Your Questions
Your Questions
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
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
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
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
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
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
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
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
Indianapolis,Indiana
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?
Thanks
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
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
Indianapolis,Indiana
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
Indianapolis,Indiana
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. Besides 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
Q: Dr. Eppley, My question is about the appropriate age for my son’s skull surgery. I wasnt to get the flat back of his head fixed by an onlay cranioplasty procedure that you have described. He is now 18 months old. Should I wait until my son is older?
A: There is no right or wrong answer to that timing of surgery question. Such 'cosmetic' skull surgery in a child is unique because they are not in a position to pass judgment about the value/benefits of the procedure. (and they won't be for a long time) Thus it requires the parents to determine the merits of the skull reshaping procedure as they look at the child's long lifespan and their psychosocial development. While that is not that helpful, you have to look at the magnitude of the skull deformity and determine if improving it early justifies surgery. It can be done at anytime as age is not a criteria (beyond 18 to 24 months old) for the surgery. You just want to be sure that the deformity has no chance to improve on its own with future skull growth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son is 5 years old and has undergone a craniectomy of the right parietal skull bone which is quite large when he was 4 years old. We want to know which cranioplasty procedure would be best for him, bone cement or autologous bone transplant from the adjacent side of the skull? He is otherwise neurologically fine with no functional or developmental deficits.
A: To give a very specific answer as it relates to your son, I would need to know some more information about his defect including reviewing a CT scan and see pictures of him. But I can make some general comments about skull reconstruction in children. When you have large skull defects in young children, the reconstuction options are somewhat more limited because you really don’t have the ability to use a cranial bone graft. While a cranial bone graft, what you call an autologous bone transplant, can be done you essentially would be ‘robbing Peter to pay Paul’ do to speak. In children the skull is not think enough to harvest a split-thickness cranial graft. This using a cranial bone graft just creates the same problem you are trying to solve somewhere else. Thus one is forced to use a variety of synthetic methods for the skull reconstruction. These could include bone cements (resorbable and non-resorbable), metal meshes (one I wouldn’t do), and a assortment of synthetic implant material that are either preformed or custom-made from a CT scan. (e.g., HTR-PMI) There are advantages and disadvantages to all of these synthetic approaches and that needs to be discussed on an individual case basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, how much does cranioplasty cost, ranging from the lowest to the highest cost? In addition, can you make my eyelashes and eyebrows thicker by doing hair transplants?
A: In answer to your questions:
1) The cost of cranioplasty can vary significantly based on what type and size of skull problem is being treated and what meterial may be used if augmentation is being done. But for the sake of some general cost ranges, it can vary from $6500 to $15,000. To better answer your question, I would need to know more specifics as to your skull concerns.
2) Eyebrows can be thickened with hair tranplantation techniques. The use of single follicle transplants are used with anywhere from 50 to 200 eyebrows needed per brow.
3) Eyelashes are best thickened and lengthened with the use of the topical drug, Latisse. This popular drug is well known to increase lash length by 30%, thicken the shafts by 30% and make them grow faster. Essentially, Latisse for eyelashes is like Rogaine for scalp hair. If one has no eyelashes at all, hair transplants can be done but it rare to do so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few questions about cranioplasty for my infant son.
1) I’ve read when it comes to cranioplasty, if done correctly and of course by the right surgeon, the scar would be generally “fine” not thick and the hair would eventually regrow on the scar after healthy healing, any truth to this theory?
2) If my recollection serves me correctly, I read when you inserted Kryptonite it was basically sort of like rolling the dice for the most part, because you didn’t EXACTLY know how it was going to turn out. It was basically a wait and see approach. Is it like this with the approach of inserting material in the skull? Or you pretty much have a good general idea by measuring and/or imaging of what it’s possibly going to look like before the surgery?
3) Since my son needs augmenting on the top of his head (right side) to correct/improve the head height differential, and also needs the reconstructing of his parietal bone, can this be done with one incision? Or you need 2 incisions?
