to your general question, augmentation of the occiput (back of the head) would in no way preclude one from participating in form of sporting activity including contact sports. The strength of the cranioplasty material up against the rigid skull bone makes for a very hard construct that has the same strength as that of natural skull bone. This makes it highly impact resistant to the infrequent contact to the head that may occur in most sports.

Dr. Barry Eppley

Indianapolis, Indiana