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
Q: Dr. Eppley, I am interested in skull augmentation. I haven’t managed to find any possibility here for my skull flat shape and also smaller size, which is always a problem due to hiding its flatness in a puffy hair and that takes a lot of time and doesn’t allow me to wear the desired hair style. I’m 34 years old and I am struggling with such issue for a lifetime, and now I’m seriously looking for a permanent fix. My forehead is also flat and what I’ve lately done was to get injected fillers in my forehead, its corners and all over it, for creating a nicer curvature which is not a permanent but only temporary one, then within 1 year or a year and a half, I need to re-do this process which is not the most desirable fix, also only temporary. I’ve been reading about a latest discovery, Kryptonite, and also learning about you Dr Eppley from online and also searching your website, and I’ve noticed you’re extremely experienced and a specialist in such matters. I’d like to kindly ask about your opinion, if some injections with suitable bone adhesive (Kryptonite or otherwise) would solve my problem permanently, without any side effects or other later surprises? I’m aware the injections would be the quickest fix, especially when 1.5 cm to 2 cm height in my skull’s curvature would be perfect and also a bit at the top back, plus a bit on the laterals for creating more volume around, therefore in a nutshell needing some attached patches in the right spots of my skull. I’m also reading online that such injections would have some side effects and in the longer term may bring some problems, not sure if that’s correct or not? If possible, I’d appreciate it receiving your kind reply regarding such procedures, or if it’s better going for a whole skull patch addition through a more complex operation? Obviously, I’d prefer the simplest but most efficient procedure, but if such quick injectable permanent safe fixes don’t exist, please kindly elaborate about the best fit in my case, in order for my forehead to be considered as well and curved accordingly with no weird marks after a possible operation or implants.
A: The simple answer to your question is that no method injectable skull enlargement works well and has lots of complications. Kryptonite is no longer available and has been removed from clinical availability. The only effective method of significant skull augmentation (and a 1.5 to 2 cm enlargement would be considered significant) is a two-stage surgical procedure. The first stage is the placement of scalp tissue expander (to gain the room for the bone expansion) and the second stage is the placement of a custom skull implant made from a 3D CT scan. Like all surgical procedures, they are not risk free but this approach has had few complications in my experience.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a custom implant in the subnuchal region of my occipital skull. I know that fat grafting is another options to augment this area due to the neck muscles attaching to the skull there. My questions are what are the possible complications could be, and if you have seen these types of complications in any of the other skull shaping patients you’ve operated on. Hypothetically, in my case, I believe that such an operation could involve clearing/removing a 2cm width band under and parallel to the nuchal ridge on one side before in order to have the implant attached. Would this have a severe effect on head and neck movement and/or cause long term pain?
If this is not a viable option I’m curious as to whether an implant could be placed in a pocket over the muscles/tendons and not directly against the skull. I have read that implants used in other areas (ie. breast implants) are at times placed within or over muscles and are not secured to any hard body structure. Could an implant be placed in the subnuchal area over the tendons, thus avoiding their separation from the skull? Subsequently if there was an implant placed this way, and if a portion of the implant extended to an area of the skull without/ not covered in tendons, could it then be attached there? Alternatively is there a method of fixation to the skull that could occur through the tendons (i.e., with screws) to secure an implant in place. I ask this after reading of non-secured implants causing erosion of tissue with micro-movement over time.
At this time I am willing and able to pursue a surgery if there could be an intervention that was safe effective visually and that is stable over time. I would be grateful for any input you may have.
A: Placement of a subnuchal skull implant for low occipital/upper neck augmentation would have to be placed on top of the muscular fascia as opposed to under it against the bone. Stripping the muscular attachments off the bone is associated significant discomfort and recovery of neck motion. Once in the subcutaneous tissue plane between the skin and the fascia the implant will generate a layer of scar around it which will keep it in placed. (much like a breast implant)
The only anatomic risk of placing an implant in this area is the greater occipital nerve. Fortunately this nerve lies under the muscular fascia and does not common through until higher up over the bone.
