Your Questions
Your Questions
Q: Dr. Eppley, I am very interested in skull reshaping surgery. Since I was young I always thought my head shape was oddly shaped making it unpleasant to cut my hair short, wear hats, or even have different hairstyles. I would like to know how long you have been doing this surgery because a surgery like this can go very right or very wrong unless someone is very experienced in doing it. I know that the same surgery is also done in Korea but I would rather not go so far. I always hoped that a surgery would be able to fix my head shape, I just never knew that there were surgeons out there who could do it. My head is flat in the back and is not even symmetrically flat as one side (the left) is more flat than the other. Please tell me what you think can be done.
A: There are many options in skull reshaping surgery. I would need to see some pictures of your head shape to determine what needs to be done exactly. But by your description it sounds like a case of a flat back of the head (occipital brachcephaly) with some asymmetry to it. Thus the surgical treatment would be augmentative as an onlay cranioplasty approach, probably using PMMA as the material as the volume addition would be at least 60 grams maybe more.
I have done many such skull reshaping surgeries, and many other variations of it, for over 10 years based on a lot of craniofacial plastic surgery and biomaterials experience previously.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in an unusual form of skull reshaping. I am currently investigating possible procedures that could change my skull contour. I have congenital skull asymmetry/tilt, and have attached a simple drawing approximating the current shape of my skull. The area I would like to treat is on the left side of my posterior skull/occipital bone. If possible I would like some reduction of the skull near the occipital bone/protuberance and nuchal ridge on that side. In addition to this I would like to increase the volume beneath the ridge with a fat transfer. The goal of this would be to make it appear as if the nuchal ridge was lower on that side than what it actually is. My understanding thus far is that a solid implant would not be suited to this area as it could not be secured and it would have to lie on top of tendons/nerves and I’d prefer a more long lasting treatment over temporary fillers. Assuming there is enough bone that some can be safely removed, what amount (i.e. how many mm) can this part of the skull usually be reduced? I’ve seen photos of fat transfers treating various defects on different parts of the body and am curious how much projection could potentially be possible. The area I would like to increase volume in is roughly 2cm wide and 7cm long with varying depth. The depth would vary up to a max of 1cm. I know that fat transfers are unpredictable and can take multiple sessions, but I’m curious is this would be potentially feasible. My weight is stable and does not fluctuate much. In your estimation would these procedures be technically possible or something that you could potentially perform? I would very much appreciate your input.
A: Skull reshaping can be done for a wide variety of bone issues. The area to which you want to reduce is known as the nuchal ridge of the occipital bone. It is actually where the posterior neck muscles attach to the skull. As a result it is very thick to accommodate the pull of these strong neck muscles, illustrating the biologic principle of form following function. This is why it is a raised edge of bone and can be substantially reduced in its prominence by a burring technique. As for augmenting the area below it, fat injections can be done but I would have little confidence that they would create, even if they survive, a raised ridge presence. You would be better served to have an actual implant placed down that low and secured to the bone. Since some of the neck muscle tissues has to be released anyway to do the burring, it would be more reliable to attached a small silicone implant with those dimensions to create an assured permanent ridge effect.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull reshaping. I am a 32 year-old man with an odd-shaped head with a prominent ridge running own the middle. While I could always feel it, it never bothered me until I started to lose my hair. Now I feel like an alien with this visible ridge on my skull. Can it be reduced?
A: Skull reshaping can involve reduction of prominent bony areas or bony buildup of deficiencies. One particular bony skull excess is the sagittal ridge or crest that occurs in the midline of the head. It usually occurs due to a mild anomaly of how the sagittal suture closes after birth. As a result it can develop excessively thickening creating a ridge or crest in the midline of the head that is especially noticeable in men that have short hair or shaved heads.
Because it is a bone protrusion or thickening it can be reduced to a more normal skull contour without risk of exposing the dura or penetrating into the brain. This procedure is done under general anesthesia through an incision placed at the back end of the crest. A scalp flap is elevated exposing the crest that is reduced with the use of a burr creating a smoother upper skull contour. The scalp tissue is closed without use of any drains and only a head dressing is used for the night after surgery after which it can be removed. These small scalp incisions can heal remarkably well.
