Your Questions
Your Questions
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: Dr. Eppley, I have a question about Kryptonite bone cement. Can it be used to build up the jawline. I was born with hemifacial microsomia and my jaw on one side is short not very full. My bite has been corrected by a jaw osteotomy previously but the overall side of the jaw is still small and too thin. Would this be a good use for this type of bone cement material? Also what would happen it is got infected after surgery?
A: Kryptonite bone cement is FDA-approved for all craniomaxillofacial bone applications whether it is as an inlay, onlay or any combination thereof. Therefore, it is appropriate to use it as an onlay augmentative material for the mandible or any other facial bone for either reconstructive or cosmetic indications. So it could be safely used for jaw onlay augmentation.
Having 20 years experience as a craniofacial plastic surgeon with a lot of experience in biomaterials in the craniofacial region, Kryptonite has a very steep learning curve with its use. It handles completely different than every other bone cement material used in craniomaxillofacial surgery. It would also be a challenge in getting into a site with difficult access such as the jawline. What I have learned in complex cases like yours is to first get a 3-D craniofacial model made from a CT scan. Then use that either to premake the desired implant for other synthetic materials or use it sterilized during surgery to custom make an implant intraoperatively out of Kryptonite. This will help tremendously in getting the best contour shape and in its placement.
Once an implanted material gets infected, Kryptonite or otherwise, antibiotics will not usually solve it. The material must be removed to cure the infection. The material is simply inoculated, particularly a porous material, and you can’t get rid of the bacteria with drugs alone. They will only provide a temporary amelioration of the infection which will return as soon as the antibiotics are stopped. Clearly this is a problem to be avoided which is why I always mix in antibiotic powder with any bone cement material in the preparation process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in kryptonite bone cement treatment as a craniomaxillofacial treatment for a small skull deformity. I have an area just below my hairline where there is a bonelike material that protrudes a few mm from the rest of my forehead and is unsightly but doesn’t hurt at all. It happened after an accident a few years ago. Can kryptonite be injected into the surrounding area to make the surrounding area more natural in appearance? If so how much? And what are the likely complications?
A: While I don’t know exactly what your skull area of concern looks like, the use of injectable Kryptonite can work very well for small skull contour problems. Done through a small incision close to the skull defect, it can be injected into and around the area of bone irregularity as an onlay contouring material. The biggest challenge with its use is to get an absolutely smooth contour and not to overcorrect the problem or build out too much of a contour. Other than that this is a very simple technique with very little to no real recovery, particularly in such small skull areas The cost of the procedure depends on the size of the defect and the amount of material needed. I would need to see a picture of the problem to determine the suitablity of an injectable skull contouring approach and an accurate estimate of the cost.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have consulted Dr. Eppley before about jaw implants and noticed in a recent article that he is using Kryptonite Bone Cement that is injectable. Could this be used to augment the jaw or cheeks and chin instead of having a full blown surgery? Just curious if it can’t because if it can be used in skull recontouring the use for facial recontouring seems like a logical extension of its use. After all, bone is bone and why would it not adhere to the jaw/cheeks/chin as well?
A: Currently, the use of Kryptonite Bone Cement as an injectable method is for skull recontouring only. While in theory it could be used for facial augmentation (cheek and chin implants) as well, there are two major problems with this application. First, the material must be injected and then shaped by external molding. Making a flat shape on a skull by using external digital molding can easily be done, trying to make a more complex shape like a cheek or a chin is another material.Whatever shape you get after four minutes after injection is what it will permanently be. To adhere to bone the periosteum must first be raised just like an implant. Injecting onto the bone does not make go under the periosteum alone. If he material does not completely go under the persiosteum and adhere to the bone, it will rock and be mobile. Secondly, the cost of Kryptionite is 10 to 20X what a facial implant will cost. For the skull, all competitive materials cost thousands of dollars in material cost as well. For the face, however, facial implants are far less expensive and have established shapes that work. It simply is not cost effective for the patient to use Kryptonite for facial bone augmentation, even if it worked just as well.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I have a son that is 3 and a half years old. He has plagiocephaly, the back right side of his head is flatter than the left. From a birds eye view his head appears somewhat crooked. I have read about injectable Kryptonite and was wondering if my son would be a candidate for this. At what age would he be able to have this procedure? Thank you so much for your time!
A: Thank you for your inquiry. The use of an injectable cranioplasty technique using Kryptonite Bone Cement for improving the skull contours in children and adults with plagiocephaly is new and the first cases of it are just beginning to be done. It is a very simple procedure that, just like an open cranioplasty, adds material on top of the deficient skull bone to build it out. Its advantage is not only its simplicity but that it avoids a long scalp scar and a more extensive operation. The age at which it can be done is really determined like any cosmetic procedure, when the patient (pr parent) feels that it is warranted and the effort is worth it. It really could be done any age as long as the child is healthy and the parents feels the problem is significant enough that it would be in the child’s long-term interest. Given its simplicity, there really is no significant recovery afterwards. The material within a day becomes just as hard as the surrounding skull bone and can not be displaced or deformed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m a male in my thirties and I would like to have surgery to give my orbital rim and forehead a more masculine (protruding) appearance. I had a craniotomy 3 years ago which has left a dent on my forehead which I would like to eliminate. I understand that solid HA is more porous than the moldeable putty type which would allow tissue growth and ossification. I would like to know answers to the following questions. 1) In order to make my forehead more prominent would it be possible to use 3-D CT scan technology to customize a solid HA implant instead of using moldable HA paste? 2) Could the customized HA implant be made with an interior mesh to make it less brittle? 3) Would a customized HA implant in solid form be easier to work with than HA in paste? 4) Could using a solid HA implant present problems such as fluid accumulation, visible borders, migration or extrusion. I thank you for your time.
