Your Questions
Your Questions
Q: Dr. Eppley, Six months ago I had a small dent on the top of my head repaired using an injectible cranioplasty technique. Since then, I have noticed a small piece has broken off and the implant is a bit more raised then I expected. The doctor that performed the procedure said that it may feel raised for up to a year and we should readdress it at that point. I’ve read a lot of your articles and in hindsight I should have come to you for the procedure. However, I must deal with the issues as they are. My questions to you are: is it normal for a piece to chip off? Should the area be slightly swollen up to 6 months? What are my repair options?
A: Thank you for your inquiry. Can you tell me more about this injectable cranioplasty technique. What material was used and how was it injected? While this is a complication that I have not seen, I could envision it occurring depending upon the material. It could only really occur with a hydroxyapatite cement material not with PMMA bone cement. But more likely than not it is not a broken off piece of material. It likely is an edge or surface irregularity that has become apparent as the swelling subsided and the scalp tissues adhered back down. Since this takes months to occur, the visible edge may not have been seen for awhile. What you see now is not going to go away. If it is just only one area, a small incision directly over it to remove it would seem the logical approach. Also a small incision can be used to introduce a rasp to smooth the material down if it is an hydroxyapatite
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in injectable skull augmentation. I heard there is a different technique to fixing a flat head with an injection and without the need of scarring. Is this true?
A: The simple answer is that there is really no effective method of injectable skull augmentation that really works. Injectable synthetic fillers and even fat can be injected but they are not permanent, can not add significant volume and can not make a smooth contour or shape. Injected fat has received some notoriety recently as a forehead augmentation technique but the tissues in the scalp are very dense and do not provide a good injection plane to get the same volumetric changes that can be achieved in other places like the face, breasts or buttocks.
They are injectable methods (really minimal incision) of cranioplasty where the scalp tissues are lifted and the pocket above the bone made for the augmentation material. Then through a small incision, a bone cement material can be injected through a tube in the pocket over the skull bone deficiency and molded into shape from the outside. While this allows a cranioplasty to be done in an essentially scarless manner, this technique is plagued by the potential for irregularities and palpable edges. I have used this injectable cranioplasty method numerous times and I still consider it a technique in evolution. Its use at this time should be reserved for select skull deficiencies and a motivated patient who is willing to accept the aesthetic risks associated with it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 48 years old and have thinning hair on top to the point of shaving it all off. Unfortunately, I would describe my skull as having an embarrassing mild case of some type of craniosynostosis. In simplest layman’s terms, it could be described as having a dip where the soft spot was. In a little more medical terminoligy, it appears that the coronal sutures (which can be seen) move forward from the center instead of lateral or straight across. Towards the front from there, a dip shows where the anterior fontanelle was. I realize that only a very limited diagnosis can be done from this description without photos or an office visit, but if any of these questions can be answered, it may be in my interest to further pursue treatment. After reading some of your blogs, it sounds like there may be some type of injection that can be used (instead of surgical implant. Is this true? If so, what does it entail….how good and permenant are the results or what are the side effects?; Are there scars left? Is that something that can be done as an outpatient procedure? Can it be done in one visit? What is the complete process of steps to do from start to finish? Do you have an approximate cost? Do you know if any insurances would cover such a procedure? An implant is probably out of the question, but that may be the only option.
A: Your fundamental question is whether an injectable cranioplasty may be an option for your skull deformity. Bt description, you have what I term a large skull ‘dimple’, a circular depressed area somewhat like a crater. They often occur where the original anterior or posterior fontanelles were and represent delayed or incomplete fusion of the bone. (usually just a contour deformity where the four bone edges merged to close the soft spot) You are correct in assuming that an open cranioplasty with the application of an hydroxyapatite bone cement to recontour the area would be the perfect skull contour solution. However, a larger scalp incision in a balding male may have its own aesthetic issues so the pursuit of an injectable approach has merit.
The concept of an injectable cranioplasty should not be confused with that of traditional injectable fillers for aesthetic facial applications. It does require a very small incision which is necessary to lift up the adherent scalp tissues around the bone defect and to make a pocket for the injectate to be placed. What makes it injectable is that the characteristics of the bone cements are such that they can be placed through this small incision by a syringe or tube and molded into and around the defect by hand from the outside. Thus, an injectabr cranioplasty is probably better termed a ‘limited incision’ cranioplasty as it relates to the surgical access and not just the flow characteristics of the bone cement material.
An injectable cranioplasty is a fairly simple procedure done in a one hour procedure under general anesthesia. There is very limited recovery and no physical restrictions after surgery. General cost ranges would be between $4500 and $5500 for the procedure. This is not a procedure that would be covered by insurance since it is an aesthetic skull contouring and is not provided any functional improvement. While almost all such skull dimples are partial-thickness contou defects, it never hurts to get a preoperative 3D CT scan to clearly visualize the skull defect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 23 year old male with an indentation on the back left area of my skull. It has been there as long as I can remember. It is made worse by the the fact there is a slight bone protrudence to the right of the indent. I have no idea if it is congenital or not. This is clearly visible when my hair is cut short and I am looking to get it fixed. I have attached pictures so you can take a look. I have done a little research and discovered kryptonie, the bone cement and was wondering if that would be an option, or would you recommend something else? I have seen a plastic surgeon in where I am from but he’s not too sure if he could even help. I stumbled across your website and from your previous work, I am very interested in your opinion and setting up a consultation/procedure. I would much rather prefer to make only one trip if possible. I would like to know what are your thoughts on my skull and have you ever dealt with a case like mine before? Would a large incision with scarring be the only way to go about fixing this? Also, what is a rough estimation to what it would cost? Thanks so much for taking the time to read my email.