In summary the sagittal ridge is a midline bone protrusion that can be reduced through a minor skull reshaping procedure using small scalp incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping of the back of my head. I am 45 years and I have a small spot of protruded ridged edge at the back of my head from birth. I have never been comfortable with it and I wish it could be corrected for a normal round shape back head. I wish to know if/how it could be corrected. If possible, what’s the cost implication and how the duration of the treatment and possible medical implications if any. I have attached some photos for your examination and prompt response, I may send you more pictures if you so request. Thanks.
A: Your head problem could be solved by a minor skull reshaping procedure. Your ‘spot’ or bump of bone on the back of your head is a raised area over your original posterior fontanelle area that you had an an infant. This is a common area of minor skull contour deformities from indentations to raised ridges. Your midline occipital ridge can be reduced by a burring technique through a small incision. This is a one hour procedure done under general anesthesia as an outpatient procedure. There are no medical implications by taking a small amount of the outer cranial table. Other than some temporary swelling and small fine line scar from the incision there are no potential complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a back of the head skull reshaping procedure for the back of my head. When I cut my hair everybody can see the lump so I’m very frustrated about that and I like to know about this procedure to see what can be done to make that bone reduced in size by in filling around it. I was born like this and it has been there as long as I can remember. What can you do to fill around that bone is sticking out to reduce that size so make it look better? Thank you!
A: Skull reshaping of the back of the head is common for many types of contour issues. I believe the lump on the back of your head to which you refer is a variant of what I call the occipital knob deformity. This lump of thickened bone occurs at the confluence of the nuchal ridge line of the occipital skull in the midline. One could argue whether this bone is too thick or whether the bone that is around it is deficient, either problem of which makes it stick out. From reading your description, it sounds like your concept of contour improvement would come from building up the bone around it using a bone cement material. That is probably the most effective contour approach and would completely eliminate that appearance. That is a very straightforward procedure to do using about 30 grams of material through a small (8 to 9 cm) horizontal incision in the occipital area above the lump and could be done as a 90 minute procedure under anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.
A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)
Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.
Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures, the order that are done on does not make a difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had skull reshaping with bone cement last year in South Korea as my back of head was pretty flat. Since then I wasnt told that much information and may have put pressure on the left side of the back of my head, and now the left side is flat. can you fix this and is it safe to re apply more bone cement on top?
A: Since skull reshaping bone cement is permanent and does not move or degrade, the appearance of flatness on one side of the back of your head has nothing to do with what you did. (put pressure on it) This flatness has likely reappeared because all of the swelling has finally gone done and the complete result of the skull augmentation procedure is not evident. In other words, the application of the bone cement was likely not symmetric. When correcting a total flattening of the back of the head, the hardest thing to do surgically is to get both sides even. (symmetry) This is not a rare postoperative problem.
The good news is that this is a very correctable skull problem through the application of more bone cement on the flatter side. There is no problem with placing new bone cement on top of older or pre-existing bone cement in skull reshaping surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am possibly interested in skull reshaping surgery. I have occipital plagiocephaly. My head is clearly flat on the back left side of my head. I am 67 years old and losing my hair which makes it more noticeable. Can surgery correct this at my age or is it too late?
A: Age is not a physical issue for this skull reshaping procedure as long as one is in good health for the surgery. Since the procedure is an extra cranial procedure (onlay augmentation), it is no more complicated to go through than many other cosmetic facial surgeries. Age is only a limitation if one decides that they are too old to care about it…then it is too late.
I would be happy to look at any pictures that show the flatness on the left side of the back of your head.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping to reduce the width of my head. I have a large head and I’m embarrassed about it. I have to buy larger hats than everybody else and it’s a hassle to wear sunglasses or prescription glasses because my head is so large that it squeezes and gives me a headache. I have to order special made ones if I want them to be comfortable. I understand that it’s not really a problem, but I’ve been self conscious about it for years and I want something done to stop constantly thinking about it. I would like a procedure that would make my head smaller in width. What could you do?