4) For cranioplasty the scar will be approx. 4 inches correct (give or take)?
A: You have wisely and correctly interpreted what you have read. All four assumptions are correct.
1) Scalp scars in infants tend to be very fine. I would not always assume that hair will growth through the scar however.
2) Open cranioplasties do not generally have the contour/smoothness issues that are associated with an injectable approach because you can see what you are doing.
3) Only one incision would be needed.
4) The scalp scars are generally not longer than 8 to 10 cms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, regarding the skull augmentation will the bone cement be set beneath the periosteum. Could that involve any risk of “osteolysis”? Could the bone cement be put on the periosteum instead? Thanks!
A: Your question is an interesting one and is only relevant based on the type of cranioplasty material that may be used. When using any of the hydroxyapatite (HA) formulations, you definitely want to be under the periosteum for two good reasons. First, the material does bond directly to bone with no risk of osteolysis and you want to take advantage of this biologic benefit. Secondly, if HA materials do not bond to the bone they will ultimately be unstable and may likely shift position afterwards and develop fractures or fragmentation of the materials at their feather edges. When it comes to poly methylmethacrylate (PMMA) cranioplasty material, this can be placed on top of the periosteum and will set up and will likely not shift or fragment afterwards particularly if microscrew anchorage is used. PMMA materials, unlike HA, do have a known and low risk of settling into the bone a little bit and are what you refer to as ‘osteolysis’. But this is not a particularly progressive process and is self-limiting. Conversely, I have greater concerns for its effects on the overlying scalp and tissue thinning. Therefore I think it more important to provide as much barrier between the material and the overlying scalp tissues as possible and would recommend staying beneath the periosteum for this important long-term reason.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My skull shape is rather problematic. I have a weak forehead (probably about 1 inch), the problem is that the top of my head is not round, there is a noticeable gap, once you hit my hairline, my skull goes flat, it isn’t until about 2 inches further that there is a slope where it increases. I could upload and send you pictures so you can see. Would it be possible to actually build up that ‘missing’ forehead? My other question involves my face width from ear to ear. With the weak forehead, and noticeable cheekbones, and jaw…they add up to making it appear as if I am fat. Other than removing buccal fat, is it possible to shave off some of that and moving the bones further in to reduce the width? Thank you for your time.
A: I would first recommend that you send me some pictures for my assessment. But to provide some general comments, the forehead can definitely be built up with cranioplasty material. The buildup can be extended back up into the skull area. This would need to be done through an open coronal (scalp) approach. When it comes to the face, however, such bony width reductions are much more limited and unlikely to be able to do what you want to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a severe skull shape problem that has been with me all my life. My skull is weirdly shaped like an alien. I am tired of being made fun of because of my head shape. I have seen a few doctors by they all say that nothing can be done and I should just live with it. I know you are an expert in this area so I thought I would ask you as no one else seems able to help. Attached are some pictures from different angles.
A: Thank you for sending your pictures. The shape of your skull appears to be the result of a congenital sagittal craniosynostosis condition that has been undiagnosed and untreated. This explains the very long, higher and narrow head shape that you have. Unlike the surgery done as an infant for this condition (take the bone apart, some of it completely off and put it back reshaped), that approach can not be done as an adult. The best that can be done now is to reshape the skull somewhat from manipulations on the outside. This would entail some reduction of the prominent midline ridge and some reduction contouring of the forehead. The sides would then be built up to make it wider. This type of cranioplasty requires being done through an open scalp incision for access to all of the skull areas. This would provide some definite improvement although it can never be an ideal or perfectly normal shaped skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have a normal shaped-head. I have neurosurgery two years ago and the bone flap had to be taken out and frozen due to brain swelling afterwards. It was put back in at a second operation but as it healed it became very uneven. I have dents and visible screwheads throughout my entire forehead. One of the screws also became loose and had to be removed later. Also my forehead is so narrow and looks like an alien. I just want to look close to what I used to before the accident, a more normal shape head with noindents and bumps sticking out. You can see in my forehead photos how unusual my forehead looks.
