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

What Craniofacial Surgery Procedures Does My Grandson Need?

Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his  face and skull. My friend found your contact details in the Internet. I have a few questions to you:

1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the  maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?

2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?

3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.

4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?

Thank you so much for your reply.

A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.

While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.

From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.

From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.

The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Do You Shave Hair For An Occipital Cranioplasty?

Q: Dr. Eppley, I have a few questions regarding occipital cranioplasty. the back of my head is kind of flat and it’s been bothering me since high school. As I get older I notice that it gradually get flatter, to a point where I don’t tie up my hair anymore because I am so self conscious about it. Now that I am 36 years old and am financially capable of fixing this problem, I am contemplating on getting the surgery done.

Below are my questions:

1. If I decide to have the occipital cranioplasty done, will I have to shave all my hair off for the surgery? 

2. Since I will have extra material at the back of my head will it affect the growth of my hair or the health of my scalp?

3. What are the possible side effects of the surgery?

4. Do you have patients who already had the surgery done for solely aesthetic purposes? And are the cases with these patients successful?

5. Where is the best place to have the surgery done? ( country/state/doctor)

Your advise will be much appreciated.

A: Thank you for your inquiry. In answer to your questions

1) No hair is ever shaved to perform an occipital cranioplasty.

2) Any placement of material on the skull bone does not affect the growth of the hair or the health of the overlying scalp tissues.

3) While infection is always a concern when any material is placed in the body, that is not a problem I have yet seen in cranioplasty. The most common side effects for any form of cranioplasty are aesthetic is the material smooth, even and symmetric? Was the buildup enough?

4) Most skull augmentations that I perform today are done exclusively for aesthetic purposes. The most common type of aesthetic cranioplasty that I perform is to treat a flat back of the head.

5) I can not speak for who else in the world performs aesthetic cranioplasties, I only know that I do.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Depressed Skull Fracture Be Fixed?

Q: Dr. Eppley, I incurred a closed depressed skull fracture from a head-butt when I was 22. I am now 28. The depression in my skull has bothered me emotionally since it happened and I have some physical pain too (I feel like there is constant pressure on the area). When I participate in rigorous physical activity (such as running) I get severe head aches. I hope to get surgery to elevate the depression and was interested to know more about possible procedures.

A: If you are having symptoms of headaches and pain from your depressed skull fracture, the first thing you need to do is to consult a neurosurgeon to be certain that there is no undue pressure on the brain. While I would doubt that is the case after this many years, it would be an important first step to do. That is the only reason that the skull fracture would be elevated and that will require an open craniotomy to accomplish. If your neurosurgical work-up is negative then the depressed skull area can be treated for its cosmetic appearance by an onlay cranioplasty to build up the outside of the bone. A skull fracture is not elevated by craniotomy for a cosmetic change only.

Dr. Barry Eppley


What Is The Typical Cost Of Correcting A Flat Head?

Q: Dr. Eppley,  growing up I have been called all sorts of names, but the one I hated the most was flat head. I eventually grew my hair out as an adult and spiked it out or make it poofy in the back. I never thought it was possible to get your skull reshaped until I came upon reading your page, and taking a look at a couple of your operations. My head is flat posterior parietal to the occipital bone. I’m an Asian male, and not everyone has it, but it’s highly common in our race, but I absolutely hate it. I been wondering about the price of operation, and maybe consider it in the future. I have many times down myself into seeking this operation, or even research about it. I have a couple pictures of my head to show, but not sure where to put picture attachment. Please respond back, thank you.

A:  Thank you for your inquiry. About one-third of the patients that I perform surgery on for correction of a flat back of the head in one area or the other are of Asian descent. So I recognize the ethnic component to it. I would be happy to review any pictures of your head which you can attach as a reply to this e-mail. The typical cost range for an occipital skull augmentation procedure would be in the $7500 to $9500 range depending upon the volume of material needed and the time to

do the procedure.

Dr. Barry Eppley


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



How Much Material Is Needed For My Predicted Skull Augmentation Result?