A: Skull reshaping can provide numerous skull shape changes and one of those is in the reduction of its width. In looking at your head shape, it easy to see your concerns with a fair amount of temporal convexity, bulging of the anterior temporal lines and a general side to side large cranial outline. While there are limits to how much the skull be reduced, there are some visible changes that can be achieved. The bulging on the sides of your head (temporal area above the ears) can be reduced by temporal muscle reduction/shortening and the anterior temporal lines (transition between the sides of the head and the top) can be reduced by about 5 to 7mms. These manuevers will never make your head width as small as you would like but they can make a visible difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of skull or face reshaping. I would like to know based on the photos/info provided what would you assume is the cause of my skull/face defects? So basically I have a protrusion of my right forehead area as well as on the scalp area (right side mainly)and extends but decreases to the left side of my top head area giving a “Gumby” appearance, slanted, lopsided wichever one. I also have a cone looking shape on the back top of my head, as well as my right jaw is sunken in slightly, my right ear is further back than the left, and my right eye slightly bulges. Hopefully this info gives you some clues to let me know what I may have. I would also like to know the best approach to fix the issue and if possible see what it could look like if corrected. Thanks a lot.
A: Everything that you are describing and demonstrating in your pictures is most likely the result of a congenital skull plagiocephaly anomaly. This is fundamentally a developmental problem with the skull base from which the skull and face shape becomes slightly twisted and asymmetric. The key question now is what can and should be done with the constellation of skull and face asymmetries that exist. While there are numerous surgical procedures for all of these issues, they are aesthetic trade-offs (scars) for doing so and these must be considered very carefully. The question that I would ask you is which one or two of these issues bothers you the most and would like to see improved/corrected?
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in flat back of head surgery correction. I am ready to take the next steps for cosmetic skull augmentation surgery for the flat back of the head. I have a few concerns/questions and hoping you will be able to clear them for me. I have read the case studies and advice on your website and it gives me tremendous hope of having more normal head shape. My problem is that I have a rather flat back with bulges over both ears. My questions are as follows:
1) Based on your articles, I see you can build up 10 to15 mms on the back of the head in one attempt. I believe I may need more than 20 to 25 mms, so can you add 10 to 15mms in first attempt and then stretch the scalp further and in the second attempt add the remaining 10mm? Is that possible?
2) Is there ever of any possibility of this cranioplasty material getting loose? For instance if a person falls down etc.?
3) Will you be able to burr down the bulges on top of my ears? If so, how much?
4) I am a man who is starting to lose hair a little bit. Will the scar be substantial and show up?
5) What is the total time required for surgery and recovery if it is 10-15 mm augmentation versus a second attempt for the additional 10mm?
A: What you are describing is having a bilateral flat back of the head known as brachycephaly. (as opposed to flatness on just one side which is known as plagiocephaly) This is why you have bulges over both ears, the brain grew the bone out to the sides as opposed to pushing out normally in the back. This flat back of head surgery involves a build up across the back of the head with some width reduction. In answer to your questions:
1) If you need to have as much as 25mm of occipital bone buildup, you first need scalp tissue expansion and then secondarily add all the material volume needed. Once the scalp is lifted and stretched, its becomes scarred and will have little stretch. So trying to double the material volume later will not work. The choice is then settle for either two-thirds of what you need or make it a two-stage procedure.
2) Tiny titanium screws are first added to the bone and then the material is applied. This gives it something to forever be anchored, much like it done with construction concrete. Loosening of the material as yet to be a cranioplasty problem I have seen.
3) The protruding bone around the ears can be reduced about 5 to 7mms on each side.
4) While there is a scalp incision involved, it can heal remarkably well even in bald men. I am consistently surprised how well it heals in the scalp. Will there be a scar…yes. Will the scar be substantial…no.
5) The surgical time for a one-stage occipital augmentation is 2 hours. If it is a two-stage occipital augmentation procedure with a first-stage tissue expander the operative times are 1 and 2 hours respectively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My son needs skull reshaping surgery. He is currently six yearrs old and will turn seven later this year. I have many concerns for my son. My son has never had a hair cut in his entire life. I braid his hair down in efforts to try to disguise the deformity located on the right side of his head. We are African-American and one day, after my son graduates from college, he will need to be appropriate to interview for jobs. No one will want to hire my son with braids in his hair. He needs to be able to cut his hair and wear suits proudly. Also, both his grandfather and father are bald. What happens to my son if his hair pattern follows in that same direction? When my son was born, his head shape was absolutely perfect. I want my son to be able to fit in with society and not be ashamed or judged on his deformity. My son is an innocent child and if there were anyway I could take his place I would. Please help us.