A: The re-implantation of skull bone flaps, while necessary, is often fraught with bony resorption and irregularities. In addition, the metal hardware used to place it often become visible or loose as you have experienced. The good news is that vast improvement can be obtained by an onlay cranioplasty. Using your original scalp incision, the bone can be re-exposed, all existing metal hardware removed and the entire forehead and skull area covered and built up in a smooth and symmetrical fashion using any of the several available cranioplasty materials. This is a highly successful procedure that is not associated with any of your prior problems with bone flap replacement surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been doing a lot of research to find out ways to fix an indentation I have on the left side of my skull and I read on your website about a procedure that you do using kryptonite bone cement to reshape irregularities in the skull. These irregularities were caused from birth. I would like to send you some pictures to see if my problem can be corrected using this method. Also other then overcorrection are their any other risks with this type of surgery? Another question I have is does insurance cover it, or is it considered purely cosmetic.
A: Of the available cranioplasty materials, Kryptonite is no longer available for use. The company that produced it has withdrawn it for any further sale currently. Therefore, there is no longer any injectable approach to skull augmentation or indentation correction. An open cranioplasty incision would be needed to place any of the other cranioplasty materials. Other than the scar, minor contour issues remain as the only risk. Skull reshaping or indentation correction is not a procedure that would be covered by insurance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a bone cement for 10 months on my forehead and this was done by my neurosurgeon. He had to elevate the depression on my forehead and on my frontal sinuses due to an accident 10 years ago. I am planning to learn mixed martial arts in a few months but I am worried that my bone cement will get hit and break. Is my bone cement as strong as the rest of my skull? Thank you very much!
A: The term ‘bone cements’ refers to a family of synthetic materials that can be used for cranioplasty purposes. Historically, this used to refer to the material PMMA or acrylic which has been used for over fifty years in cranioplasty surgery. This is still a very common material that is used by many neurosurgeons in particular. It is mixed together and creates a very strong composition similar to what most people known as plexiglass. This would resist any type of trauma much like normal skull bone would do. In the past decade new cranioplasty materials composed of various forms of hydroxyapatite have emerged which are also known as hydroxyapatite cements (HAC) or bone cements. These are not nearly as strong and are much more brittle. These are more likely to fracture if exposed to trauma.
Your cranioplasty was an onlay or augmentative one in which whatever material was used was placed on top of existing but depressed skull bone. This is much more supportive of the cranioplasty material than if it was used to replace a full-thickness cranial defect so impact resistance is greater regardless of the material used.
If you had a PMMA cranioplasty I would have no concerns whatsoever about sustained implacts. If this was a HAC cranioplasty, however, I would be more cautious.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in building up the back of my head. It slopes backward and is flat and makes my head look asymmetric and unbalanced. I have attached pictures so you can see that the back of my head slopes downwards in an abrupt manner. By adding a round and nice piece my head would maybe look normal and my ears would even look smaller. But I have a few questions:
- So what would be the next step for me?
2. Seen from the pictures, do you assess that significant scalp stretch is required?
3. What if I’m active in sports and wrestle alot ie, is there a risk of misshape in the future?
4. What method do you feel is the most adequate for my head?
5. Would hair transplantation be necessary?
6. What is the recovery time?
7. What are the approximate costs?
I am aware that there may be scalp scars but that’s less severe than the current situation.
A: In answer to your questions:
1) The next step is to have either a phone or Skype consultation. This would be the best way to go over the different cranioplasty methods and their advantages and disadvantages. No cranioplasty method is perfect and each patient make make their choice based on good information. I have done occipital cranial augmentation by every conceivable method so I am very familiar with each of them and their indivdual pluses and minuses.
