Your Questions

Q: Dr. Eppley, I am a 23 year old male and i have a concern about my headshape. My head is looking very small on my body, although I have an average circumference of 57 cm at a height of ~180cm. I have a slim face, but the main problem is, that my head gets narrower too much at the top, so it’s a little bit shaped like an egg. I have a long neck and wide shoulders, in combinations of that, it looks just weird. I already read at your page what can be done , but I have still some concerns about getting an implant. Is there a guarantee that it is lasting a life long? Is it as hard as bone, so if someone touches my head will it feel like real skull? And is there a chance that it can move / slip around after some time? I just want to solve this problem and never be confronted with it again, so I am looking for a permanently and safe solution.. What other options do I have if  don’t want to get an implant? Can the bone be restructured, or is it as risky as it sounds?

A: In answer to your skull implants questions:

1) The only safe and effective skull augmentation method is an implant. Moving/expanding the skull bone is not an option in an adult.

1. Skull implants will last a lifetime, will never breakdown or degrade or need to be replaced. They are made of a polymerized silicone material that will only break down at temperatures of greater than 375 degrees F.

1. Skull implants will feel just like bone and will not move around or become displaced.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions and concerns about skull implants and would really appreciate it if they can be answered in detail.  I am very serious about this operation and would like to find out more about it. 

1) Let’s say I will get this operation during this month, how long will it be approximately before the incision will become unnoticeable? Also, Will I need to be wearing a hat for a certain amount of time until everything clears out to conceal it or no?

2) In what place will the incision be made and is 9 cm going to be the maximum for the incision?

3) Just out of curiously, will the implant be detectable when doing an x-ray or any type of scan at any doctor’s office or will it read as a single part of the skull?

4) Would you say this is a fairly easy operation?

5) Are there going to be any chances of infection/ nerve damage or any complications in the future or during the procedure?

6) Also, once the implant is inserted is it somehow attached or no? Or is it just inserted and the opening is closed?

Do you have any photos of how the incision/scar looks like right after it is closed?

7) Is it true that the thinner the custom implant is or the less material there is, the smaller the incision that needs to be made? Also, is it the patient’s choice or no?

8) Based on your experience, how likely is it that people around you will notice drastic changes of the shape of the head after the operation? Is it significantly noticeable or not noticeable at all?

9) It says on your website that the implants can be sectioned into 2 pieces and reassembled once inserted. Will this have an impact on the length of the incision or no?

10) After the surgery has already been done when can I see the incision disappear?

11) In the previous email you mentioned that it is better to do hair transplant using FUE in my crown area around 6 months after the surgery. Is there a particular reason why there is a need to wait for so long? If I decide to do the FUE before the surgery if it fine, how long must I wait before I can do this operation? Is there a specific time? Can I do it the next day?

12) Does the amount of silicone used affect the price in any way?

13) Is there going to be a significant difference in how it feels after the silicone is placed or no?

14) I am a casual smoker and I smoke very little. I would say I smoke around 1 pack per every two months or so. Also, I don’t smoke every day. Will this have any effect on the post op results such as healing time, etc?

Thank you and regards

A:  In answer to your questions about skull implants:

1. Provided one has hair for coverage the scalp incision would be fairly undetectable in short period of time. If one has a shaved head the incision will take several months before it fades considerably. The wearing of a hat or head wear is a personal choice, not one that I advocate either for or against.
2. The incision placement would be based on what type of skull implant is used and its size. Without knowing these specifics I can not give a more specific answer. In general, however, most skull implant incisions are placed posterior more towards the crown of the skull area.
3. Silicone skull implants are not detectable in plain x-rays. Their outline will be seen in CT or MRIs however.
4. Placing skull implants can be a straightforward operation for those plastic surgeins who are very experienced in placing them.
5. While infection is always a risk with any type of implant place in the body, it is not a problem I have yet seen in skull implants. Any other potential long-term concerns are related to the overall size of the implant but, in general, there is no risk of permanent nerve damage.
6. I generally do place very small screws to secure the implant and use perfusion holes throughout the implant so tissue can grow through it between the overlying scalp and the underlyng bone. Thus making dosens of tissue connections through the implant.
7. There is no question that the size and thickness of the skull implant affect how long the incision need to be to place it.
8. I don’t think skull/head shapes are physical features that draw as much scrutiny as other facial features.
9. While in some cases I do section very larges skull implants or are forced to based in their size or shape, it is not a preferred method as the integrity of the fit to the bone is most assured by placing them in the manner that they were fabricated.
10. Incisions/scars do not disappear or go away completely. Their redness and visibility certainly improve with time and is a process of 3 to 6 months for maximal scar appearance improvement.
11. When you induce changes to the scalp you do not want to put too close together traumatic (surgical) events. This stresses the blood flow to the scalp. This may cause hair shedding or, at worse, a devascularizing event where scalp loss may even occur. (I have not seen it but even the robust blood supply to the scalp is not immune to adverse vascular events) Therefore in elective scalp/skull surgery caution is prudent about the spacing of repeated surgeries.
12. The cost of skull implants is not influenced by volume but by their method of manufacture.
13. A silicone material placed on bone will feel like bone.
14. You would be well advised to avoid any smoking for at least 3 weeks before and 3 weeks after surgery. Nicotine is a potent vasconstricting agent and carbon monoxide competes for space on the hemoglobin molecule with oxygen. Good blood vessel perfusion and oxygen levels provide for the best tissue healing possible and lowers the risk of infection.