A: Skull reshaping surgery by an onlay cranioplasty is most commonly performed for flat areas on the back of the head. I am assuming that his flatness is on one side of his head in the back of his head. Such a skull deformity is very amenable to being built up by an onlay cranioplasty procedure by putting material on top of the bone. This does require a scalp incision to do it, located more to the back of his head. He does not have to shave his head or unbraid his hair to do it. In fact, having braids in his hair is the best hair management for the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about the injectable, minimally invasive cranioplasty skull reshaping procedure that you mention on your website. I am in my 50s and considering shaving my head after years of trying to deal with cosmetic issues related to thinning. I have been reluctant to do so due to an uneven flat spot on the back of head until I happened upon your site that describes ways to correct it.
A: The pure injectable cranioplasty skull reshaping approach has largely been abandoned due to an inability to get it completely smooth throughout the augmented area. That has been modified to a ‘minimal incision’ cranioplasty with a small incision about 2 to 3cms long. With this more open approach the material can be placed and then more carefully smoothed at the edges so there is not a step-off between the cranioplasty material and the natural bone. This can be a very good procedure as long as the size of the skull flattening is not too big.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I have a 16 yr. old son who was diagnosed with plagiocephaly at a year old. He wore a helmet for several months and I’ve tried various therapies over the years but at 16 his head is still a little flat on the back right side of his head. It’s really only noticeable from a bird’s eye view and not straight on. He never talks to me about it and it is slight but I would like to offer him an alternative if it becomes bothersome to him. I’ve read about the injectable kryptonite and want to learn more about this. My son is a soccer player so I wanted to ask you if heading the ball would be an issue with this if he were to ever have the procedure done. Thanks so much!
A: The surgery that I have evolved to today with a unilateral occipital plagiocephaly is a minimal incision cranioplasty using PMMA. (acrylic bone cement) The kryptonite material is no longer available. This is the same technique only using a different material. Through a 1.5 inch incision in the scalp, the material is placed into position using a funnel technique and then shaped externally as it sets. Most patients need somewhere between 30 and 60 grams of material to provide better skull symmetry between the two sides. This material is actually stronger than bone so it is more resistant to blunt head trauma than your native skull bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have the flat spot on the back of my head built up. I understand that various materials can be used to do it but don’t know which one would be better. What are my options?
A: Bone cements in cranioplasty can be either polymethylmethacrylate (PMMA) or various calcium-containing materials. All of these materials are joint powders and liquids that are mixed in surgery to create a self-curing putty that offers enough set times to create the desired shape on the bone. The most ‘natural’ bone cement is that of the synthetic calcium compositions, of which the most common ones used are calcium phosphate-based also known as hydroxyapatites. (HA) They are natural to the bone because the inorganic mineral content of human bone is hydroxyapatite. Another calcium-containing bone cement is that of calcium carbonate, known commercially as Kryptonite. It offers superior biomechanical properties (less prone to fracture) than the calcium phosphate-based masterials but is no longer commercially available. Whether PMMA or HA is better for any cranioplasty is based on a variety of factors (cost, inlay vs onlay, size of incision) and not necessarily because one is more natural or more synthetic. There are different material properties for each type of bone cement and these must be considered also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a considerably flat occiput since infancy as I’ve noticed in pictures from that time. The vertex of my skull also slopes downwards towards the frontal lobe. This gives a “cone-shaped” appearance to my head when my hair is cut short. This has never been a concern to me, but in recent years I have began to develop male pattern baldness. Although I am currently taking drugs to hopefully slow its onset, I must be mindful of my skull shape should the treatment be ineffective. Having spent a considerable amount of time browsing your website, I’ve determined I may benefit from an implant to the occiput of my skull.
My questions are: what is the cost of such a surgery? Is there anything that can be done to flatten the vertex of my skull, or would an implant to the occipital lobe just exaggerate the slope? Would surgery require me to shave my head? Best and worse case scenarios, how big is the scar post-op?