Dr. Barry Eppley
Q: Dr. Eppley, I called you last week regarding my upcoming skull surgery with Dr. Eppley. I was wondering if there are clearly defined size restrictions on the silicone implant. My head is small all the way around so I’d like to augment both the front sides and the back. However I’m not sure if this would be possible without tissue expansion. Presumably, the answer would depend on how much I wanted to augment each area, so I’m wondering if there are some kind of numerical limits on that.
I am primarily concerned with augmenting the frontal sides, so I need to figure out how much width I would need to sacrifice there in order to be able to do a little bit of an increase in the back as well. This is not something I would want to guess on or eyeball, so a little more clarification would be really helpful.
Additionally, I want to make sure that if for any reason I have problems with the implant, I can get it removed quickly and for a small/ reasonable fee. I’m sure I will love it, but I just want to know that it can be removed if I really hate it for any reason.
A: Your assumption that there are size limitations for skull implants based on how much the scalp can stretch is a correct assumption. Unfortunately there are no established methods or means to determine what that limit. It is exclusively based on my experience in doing skull implanty procedures. If the implant is being placed through an open coronal approach, the scalp does become fairly ‘stretchy’ and good numbers are about 7mm to 9mms all the around. That may not sound like much but in skull implants which cover a broad area that effect can be quite profound and more than one would think.
The beauty of silicone skull implants is that they are relatively easy to place and reverse if desired.
Dr. Barry Eppley
Q: Dr. Eppley, Hi. I have about a half inch of bone loss in my parietal regin going all the way to the back of my head and bone loss in my back of my head. I saw that you performed an implant on some with a similar problem with silicon. I wanted to know if there was anything else available because I don’t feel comfortable about putting silicon in my body. Would fat transfer work or would you recommend something else. I have had this problem for years, but hair is thinning out and I am not able to cover it up like I used to. Thank you!
A: There are lots of different materials that can be used for skull augmentation or fill in of defects.The one major issue with all of them is that wide open exposure is needed to apply them to the bone site. In other words, a long scar across the top of your head. The reason that custom silicone implants are one of the most popular forms of skull augmentation is that they can be placed through much small and more discrete incisions and do not run the risk of any contour or edge transition problems. There are no effective injectable methods of skull augmentation. While fat can be injected, its survival is highly unpredictable as well as how smooth it might be. (which it wouldn’t) But there are no adverse effect from using fat other than how well it may or may not work.
Dr. Barry Eppley
Q: Dr. Eppley, I have few question regarding forehead augmentation and back of the head augmentation. I would appreciate your kind answers to each of them one by one.
1. Which procedure is more durable, bone cement or implant?
2. Can you please tell the advantages and disadvantages of each?
3. Is it possible that bone cement is filled without cutting the scalp, so we fill the scalp by injection three to four time(interval of ten days) and it may increase the whole head size?Because i fear of cutting scalp and tissue expander.
4. Is bone cement strong enough like skull bone?
5. Which procedure do you recommend?
A: For forehead and occipital (back of the head) augmentation, there are two basic materials that be used…bone cement and preformed implants. In answer to your questions:
- Both material are equally durable. Neither can degrade, be broken down or will ever need to be replaced because they ‘wear out’.
- Each material type has its own unique advantages and disadvantages. Bone cements must be mixed, applied and shaped during surgery thus taking more operative time to do. Preformed implants are made before surgery off of a 3-D CT scan of the patient’s skull. By computer design they provide the best and most symmetrical augmentation with the least risk of any irregularities at the implant-bone transition areas. They can also be done with less operative time. From a cost standpoint, they are roughly equal.
- With either approach, a scalp incision is needed. There is not injectable cranioplasty technique for this size of skull augmentation areas. There is no need for a tissue expander with your dual augmentation.
- The resistance to fracture is roughly equal between PMMA bone cements and skull bone.
- I find both procedures can make for successful skull augmentations. The choice between the two is a matter of personal preference and which one sounds better for each patient. Both type of forehead and skull implants can be done very successfully.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in skull augmentation I was wondering if you ever use an inflatable under the crown of skull to inflate skin so you can have more room to shape head? My niece needed an inflatable on her leg when she was young, which they used when they removed cancerous skin. I believe they can do this if area on skull needs extra skin to cover cement. If you do this, maybe you can tell he how much and my procedure can be a two step procedure. If I can pay for this and come back when time for procedure to correct and reshape flat areas. Please let me know. Not sure what the procedures are called but I may need more serious fix and may need more room for reshaping.
