Your Questions
Your Questions
Q: Dr. Eppley, I was surfing the web when I came across your blog. As I was reading I got excited in hopes that you could be help for me. I am 35 yrs of age and all my life I have avoided anyone touching my head or getting my hair wet in public places such as a pool. The reason is that one side of the back of my head is flat. I think the medical term for it is deformational plagiocepahly. The back of my head is flat, my left side to be exact. In addition, my forehead is somewhat flat as well. This condition has severely bothered me. Growing up as a child was difficult, I had plenty jokes directed at me for the shape of my head. I have used a blow-dryer most of my adult life to camouflage this area as best I can. I would hope that you can help me. What can be done for it?
A: You are describing deformational plagiocephaly to a tee… a twisting of the skull during growth that creates a flattening on the back of one side of the head and a similar but more modest flattening on the opposite forehead. In severe occipital flattening in adults, I have performed cosmetic skull reshaping through an onlay cranioplasty technique. Most cases of a flat back of the heads have their locations up high above the ear level. Through a small vertical incision, the bone can be built up using either hydroxyapatite or acrylic. (PMMA) There are some advantages and disadvantages to either material and they need to be reviewed carefully with the patient. But the surgery is fairly easy to go through, one’s recovery is very quick, and the results are immediate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long pointy head that is completely abnormal. It has looked this way since I was born. I have managed to get along in life and be a very productive person at 30 years of age. But I always wear a hat and never let anyone see me without it. My other brothers have completely normal head shapes. I would do anything to have a more normal head shape and live a more normal life. I know you have a lot of experience in reshaping of skulls, so I am very interested in your recommendations. I have attached pictures of me with a closely cropped haircut. Please help me.
A: Thank you for sending all of your pictures and describing your situation. I have great empathy for your head concerns. It appears you have a rather classic case of undiagnosed and untreated sagittal craniosynotosis. The AP cranial dimension is long, the transverse cranial dimension is narrow and there is frontal bossing which is wider than the occiput. This condition is rare to see in adults these days since almost all of them are treated as infants with the advent of widespread craniofacial surgery since the 1980s.
First, let me start off by saying what can’t be done. The traditional approach to sagittal craniosynostosis is complete cranial bone remodeling. But that can only be done in infants where the bone is very thin and pliable and one can work with the molding influence of the growing brain. As an adult, such a procedure can not be done as the bone is too thick and not pliable, the extent of surgery and the bleeding would have a high risk of significant complications, and there is not growth of the brain to fill the underlying dead space that is created.
While the bone can not be removed and reshaped, a camouflage skull reshaping approach can be done. This would consist of some burring reduction of the sagittal ridge and the frontal bossing and augmentation of the parasagittal skull and temporal regions. The combination of these reduction and augmentation procedures, while not making any shortening in the cranial AP dimension can give an improved appearance to the skull shape. I have attached some imaging which I think is achieveable.
To embark on this cranioplasty approach, good treatment planning is needed. This would consist of getting a 3-D craniofacial CT scan and then have an exact skull model made from it. It is off of this patient-specific skull model that the exact dimensional changes can be planned and the volume and shape of the needed implants fabricated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to ask if it is possible to reduce the width of head? The width of the upper part of my head above the ears is big on both sides. Is there any possibility to reduce it? I am 30 years old and it has bothered me my whole life. Thank you for taking the time to answer.
A: The thickness of the side of the heads is influenced by both bone and soft tissues. The area directly above the ears is part of the temporal area and the thickness of the underlying temporalis muscle can have a major role in its thickness. The influence of this muscle decreases as one gets closer to the transition of the skull from a vertical to a rounder more horizontal orientation as it thins out. Depending upon where the bulge or too wide portion of the side of the head is located, some reduction is possible. I have performed successful reduction in this area by releasing and resecting the posterior portion of the temporalis muscle and some outer table skull burring. This can make for a 5 to 7mm reduction per side, which could be mean up to a 1.5cm reduction in head width. If the extreme width of the head extends more superiorly, then not as much reduction can be done and the procedure may not be worthwhile to undergo.