I appreciate your time and consideration.
A: It is always more effective to augment the occiput than it is to reduce the vertex. While some bone reduction can be done, there is a limit based on the thickness of the skull to around 5 to 7mms of reducytiopn. The augmentation of the occiput can be as much as 15 mms. But put together a significant change can occur.
For skull reshaping surgery we do not shave any hair although we always appreciate any patients who would like to do so. As a ballpark figure the total cost of this surgery is in the range of $9500.
While all of these issues are relevant, none are more significant than the consideration of a scalp scar in a male. That is the key issue of whether this may be a good procedure for any patient but particularly in men who may have less hair to camouflage it. The scar is placed more to the back of the head keeping it within the stable hairline of most balding men. It is a long scar (12 to 14 cms) but thin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cranioplasty augmentationsurgery but have a few more questions.
1. Is this correction permanent meaning is it reversible? is it expected to last a lifetime?
2. You mention PMMA is harder than hydroxyapatite, will i feel the difference?
3. Is the hardness of hydroxyapatite similar to real bone? Will it feel more natural to me?
4. Will I experience foreign body sensation with this “implant”
5. I’m not an expert on the anatomy of the skull but i’ve read that there are gaps between the bones of the skull even when they are fused. how will this type of correction subtle dynamics of contraction and expansion of my skull bones, once a material like hydroxyapetite is plastered onto them?
6. Is there potential for leakage/breakage of material and if so what are the health, carcinogenic, or risks.
7. Is there risk of allergic reaction to the material?
Thank you for the work that you do.
A: In answer to your questions:
1) All cranioplasty materials are permanent, meaning that they do not degrade, break down, and never need to be replaced because they wear out. They are, however, fairly easily removed so they are completely reversible.
2) There is no external feeling difference between PMMA and HA. Their biomechanical differences are largely that of laboratory testing.
3) There are no feel differences between PMMA and HA and they will feel both natural and just like your own bone.
4) Patients do not report that they feel like they have a skull implant in place. It feels just like bone.
5) There are no gaps between adult skull plates. That is an in utero and neonatal phenomenon.
6) Cranioplasty materials are fully polymerized and do not break down, leak, or degrade over time. There are no long-term health or carcinogenic risks.
7) While infection can occur from their surgical placement, there is no known risk of an allergic reaction to HA and very rare risk to PMMA.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My daughter had craniosynostosis. After which she was left with plagiocephaly(right side). Was wondering what are the best options for her, she has 5mm deformity after wearing the helmet for 1 year. Now she is 9 years old. Need to know if the surgery can be done anytime or there is a certain period that is beneficial for the kids.
A: Once the skull has undergone much of its growth spurt and it is clear that ongoing growth is not improving the asymmetry, it is reasonable to consider an onlay skull augmentation. The decision to do so is based on an aesthetic judgment since there are no neurologic benefits to doing it. So the question is not whether it can be done but whether it should it be done. At 9 years of age, that is a decision for the parents to consider or to allow the child to decide for herself when she is old enough to do so.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Hi, I have a weird shaped head where the back of my head really sticks out so it looks long from a side view. Are there any implants that can be inserted to give it a more rounded normal shape or can the skull be reduced slightly at the back. Thanks.
A: Some reduction of an occipital skull prominence can be done which is usually about 7mms. The bone above the prominence can also be augmented to make the top part more round as it goes into the top of the skull and beyond. If done together this will create a better skull reshaping of the back of the head than either procedure done alone.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Thank you for your follow up on my questions about reshaping the top of my skull.. I realize that you are a surgeon in high demand and you taking the time to follow up is very impressive and kind. The cost is fair given the amount of work that needs to be done. The 10″ incision is my only concern. How large would the incision need to be if we simply build up the uneven side and leave the bump untouched. What would the cost be if we went this alternative route?