A: When it comes to skull reshaping or skull augmentation, you are referring to a two-stage approach initially using a tissue expander. For larger amounts of skull augmentation, particularly for a flat back of the head, more scalp is needed. A small scalp tissue expander, slowly inflated over six weeks, creates more than enough extra scalp tissue to cover any degree of augmentation desired.
Dr. Barry Eppley
Q: Dr. Eppley, I’m currently struggling with a flat back of the head and a small head too. Can skull reshaping surgery be done on me to add any implant to mainly the back and top parts of my skull that would give me a decent sized head that is also well rounded ? How effective is this surgical procedure and what are the possible negative effects of any implant on my actual skull?
A: Skull reshaping (augmenting a flat area) can be done to almost any part of the skull and its limits are based on how much the scalp can stretch to accommodate the volume of augmentation. Based on what one’s expectations are, it can be a highly effective procedure. I would have to see some pictures of your head that show the flatness and then do some computer imaging to see if what skull augmentation can do is sufficient. It is always important before surgery to find out if the changes meet a patient’s expectations and to determine how much volume is needed to create that augmented effect.
There are no known long-term effects of the materials used in skull augmentation as it relates to the bone or the overlying scalp tissues. Bone resorption is not known to occur nor is scalp thinning over it.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in skull reshaping for a flat spot on the back of the head. My son is twelve and has a noticeable flat on the back of the right side of his head. He has not said anything about it yet. In preparation for the possibility of coming to see you, I have an important question. Does getting kryptonite mean he will never be able to play contact sports such as football again?
A: Skull reshaping that involves building out flat or depressed areas is done by applying a bone cement material on the outer aspect of the skull. In answer to your specific question, kryptonite as a cranial augmentation material is no longer available and has not been so since late 2011. In answer to your general question, augmentation of the occiput (back of the head) would in no way preclude one from participating in form of sporting activity including contact sports. The strength of the cranioplasty material up against the rigid skull bone makes for a very hard construct that has the same strength as that of natural skull bone. This makes it highly impact resistant to the infrequent contact to the head that may occur in most sports.
Dr. Barry Eppley
Q: Dr. Eppley, I am very sorry to disturb you, I live in a remote area of Russia, and my grandson was born with craniofacial distortions of his face and skull. My friend found your contact details in the Internet. I have a few questions to you:
1) Is it possible to enhance at the same time (by one surgery) my grandson’s forehead and back of his head? They are both too flat and the maximum distance between his eyebrow line and the back of the head is 14.7 cm only. By how much is it possible to make this length longer?
2) What should it be done with his medium face? Will it be the treatment by implants, or it is possible to put there human grease/fat?
3) What else could you recommend on him ? We know that he also needs the surgeries on his jaws.
4) How much will it cost us to get the above mentioned treatments ( 1) and 2) points) at your clinic in the USA?
Thank you so much for your reply.
A: Thank you for your inquiry. In looking at your grandson’s pictures, it is clear that he was born with some form of craniofacial deformity, most likely one of the craniosynostoses. (Crouzon’s etc) It also appears based on the scars on his forehead that he may have had some initial efforts at craniofacial surgery when he was younger.
While you did not state his age, he appears to be a mid-teenager at least. I will separate his craniofacial concerns for this discussion into cranial (skull/forehead) and face.
From a skull standpoint he has a short front to back distance typical of many congenital craniosynostoses. He is shorter in the back than in the front in my assessment. The back (occiput) can be augmented significantly (up to 2 cms.) and the forehead smoothed out for a better contour. The most relevant issue here is where is his previous coronal (scalp) incision as that will determine how to approach is skull augmentation reshaping.
From a face standpoint there are two directions to go. Ideally he needs pre- and postsurgical orthodontics and a LeFort I midface advancement with a sliding chin genioplasty. The key there is orthodontic preparation. If this is not possible, the second approach is to camouflage the bony deformities by a combination of orbital, cheek and paranasal implants combined with a sliding genioplasty. (see attached imaging) That could be done at the same time as skull augmentation.
