Q: Dr, Eppley, I am interested in a cranioplasty procedure.I have a depression on both sides of my skull and the back goes in little also. I have thick hair which covers it up. but, it really bothers me. I’m not sure how my skull go the way it did. but I would like to know if its can be fixed and is it safe. I was also reading about Osteobond from another plastic surgeon. what do you know about that…. thanks.

A: There are two cranioplasty materials to fix skull depressions/contour issues, bone cements (like Osteobond) or a custom silicone skull implant. Having done hundreds of skull augmentations, I have largely moved away from bone cements for many aesthetic skull augmentations due to access and contour issues with them. To properly place bone cement materials, a long scalp incision is needed. This is the only way to place and properly smooth out the intraoperatively applied and shaped bone cements. Putting such bone cements in through small limited incisions is prone to a near 100% irregular contour occurrence. The large the skull augmentation the bigger this contour problem becomes. Custom made skull implants solve these problems by being perfectly smooth (because they are computer designed) and can be placed through smaller incisions than bone cements. While both cranioplasty materials can be successfully used for your described skull shape issues, it is important to understand how and why they are different.

Dr. Barry Eppley
Indianapolis, Indiana

Skull Implant

Q: Dr. Eppley, I am interested in a skull implant for my child. What is the youngest age you would fit a pediatric skull implant to a child? Can it be done under local anesthesia?My son is three years old.. He has plagiocephaly of 6mm and 92% brachycephaly. Would he be suitable for a skull implant? Would he need more surgery as he got older? How many children have you fitted with head implants? Many thanks for your time.

A: I have done onlay cranioplasty surgeries in children as young as 4 years of age using hydroxyapatite bone cements. I have yet to use a silicone skull implant in someone that young although there is no specific medical reason not to do so. It is just a request I have never had. An onlay skull implant would grow with the child as the bone underneath it expands outward. There may or may not  be some settling of the implant into the bone a e] millimeters as the skull grows but this is a passive process not an active inflammatory or ‘erosive’ biologic event.  If his occipital deficiency is 6mms I would preferentially consider preferentially consider bone cement but I am not opposed to an implant. Either way these are not procedures done under local anesthesia in children. Please send me a picture which shows his occipital plagiocephaly deformity.

Dr. Barry Eppley

Indianapolis, Indiana


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

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 Eppley


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