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