A: Understandably a long incision in your scalp is a concern, even to me given your young age and for the correction of only an aesthetic skull shape concern. But the same length of the incision is needed whether one merely reduces the high midline sagittal ridge or does a concomitant build along the side of it. The reason it needs to be of that length is that the hardest part of the skull reshaping procedure is getting the implanted material to have feather edges and blend into the surrounding skull smoothly and without a visible or palpable edge to it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Wow. Information about dents on a persons head is next to impossible to find on the internet. I have about dent on the very top of my head that is about 2 inches in diameter, so it is a fairly large dent. After an accident, some skin was literally ripped from the top of my skull. Eventually, the skin did grow back, but I have no hair there now as the hair follicles went with the skin when it was ripped from my skull. The main problem is though I have a dent in my head there too. At first I thought that all the tissue ( the matter under the skin ) didn’t grow back even though the skin did. Recently, a CT scan showed that part of my skull was thin, so now I don’t know if I have the dent because I need tissue or if it’s because of my skull. Is there any way to determine what the actual cause of this dent is, and if it’s the skull, would anything procedure done to the skull raise the tissue so that it is flush with the rest of my head?
A: While I don’t know the details of your original injury, it strikes me as unlikely that you would have pushed in your skull or removed the outer layer of cranial bone with an avulsion type injury. My suspicion is that this is more of soft tissue defect than bone. the scalp is incredibly thick in many patients particularly of your ethnicity. If you lost enough scalp to remove the hair what is healed is now a partial thickness of scalp which can certainly create an ‘indentation’. The definitive answer, however, would be the CT scan which should clearly show what the bone looks like underneath of the scalp…if the scan was done using coronal images and not just axial slices. I would need to see the the scan and pictures of your scalp defect to definitively determine the anatomic basis of your head indentation.
If it is just soft tissue you can have the defect excised and the hair-bearing scalp defect loosened and used to repair the defect. If there is a loss of bone component to it this can be simply filled in with hydroxyapatite cement (cranioplasty) and the hair-bearing scalp tissue closed over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read most of the material on your website relative to skull reduction. I have a disproportionately large head and face compared to my body. If you burr my head, how many months it will take before I can see a result? Because I assume in this kind of operations you get lots of swelling and you don’t see a result right away. So, the head will look bigger before starting to look smaller. Most importantly, I am an active person and work out every single day (aerobic, elliptical, walks). For this kind of surgery, how many weeks should I take off from the work out? And what is the worst that can happen if I work out 10 days post op, for instance? Thanks
A: While the scalp will swell after any skull reshaping procedure (the bone doesn’t), it usually takes about three weeks before the initial results start to become apparent. It will take up to three months to see the final result. There is harm in returning to working out whenever you feel comfortable, even if it just 10 days after surgery. You can not hurt the surgical result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about a year ago I received a blow to the head from the rear causing a depressed skull fracture. The fractured skull segments were removed and replaced with a titanium material. But there is the emergence of the head of the screws now seen through the scalp. Are there other ways to patche skull defects without these materials?
A: It is very common when scalp swelling goes down over time that the metal mesh and screwheads become apparent through the skin on skull reconstructive surgery. This is particularly evident in the forehead although it can be seen all over the scalp. In some cases, just the screws can be removed and leave the titanium mesh behind. But if one wants to remove all metal material, the titanium can be removed and replaced with a skull reshaping bone cement that will leave a smooth surface and no risk of visibility through the scalp.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The right side of my head (just above my ear when looking at me face on) buldges out about 5mm more than the left side. The left side looks perfect compared to the right. Would it be possible to reduce this ‘buldge’ and would the scar be noticeable? Thank you.
A: The simple answer to your questions is yes…and no. A 5 to 7mm reduction is what usually can be achieved in side of the head (temporo-parietal reduction). While most people think the reduction in this area of the skull is bony in nature, it is actually largely a muscular reduction. By releasing and shortening the posterior extension of the very large temporalis muscle, this will reduce the bulge on the side of head. (head reshaping) It is done through a fine line vertical incision over the thickest part of the bulge that is not longer than 4 to 4.5 cms in length. Usually this scar heals very well because the scalp incision is not under any tension. The noticeability of the scar would also depend on how one cuts their hair. If you shave your head I can not guarantee that the very fine line will not be seen.
