How Can I Fix The Dent In My Head Without A Bad Scalp Scar?

Q: Dr. Eppley, I’m a Caucasian male in my mid-twenties.  I had an unfortunate accident in my late teens in which I fractured my left parietal bone.  At the time, I wasn’t particularly concerned about it – I don’t  think I realized the severity of it.  Now, a few years down the line, I’m balding and I have a dent in my head.  Coupled with my hair-loss, it’s something that I’m very insecure about.  

One of the first things that I did after I decided that I want to do something about it was to see a neurosurgeon.  He sent me for CT scans, which showed that the parietal bone is indented and that the bone around it, towards the top of my skull, is raised.  The dent is very obvious, as is the fact that the back of my skull, on the left side, seems to protrude further outwards than the right.  I  feel that it gives my skull a lopsided appearance.  The neurosurgeon said that he could fix it, but that the scars that it would involve would not be a worthwhile trade-off; it may look just as bad, if not worse, than the dent.  I also saw a plastic/reconstructive surgeon – one of the leading craniofacial surgery specialists in my country – about the dent.  He gave me the option of injections using either fat or cosmetic fillers; neither of which would be permanent.  He also advised me against surgery, due to the scars that it would leave.  I don’t want to go the fat/filler injection route, since it is only temporary, and it will not do anything to fix the lumpy bone that surrounds the dent.

My questions, therefore, are as follows;

1.)  Is there anything that can be done that would fix both issues (dent and lump) without significant scarring?  I am hoping that one can remove some of the bone (it should be around 2 – 5 mm’s, by my estimates) to smooth out the lump and restore the normal contour of my skull.  I can imagine that this would not be trivial since it involves that back of my head where the bone “rounds” down towards both the back and the left side of my skull.

2.)  If surgery is an option, can bone by removed from the lumpy area and placed in the dent, or would a bone cement of some sort be used, regardless of whether or not bone is removed from the lumpy area?

3.)  How bad will the scarring be, in the event of surgery?  I found a blog (tracysigler . com/brain-surgery-experience / this-is-the-end) while I was doing my research.  Does that image offer a good benchmark of what a healed scar would look like?

The attached images shows my issues. 

Perhaps this question may also be of benefit to others visitors to your website.

Thank you kindly for your time.

A:  Thank you for your inquiry and sending your pictures. While an open approach could obviously be done to create the optimal contour skull contour through a combined reduction of high areas and filling of the defect with bone cement, one has to be careful of the scar trade-off. I have done many open cranioplasty procedures through more limited incisions (5 cms.) in that very area and the scar can be acceptable. (ironically many of these have been done on men that actually shave their head. So I would not rule out that incisional approach. I think why other surgeons have not been enthusiastic is that they were envisioning a larger more traditional coronal incision which would obviously create an aesthetic trade-off that would not put you in a better position.

The other concept to consider is an injectable cranioplasty approach just for filling in the defect. Through a small 1 cm incision, the tissues can be lifted up over the defect (pocket creation) and a bone cement introduced through a tube into the defect space and molded from the outside until set. That would certainly fill in the defect in the most minimally invasive manner in regards to the scar.

Dr. Barry Eppley