The key in any complex craniofacial problem in a mid- to late adolescent is to identify those craniofacial surgery procedures that are most practical to do that provide the greatest physical and psychological change for the patient.
Dr. Barry Eppley
Q: Dr. Eppley, I have a few questions regarding occipital cranioplasty. the back of my head is kind of flat and it’s been bothering me since high school. As I get older I notice that it gradually get flatter, to a point where I don’t tie up my hair anymore because I am so self conscious about it. Now that I am 36 years old and am financially capable of fixing this problem, I am contemplating on getting the surgery done.
Below are my questions:
1. If I decide to have the occipital cranioplasty done, will I have to shave all my hair off for the surgery?
2. Since I will have extra material at the back of my head will it affect the growth of my hair or the health of my scalp?
3. What are the possible side effects of the surgery?
4. Do you have patients who already had the surgery done for solely aesthetic purposes? And are the cases with these patients successful?
5. Where is the best place to have the surgery done? ( country/state/doctor)
Your advise will be much appreciated.
A: Thank you for your inquiry. In answer to your questions
1) No hair is ever shaved to perform an occipital cranioplasty.
2) Any placement of material on the skull bone does not affect the growth of the hair or the health of the overlying scalp tissues.
3) While infection is always a concern when any material is placed in the body, that is not a problem I have yet seen in cranioplasty. The most common side effects for any form of cranioplasty are aesthetic is the material smooth, even and symmetric? Was the buildup enough?
4) Most skull augmentations that I perform today are done exclusively for aesthetic purposes. The most common type of aesthetic cranioplasty that I perform is to treat a flat back of the head.
5) I can not speak for who else in the world performs aesthetic cranioplasties, I only know that I do.
Dr. Barry Eppley
Q: Dr. Eppley, I incurred a closed depressed skull fracture from a head-butt when I was 22. I am now 28. The depression in my skull has bothered me emotionally since it happened and I have some physical pain too (I feel like there is constant pressure on the area). When I participate in rigorous physical activity (such as running) I get severe head aches. I hope to get surgery to elevate the depression and was interested to know more about possible procedures.
A: If you are having symptoms of headaches and pain from your depressed skull fracture, the first thing you need to do is to consult a neurosurgeon to be certain that there is no undue pressure on the brain. While I would doubt that is the case after this many years, it would be an important first step to do. That is the only reason that the skull fracture would be elevated and that will require an open craniotomy to accomplish. If your neurosurgical work-up is negative then the depressed skull area can be treated for its cosmetic appearance by an onlay cranioplasty to build up the outside of the bone. A skull fracture is not elevated by craniotomy for a cosmetic change only.
Dr. Barry Eppley
Q: Dr. Eppley, growing up I have been called all sorts of names, but the one I hated the most was flat head. I eventually grew my hair out as an adult and spiked it out or make it poofy in the back. I never thought it was possible to get your skull reshaped until I came upon reading your page, and taking a look at a couple of your operations. My head is flat posterior parietal to the occipital bone. I’m an Asian male, and not everyone has it, but it’s highly common in our race, but I absolutely hate it. I been wondering about the price of operation, and maybe consider it in the future. I have many times down myself into seeking this operation, or even research about it. I have a couple pictures of my head to show, but not sure where to put picture attachment. Please respond back, thank you.
A: Thank you for your inquiry. About one-third of the patients that I perform surgery on for correction of a flat back of the head in one area or the other are of Asian descent. So I recognize the ethnic component to it. I would be happy to review any pictures of your head which you can attach as a reply to this e-mail. The typical cost range for an occipital skull augmentation procedure would be in the $7500 to $9500 range depending upon the volume of material needed and the time to do the procedure.