Indianapolis, Indiana
Q: I’m a 6 year old male looking to remove a bump on my skull bone on the back of my head. I believe this skull bump resulted from a forceps delivery during my birth. I had an MRI of my head done and it came back normal. This is something that has plagued me psychologically all my life and I’m looking for any options to improve the appearance of the back of my head. I’ve provided photos of the back of my head. As you can see from the pictures, aside from the bump, there is also a ridge that leads to the more protrusive bump. I look forward to your assessment.
A: Thank you for making the effort to take the pictures. They are more than sufficient. What you have are two specific occipital bony uprisings, one ‘abnormal’ and the other a natural part of the occiptal skull bone. One is a small round bump at the top of the occiput which is a small osteoma or benign bony ‘tumor’ That can be burred down through a small vertically-oriented incision over the bump measuring about 3 cms. or just slightly bigger than an inch. Incisions in the hair-bearing scalp in men heal remarkably well and would eventually be such a fine line scar that it would be virtually undetectable. The horizontally-oriented bony ridge across the bottom of the occiptal skull bone is known as the nuchal ridge. It is where the top of the neck muscles attach to the lower edge of the occipital skull bone. It is raised and visible, as it is for some people, for unknown reasons. It may be raised because of the need for a strong bony attachment for the neck muscles. That can actually be reduced by burring down the ridge but the issue is incisional access. It requires a linear horizontal incision across the back of the head along the nuchal line, probably of a width of about 5 cms. Either skull reshaping procedure can be performed alone or in combination. Either way it is an outpatient procedure under general anesthesia that would have a minimal recovery. The incisions would be closed with tiny dissolveable sutures and one could shower and wash their hair after two days. There would be some temporary swelling which would go away in two or three weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 30 year old male and I have a flattened skull at back, which I understand to be plagiocephaly. This has until now been fairly well-covered with hair, but I am beginning to recede at the temples, and so I am becoming increasingly concerned about it, should I go bald. I am therefore interested in exploring possible treatments- I hear you offer a cranioplasty procedure involving injectable kryptonite? I would be very interested in hearing more about this- in terms of how successful/established the procedure is, likely cost and potential risks. Any information you could provide would be really useful. I appreciate it may be difficult to provide a concrete answer without a full consultation, but any general information would be really useful.
A: I would seek out any postings that I have written using Kryptonite cement for skull reshaping which would appear on a Google search. I have written extensively about it and all of your questions would probably be answered there. In summary, it is a developing technique that is far from perfected with the biggest complication being irregularities and the potential need for a smoothing revision. But it is a simple one hour procedure that involves minimal recovery using only a one inch incision. The cost of this cranioplasty procedure is largely driven by the volume of the material that is used. The cost of the material will easily make up more than half of the cost of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hi Dr. Eppley, my question is about the Kryptonite used on plagiocephaly. My 3 yr old son has plagiocephaly with a very flat head which is a little asymmetrical. I have been told that his head is still growing and changing and that it could improve, but I don’t think so. In the past year and a half it has actually gotten worse. I want to know with his head shape if Kryptonite could be a great option for when he gets a bit older. Also are there any side effects? Does it cause irritation of the skin rubbing on the Kryptonite? His head also has a bit of slopping and is more narrow towards the front of his head. I’ve attached photos. Also with the amount of Kryptonite, how much would you say for his case if he is a good candidate for the procedure. Thank you!
A: Injectable Kryptonite cranioplasty can be a good option in the treatment of plagiocephaly because it helps build out the flatter side of the skull through a minimal incision approach. It is an onlay cranioplasty technique that causes no irritation to the underlying bone or the overlying skin. The biggest risk of this cranioplasty method is some irregularities of the augmented area given that it is done without visible molding or contouring of the material. In looking at your son’s photos, I would estimate that the total amount of material needed is about 10 grams, at most 15 grams. The material does expand as it sets so less is always needed than one thinks.