A: Your pictures show a skull indentation directly over the original site of the posterior fontanelle. This is where the back soft spot was as a baby that did not develop enough skull bone thickness as that of the surrounding skull when it fused. That indentation has probably been there since you were one or two years of age. That is why you have it and I have seen it and treated it before. Basically it is a simple indented skull area that can be built up and smoothed out. The key question is what is the best way to do it. It can be made absolutely smooth and level through a longer open incision but that is understandably not desirous due to your close-cropped hair. That leaves the other options of a minimal incisional approach (maybe 1 to 2 cms) which would allow the indented scalp soft tissues to be adequately elevated from the bone and through which some material could be used inserted. Understand that an injectable technique does not mean incision free, it means that the material as the ability to flow through tubes (not needles) and thus only a small incision is used to place it. This is best thought of as a ‘minimal incision cranioplasty’. Kryptonite as an ‘injectable’ material is no longer commercially available to do this so that leaves us with two other options, PMMA or OsteoVation. There are minor advantages and disadvantage to each material which can be discussed later. Both are liquid and powders that are mixed into an initially runny material which allows it to be pushed into a pocket by syringe created over the bone indentation after the release of the attached soft tissues.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am looking to fill the dent in the back of my head to achieve a more normal, round head. My flat spot/indentation is very obvious and noticeable from certain angles. It is located in the back left side of my head, a bit higher and closer to the top of the head. The dent leads to another minor flat spot right where the head curves from the top to the back. What I would like is an injectable cranioplasty operation and suggestions if there are any better options. Also, what is the recovery process of the operation? Thank you very much and your feedback and insight is tremendously appreciated.
A: Injectable cranioplasty is a technique that I have developed to avoid any significant scalp scarring with limited build-ups of the skull. Small back of the head indentations/flatness are the most ideal areas. The concept is based on having a cranioplasty material that is liquid enough during its initial mixing that it can be injected and then sets in a reasonably short length of time there after. A small one inch is needed to lift the scalp tissues off of the bone and develop the desired recipient pocket. It is through this small incision that the material is injected. Once injected the material must be molded into shape from the outside through the scalp. While Kryptonite was initially the material I used, it is no longer available as the manufacturer has withdrawn it from the market. (the reason I do not know) I am now working with another calcium phosphate material, OsteoVation, which I actually like its handling properties better.
While the injectable cranioplasty approach certainly has its appeal, it is not without any downside. Its biggest drawback is that getting the material smooth is a blind procedure and rarely does it ever become perfectly even. The other issue with it is cost. These materials generally cost 2X to 3X more than conventional PMMA cranioplasty material which needs to be placed through an open incision. (about 9 cms) The guarantee of optimal smoothness shape requires an open cranioplasty approach.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am giving serious consideration to getting cosmetic surgery to reshape my skull. I have an compressed area on the top right/middle section of my head near or along the coronal suture. The distorted area is roughly about 2 in by 3 in. It hasn’t been much concern for me until now that I am losing my hair. I found your page and now have hope that I won’t have to feel embarrassed every time I take off my hat for the rest of my life. My ideal plan is to have a one time low maintenance fix. I saw some of the work on your websiteand it seems very good and I think that you might be able to help me. I have attached a few photos from a couple different angles so you can see the indented area. Ideally, I am looking to simply smooth it out and make my head symmetrical without a dent or a bump.. However I’m not all to sure on the technicalities of the procedure or if it’s as simple as I’m hoping. I would appreciate your honest opinion as to whether the risk of the surgery might cause more off looking results, like a bulging area or something? I’m more than sure you a very busy person but all the information you can offer me would be appreciated. Having this surgery is a huge, potentially life changing decision. Even more so considering it is on my head and I will have to display, see, and live with the outcome. Let me know what you think.
A: Thank you for sending your pictures. I can see clearly the indentation across the top of your skull. The best and only way to treat this would be with an injectable cranioplasty approach. An open approach would leave a scar that I would not consider an acceptable trade-off. The injectable or minimal incision approach would use two very small incisions (about 1/2 to 3/4 of an inch) on both ends of the indentation. Through these, the material (Kryptonite) can be injected and molded. These incisions would heal up and be virtually undetectable later. This is a fairly simple procedure to go through with minimal pain and swelling afterwards. The only caveat to the simplicity of this approach is how even and smooth the augmentation would be. Since it is a blind procedure, all material molding is done from the outside by hand by pushing on the scalp as it sets up. As you have mentioned, it would also be important to not place too much material so the area does not become a ridge instead of an indentation. That is the artistry of the procedure. A good question is what is the likelihood of having a contour deformity that may need a secondary touch-up or rasping? In my experience so far, it has been about 50%.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hey! I have large indentation on the right side of my frontal bone. It is becoming noticeable since I have started losing my hair. I am wondering if it is possible to correct it without any visible scars. Thanks and.hope to hear from you soon.
A: For select cranial defects, the use of the new Kryptonite bone cement may make it possible to fill out or augment deficient bony areas. Because of its flow characteristics, it can be injected through long small plastic catheters into cranial areas from a small incision placed in the most inconspicuous location as possible. Studies have shown that it is injectable through catheters as as small as a 12 or 14 French size. (roughly 4 to 5mms internal diameter) Once injected it can be molded through the skin from the outside until it steps up into a firm consistency.
When defects are present on the frontal bone, it is important to recognize the exact location if this injectable technique is to be used. Defects that exist between the anterior temporal lines are bone-based and can be augmented by onlay bone materials. If the forehead defect extends beyond the anterior temporal line, this area is covered by the upper edge of the temporalis muscle. While the temporal muscle can be lifted up and material added onto the bone, this is not possible with a limited incision injectable treatment method. Defects that extend into the temporal area require the more traditional open scalp incision for access and wider exposure.
Indianapolis Indiana