Dr. Barry Eppley
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
Q: Dr. Eppley, I am interested in surgery to improve my skull shape, I would just like to clarify some things first. You mentioned 60 grams of PMMA to obtain the predictive image results which would indeed be quite good for me. However I’m wondering if this quantity would be enough to make this aesthetic difference. Indeed I’ve read that PMMA has a density around 1.2 g/cm3, thus 60g of PMMA would have a volume around 50cm3, which seems to be quite small (I checked with 50g of water).As you’re quite experienced with skull aesthetics, do you think this would be enough in my case, and are you positive that the predictive image is obtainable? Maybe it would be preferable for me to have a first stage to stretch the skin, then have a bigger implant inserted? Please excuse my uncertainty, I’m trying to find the best option I have. I have seen one of your skull reshaping surgeries on your blog of a 42y old man with a flat spot much like mine. Do you remember what kind of surgery he had? Thank you for your help and advice.
A: I can certainly appreciate your volumetric computations of the biomaterial mass. But one aspect of that assessment that is missing is how any implanted volume of material translates into a change in external appearance. One thing I have learned over the years is that small volumes can usually make a much bigger change that one would think in many cases. In other words, one can easily be fooled in seeing how something looks in your hand than when it is implanted in the human body. The use of 60grams of PMMA in skull augmentation is usually the upper limit of how much the scalp can stretch over a skull augmentation without undue tension. With longer or more full coronal incisions, one may be able to get up to 90 grams of material implanted as the scalp flaps are more fully mobilized. In your case, I would much rather take this approach as I do think that somewhere in the 60 to 90 gram material range should be more than adequate to achieve the predicted result. The patient to which you refer in the blog had 25 grams of PMMA implanted for that unilateral occipital skull augmentation result.
Dr. Barry Eppley
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
Q: Dr. Eppley, This may be a very very unrealistic but part of my head is flat and I am 21 years. I was wondering whether there was literally anything you could do to improve it at all. I am willing to pay anything for it. Maybe even a material to fill some of it in. Any ideas would be great.
A: Skull augmentation/modification is a very common surgery in my practice. One of the most common reasons that it is done is for flat areas of the skull, usually on the back part. The realistic part of this surgery is not whether it can be done but whether enough change can be done to make the procedure worthwhile. The limiting factor in all skull augmentations is how much the scalp can stretch to accomodate the expanded skull contour. I will need to see some picture of your head and the area of concern to determine if this may be a procedure for you.
Dr. Barry Eppley
Q: Dr. Eppley, I’m a 21 year-old female with a frontal bone that is raised higher than the parietal bone in my skull which appears to be flat. I’ve developed really bad anxiety over the issue and refuse to wear my hair in any other hairstyle than a bun on top of my head to conceal my odd head shape. I have also developed really intense habits over the years which include examining my head side on in mirrors up to twenty times a day, taking photos of my head regularly, and constantly touching my head and I really wish to be rid of this paranoia and live my life without worrying about what my head looks like. I’ve considered looking in to getting some form of implant inserted over the parietal bone on my skull to raise it higher than the front region and I was wondering how much this procedure would cost, what risks are involved with this procedure, and what materials are used as a form of implant and do they pose a risk of rupturing? Thank you in advance for your help, I really appreciate it.
A: Skull augmentation of the parietal/occipital bone can be easily done. Please send me a few of the pictures you have taken so I can see exactly the area and how much augmentation needs to be done. This is skull augmentation surgery done with materials like PMMA and hydroxypatite bone cement that are placed and molded on top of the deficient bone area. These materials are solid and will never rupture or become displaced. It is actually a very straightforward procedure and it is just a matter of getting the right volume in the right area to create the desired effect. It does require a incision somewhere on the scalp to achieve it but for women with good hair density this is never a scar problem. It is done as an outpatient procedure under general anesthesia. The recovery is very quick and you would be fully functional in just a few days.
Once i receive the photos so I can assess the problem, then we can provide a cost for the skull augmentation procedure.
Dr. Barry Eppley
Q: Dr. Eppley, I have some questions concerning adding implants to the top of the head. How thick can the implant be at most in your opinion? How is PMMA implants fixed to the top of the skull? Is there any risk of getting loose later and cause infection? Will it thin the skin?Thanks in advance.