Indianapolis, Indiana
Q: I am a 24 year-old male. I believe that I might have sagittal synostosis (scaphocephaly) and it has been quite a burden throughout my life. Furthermore, I have an extremely long face. I know that options are very limited for adults but I wanted to explore possible solutions (if any) to perhaps lessen the deformity. I am not sure whether the risks or thr trouble of surgery is worth and this is what I want to dicuss with you.
A: Thank you for your inquiry and photos. Scaphocephy refers to a horizontally long but narrow in width skull shape that is seen most prominently in the forehead. Ofthe this type of skull shape has a bulge in the upper forehead as well. In looking at your pictures, I can shortcut to the final conclusion fairly quickly. The risks and trade-offs of surgery are not worth it for you. You do not have enough of a ‘problem’ to justify any surgery so your assumption is correct. Your skull is not that deformed to merit a scalp or coronal scar to do some bone burring. It is best to put these concerns behind you and move on with life…and feel fortunate that whatever bothers you is not significant enough to justify surgery. Many patients are not quite so fortunate with their skull and forehead concerns.
Indianapolis Indiana
Q: I have a 3 years old with mild plagiocephaly. I’m very interested in kyptonite injection to correct that problem in the future. Here’s my question about that technique: what is the method you are using to determine where (on the head) and how many (what quantity) kyptonite you will inject? Can we see a proposed “corrected headshape” before the procedure?
A: The determination of where to place the injectable cranioplasty material is determined before surgery by what everyone feels is the flattest area on the back of the head. That area is marked out prior to surgery. The location and size of the area to be filled in is a joint decision between the parents and myself. The amount of Kryptonite material needed is the greatest variable and the real guesswork in doing the procedure. What I know from experience is that 5 grams is inadequate and 20 grams would likely be too much. Usually 10 to 15 grams of material is needed. But the diameter of the defect is measured and then a benchtop test is done to determine whether 10 or 15 grams is best prior to surgery. Computer imaging is also done based on a superior view of the back of the head to get a prediction as to what may be obtained. It is important to realize that computer imaging is a prediction and not a guarantee of the exact outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am studying to become a radiology technologist at a local community college and I am preparing a powerpoint presentation on the skull. I’d like to play Dr. Eppley’s HTR/PMI Cranial Implant Reconstruction video as seen on YouTube during my classroom presentation to demonstrate current medical procedures to repair and reconstruct features of the skull. Can I please have Dr. Eppley’s permission to show his video to my class? Also, I’d like to inform my audience to what extent x-ray and fluoroscopy C-Arms are used in HTR/PMI cranial implant reconstruction cases since these are the devices we are learning to use. Does Dr. Eppley use fluoroscopy C-Arms during these surgical procedures to assess placement of the implant? Thank you for your consideration.
A: You may certainly feel free to use my HTR/PMI video for your classroom presentation. Hopefully it will add to the value of your presentation. This method of reconstruction of large cranial defects uses a custom implant (PMI = patient matched implant) fabricated from a polymeric bone substitute known as HTR. (Hard Tissue Replacement) The implant is fabricated from a 3-D model from a CT scan taken from the patient so it is an exact fit to the skull defect. The operation for implant placement is done in an open fashion, meaning the scalp is reflected and peel back for wide exposure. Since the implant is placed under direct vision, there is no need to use any radiographic method such as a C-arm to ensure a precision fit.
Indianapolis, Indiana
Q: Hola por favor diganme si colocarse silicona solida en la parte de atras d la cabeza es bueno o malo? si mas adelnate de dañara cual es el costo y en donde puedo hacermelo,xfavor diganmee!! tengo la cabeza plana y tengo 20 años esto me ha molestado toda mi vida!! ayudaaaa xfavorrrrrr
A: A solid silicone implant is not a good idea for the back of the head for correction of flatness or asymmetry. However, an acrylic or PMMA cranioplasty is a better idea and is commonly used. This is placed through a scalp incision where the acrulic mixture is placed, shaped, and allowed to set before closure. One could anticipate a total surgical cost of around $7500 when done as an outpatient procedure.