Dr. Barry Eppley
Indianapolis,Indiana
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
Indianapolis,Indiana
Q: Dr. Eppley, Firstly, I would like to take the opportunity to thank you endlessly for the abundance of information you have on your website regarding cranioplasty. You seem to be the only person that has posted information about it, which has in turn reassured
me throughout my own medical process.
The reason for my email is to find out the best proposed solution you can present to me for my current cosmetic concern.
I have noted in some of the answers you have provided prospective patients with, you recommend using Kryptonite Bone Cement. My enquiries all relate to the use of Kryptonite Bone Cement to amend some defects I have from a past cranioplasty. I would really like to avoid having to shave off my hair where possible as it is almost as devastating as the defects themselves.
Last year in June 2012 I had a titanium plate inserted to cover the bifrontal (top front part of my head) due to replacing bone from a decompressive craniotomy after sustaining Traumatic Brain Injury. After the swelling had subsided from the insertion of the plate, I have been left with a visible line (indentation) where my plate goes across my forehead. I have also been left with a decent sized dent in the side of my face in the temple area, there also seems to be a smaller dent on the other side too. I have attached photographs so you can see the extent of my concerns.
What I would like to know is:
1. Will Kryptonite Bone Cement be suitable to use with my titanium plate? It seems to be an ideal solution to conceal the indentation along my forehead (where the plate meets my forehead) and fill in the gaps around my temple area and being injectable reduced the shaving and scarring as I would imagine.
2. If Kryptonite is not suitable, please tell me what the other options are that you would suggest.
3. Are there any side effects that I would need to be aware of?
4. Are there any long term studies on Kryptonite or proposed solutions that are available?
Many thanks in advance for your assistance, I eagerly anticipate your response.
A: In looking at your pictures and the accompanying commentary, let me answer your questions in the order that you presented them.
1) Kryptonite bone cement is no longer commercially available for reasons that are unknown to us as surgeons. But even if it were, it would not be appropriate for your case. Any injectable cranioplasty technique requires an unscarred scalp/skull area, no indwelling hardware and a defect surface area that is not unduly large. With your craniotomy history, presumably large titanium plate and the extent of the cosmetic deformity (bitemporal crossing the forehead), it is going to require an open cranioplasty approach to adequately correct. It should be approached no other way. While this is not the approach you would like to hear, the good news is that the procedure can be done without shaving any hair. I never shave any hair for an extracranial crcanioplasty procedure.
2) The only issue with an open cranioplasty is what material to use. It could be either hydroxyapatite (HA) or standard acrylic cranioplasty. (PMMA) There are some minor advantages and disadvantages with either material. I would have to see some x-rays of the extent of the plate location to answer that questions better.
3) The only real risks of this procedure are aesthetic in nature. Can a seamless transition be done in building up all the areas from the temples across the forehead. The front of head looks very much like a ‘vice’ across it so more volume is needed to build out these areas in your cranioplasty than one would think.
4) There are no long-term studies of Kryptonite that have ever been published. But this is irrevelant now since it is no longer available for clinical use.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am looking at building up the back of my head. In reading your blogs you say that you usually add about 60 grams of material. But I don’t know how that would look and whether that is enough. I went on with my experiments, but rather than water I used plasticine which conveniently has a density close to PMMA, to check the volume. I adapted it to the back of my head like an implant would be, and as you said the change is bigger than one would expect (I tried 60g and 80g). So if the trade-off for a bigger volume is ‘longer or more full coronal incision’, could you tell me what would be its size and location for 60g and 80g? (I’m not sure I’ve read around 10 centimeters for 60g on your blog) As a side question, how would you attach the implant to my skull?
A: That is a clever way to see how much volume 60 grams of cranioplasty material is. Remember that it will also look bigger than you think when placed under the scalp skin. To get this amount of material on the back of the skull, an incision of 14 to 16cms long is usually needed. Onlay cranioplasty materials are fixed to the skull by first applying small screws to the skull bone allowing them to set up about 3 or 4mms above the bone. When the material is then applied this gives it something to hang onto to like rebar used in concrete. While screw fixation may not be absolutely necessary for augmentative skull reshaping, I prefer it since it is simple to do and adds a bit of security for prevention of implant mobility.
Dr. Barry Eppley
Indianapolis,Indiana
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
Indianapolis,Indiana