A: The thickness of any skull augmentation that can be achieved is directly related to how much the scalp can expand over it. Short of a first-stage tissue expansion procedure, most scalps can stretch 5 to 7mms and have a tension free skin closure. Once you get anything over 10mm, a tension-free scalp closure may become more difficult. Anything cranial implant is secured by small titanium screws through a ‘rebar method’ when it comes to cranioplasty materials that are applied initially as liquid-powder or putty mixtures that then set up. Looseness or infection are two potential complications that I have not seen. There is always some slight tissue thinning around any body implant that expands the overlying tissue. But the scalp is very thick and any tissue thinning over a long time does not affect the skin or the hair follicles.
Dr. Barry Eppley
Q: Dr. Eppley, I am a little nervous about a cranial reshaping/augmentation procedure so if you don’t mind I have some questions regarding it. Does this type of surgery come with a high risk of complications/ what are the complications? From the location of my indentation can you give me a general idea of how big and where the location of the scar would be? How long would an open approach surgery take to correct my indentation/ how long would recover time take? How much would this surgery cost roughly? If my research is correct I understand their are different methods/ materials that can be used with an open approach can you explain them? and the pros/cons of them? What method would you recommend?
A: In answer to your questions. This is not a high-risk procedure. There are no major complications that I have ever seen. The complications are of the aesthetic nature, meaning how does it look, is it smooth, etc. You need access to both sides of the skull. There fore the incision would be bicoronal, meaning it would go across the top of the head just about from one ear to the other. Surgical time for this procedure is 2 hours. Your recovery would be very quick, so swelling but no significant pain and no real restrictions after surgery other than strenuous physical contact. That information will be passed along by my assistant. The other decisions/options about an open approach is the choice of cranioplasty material. With large surface area to be covered like your cranial indentations, the PMMA (acrylic) is the most affordable. I am not sure what you mean by method. This would be an open cranioplasty with midline bone reduction and build up of the deficient sides.
Dr. Barry Eppley
Q: Dr. Eppley, I am writing you in regards to my daughter is now two and one-half years old. The back of her head is flat (plagiocephalus) and asymmetrical (1cm difference). According to the doctors there was no need to treat with a helmet. Still the deformation is quite obvious. Is there anything that can be done about it at your clinic? I suppose she has to wait until she is 18 years old?
A: At this age, there is no form of helmet or external molding therapy that will change the shape of the skull. It is too thick at this point to be externally molded. It can be treated for its cosmetic deformity by an augmentation cranioplasty on the flattened side. That can be a very effective procedure and in some cases this is done by an injectable cranioplasty approach. This is probably the ideal procedure for plagiocephaly deformities that are mild to moderate. In laregr degrees of flattening, an open approach is better. The question is at what age should that be done. There are no hard and fast rules about the age to do this procedure. That is a personal choice of the parents. I have had requests to do them as early as age but the timing of cosmetic correction of a plasgiocephalic skull is psychological not physical.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in skull reshaping if that´s possible. I´m a 45 year-old male and I wish to know if there is any procedure to implant some type of material at the occipital area in order to increase that part of my skull and make it a little more aesthetic, because I have that part very flat. I would also like to know if that would leave me with very visible scars? I would like my skull elongated in the anteroposterior axis. Thanking you in advance.
A: There are numerous methods of skull augmentation or expansion. They all rely on adding synthetic materials to the deficient skull area in the desired shape. The two basic methods are cranioplasty materials, such as PMMA (acrylic) and hydroxyapatites, and a custom-fabricated silicone or silastic skull cap or prosthesis. There are advantages or disadvantages to each approach which fundamentally comes down to cost and the ability to get a smooth contour and the maximal amount of expansion. The limiting factor in how much expansion can be obtained is how much the scalp can expand and to get a relatively tension-free scalp closure over the augmentation material. In my experience, a safe amount of skull augmentation is about 10mm in thickness. That may not sound like a lot but it creates an effect more significant than the number suggests. All of these methods require an open approach with a scalp incision to place them. This results in a fine line scar across the upper back of the head, somewhat similar to the location of a hair transplant harvest scar.
Dr. Barry Eppley
Q: Dr. Eppley, I have concerns about my head shape. I know my head shape is not terrible but it bothers me enough to want something done. I know actually looking it over or feeling the shape would give better insight. The way it’s shaped makes it difficult for normal looking haircuts. I really want to try to do something about it so please try and help me. I think the one noticeable thing is that it’s not a smooth shape at the top, it divot’s a lot on the sides. I have attached pictures. Please let me know what you think.