You may feel free to send me some photos of your head for my assessment to see if this is a good procedure for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: The back of my head is very flat. As a child in school, they used to make fun of me because the back of my head was so flat. While I want to wear my hair short, I can’t because it becomes really apparent. I have attached some pictures showing how flat it is. Because of my longer hair, I have drawn a line indicating the actual shape of my head beneath my hair. I want to add up to an inch to the whole backside of my head to give a more rounded shape. Do you think it is possible with the Kryptonite material and not having to make a big incision across the back of my head?
A: Thank you for sending your pictures. It is easy to see, even with your hair, how flat the back of your head is. Yes it is possible to build out the back of your head with a minimally invasive cranioplasty technique using Kryptonite. However there are several caveats about the outcome with this cranioplasty method. The build-out of your skull can not go below the lowest level of the occipital bones which is about at the mid-level of the ear. (you can feel how high the end of the occipital bone sits with your fingers. Most people think that the bone goes much lower than it does. Any cranioplasty material can only be put on bone not muscle. A skull build-out of as much as an inch may be too extreme due to scalp expansion issues, a more likely result is 1/2″ to 3/4″ at the very center. (midline)
Dr. Barry Eppley
Indianapolis, Indiana
Q: How much would the injectable Kryptonite bone cement option cost. A ballpark figure would suffice, thank you.
A: The cost of injectable cranioplasty varies greatly based on the size area of the skull being treated and the amount of Kryptonite material that is being used. The actual cost of the Kryptonite material from the manufacturer is tremendously expensive and can potentially make up to 25% to 50% of the total procedure cost. The best ballpark that I can can give you is anywhere between $ 6,500 up to $12,500. The best way to get a more accurate answer is to send me some pictures of your skull or forehead concerns so I can see the size area involved.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a question about reducing a bulge on the side of my head. I have cranial/skull assymetry and wanted to know if I can get the side of my skull shaved down/reduction a bit so I can get a more even look on both sides. The right side of my head sticks out more then my left, it’s noticible expecially because of the close cut haircuts I love to get. Is shaving down or skull/cranial reduction possible or an option? I have attached some pictures of my head from the front so you can see it. It is fairly obvious I think. Thanks, hope to hear from you soon.
A: What is you have is skull asymmetry caused by a bulge in the temporo-occipital bulge region or side of the skull. It is actually a combination of fullness of the back end of the temporalis muscle and the front edge of the occipital bone where the two actually come together. Both are easy to reduce, and need to be reduced to get the narrowing effect, and about 5 to 7mms of reduction/narrowing can easily be obtained, maybe more. There is no danger to the procedure nor is there any risk to any nerves in so doing. The issue of whether this is a good procedure for you or not is completely about the vertical scar running over the bulge to do it. The scar is the only risk in doing what is otherwise a fairly simple procedure. Given your close haircuts, it is a question of the trade-off of a more symmetrical skull versus that of a fine line scar when considering a skull reduction procedure.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Doctor Eppley. I’m a 19 years of age male and I have a mild flat spot on the back of my head. It’s not that bad but I would still like to know if it’s possible to treat it and be able to achieve good aesthetic results and shape it to be more round. Also, I have read some questions and answers of people that have have a similar problem, and you responded by saying that this problem can be treated by using regular cranioplasty making a large incision, or by injecting Kryptonite with a much smaller incision. What is the difference between the two, in terms of healing process, reliability, aesthetics? etc. Is the surgery going to leave any visible permanent scars? I’m really looking forward for your response.