Q: Dr. Eppley, I am interested in surgery to improve my skull shape, I would just like to clarify some things first. You mentioned 60 grams of PMMA to obtain the predictive image results which would indeed be quite good for me. However I’m wondering if this quantity would be enough to make this aesthetic difference. Indeed I’ve read that PMMA has a density around 1.2 g/cm3, thus 60g of PMMA would have a volume around 50cm3, which seems to be quite small (I checked with 50g of water).As you’re quite experienced with skull aesthetics, do you think this would be enough in my case, and are you positive that the predictive image is obtainable? Maybe it would be preferable for me to have a first stage to stretch the skin, then have a bigger implant inserted? Please excuse my uncertainty, I’m trying to find the best option I have. I have seen one of your skull reshaping surgeries on your blog of a 42y old man with a flat spot much like mine. Do you remember what kind of surgery he had? Thank you for your help and advice.

A: I can certainly appreciate your volumetric computations of the biomaterial mass. But one aspect of that assessment that is missing is how any implanted volume of material translates into a change in external appearance. One thing I have learned over the years is that small volumes can usually make a much bigger change that one would think in many cases. In other words, one can easily be fooled in seeing how something looks in your hand than when it is implanted in the human body. The use of 60grams of PMMA in skull augmentation is usually the upper limit of how much the scalp can stretch over a skull augmentation without undue tension.  With longer or more full coronal incisions, one may be able to get up to 90 grams of material implanted as the scalp flaps are more fully mobilized. In your case, I would much rather take this approach as I do think that somewhere in the 60 to 90 gram material range should be more than adequate to achieve the predicted result. The patient to which you refer in the blog had 25 grams of PMMA implanted for that unilateral occipital skull augmentation result.

Dr. Barry Eppley


Can The Sides Of My Skull Be Built Up Even Though There Is Muscle There?

Q: Dr. Eppley, my question is regarding your last article about cranioplasty. Near the end you include the following statement: “The limiting factor is that the narrow skull beyond the temporal lines can not be augmented with material as it is covered with temporalis muscle.” I’m considering having a cranioplasty for enlargement (aesthetic reasons, exclusively) and you are my first option to having the procedure done but I would like to have the aforementioned area enlarged as well as all the others. I would like to know if there’s a solution for this.

A: The normal anatomy of the skull is that under the scalp across the top (between the temporal lines) is only bone while at the sides there is a layer of relatively thick temporalis muscle under which the bone lies. Whether it is a cranioplasty that involves temporal skull augmentation or bone reduction, the temporalis muscle must be considered and managed. There are two basic approaches when extending skull augmentation beyond the temporal lines down along the sides. The first approach is to leave the muscle alone and merely place the material on top of the temporalis fascia. When so doing, it is critical to feather the material to a very tapered edge to avoid a palpable or visible edge demarcation. This approach is best used when the amount of material/augmentation that needs to extend beyonf the temporal line is minimal. When more substantial augmentation is needed that extends further down into the temporal region, a submuscular approach is used. The upper edges of the muscle are released and the material is placed undeneath it. The key to this approach is that the muscle must be resuspended back up over the material to the temporal line as much as possible. This is done by suturing the upper edge of the temporalis fascia to the material as close as possible to the original temporal line.

Dr. Barry Eppley

Indianapolis, Indiana

Is Fixing A Flat Spot On My Head Realistic?

Q: Dr. Eppley, This may be a very very unrealistic but part of my head is flat and I am 21 years. I was wondering whether there was literally anything you could do to improve it at all. I am willing to pay anything for it. Maybe even a material to fill some of it in. Any ideas would be great.

A: Skull augmentation/modification is a very common surgery in my practice. One of the most common reasons that it is done is for flat areas of the skull, usually on the back part. The realistic part of this surgery is not whether it can be done but whether enough change can be done to make the procedure worthwhile. The limiting factor in all skull augmentations is how much the scalp can stretch to accomodate the expanded skull contour. I will need to see some picture of your head and the area of concern to determine if this may be a procedure for you.

Dr. Barry Eppley

Indianapolis, Indiana