A: I have reviewed your pictures and read your concerns. The exact area to which you refer is the transition zone between the superior attachment of the temporalis muscle and parasagittal bony skull area. There are many people who have an indentation or steep transition between these two aesthetic skull zones. In some people it is more severe and noticeable. That area could be augmented, it is a question of how that can be done. The method that would provide the smoothest and best contour result is an open skull augmentation (cranioplasty) using either PMMA or hydryoxyapatite. The use of an open cranioplasty involves a croronal incision and resultant scar may not be acceptable in many male patients. An alternative approach is an injectable cranioplasty using Kryptonite bone cement. While this does not have any scar concerns, there is a potential issue of visible edges in the anterior aspect of the defect in the upper forehead.
Dr. Barry Eppley
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
Q: Dear Dr. Eppley, I have done a lot of reading on your website and interested in the cranioplasty procedure to fix the flat spot on the back of my head (on the top area on the back). I am a female and have noticed this since my teens and always thought there was no help until I came upon your website, now I am hopeful. I am scared and nervous about this procedure and have several questions:
1) Is this a new procedure because I don’t see where this has been performed for purely cosmetic purposes before by other doctors?
2) Would you say the injectable approach doesn’t achieve as much as an effect as the open incision approach?
3) Also, in the open incision approach, I know you use either PMMA or HA materials. If the PMMA is used, does that mean you will need to use screws to attach the material? Is it riskier than using HA since screws are used?
4) When did you first start performing this procedure and approx how many have you done?
5) Have there been any complications with any of them? If so, what were the complications and how did you fix them?
6) I live in Houston, TX and would be traveling alone. From what I read, this is an outpatient procedure, therefore I am concerned about being without care the first night after surgery. Would you recommend that I get this done in the hospital as inpatient, so I am under care?
7) Also, how do you determine how much material to add?
8) Do you place expanders to stretch out the skin if I want more material added to achieve my desired result?
9) Will there be a noticeable difference afterwards?
10) Do you take any sort of imaging to determine the shape you plan to mold?
11) Will you ‘sketch’ out the final shape beforehand so I know what results to expect?
12) How many visits will this procedure require? Including pre-op and post op/follow-up visits?
13) What is the recovery? How many nights will I need to spend in IN? When am I ok to fly back home? When can I go back to work?
A: In answer to our detailed questions:
1) Although this is a relatively ‘new’ procedure from a cosmetic standpoint, it is based on the decades old principle of reconstructive cranioplasty from craniofacial plastic surgery. The only thing that is really new about it has been the development of some new cranioplasty materials to use.
2) The injectable approach can achieve just as much as an open approach. It is about volume of material used and its costs that partially controls the result achieved.
3) There is no increased risk of screw fixation for a PMMA cranioplasty technique.
4) I have done cranioplasties for nearly twenty years. In the past three years, I have developed some techniques for cosmetic skull augmentation.
5) The main complication with an injectable approach is getting a smooth contour to the material. I have had one wound healing complication from an open PMMA cranioplasty when using an old hair transplant scar for access.
6) Having an occipital cranioplasty as an outpatient is just fine. Patients report virtually no pain afterwards.
7) One of the key issues is how much material to use. That will be determined by the approach used and what the scalp tissues can tolerate. My experience has shown that open cranioplasties through small incision use about 30 to 40 grams with either PMMA or HA. Injectable kryptonite usually uses 25 grams for the occipital region.
8) While the use of tissue expanders does allow for more material to be placed, it has not been necessary in my experience. This would also make the procedure an unappealing two-step process.
9) There will be a noticeable appearance afterwards. It is a question of how much.
10) No imaging is required. It is an artistic molding based on the extent of the defect and the patient’s after surgery shape desires.
11) Computer imaging can be helpful in understanding what to expect.
12) There are no after surgery visits required for an occipital cranioplasty. A good presurgical consultation can be done by phone or Skype video in addition to seeing patient pictures. Patients come in the day before surgery for a formal consultation.
13) Most patients return home the very next day and return to work in just a few days after
Dr. Barry Eppley