2) Stretch of the scalp is always needed because the material occupies space. The question is how much stretch can the scalp safely do. That is what limits how much material/augmentation can be achieved.
3) All cranioplasty materials set up and become solid like bone so no deformation will occur later with impact or trauma.
4) The best method for you require your understanding of each approach.
5) I do not envision hair transplantation being needed for the scar later.
6) The recovery is quite quick, being just a few days.
7) The cost will depend on the technique used, which is yet to be determined. The costs could range from $6500 to $9500 depending upon what cranioplasty material is used.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year old male. Seven years ago I was diagnosed with a right frontal lobe tumor and underwent craniotomy. The procedure went well and all has healed medically well. However the bone flap due to the nature of the cutting process sits slightly lower than my normal skull. Not by a huge amount but about 2-3mm at the most, but is noticeable. I am wondering if cranioplasty can be performed to build a couple millimeters on the flap and thus smooth the forehead/skull? I already have an incision scar in the hair bearing area which starts in the top centre of the forehead and extends to just behind/above the right ear. I presume this can be re-opened. The bone flap is fairly well aligned just above the ear, but towards the top and front, slightly lower. It is the step in the visible part of the forehead which is of most significant in improving. Can you able to advise on possibility, risks, and estimated costs? Much appreciated.
A: An onlay frontal cranioplasty will solve the forehead contour problem of your bone flap very successfully. Using your old scar, the area to be augmented can be easily accessed and built up. While there are a variety of cranioplasty materials to use, and that selection affects costs, I would prefer to use an hydroxyapatite paste material which hardens shortly after application. That would be the most ‘natural’ material to use that would serve you best over your long remaining lifetime. This would be a one hour procedure done under general anesthesia and the estimated total costs would be in the $7500 to $8500 range.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 24 year-old male seeking help and guidance about my head shape. I have caphocephaly which was untreated from childhood and now as an adult I find the appearance of my head very troubling. I am concerned in particular about the temporal hollowing and frontal bossing of my head shape. Is there something that can be done about this?
A: As you have well described, you have a classic case of mild to moderate scaphocephaly with bicranial narrowing from front to back with a midline ridge. While the bone can not be changed at this point, there is room for substantial cosmetic improvement through cranioplasty techniques. I envision a cranial reshaping procedure in which some of the midline ridge from the forehead is reduced but, more effective, would be augmentation in the parasagittal areas from the forehead to the top of the head. This would produce some greater width or roundness to your forehead and frontal skull. Due to the volume of material needed, I would use PMMA for cost purposes. This would need to be done through a bicoronal incision in the hairline. The temporal narrowing could be partially improved by either extending the cranioplasty into the upper temporal area or placing temporal implants in the subfascial plane.
While you can not completely correct the skull and forehead narrowness, substantial improvement can be done which would be enough to no longer be seen as having scaphocephaly.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am curious about the use of hydroxyapatite or kryptonite bone cement for the use of building up areas of the cranium that are asymmetrical. Is hair loss something that occurs over the area where either of those two materials would be applied or is hair growth unaffected by having those materials placed onto the cranium?
A: Hair loss is not a potential complication of any cranioplasty procedure. I have been asked this question many times and it is an understandable concern.The blood supply to the scalp is extensive as the scalp is one of, if not the most, vascularized skin structures on the body. More pertinently, the scalp is tremendously thick often being 1.5 to 2 cms in tissue thickness. The hair follicles reside just under the skin in the top layer of the scalp, being in the upper 10% to 20% of its thickness. When raising a scalp flap for any cranioplasty procedure, the entire thickness of the scalp is raised off of the bone. Thus the plane of dissection and flap elevation is far away from where the hair follicles may be injuried. The only risk to hair follicles is in the making of the scalp incision not in the raising of the scalp flap or from the cranioplasty material underneath it. Such limited damage can be avoided by careful angulation of the incision, not using cautery in the upper level of the scalp and in careful scalp incision closure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley I am just wondering how I am able to fix the dent in my forehead above my brow bone? I want a more smoother look. How much would the procedure cost?