Dr. Barry Eppley

Indianapolis, Indiana

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

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about implants for skull reshaping. These are the questions that I would like for you to answer. Thank you for taking the time to answer them. 

1) My main concern is to eliminate the cone shape at the top of my head. It appears that using implants would give me better results than just burring the scalp. Which one of the two do you believe would give me the best possible aesthetic look? Meaning the most proportional/normal looking head? If I can achieve a normal shaped head, “with implants only” I do not see the need for you to burr the scalp. However, if you believe that implants “alone” cannot give me the best possible shaped head, I would go with the option where you burr and insert implants. I don’t think I would have a problem with the height of my sagittal crest if the sides of my head would not be so slanted. 

2) If you only use implants and do not burr the skull down, would this create too much tension on the top of my head? Will the skin on my head once pulled over the implants create too much tension that would then lead to pain in my head? 

3) Am I going to be limited in the kinds activities I could take part in? For example, would an activity like diving head first into water be considered unacceptable for fear that the implant will move out of place? 

4) Does this procedure require maintenance? Will I have to replace the implants after time goes by? Or can I can I live out my life without having to worry about it again?

5) What kind of material are the implants made from?

6) How long until the scar is completely healed, or the time frame when I will know the scar will look as good as it’s going to look?

A: 1) That is why I do computer imaging to look at all options available for skull reshaping. By looking at the head shape outcomes from all three methods, YOU can make that determination. This is a purely aesthetic judgment of what you think looks the best.

2) No, The skull implants are not that big.

3) No, you would have no physical restrictions and they will not become displaced no matter what you do.

4) The skull implants are permanent and will never need to be replaced.

5) They will be custom implants made of solid silicone elastomer and will feel just like bone.

6) Scars take put up to six months to fully mature. Although many scalp scars do well and mature before that time period.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering getting the custom skull implant for skull augmentation to build up the back of my head. Can you please share your experience of this type of skull implant surgery you have performed?

A: When considering preformed silicone implants for occipital or any skull augmentation, there are two basic methods to do it. Here in the U.S., a custom fabricated implant is always used since there are no preformed skull implants that are commercially available. It is always hard to argue with a custom implant since that is the ideal way to get a perfect fit and have it made to correct any existing asymmetries. That is the approach I have used over eight forehead/temporal augmentations and one occipital augmentations in the past two years. That being said, I have placed a few preformed skull implants (top and back) on international patients who brought the implant with them from overseas manufacturers. (they are illegal to directly import into the U.S. since they are not FDA-approved)

I do think such silicone implants do have role to play in forehead and occipital augmentations for the reasons discussed even if there is a modest increase in the infection rate. (out of 9 such skull implants in the past two years, I have had two infections that necessitated their removal (22%). This is contrasted to over 100 PMMA skull augmentations with no infections seen even in three cases where the implants became exposed due to wound dehiscences. (0%)

That begin said, I am enthusiastic enough about using preformed implants that I am now working with a major manufacturer to create a set of three sizes for occipital skull implants. For many patients this simplifies the procedure, allows for a slightly small incision and creates a moth contour even if it does not have perfect adaptation to the underlying bone.

Dr. Barry Eppley

Indianapolis, Indiana