A: Thank you for your excellent and thoughtful cranioplasty questions. I can answer of your HA cranioplasty questions by saying that I really don’t use the HA pastes anymore. In their day they were state of the art and they were wonderfully moldeable, but they are brittle. This is no different that HA blocks or HA custom implants which actually are just as brittle and much harder to work with. The newest and more improved cranioplasty material is Kryptonite Bone Cement. It offers easy molding and shaping into the defect, sets up and gets just as hard as bone, and is truly porous (unlike most HAs which are not except the blocks) which allows tissue ingrowth. This is clearly the superior cranioplasty material and eliminates all of your stated concerns and questions.
Therefore, based on these working properties of Kryptonite, HA is no longer used and a 3-D CT scan model is not necessary beforehand since there is no advantage to making a pre-formed implant. (which is now a disadvantage and very costly)
I see no problems at all doing forehead and orbital rim augmentation and any contouring of a forehead indentation with Kryptonite Bone Cement through your existing scalp scar and open approach.
Indianapolis, Indiana
Q: I am very interested in learning more about the Kryptonite Bone Cement for injectable cranioplasty. I am a 36 year old female with a very unusual shaped head in which I have always hid behind various hairstyles for shame of the overall appearance of my head. I strongly believe that the shape of my skull may be the result of some form of untreated craniosynostosis or other undiagnosed craniofacial disorder. Or maybe it might just be plain old bad genes.
My skull is very narrow and somewhat small. The shape of my forehead slopes back at such an undesirable angle and is very flat and narrow in width. The resulting slope of my forehead extends up into the top of my skull of which I can only describe as a point. There is somewhat of a flatness in the center of my skull and the back of my skull is very flat and extremely narrow in width as well. I am also very hollow in the frontal view at my temple area around my eyes with very wide cheekbones and a deficient jaw and chin. I have always wondered if there were any such cosmetic procedure that could help in this kind of skull case.
My questions are: 1) What are the biggest benefits of using the older PMMA and HA methods over the new Kryptonite Cement method? How long has Kryptonite Bone Cement been used? 2) Can it be used for adding volume to reshape an entire skull like mine, making it more rounded and add mass in largely deficient areas? 3) Can it be done with scalp hair in place or does the hair need to be shaved for a better view of the entire head? 4) Is there any chance that the material will become detached from the skull and slide out of position? 5) Will the scalp expand and conform to the newly added volume comfortably? 6) Can it be used in place of such procedures as chin and jaw implants?
A: Thank for your insightful questions in regards to your craniofacial concerns. My answers would be as follows. 1) All three cranioplasty materials will work in an open scalp approach. Only Kryptonite can be injected. There are substantial cost differences between the material cost of HA and Kryptonite being over 10X the price of PMMA. For very large scalp areas, the issue of cost makes PMMA the only practical choice for most patients. 2) All the materials can be used over large skull areas. In larger areas, the cost of PMMA makes it the material of choice. 3) For large skull areas, the hair would have to be shaved to see what one is doing. For an isolated forehead cranioplasty, the hair is not shaved. 4) No, all cranioplasty materials stick quite well to the underlying bone. 5) The scalp can expand to a large degree but the skull must not be expanded (built out) greater than what can be closed over it. 6) No as yet. Kryptonite has not been yet tested for use in this way. For now, standard facial implants are more predictable and far less expensive.
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
Q: I read in Dr. Eppley’s blog about using Kryptonite Bone Cement for pectus excavatum. I had the Nuss procedure done 5 years ago and breast implants done 4 years ago. I got very good results with the procedure and implants with the lower part of my ribs; however, the upper area (below the collarbone) is still indented. I would like to inquire about this procedure and whether or not I would be a viable candidate.
A: Kryptonite bone cement is a new type of bone filler/replacement that works well as an onlay, meaning to build out a bone surface to create a better contour. Currently it is approved in the United States for cranioplasty, the filling in or building out of skull bone contours. While it has never been formally tested for use on the sternum, there is no reason to think that it would not work just as well there as on the skull. What makes Kryptonite a possibility in the sternum is that it can be injected after it is mixed before it sets up into a hard mass. This is a very unique characteristic of a bone cement and no prior ones have ever had this physical property. As valuable as that material property is in the skull, it becomes a critical material characteristic in the sternum as incisions of any size are easily seen there.
For an upper sternal problem, a small incision inside the sternal notch can be used to develop the subperiosteal/supraperiosteal pocket. It is into this pocket that the material is injected and molded. The critical step in injectable sternoplasty, like injectable cranioplasty, is to make a good recipient pocket that matches the external outline of the contour defect.
Indianapolis, Indiana