A: You are referring to the area above the brow ridges where you would like it to be more smooth and confluent as it goes upward into the upper forehead. That is a common request amongst females that I get. This involves adding material above the brow bone so that it creates a flatter, or even a convex shape, to the forehesad area. This has to be done through an open scalp (coronal incision) That cost for this type of frontal cranioplasty procedure is in the range of $8500. Several features influence the cost of the procedure including the type of material used for the cranioplasty procedure. (hydroxyapatite vs. kryptonite vs acrylic) This is an outpatient procedure that usually takes about 2 hours to complete. There would be some swelling of the eyes afterward as gravity pulls swelling downward. The trade-off for this forehead improvement is a permanent fine line scar in the hairline and some slight permanent numbness of the scalp near the incision line.
You may feel free to send me some pictures of your forehead for my assessment and your suitability for this procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a problem with the whole upper back of my skull, it is quite flat. It is not hereditary because my other brothers and sisters have normal skulls. I wonder if my mother had me always lying on my back on a pillow during my infancy. Thus far I have always been able to camouflage it by back-combing my hair and using spray to add volume but now, with age, it isn’t very easy anymore. It is constantly on my mind and I was considering the purchase of a wig. I will and never have gone with my head under water at a pool or ocean. Could enough material during a cranioplasty be added to make a difference given that there isn’t that much loose skin back there?available. Have you had much experience in that particular field? From what I read on the internet, most women are rather more interested in a derriere augmentation.
A: While the scalp does feel fairly adherent, it does move more freely than you would think once mobilized in the subgaleal plane. With wide undermining (the entire scalp can be easily undermined) and scoring of the galea, some laxity of it can be obtained. For the back of the head, you can probably build out the bone by cranioplasty but about 1 to 1.5cms at the center (tapering to the sides of the skull) and still get good scalp coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello Dr. Eppley I am a 25 year old male who has been through several extensive surgeries due to craniosynostosis as a child. The last reconstruction surgery done was when I was 18. Unfortunately my Dr. wasn’t as concerned with the cosmetic outcome as I was. I feel that my head is to narrow both from ear to ear and back to the forehead. Additionally my forehead has irregularities and is not proportional. I feel that I need to widen my entire skull, giving it more girth. Augmenting the back of my skull, as well as the sides, starting in my temple regions, then along the front of the forehead so that my eyebrow line is defined rather than flat.
Also during surgery they left me with a 1.5″ wide scar from ear to ear. Towards the top of my head it actually creates a deep groove. Last but not least, I feel that my hairline is extremely close to my eyebrow line, and my left temple area of hair grows too far in towards the middle of my forehead. What would need to be done to improve all my skull imperfections and correct the proportions of it? Is there a way to make my scar smaller or vanish possibly by cutting along onside and folding my scalp over it? Finally, can I bring back my hairline and fix the side area as well? Since these are all things cause by a brith defect/disease what if any could possibly be covered under insurance?
A: Based on your concerns and objectives, I think it is possible to provide improvement for some but not all of them. Nor could whatever can be maximally done occur all in one surgery. Adding material to your skull (cranioplasty) is often best done for the forehead and front of the skull which is the most aesthetically visible. This should be your primary focus. While material can be added to the back of your skull, you can do not both front and back at the same time. Your coronal scalp scar may be able to be reduced depending upon how tight your scalp tissues are. It can certainly be narrowed, it is just a question of how much. Your concept of de-epithelization of the scar and advancing the other portions of the scalp over it for closure is the correct approach. Changing the position of your frontal and temporal hairlines, however, is not realistic as there is no procedure to really make that happen other than how the hairline may change slightly with the scalp scar excision and closure may cause.
Whether insurance will cover such a procedure must be determined by a process known as pre-determination.
Indianapolis Indiana