A: By your own description, you have a mild depression on the back of your head. That would indicate that an open form of cranioplasty with causes a long scar would not be an appropriate solution. With that approach, the treatment may cause a worse aaesthetic problem (scar) than the area of skull flattening. That leaves you with the option of the injectable Kryptonite approach. That uses a very minimal incision and the resultant scar is never an issue. It is a minimalist procedure with very little reovery. The material sets up with the consistency of bone so it is very stable and impact resistant. The only potential issue with this approach is trying to get a nice smooth round profile which for just one side of skull flattening is very achievable.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had considering having a revisional PMMA cranioplasty as I am dissatisfied with the results of my first one. There are bumps and irregularities across my forehead. I have been advised before that getting a flush integration of the material to the bone, with respect to the edge of the material and the surrounding bone, is difficult to accomplish. This is evident in my current implant where I can really feel the edge of the material especially around the top part of my head where there is very visible indention where the material is raised from the rest of my head and also on the right lateral portion of my forehead where there is a large visible lump. Without considering the presence of the scar, this visible raised portion makes wearing my hair short impossible. If you were to perform secondary cranioplastic surgery can you achieve a smooth finish with the implant and surrounding bone and how would you address the problem of tapering the existing PMMA material. Would you shave it down? Remove it and re-apply? Add more material to surrounding bone and then feather it off???
A: The key to getting a good edge and smoothness of PMMA in a revisional cranioplasty is to add it, allow it to set, and then using a handpiece and burr to carefully feather and smooth all edges. While it is tedious to do and causes a lot of shave debris, it is essential to do this step. You must have perfectly smooth edges that blend perfectly in all directions or you will have visible edges later when the swelling goes down. Even though the scalp is thick and seems like it would hide any bumps or edges, it will not once the swelling goes away and the skin contracts down to the implanted material. One has to remember that the skull is smooth for a reason, even if one doesn’t like its original shape.
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: I have had forehead reshaping surgery about a year ago with PMMA resulting in a very unsatisfactory result. None of the areas I was concerned with have been addressed and there is significant visible irregularities as a result of the surgeons incompetence at the task. I wanted to know how long I should wait before seeking revision surgery? I would ideally like to have it nine months after the first surgery. Also how would the existing material (PMMA) affect how the surgery will be performed? Is there a greater risk of infection or is the surgery going to be significantly more difficult??
A: Sorry to hear of your unsatisfactory outcome from your cranioplasty procedure. From a technical standpoint, you could have revisional surgery at any time. There is no advantage or disadvantage to doing it now or years down the road. The material is set and stable and can be smoothed and rehaped, or added to, at any time. There is no increased risk of infection or increased difficulty in performing the procedure at any point. Revisional cranioplasty, when PMMA is the indwelling material, is actually slightly easier to do as the scalp tissues lift off of the material very easily as they do not bind or adhere to the PMMA. PMMA becomes encapsulated rather than integrated to the overlying soft tissues and the underlying bone. My observation is that patients having secondary scalp flaps raised report little to no pain afterwards although the swelling and the bruising will likely be similar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I was wondering if it is possible to shave down certain parts of the skull. My forehead isn’t the way I want it to be shaped. I am trying to get my forehead to stick out a little less. Is it possible to shave the skull down? And if so how much can be taken off?
A: The thickness of one’s skull can be taken done by burring. How much it can be reduced is determined primarily by the thickness of one’s outer cortex. The skull has three bony layers, an outer hard cortex, an inner spongy marrow space and and an inner hard cortex. While the burring reduction can be taken down past the outer cortex into and through the marrow space, that causes a lot of bleeding and can make for an irregular surface. Therefore for practical reasons, the outer cortex is usually the only skull thickness reduced when done for cosmetic purposes. That can vary in different skull areas but in the forehead in a man, that may be up to 5mms or so.
The more significant rate-limiting step for male forehead reduction is the incision needed for access to do the procedure. A scalp incision is needed to turn down the scalp so the bony forehead is exposed for reduction. Given the unstable frontal hairlines and hair densities of most men, forehead surgery of any kind may not be worth the trade-off of a scalp scar.
Dr. Barry Eppley
Indianapolis, Indiana
